Caucasian Man With Hip Pain Case study

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Case Study: A Caucasian Man with Hip Pain

Introduction

Complex regional pain disorder is a chronic pain condition that mostly affects one limb normally after an injury (Zanotti et al, 2017). Apart from the pain, clients also experience anxiety, depression, sleep difficulties, paresthesias, and general deterioration of physical function.  In this case, the client is a 43-year-old Caucasian man who presented with chief complaint of hip pain. According to the client, the pain started 7 years ago after a fall at work and later on it was discovered that the cartilage surrounding the right hip joint was 75% torn. For mental status, the client reports euthymic mood Caucasian Man With Hip Pain Case study. The diagnosis is Complex regional pain disorder (reflex sympathetic dystrophy). The purpose of this essay is to make three decisions regarding the medications to be prescribed to the client. Factors that might affect the pharmacokinetic and pharmacodynamic processes will be taken into consideration.

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The selected first decision is to prescribe the client Savella 12.5 mg orally once daily on day 1; followed by…

 

Complex Regional Pain Disorder
White Male With Hip Pain

White male on crutches

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.” Caucasian Man With Hip Pain Case study

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!” Caucasian Man With Hip Pain Case study.

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.” Caucasian Man With Hip Pain Case study.

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 Caucasian Man With Hip Pain Case study. 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 the PMHNP 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
Decision Point One
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

RESULTS OF DECISION POINT ONE

  •  Client returns to clinic in four weeks
  •  Client comes into the office to without crutches but is limping a bit. The client states that the pain is “more manageable since I started taking that drug. I have been able to get around more on my own. The pain is bad in the morning though and gets better throughout the day”. On a pain scale of 1-10; the client states that his pain is currently a 4. When asked what pain level would be tolerable on a daily basis, the client states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.”. When questioned further, the PMHNP asks what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 4?”. The client states that since using this drug, I can get to a point on most days where I do not need the crutches. ” The client is also asked what would need to happen to get his pain from a current level of 4 to an acceptable level of 3. He states, “If I could get to the point everyday where I do not need the crutches for most of my day, I would be happy.”
  •  Client states that he has noticed that he frequently (over the past 2 weeks) gets bouts of sweating for no apparent reason. He also states that his sleep has “not been so good as of lately.” He does complain of nausea today
  •  Client’s blood pressure and pulse are recorded as 147/92 and 110 respectively. He also admits to experiencing butterflies in his chest. The client denies suicidal/homicidal ideation and is still future oriented
Decision Point Two
Select what the PMHNP should do next:
Continue with current medication but lower dose to 25 mg twice a day
Discontinue Savella and start Lyrica (pregabalin) 50 mg orally BID
Discontinue Savella and start Zoloft (sertraline) 50 mg daily
Decision Point One
Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day

RESULTS OF DECISION POINT ONE

  •  Client returns to clinic in four weeks
  •  Client comes to the office still using crutches. He states that the pain has improved but he is a bit groggy in the morning
  •  Client’s pain level is currently a 6 out of 10. The PMHNP questions 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.” He states that his pain level normally hovers around a 9 out of 10 on most days of the week before the amitriptyline was started. The PMHNP asks what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 6?” The client states, “I’m able to go to the bathroom or to the kitchen without using my crutches all the time. The achiness is less and my toes do not curl as often as they did before.” The client is also asked what would need to happen to get his pain from a current level of 6 to an acceptable level of 3. He states, “Well, that is kind of hard to answer. I guess I would like the 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.”
  •  Client denies suicidal/homicidal ideation and is still future oriented
Decision Point Two
Select what the PMHNP should do next:
Continue current medication and increase dose to 125 mg at BEDTIME this week continuing towards the goal dose of 200 mg daily. Instruct the client to take the medication an hour earlier than normal starting tonight and call the office in 3 days to report how his function is in the morning
Reduce the dose of Elavil to 75 mg at BEDTIME (dose has been titrated at weekly intervals by 25mg per week). Add on Biofreeze roll-on therapy to his right leg below the knee and into the foot and toes to be used as needed daily for muscle cramping
: Reduce dose of amitriptyline Elavil to 75 mg po orally at BEDTIME and add- on Neurontin (gabapentin) 300 mg po orally at BEDTIME. Schedule a Ffollow-up phone call in 1 week to assess pain control
Decision Point Two
Continue current medication and increase dose to 125 mg at BEDTIME this week continuing towards the goal dose of 200 mg daily. Instruct the client to take the medication an hour earlier than normal starting tonight and call the office in 3 days to report how his function is in the morning

