Diagnoses Of Complex Regional Pain Disorder Discussion

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.” Diagnoses Of Complex Regional Pain Disorder Discussion

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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!” Diagnoses Of Complex Regional Pain Disorder Discussion

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. Diagnoses Of Complex Regional Pain Disorder Discussion

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 Tree

Decision point 1:

Neurontin 300mg orally at bedtime with weekly increases of 300mg per day to a max of 2400mg if needed. Diagnoses Of Complex Regional Pain Disorder Discussion

Results:

• Client returns to clinic in 4 weeks
• Returns to office and seems to be in agony. He states the Neurontin did not help him at all. He also states that he is foggy in the morning. His current pain level is 9/10. You question the client on what would be an acceptable pain level. He states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.” The client is also asked what would need to happen to get his pain from a current level of 9 to an acceptable level of 3. He states, “ I guess I would like this achiness and throbbing in my right leg to not happen every day or at least not several times a day. I also could do without my toes curling in like they do. That really hurts.”
• Denies SI/HI and is still future oriented. He does seem to be discouraged throughout the interview about his current pain. Diagnoses Of Complex Regional Pain Disorder Discussion

Decision Point 2:

Options:

• Continue with Neurontin but double the current dose (600mg PO 4 times a day) – No b/c he already experiencing brain fog from Neurontin, increasing will only make it worse.
• Increase Neurontin dose to 900mg PO TID and add Celexa 20mg PO daily. Increase dose to max of 40mg daily. – No b/c he already experiencing brain fog from Neurontin, increasing will only make it worse.
• Discontinue Neurontin. Start Zoloft 50mg orally daily and titrate at weekly intervals to a dose of 200mg – chose because the pain did not ease at all and he was foggy in the mornings. It is best to D/C Neurontin. Diagnoses Of Complex Regional Pain Disorder Discussion

Results:

• Client returns in 4 weeks
• Current pain level 5/10. Appears anxious, which is a new presentation. He states he feels ‘amped up’ and he cannot seem to control it.
• States he hasn’t been able to get an erection in over a week and think his pain may be causing erectile dysfunction.
• Although client’s pain is “more manageable than it has been before”, he thinks it may have gotten the best of him. His new problems really have him discouraged.

Decision Point 3:

Options:

• Reduce Zoloft to 100mg per day. Give the client a short course (2wks) of Ativan to help with anxiety. – Zoloft has helped with pain, should not reduce. If reduced the pain will increase.
• D/C Zoloft and start Prozac 40mg orally daily. Give the client a short course (2wks) of Ativan to help with anxiety. – Zoloft has improved pain. Zoloft and Prozac are both SSRI and side effects are anxiety and erectile dysfunction.
• Add on Wellbutrin XL 150 mg orally in the morning. Give the client a short course (2wks) of Ativan to help with anxiety. – Counsel on SSRI and side effects (anxiety & erectile dysfunction). Adding benzodiazepines, like Ativan for 2 weeks should assist with anxiety. Erectile dysfunction is a side effect to SSRI and adding Wellbutrin will help with it. Wellbutrin will not overlap the Zoloft.

Please read attached Word document of case study with decision tree. Diagnoses Of Complex Regional Pain Disorder Discussion

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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. Diagnoses Of Complex Regional Pain Disorder Discussion