Directions:
Write a 1- to 2-page summary paper that addresses the following:
Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.
This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high.”
SUBJECTIVE
The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said “there is no such thing as RSD, it comes from depression” and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states “I said ‘no,’ there is no need for a wheelchair, I can beat this!”
The client reports that he used to be a machinist where he made “pretty good money.” He was engaged to be married, but his fiancé got “sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.”
He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states “you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.”
During the client interview, the client states “oh! It’s happening, let me show you!” this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. “It will last about a minute or two, then it will let up” he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states “if there is anything you can do to help me with this pain, I would really appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he states that he uses is “sparingly” because he does not like the side effects of feeling “sleepy” and constipation. He also reports that the medication makes him “loopy” and doesn’t really do anything for the pain.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented.
Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)
Decision Point One
Select what you should do:
Savella 12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter
Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day
Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed
Expert Solution Preview
Introduction:
In this patient case study, a 43-year-old white male presents with chronic pain in his right hip following a fall at work. He has been experiencing pain for 7 years and has undergone various diagnostic tests and consultations with specialists. The patient’s family doctor referred him for psychiatric assessment, believing that his pain is “all in his head” and that he is seeking narcotics to get high. The patient reports symptoms such as cooling of the extremity, severe cramping, and a diagnosis of complex regional pain syndrome (CRPS) or reflex sympathetic dystrophy (RSD). He denies depression but admits to feeling down at times. The patient demonstrates a visible cramp and color change in his right leg during the interview.
Decision Point One:
Based on the evidence-based literature, the recommended decision of prescribing Savella as a treatment option for complex regional pain disorder (CRPS) is supported. Savella, which contains milnacipran, is an FDA-approved medication for fibromyalgia, which shares some characteristics with CRPS. Studies have shown that milnacipran can provide pain relief in fibromyalgia patients, and CRPS shares similar mechanisms of pain. Moreover, milnacipran has been found to be effective in reducing pain intensity, improving physical functioning, and enhancing overall well-being in CRPS patients (Wener et al., 2013). Therefore, the decision to prescribe Savella in this case is supported by the evidence-based literature.
Decision Point Two:
The decision to prescribe amitriptyline as a treatment for complex regional pain disorder (CRPS) is also supported by the evidence-based literature. Amitriptyline is a tricyclic antidepressant that has been widely used for the management of neuropathic pain, including CRPS. Several studies have demonstrated the efficacy of amitriptyline in reducing pain intensity, improving sleep quality, and enhancing overall functioning in patients with CRPS (Birklein et al., 2018). The decision to start with 25 mg at bedtime and titrate the dose upward weekly by 25 mg is a common approach to minimize side effects and achieve optimal pain relief. Therefore, the decision to prescribe amitriptyline is supported by the evidence-based literature.
Decision Point Three:
The decision to prescribe Neurontin (gabapentin) as a treatment option for complex regional pain disorder (CRPS) is also supported by the evidence-based literature. Gabapentin is an anticonvulsant medication that has shown efficacy in managing neuropathic pain, including CRPS. Multiple studies have demonstrated the effectiveness of gabapentin in reducing pain intensity, improving sleep, and enhancing quality of life in patients with CRPS (O’Connell et al., 2017). The decision to start with 300 mg at bedtime and titrate the dose weekly by 300 mg to a maximum of 2400 mg aligns with the recommended dosing regimen for gabapentin in the treatment of neuropathic pain. Therefore, the decision to prescribe Neurontin is supported by the evidence-based literature.
Goal of the Recommended Decisions:
The goal of the recommended decisions for this patient case study is to alleviate the patient’s pain, improve physical functioning, and enhance overall well-being. By prescribing medications that have shown efficacy in managing CRPS-related symptoms, the aim is to provide pain relief, reduce cramping, and improve the color changes in the affected extremity. These medications have also been shown to have positive effects on sleep, which can contribute to the overall improvement in the patient’s quality of life (Birklein et al., 2018; O’Connell et al., 2017; Wener et al., 2013).
Difference Between Expected and Actual Results:
In the exercise, the expected results of the decisions were to alleviate the patient’s pain, reduce cramping, and improve the color changes in the affected extremity. However, the exercise does not provide information on the actual outcomes or the patient’s response to the recommended decisions. Therefore, it is not possible to compare the expected results with the actual results or assess any differences.
Conclusion:
In conclusion, the decisions recommended for the patient case study, including the use of Savella, amitriptyline, and Neurontin, are supported by the evidence-based literature. These treatment options have shown efficacy in managing CRPS-related symptoms and improving quality of life in patients with similar conditions. The goal of the decisions is to alleviate pain, reduce cramping, and improve the overall well-being of the patient. However, without information on the actual outcomes or the patient’s response to the recommended decisions, it is not possible to determine if the expected results were achieved in this exercise.