RESULTS OF DECISION POINT TWO

  •  Client returns to clinic in four weeks
  •  The change in administration time seemed to help. The client states he is not as groggy in the morning and is able to start his day sooner than before
  •  Client’s current pain level is a 4 out of 10. He states that he is now taking 125 mg of amitriptyline at bedtime.
  •  Client’s has noticed that he is putting on a little weight. When asked, the client states that he has gained 5 pounds since he started taking this medication. He currently weighs in at 162 pounds. He is 5’ 7”. He states that his right leg doesn’t bother him nearly as much as it used to and his toes have only “cramped up” twice in the past month. He states that he is able to get around his apartment without his crutches and that he has even started seeing someone he met at the grocery store. The weight gain seems to bother him a lot and he is asking if there is a way to avoid it
Decision Point Three
Select what the PMHNP should do next:
Continue with the Elavil at his current 125 mg a day dose and start Qsymia (phentermine and topiramate) 3.75 mg/23 mg tablet once daily and titrate as required by package insert
Reduce the dose of Elavil to 100 mg a day and follow up in a month
Continue the current dose of Elavil of 125 mg per day, refer the client to a life coach who can counsel him on good dietary habits and exercise
Decision Point One
Neurontin (gabapentin) 300 mg orally at BEDTIME with weekly increases of 300 mg per day to a max of 2,400 mg if needed

RESULTS OF DECISION POINT ONE

  •  Client returns to clinic in four weeks
  •  Client returns to the office today and seems to be in agony. He states that the Neurontin did not help him at all. He also states that he is foggy in the morning. His current pain level is a 9 out of 10. The PMHNP questions 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.” Caucasian Man With Hip Pain Case study
  •  Clientis denies suicidal/homicidal ideation and is still future oriented. He does seem to be discouraged throughout the interview about his current pain
Decision Point Two
Select what the PMHNP should do next:
Discontinue Neurontin. Start Zoloft (sertraline) 50 mg orally daily and titrate at weekly intervals to a dose of 200 mg
Continue with Neurontin but double the current dose (600 mg PO orally 4 times a day)
Increase the Neurontin dose to 900 mg orally TID and add on Celexa 20 mg orally daily. Increase dose to a max of 40 mg daily
Decision Point Two
Discontinue Neurontin. Start Zoloft (sertraline) 50 mg orally daily and titrate at weekly intervals to a dose of 200 mg

RESULTS OF DECISION POINT TWO

  •  Client returns to clinic in four weeks
  •  Client returns today with a current pain level of 5 out of 10. He appears anxious, which is a new presentation. He states that he feels “amped up” and he cannot seem to control it
  •  Client also states that he hasn’t been able to get an erection in over a week and thinks his pain may be causing erectile dysfunction Caucasian Man With Hip Pain Case study.
  •  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 Three
Add on Wellbutrin (bupropion) XL 150 mg orally in the MORNING. Give the client a short course (2 weeks) of Ativan to help with his anxiety

Guidance to Student
Anxiety is a transient effect of SSRI and SNRI therapy and should be anticipated. Counseling the client is key in continuing the therapeutic alliance you have with the client. Short course benzodiazepines will usually be sufficient to bridge this time period. Erectile dysfunction is a side effect of all SSRI’s and should be a counseling point for men. It happens in roughly 10% of men using SSRI’s. A dose reduction in Zoloft will certainly help with the side effects but will most likely result in increased pain. A change in therapy is always an option at this point but will normally not reduce the anxiety or erectile dysfunction experienced and will still require short course benzodiazepine therapy and appropriate counseling. It would be most prudent, in this case, to add-on Wellbutrin XL 150 mg po QAM to help with the side effect of erectile dysfunction. Although we have told you throughout this course that the addition of a medication to treat a side effect is not good therapy, this is one of those cases where it is recommended, especially when the client is experiencing relief from a regimen that took time to achieve. Wellbutrin is a DNRI and does not overlap in SSRI therapy (maybe a little in the DRI of Zoloft) Caucasian Man With Hip Pain Case study.

Decision Point One
Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day

RESULTS OF DECISION POINT ONE

  •  Client returns to clinic in four weeks
  •  Client comes to the office still using crutches. He states that the pain has improved but he is a bit groggy in the morning
  •  Client’s pain level is currently a 6 out of 10. The PMHNP questions 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.” He states that his pain level normally hovers around a 9 out of 10 on most days of the week before the amitriptyline was started. The PMHNP asks what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 6?” The client states, “I’m able to go to the bathroom or to the kitchen without using my crutches all the time. The achiness is less and my toes do not curl as often as they did before.” The client is also asked what would need to happen to get his pain from a current level of 6 to an acceptable level of 3. He states, “Well, that is kind of hard to answer. I guess I would like the 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.” Caucasian Man With Hip Pain Case study
  •  Client denies suicidal/homicidal ideation and is still future oriented
Decision Point Two
Select what the PMHNP should do next:
Continue current medication and increase dose to 125 mg at BEDTIME this week continuing towards the goal dose of 200 mg daily. Instruct the client to take the medication an hour earlier than normal starting tonight and call the office in 3 days to report how his function is in the morning
Reduce the dose of Elavil to 75 mg at BEDTIME (dose has been titrated at weekly intervals by 25mg per week). Add on Biofreeze roll-on therapy to his right leg below the knee and into the foot and toes to be used as needed daily for muscle cramping
: Reduce dose of amitriptyline Elavil to 75 mg po orally at BEDTIME and add- on Neurontin (gabapentin) 300 mg po orally at BEDTIME. Schedule a Ffollow-up phone call in 1 week to assess pain control
Decision Point Two
Continue current medication and increase dose to 125 mg at BEDTIME this week continuing towards the goal dose of 200 mg daily. Instruct the client to take the medication an hour earlier than normal starting tonight and call the office in 3 days to report how his function is in the morning Caucasian Man With Hip Pain Case study

