Complex Regional Pain Disorder Case Study Summary Paper

Case Study Summary

The client is a 43-year-old white male who presents to the clinic with a chief complaint of pain. He is walking with a set of crutches. He reports that his family physician sent him for a psychiatric review because they thought his pain was all in his head and he just wants to get high. He reports that the pain started seven years ago after a fall. He has had numerous tests including a head CT, X-rays and MRIs. The surgeons said he was too young for a total hip replacement surgery to correct a torn cartilage on his right hip. Since then, he has been on pain medications and has been experiencing other symptoms like numbness of the lower extremities and cramping.  His family doctor has been giving him hydrocodone but he does not like the side effects of constipation and sleepiness and it does not relieve the pain. Based on the evaluation, a diagnosis of complex regional pain disorder was made. Complex Regional Pain Disorder Case Study Summary Paper

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Decision Point One- Savella 12.5 mg orally O.D day 1; then 12.5mg BD day 2 and 3; followed by 25mg BD on days 4-7, followed by 50mg BD thereafter.

Reason for Decision selection and Expected Outcome: The patient has been diagnosed with complex regional pain syndrome, which he says has reduced his quality of life and he cannot function as he used to. Savella is a selective serotonin and norepinephrine reuptake inhibitor (SNRI), which increases the level of neurotransmitters available for reuptake by the brain hence reducing pain. This drug has been recommended for chronic pain management such as in this case (Hilda Onuțu et al., 2019). The expectation of this treatment is to reduce the patient’s level of pain perception, which will in turn improve his quality of life.

Difference between expected and Actual outcome: The patient comes back after 4 weeks and reports the pain to have reduced to a lower level but would love it to be reduced even more. He also reports side effects like bouts of sweating, sleep disturbance, and a feeling of butterflies in her chest. Savella is known to produce these adverse effects and they could be reduced by lowering the dose.

Decision Point 2- Continue with current medication but lower dose to 25mg BD

Reason for selection and expected outcome: Since the patient’s pain has been responding to the initial dose of Savella minus the adverse effects, it would be wise to maintain the same treatment. However, to reduce the side effects, a lower dosage of the drug is a good option. The expected outcome is pain management and reduced side effects in coming weeks.

Difference between expected and actual outcome: Patient comes in after another 4 weeks with no palpitations and sleeping better but complains of waking up frequently due to pain. He is now using the crutches again and says his pain is at a 7. Complex Regional Pain Disorder Case Study Summary Paper

Decision point 3- Change Savella to 25 mg orally in the morning, and 50 mg orally at bedtime

Reasons for selection and expected outcome: it is clear that the patient’s diagnosis is neurological and will not completely respond to treatment. The next step will be to explain this to him and advise him to consider other non-pharmacological options for pain control (Murnion, 2018). Since his initial response to the drug was good, the best option would be to lower the dose when the pain is more bearable and increase it at night to help him sleep better, while lowering the side effects as well.

Difference between expected and actual outcome: The patient now reports a pain level of 4 out of 10. He now has a normal pulse rate and blood pressure. At this point, I would advise the patient to learn how to cope with this level of pain because it cannot be eliminated completely and further dose modification will not be practical (Stanton-Hicks, 2018). Other modalities like physiotherapy may help him to cope with the pain and allow him to function normally.

Conclusion

The management of complex regional pain syndrome requires a multidisciplinary approach in both the diagnosis and treatment decisions. Since it is not possible to completely eliminate the pain, the goal of treatment is to reduce it to the lowest possible achievable level that is compatible with a better quality of life (Bunton, Breslin & Uddin, 2017). The patient should be informed of this prior to the treatment and they should also be advised to learn coping mechanisms for some level of pain. Complex Regional Pain Disorder Case Study Summary Paper

References

Bunton, T. J., Breslin, P., & Uddin, Z. (2017). Basic Psychopharmacology for the Treatment of Pain in the Rehabilitation Patient. In Comprehensive Pain Management in the Rehabilitation Patient (pp. 403-409). Springer, Cham.

Hilda Onuțu, A., Sebastian Dîrzu, D., & Petrișor, C. (2019). Serotonin reuptake inhibitors and their role in chronic pain management. Serotonin. https://doi.org/10.5772/intechopen.80711

Murnion, B. P. (2018). Neuropathic pain: Current definition and review of drug treatment. Australian Prescriber, 41(3), 60-63. https://doi.org/10.18773/austprescr.2018.022

Onuțu, A. H., Dîrzu, D. S., & Petrișor, C. (2018). Serotonin Reuptake Inhibitors and Their Role in Chronic Pain Management. In Serotonin.

Stanton-Hicks, M. (2018). Complex regional pain syndrome. Fundamentals of Pain Medicine, 211-220. https://doi.org/10.1007/978-3-319-64922-1_23

Complex Regional Pain Disorder
White Male With Hip Pain

BACKGROUND
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.” Complex Regional Pain Disorder Case Study Summary Paper

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. Complex Regional Pain Disorder Case Study Summary Paper

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 1: Savella 12.5 mg 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.
Decision 2: Continue with current medication but lower dose to 25mg twice a day.
Decision 3: Change Savella to 25mg orally in the morning and 50mg orally at bedtime. Complex Regional Pain Disorder Case Study Summary Paper

Guidance to Student

The client has a complex neuropathic pain syndrome that may never respond to pain medication. Once that is understood, the next task is to explain to the client that pain level expectations need to be realistic in nature and understand that he will always have some level of pain on a daily basis. The key is to manage it in a manner that allows him to continue his activities of daily living with as little discomfort as possible. Next, it is important to explain that medications are never the final answer but a part of a complex regimen that includes physical therapy, possible chiropractic care, heat and massage therapy, and medications. Savella is a SNRI that also possesses NMDA antagonist activity which helps in producing analgesia at the site of nerve endings. It is specifically marketed for fibromyalgia and has a place in therapy for this gentleman. Tramadol is never a good option along with other opioid type analgesics. Agonists at the Mu receptors does not provide adequate pain control in these types of neuropathic pain syndromes and therefore is never a good idea. It also has addictive properties which can lead to secondary drug abuse. Reductions in Savella can help control side effects but at a cost of uncontrolled pain. It is always a good idea to start with dose reductions during parts of the day that pain is most under control. The addition of Celexa with Savella needs to be done cautiously. Both medications inhibit the reuptake of serotonin and can, therefore, lead to serotonin toxicity or serotonin syndrome.

To Prepare
Review the interactive media piece assigned by your Instructor.
Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.
By Day 7 of Week 8
Write a 1- to 2-page summary paper that addresses the following:

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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. Complex Regional Pain Disorder Case Study Summary Paper