\u00a0\u00a0
\nBACKGROUND
\nThis week, a 43-year-old white male presents at the office with a \u00a0chief complaint of pain. He is Helped in his ambulation with a set of \u00a0crutches. At the beginning of the clinical interview, the client reports \u00a0that his family doctor sent him for psychiatric assessment because the \u00a0doctor felt that the pain was \u201call in his head.\u201d He further reports that \u00a0his physician believes he is just making stuff up to get \u201cnarcotics to \u00a0get high.\u201d \u00a0
\nSUBJECTIVE
\nThe client reports that his pain began about 7 years ago when he \u00a0sustained a fall at work. He states that he landed on his right hip. \u00a0Over the years, he has had numerous diagnostic tests done (x-rays, CT \u00a0scans, and MRIs). He reports that about 4 years ago, it was discovered \u00a0that the cartilage surrounding his right hip joint was 75% torn (from \u00a0the 3 o\u2019clock to 12 o\u2019clock position). He reports that none of the \u00a0surgeons he saw would operate because they felt him too young for a \u00a0total hip replacement and believed that the tissue would repair with the \u00a0passage of time. Since then, he reported development of a strange \u00a0constellation of symptoms including cooling of the extremity (measured \u00a0by electromyogram). He also reports that he experiences severe cramping \u00a0of the extremity. He reports that one of the neurologists diagnosed him \u00a0with complex regional pain syndrome (CRPS), also known as reflex \u00a0sympathetic dystrophy (RSD). However, the neurologist referred him back \u00a0to his family doctor for treatment of this condition. He reports that \u00a0his family doctor said \u201cthere is no such thing as RSD, it comes from \u00a0depression\u201d and this was what prompted the referral to psychiatry. He \u00a0reports that one specialist he saw a few years ago suggested that he use \u00a0a wheelchair, to which the client states \u201cI said \u2018no,\u2019 there is no need \u00a0for a wheelchair, I can beat this!\u201d \u00a0
\nThe client reports that he used to be a machinist where he made \u00a0\u201cpretty good money.\u201d He was engaged to be married, but his fianc\u00e9 got \u00a0\u201csick and tired of putting up with me and my pain, she thought I was \u00a0just turning into a junkie.\u201d \u00a0
\nHe reports that he does get \u201cdown in the dumps\u201d from time to time \u00a0when he sees how his life has turned out, but emphatically denies \u00a0depression. He states \u201cyou can\u2019t let yourself get depressed\u2026 you can \u00a0drive yourself crazy if you do. I\u2019m not really sure what\u2019s wrong with \u00a0me, but I know I can beat it.\u201d \u00a0
\nDuring the client interview, the client states \u201coh! It\u2019s \u00a0happening, let me show you!\u201d this prompts him to stand with the \u00a0Helpance of the corner of your desk, he pulls off his shoe and shows \u00a0you his right leg. His leg is turning purple from the knee down, and his \u00a0foot is clearly in a visible cramp as the toes are curled inward and \u00a0his foot looks like it is folding in on itself. \u201cIt will last about a \u00a0minute or two, then it will let up\u201d he reports. Sure enough, after about \u00a0two minutes, the color begins to return and the cramping in the \u00a0foot\/toes appears to be releasing. The client states \u201cif there is \u00a0anything you can do to help me with this pain, I would really appreciate \u00a0it.\u201d He does report that his family doctor has been giving him \u00a0hydrocodone, but he states that he uses is \u201csparingly\u201d because he does \u00a0not like the side effects of feeling \u201csleepy\u201d and constipation. He also \u00a0reports that the medication makes him \u201cloopy\u201d and doesn\u2019t really do \u00a0anything for the pain. \u00a0\u00a0\u00a0
\nMENTAL STATUS EXAM
\nThe client is alert, oriented to person, place, time, and event. He \u00a0is dressed appropriately for the weather and time of year. He makes good \u00a0eye contact. Speech is clear, coherent, goal directed, and spontaneous. \u00a0His self-reported mood is euthymic. Affect consistent to self-reported \u00a0mood and content of conversation. He denies visual\/auditory \u00a0hallucinations. No overt delusional or paranoid thought processes \u00a0appreciated. Judgment, insight, and reality contact are all intact. He \u00a0denies suicidal\/homicidal ideation, and is future oriented. \u00a0
\nDiagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)
\n\u00a0\u00a0Decision Point One <\/p>\n
Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day \u00a0\u00a0
\nRESULTS OF DECISION POINT ONE<\/p>\n
Client returns to clinic in four weeks
\nClient comes to the office still using crutches. He states that the pain has improved but he is a bit groggy in the morning \u00a0
\nClient’s pain level is currently a 6 out of 10. The PMHNP questions \u00a0the client on what would be an acceptable pain level. He states, \u201cI \u00a0would rather have no pain but don\u2019t think that is possible. I could live \u00a0with a pain level of 3.\u201d He states that his pain level normally hovers \u00a0around a 9 out of 10 on most days of the week before the amitriptyline \u00a0was started. The PMHNP asks what makes the pain on a scale of 1-10 \u00a0different when comparing a level of 9 to his current level of 6?\u201d The \u00a0client states, \u201cI\u2019m able to go to the bathroom or to the kitchen without \u00a0using my crutches all the time. The achiness is less and my toes do not \u00a0curl as often as they did before.\u201d The client is also asked what would \u00a0need to happen to get his pain from a current level of 6 to an \u00a0acceptable level of 3. He states, \u201cWell, that is kind of hard to answer. \u00a0I guess I would like the achiness and throbbing in my right leg to not \u00a0happen every day or at least not several times a day. \u00a0I also could do \u00a0without my toes curling in like they do. That really hurts.\u201d\u00a0