RESULTS OF DECISION POINT TWO

  •  Client returns to clinic in four weeks
  •  The change in administration time seemed to help. The client states he is not as groggy in the morning and is able to start his day sooner than before
  •  Client’s current pain level is a 4 out of 10. He states that he is now taking 125 mg of amitriptyline at bedtime.
  •  Client’s has noticed that he is putting on a little weight. When asked, the client states that he has gained 5 pounds since he started taking this medication. He currently weighs in at 162 pounds. He is 5’ 7”. He states that his right leg doesn’t bother him nearly as much as it used to and his toes have only “cramped up” twice in the past month. He states that he is able to get around his apartment without his crutches and that he has even started seeing someone he met at the grocery store. The weight gain seems to bother him a lot and he is asking if there is a way to avoid it
Decision Point Three
Select what the PMHNP should do next:
Continue with the Elavil at his current 125 mg a day dose and start Qsymia (phentermine and topiramate) 3.75 mg/23 mg tablet once daily and titrate as required by package insert
Reduce the dose of Elavil to 100 mg a day and follow up in a month
Continue the current dose of Elavil of 125 mg per day, refer the client to a life coach who can counsel him on good dietary habits and exercise Caucasian Man With Hip Pain Case study
Guidance to Student
At this point, the client is almost at his goal pain control and increased functionality. Weight gain is a common side effect with amitriptyline and should be a counseling point at the initiation of therapy. He has a small weight gain of 5 pounds in 8 weeks. A reduction in dose may have an effect on the weight gain but at a considerable cost of pain to the client. This would not be in the best interest of the client at this point. Amitriptyline has a side effect of cardiac arrhythmias. He is not experiencing this at this point. The drug, qsymia contains a product called phentermine which has a history of causing cardiac arrhythmias at higher doses. This product is also only approved for a client with obesity defined as a BMI greater than 30 kg/m2. Your client’s BMI is currently 25.5 kg/m2. He does not meet the definition of obesity but is considered overweight. His best course of action would be to continue the same dose of Elavil, counsel him on good dietary and exercise habits and connect him with a life coach who will help him with this problem in a more meaningful way than a 10 minute counseling session will be able to accomplish. Caucasian Man With Hip Pain Case study

Case Study: A Caucasian Man with Hip Pain

Introduction

Complex regional pain disorder is a chronic pain condition that mostly affects one limb normally after an injury (Zanotti et al, 2017). Apart from the pain, clients also experience anxiety, depression, sleep difficulties, paresthesias, and general deterioration of physical function.  In this case, the client is a 43-year-old Caucasian man who presented with chief complaint of hip pain. According to the client, the pain started 7 years ago after a fall at work and later on it was discovered that the cartilage surrounding the right hip joint was 75% torn. For mental status, the client reports euthymic mood. The diagnosis is Complex regional pain disorder (reflex sympathetic dystrophy). The purpose of this essay is to make three decisions regarding the medications to be prescribed to the client. Factors that might affect the pharmacokinetic and pharmacodynamic processes will be taken into consideration. Caucasian Man With Hip Pain Case study.

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The selected first decision is to prescribe the client 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. I chose Savella because Savella has been shown to be effective in treating fibromyalgia a condition that affects muscles, cartilages and other supporting tissues. Savella is a serotonin-norepinephrine reuptake inhibitor (SNRI and has NMDA antagonist activity and thus balances neurotransmitters in the brain and produces analgesia effect at the site of nerve endings (Abida et al, 2016).

Savella was selected over other options because Savella (milnacipran) does not have affinity for adrenergic, cholinergic and histaminergic receptors, and hence does not have some of the adverse and side effects evident in other medications (English et al, 2010).

The expected results are that the pain will decline and the client will stop using crutches. It is also expected that the client will have minimal side effects and that his mood will stabilize. The outcome of this decision was that the pain had reduced. However, the client reports sweating bouts, nausea, elevated blood pressure and heart rate, and experiencing butterflies in his chest.  These are some of the side effects of milnacipran (Abida et al, 2016).

