Posted: September 10th, 2024

Summary of Patient Case Study and Treatment Decisions A 43-year-old white male

Summary of Patient Case Study and Treatment Decisions

A 43-year-old white male presented with chronic pain, initially attributed to a fall at work seven years prior. Despite extensive diagnostic evaluations, including x-rays, CT scans, and MRIs, the patient was diagnosed with complex regional pain syndrome (CRPS) by a neurologist. However, his family doctor dismissed this diagnosis, attributing the symptoms to depression. The patient sought psychiatric evaluation due to persistent pain and skepticism from his primary care provider regarding his condition.

Decision Point One: Treatment Options
The first decision involved selecting an appropriate medication to manage the patient’s CRPS. The options included Savella, Amitriptyline, and Neurontin. Neurontin (Gabapentin) was chosen due to its efficacy in treating neuropathic pain, which aligns with the symptoms of CRPS (Dworkin et al., 2018). Gabapentin is known for its ability to modulate neurotransmitter release, thereby reducing pain perception (Moore et al., 2019).

Evidence-Based Support for Decisions
The decision to prescribe Neurontin was supported by evidence-based literature. Gabapentin has been shown to be effective in managing neuropathic pain conditions, including CRPS, by decreasing the excitability of neurons in the central nervous system (Finnerup et al., 2021). Studies have demonstrated its efficacy in reducing pain intensity and improving quality of life in patients with similar conditions (Attal et al., 2018).

Goals and Expected Outcomes
The primary goal of prescribing Neurontin was to alleviate the patient’s pain and improve his functional status. By targeting the neuropathic component of CRPS, it was anticipated that the patient would experience a reduction in pain episodes and an improvement in mobility (Harden et al., 2019). Additionally, addressing the pain effectively could potentially improve the patient’s mood and overall outlook on life.

Comparison of Expected and Actual Outcomes
The expected outcome was a significant reduction in pain and improvement in daily functioning. However, the actual results may vary depending on individual response to medication. In some cases, patients may not achieve complete pain relief, necessitating adjustments in dosage or additional therapies (O’Connell et al., 2020). If the patient did not experience the anticipated relief, it would be crucial to reassess the treatment plan and consider alternative or adjunctive therapies.

Conclusion
The treatment decisions for this patient were grounded in evidence-based practices, with the aim of effectively managing CRPS symptoms. Neurontin was selected due to its proven efficacy in neuropathic pain management. The goal was to reduce pain and enhance the patient’s quality of life, although individual responses to treatment can vary. Continuous evaluation and adjustment of the treatment plan are essential to achieving optimal outcomes.

References
Attal, N., et al. (2018). Pharmacotherapy for neuropathic pain in adults: A systematic review and meta-analysis. The Lancet Neurology, 17(2), 162-173.

Dworkin, R. H., et al. (2018). Recommendations for the pharmacological management of neuropathic pain: An overview and literature update. Mayo Clinic Proceedings, 93(9), 1231-1245.

Finnerup, N. B., et al. (2021). Neuropathic pain: From mechanisms to treatment. Physiological Reviews, 101(1), 259-301.

Harden, R. N., et al. (2019). Complex regional pain syndrome: Practical diagnostic and treatment guidelines. Pain Medicine, 20(2), 180-195.

Moore, R. A., et al. (2019). Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database of Systematic Reviews, 2019(4).

O’Connell, N. E., et al. (2020). Interventions for treating pain and disability in adults with complex regional pain syndrome. Cochrane Database of Systematic Reviews, 2020(5).

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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

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Complex Regional Pain Syndrome: A Case Study Analysis

Complex regional pain syndrome (CRPS) is a challenging condition that often perplexes both patients and healthcare providers. This paper examines a case study of a 43-year-old white male presenting with symptoms consistent with CRPS and analyzes the treatment decisions made based on current evidence-based literature.

Case Summary and Decisions

The patient, a former machinist, reports a 7-year history of pain following a work-related fall. Despite numerous diagnostic tests, including x-rays, CT scans, and MRIs, no definitive cause was identified until four years ago when a 75% tear in the cartilage surrounding his right hip joint was discovered. The patient’s symptoms have since evolved to include cooling of the extremity and severe cramping, leading to a diagnosis of CRPS by a neurologist. However, the patient’s family doctor dismissed the diagnosis, attributing the symptoms to depression.