\nClient denies suicidal\/homicidal ideation and is still future oriented \u00a0<\/p>\n
Decision Point Two <\/p>\n
\u00a0Continue \u00a0current medication and increase dose to 125 mg at BEDTIME this week \u00a0continuing towards the goal dose of 200 mg daily. Instruct the client to \u00a0take the medication an hour earlier than normal starting tonight and \u00a0call the office in 3 days to report how his function is in the morning \u00a0\u00a0\u00a0\u00a0
\nRESULTS OF DECISION POINT TWO<\/p>\n
Client returns to clinic in four weeks
\nThe change in administration time \u00a0seemed to help. The client states he is not as groggy in the morning and \u00a0is able to start his day sooner than before
\nClient’s current pain level is a 4 out of 10. He states that he is now taking 125 mg of amitriptyline at bedtime.\u00a0
\nClient’s has noticed that he is putting \u00a0on a little weight. When asked, the client states that he has gained 5 \u00a0pounds since he started taking this medication. He currently weighs in \u00a0at 162 pounds. He is 5\u2019 7\u201d. He states that his right leg doesn\u2019t bother \u00a0him nearly as much as it used to and his toes have only \u201ccramped up\u201d \u00a0twice in the past month. He states that he is able to get around his \u00a0apartment without his crutches and that he has even started seeing \u00a0someone he met at the grocery store. The weight gain seems to bother him \u00a0a lot and he is asking if there is a way to avoid it\u00a0<\/p>\n
Decision Point Three <\/p>\n
\u00a0Continue \u00a0the current dose of Elavil of 125 mg per day, refer the client to a \u00a0life coach who can counsel him on good dietary habits and exercise \u00a0\u00a0\u00a0\u00a0
\nGuidance to Student
\n \u00a0At this point, the client is almost \u00a0at his goal pain control and increased functionality. Weight gain is a \u00a0common side effect with amitriptyline and should be a counseling point \u00a0at the initiation of therapy. He has a small weight gain of 5 pounds in 8 \u00a0weeks. A reduction in dose may have an effect on the weight gain but at \u00a0a considerable cost of pain to the client. This would not be in the \u00a0best interest of the client at this point. Amitriptyline has a side \u00a0effect of cardiac arrhythmias. He is not experiencing this at this \u00a0point. The drug, qsymia contains a product called phentermine which has a \u00a0history of causing cardiac arrhythmias at higher doses. This product is \u00a0also only approved for a client with obesity defined as a BMI greater \u00a0than 30 kg\/m2. Your client\u2019s BMI is currently 25.5 kg\/m2. He does not \u00a0meet the definition of obesity but is considered overweight. His best \u00a0course of action would be to continue the same dose of Elavil, counsel \u00a0him on good dietary and exercise habits and connect him with a life \u00a0coach who will help him with this problem in a more meaningful way than a \u00a010 minute counseling session will be able to accomplish.\u00a0
\nInstructions on how to complete the assignment
\n\u00a0
\nExamine Case Study: A Caucasian Man With Hip Pain. \u00a0You will be asked to make three decisions concerning the medication to \u00a0prescribe to this client. Be sure to consider factors that might impact \u00a0the client\u2019s pharmacokinetic and pharmacodynamic processes.
\nAt each decision point stop to complete the following:<\/p>\n
Decision #1 \u00a0\u00a0\u00a0<\/p>\n
Which decision did you select?
\nWhy did you select this decision? Support your response with evidence and references to the Learning Resources.
\nWhat were you hoping to achieve by making this decision? Support \u00a0your response with evidence and references to the Learning Resources.\u00a0
\nExplain any difference between what you expected to achieve with \u00a0Decision #1 and the results of the decision. Why were they different?<\/p>\n
Decision #2 \u00a0\u00a0\u00a0<\/p>\n
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
\nWhat were you hoping to achieve by making this decision? Support \u00a0your response with evidence and references to the Learning Resources.\u00a0
\nExplain any difference between what you expected to achieve with \u00a0Decision #2 and the results of the decision. Why were they different?<\/p>\n
Decision #3 \u00a0\u00a0\u00a0<\/p>\n
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
\nWhat were you hoping to achieve by making this decision? Support \u00a0your response with evidence and references to the Learning Resources.\u00a0
\nExplain any difference between what you expected to achieve with \u00a0Decision #3 and the results of the decision. Why were they different?<\/p>\n
Also include how ethical considerations might impact your treatment plan and communication with clients.<\/p>\n
\u00a0<\/p>\n","protected":false},"excerpt":{"rendered":"
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