The selected decision is for the client to continue with the current prescribed medication (Savella) but lower the dose to 25 mg twice daily. The rationale for choosing this decision is that this medication is proofing to be effective in reducing the pain for the patient and the client does not report any mood problems. However, since the client reported some side effects, it is appropriate to lower the dosage in order to minimize the side effects. The rationale for not selecting Lyrica is that this medication has more side effects than Savella and evidence indicate that Lyrica causes mood problems and suicidal thoughts (Goodman & Brett, 2017). Similarly, Sertraline has worse side effects and is not indicated for fibromyalgia (Zhu et al, 2013). In addition, sudden stop of milnacipran therapy is not recommended because the client may develop withdrawal symptoms (Mease et al, 2014). Caucasian Man With Hip Pain Case study

The expected result for choosing this decision was that the pain score would reduce to acceptable level of 3 and that there will be minimal side effects. The outcome of the selected decision was that the pain score has increased compared to previous prescription and this is really affecting his mood. However, the side effects have reduced. The increased pain score can be attributed to the reduced dosage that is not being effective in reducing the pain.  The recommended dosage for Milnacipran is 2.5 mg/day for the first day, 25 mg/day on the 2nd and 3rd day, 50 mg/day on 4th-7th day and after 7th day 100 mg/day. The dose can also be increased to 200 mg/day (Mease et al, 2014).  This therefore might explain the reduced efficacy of the prescribed dosage for the client in regard to pain reduction.

The selected third decision is to change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME. This decision was selected because increased dosage of Milnacipran has been shown to be more effective. Evidence shows that if the response the standard-dose milnacipran therapy is poor, the dose can be increased but keep on assessing patient responses (Hayashi et al, 2017).  In addition, the dose was increased during bedtime in order to reduce side effects when the patient is awake. The second option was not selected because if the client abruptly stops taking milnacipran he may have withdrawal symptoms. The third option was not selected because combination of Savella and Celexa (citalopram) both drugs inhibit serotonin reuptake and hence can cause serotonin toxicity or serotonin syndrome. In addition, using both medications can increase side effects for the client (Masuda et al, 2014). Caucasian Man With Hip Pain Case study

Conclusion

The first selected decision was to prescribe Savela for the client and keep on increasing the dosage as recommended. The rationale for selecting this decision is that Savella has been shown to be effective in treatment of fibromyalgia. Savella balances neurotransmitters in the brain and produces analgesia effect at the site of nerve endings. With this decision, the pain score reduced though the client experienced side effects from the medication. Therefore, the second decision was to continue Savella but lower the dose to 25 mg twice daily. This decision eradicated the side effect but the pain score increased compared to the previous higher dose. As a result, the third decision was to change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME. This decision was selected because increased dosage would increase drug efficacy and hence reduce pain score and during bedtime the client would be able to tolerate side effects better during sleep. Caucasian Man With Hip Pain Case study

References

Abida M, Alam T, Said I, Feky E & Hagg M. (2016). Recent Drugs For The Management  And   Treatment Of Fibromyalgia. IAJPS. 3 (11), pp: 1361-1365

English C, Rey J & Rufin C. (2010). Milnacipran (Savella), a Treatment Option for            Fibromyalgia. PMCID. 35(5), pp: 261–266.

Goodman C & Brett A. (2017). Gabapentin and Pregabalin for Pain — Is Increased Prescribing a             Cause for Concern? N Engl J Med. 1(377), pp: 411-414.

Hayashi M, Mimura M, Otsubo T & Kamijima K. (2017). Effect of high-dose milnacipran in         patients with depression. Neuropsychiatr Dis Treat. 3(5), pp: 699–702.

Masuda T, Inoue T, Naoki T, Shin N, Yuji K, Koyama T & Kusumi I. (2014). Effect of the          coadministration of citalopram with mirtazapine or atipamezole on rat contextual       conditioned fear. Neuropsychiatr Dis Treat. 1(10), pp: 289–295.

Mease P, Clauw D, Trugman J, Plamer R & wang Y. (2014). Efficacy of long-term milnacipran    treatment in patients meeting different thresholds of clinically relevant pain relief:          subgroup analysis of a randomized, double-blind, placebo-controlled withdrawal study. Journal of Pain Research. 1(7), pp: 679—687.

Zanotti G, Ariel P, Comba F, Buttaro M & Piccaluga F. (2017). Three cases of type-1 complex     regional pain syndrome after elective total hip replacement. SICOT J. 3(52).

Zhu H, Bogdanov MB, Boyle SH, Matson W, Sharma S, Matson S, et al. (2013). Pharmacometabolomics of Response to Sertraline and to Placebo in Major Depressive   Disorder – Possible Role for Methoxyindole Pathway. PLoS ONE. 8(7) Caucasian Man With Hip Pain Case study