During the clinical interview, the patient demonstrated visible signs of CRPS, including purple discoloration of the right leg from the knee down and foot cramping. The patient reported using hydrocodone sparingly due to side effects and limited pain relief. Based on the presented symptoms and history, three treatment options were considered:

Savella (milnacipran) 12.5 mg orally once daily, gradually increasing to 50 mg BID
Amitriptyline 25 mg po QHS, titrating upward weekly by 25 mg to a max dose of 200 mg per day
Neurontin (gabapentin) 300 mg po BEDTIME, with weekly increases of 300 mg per day to a max of 2400 mg if needed
Evidence-Based Support for Decisions

The treatment options considered for this patient are supported by evidence-based literature. According to the Mayo Clinic, antidepressants and anticonvulsants are commonly used to treat pain originating from a damaged nervous system, which is characteristic of CRPS (Mayo Clinic, 2023). Specifically, amitriptyline (a tricyclic antidepressant) and gabapentin (an anticonvulsant) are mentioned as potential treatment options.

Mackey et al. (2007) reviewed pharmacologic therapies for CRPS and found evidence supporting the use of tricyclic antidepressants and anticonvulsants. The National Health Service (NHS) in the UK also recommends amitriptyline as one of the most widely used tricyclic antidepressants for treating CRPS (NHS, 2023).

While Savella (milnacipran) is not specifically approved for CRPS, it is FDA-approved for fibromyalgia, another chronic pain condition. Its mechanism of action as a serotonin and norepinephrine reuptake inhibitor suggests potential benefits in managing chronic pain (Health Psychology Research, 2021).

Expected Outcomes and Actual Results

The primary goal of the recommended treatments was to alleviate the patient’s pain and improve his quality of life. Each medication targets different aspects of pain perception and transmission:

Savella (milnacipran) aims to increase serotonin and norepinephrine levels, potentially reducing pain perception and improving mood (Health Psychology Research, 2021).

Amitriptyline, as a tricyclic antidepressant, is expected to modulate pain signals and potentially improve sleep, which is often disrupted in chronic pain conditions (NHS, 2023).

Neurontin (gabapentin) is intended to reduce nerve pain by affecting calcium channels in the nervous system (Mayo Clinic, 2023).

While the actual results of these decisions are not provided in the case study, it is important to note that treatment outcomes for CRPS can vary significantly between individuals. Dey et al. (2023) emphasize that CRPS management often requires a multidisciplinary approach, combining pharmacological interventions with non-drug treatments such as physical therapy and psychotherapy.

The expected outcomes may differ from actual results due to several factors:

Individual patient response: CRPS is a complex condition, and patients may respond differently to various treatments.

Severity and duration of symptoms: The patient’s long-standing symptoms may affect treatment efficacy.

Potential side effects: As noted with the patient’s previous experience with hydrocodone, side effects can limit medication adherence and effectiveness.

Psychosocial factors: The patient’s determination to “beat this” and his past experiences with healthcare providers may influence treatment outcomes.

Conclusion

The treatment decisions made for this CRPS case study are generally supported by current evidence-based literature. However, it is crucial to recognize that CRPS management often requires a personalized, multidisciplinary approach. Regular follow-ups and adjustments to the treatment plan may be necessary to achieve optimal outcomes. Future research should focus on developing more targeted therapies for CRPS and improving our understanding of individual patient responses to various treatment modalities.

References

Dey, S., Chakraborty, A., & Mukhopadhyay, S. (2023). Complex Regional Pain Syndrome. In StatPearls. StatPearls Publishing.

Health Psychology Research. (2021). Milnacipran for the Treatment of Fibromyalgia. Open Medical Publishing.

Mackey, S., & Feinberg, S. (2007). Pharmacologic therapies for complex regional pain syndrome. Current Pain and Headache Reports, 11(1), 38-43.

Mayo Clinic. (2023). Complex regional pain syndrome – Diagnosis & treatment. https://www.mayoclinic.org/diseases-conditions/crps-complex-regional-pain-syndrome/diagnosis-treatment/drc-20371156

Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed

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Tags: A 43-year-old white male presented with chronic pain, chronic pain management, Complex Regional Pain Syndrome, CRPS treatment, Gabapentin