CASE STUDY

 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.”

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 (There were three options of medications to start the patient with. I choose the one below. Based on the patient’s given symptoms, his conditions most aligns with fibromyalgia. Based on current research, the most effective treatment for fibromyalgia is some form of antidepressant, either TCAs or SNRIs (Rosenthal, L. & Burchum, J. 2018). Of the options given, I chose Savella, which is an SNRI known to be effective in the treatment of fibromyalgia)

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 (see below the result of the first decision)

•  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, you ask 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  ( See below  the options to select what to do next)

Select what you 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 Two (See below the option I have selected. I chose to decrease the dosage of the Savella because though there were side effects, the patient had experienced the positive benefits of the mediation)

Continue with current medication but lower dose to 25 mg twice a day

RESULTS OF DECISION POINT TWO (see below result of the second decision)

•   Client returns to clinic in four weeks
•  Client comes to office today with use of crutches. He states that his current pain is a 7 out of 10. “I do not feel as good as I did last month.”
•  Client states that he is sleeping at night but woken frequently from pain down his right leg and into his foot
•  Client’s blood pressure and heart rate recorded today are 124/85 and 87 respectively. He denies any heart palpitations today
•  Client denies suicidal/homicidal ideation but he is discouraged about the recent slip in his pain management and looks sad

Decision Point Three (See below  the options to select what to do next)

Select what you should do next:

Change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME

Discontinue Savella and start tramadol 50 mg orally every 6 hours. Client may increase to 100 mg orally every 6 hours if pain is not adequately controlled

Reduce Savella to 12.5 mg orally BID and start Celexa (citalopram) 10 mg orally daily

 

Decision Point Three (See below the option I have selected. I chose to continue the morning dose and increase the evening dose of Savella because. Tramadol is an opioid analgesic, which has little effect on neurologic pain (Ciulla-Bohling, R. 2019), so it would not be effective for this patient. Adding Celexa to the Savella can be dangerous because both medications inhibit the reuptake of serotonin and can, therefore, lead to serotonin toxicity or serotonin syndrome.

 

Change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME

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:

• 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.

Please do the assignment in this format

 Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.

 Decision #1

• , 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.

Decision #2

• , 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.

Decision #3

• , 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.

(In other words, the assignment will have 4 Heading:  Summary, Decision1, Decision 2, Decision 3) you can use more sources if needed to

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Solution

Decision Tree for Neurological and Musculoskeletal Disorders

The assigned case provides useful insights into the health condition and wellbeing of the 43-year old white male who presents at the psychiatry clinic with a chief complaint of severe and persistent pain. Purpose of the assignment is to examine a series of key decision points aimed at assisting the patient with a musculoskeletal disorder to achieve higher therapeutic response to the selected medications.

Summary of Case Study

A myriad of patient factors including the occupational accident, the use of crutches, and results of the numerous diagnostic tests (CT Scans, x-rays and MRIs) should be considered in the decision-making process to ensure the treatment plan is tailored to meet the distinct needs, realities and conditions experienced by this particular patient.  In view of the Budapest criteria, complex regional pain syndrome is characterized by persistent inflammation and chronic pain that often affects the leg or arm following an injury (Goebel et al., 2017). Some of the warning signs and symptoms associated with the complex regional pain disorder (CRPD) include throbbing pain or continuous burning in the arm, hand, leg or foot; joint stiffness, damage and swelling; changes in skin color and texture; sweating of the pain area; sensitivity to cold or touch; reduced capacity to move the affected body area; and changes in skin temperature (Xu et al., 2021). Moreover, the pursued decisions namely: (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; (2) Continue with current medication but lower dose to 25 mg twice a day; and (3) Change Savella to 25 mg orally in the morning and 50 mg orally at BEDTIME. Combined, these decisions sought to alleviate the pain experienced by the patient by addressing the symptoms through ensuring sustained and high therapeutic response.

 

Decision 1

The decision to begin with a starting dose of Savella at 12.5 mg BID, 25 mg and subsequently, 50 mg BID is based on the available evidence-based literature. In reference to recent neuropathic pain guidelines, Yehya et al. (2019) indicated that Savella medication is a common selective serotonin and norepinephrine reuptake inhibitor (SNRI) that is utilized in enhancing symptoms of CRPD. Considering the status of Savella as a first-line neuropathic coanalgesic, the decision was focused on relieving chronic pain and offering sedation. Whilst the use of Amitriptyline and Neurontin are considered second-line treatment for chronic pain, they these treatment options are associated with a range of side effects (Goh et al., 2021). And hence, the decision to use Savella sought to avoid the possible side effects associated with the other decisions including severe dizziness, seizures, muscle spasms, persistent heartburn, eye pain, weight gain, difficult urinating, depression, reduced vision, fever and sexual dysfunction.

Decision 2

Derry e al. (2015) established that abrupt discontinuation of Savella is not encouraged, and hence reducing the dosage from the initial dose of 50 mg to 25 mg twice a day sought to avoid the serious side effects of Savella (e.g. dark urine, easy bruising, yellowing eyes or skin, difficult or painful urination, abdominal pain and pounding heartbeat). This decision aimed at sustaining the positive therapeutic response initiated by the first decision, and to avoid advance events associated with a higher dosage or a change in dose (Walters, 2017). On the other hand, the other two decisions namely: (1) discontinue Savella and start Lyrica (pregabalin) 50 mg orally BID and discontinue Savella and start Zoloft (sertraline) 50 mg daily could be dangerous to the patient due to the risk of hypersensitivity and adverse side effects associated with Lyrica and the possibility of serotonin toxicity or serotonin syndrome in the case of dosage modifications in favor of Zoloft (Shin & Cheng, 2021).

Decision 3

Yehya et al. (2019) noted that Savella is an effective SNRI for the treatment of chronic neuropathic pain, and hence, its high analgesic efficacy makes it a first-line treatment for CRPD.  The aim of adopting this particular decision is to amply the clinically-relevant benefits associated with proper therapeutic doses in relation to reduction of pain severity and frequency (Goebel et al., 2017). On the other hand, the discontinuation Savella and starting of Celexa (citalopram) in addition to the reduced savella dosage might lead to adverse events since both treatment options inhibit reuptake of serotonin and could contribute to the occurrence of serotonin syndrome (Walters, 2017).

Conclusion

With a diagnosis of complex regional pain syndrome, the proposed treatment plan entails providing the recommended dosage of Savella as an effective and safe first-line SSRI. Increased therapeutic response is determined by reduction in chronic pain, avoidance or prevention of possible side effects and adverse events, and better patient outcomes.

 

References

Derry, S., Phillips, T., Moore, R. A., & Wiffen, P. J. (2015). Milnacipran for neuropathic pain in adults. The Cochrane database of systematic reviews, 2015(7), CD011789. https://doi.org/10.1002/14651858.CD011789

Goebel A, Bisla J, Carganillo R, et al. (2017). A randomised placebo-controlled Phase III multicentre trial: low-dose intravenous immunoglobulin treatment for long-standing complex regional pain syndrome (LIPS trial). Southampton (UK): NIHR Journals Library; 2017 Nov. (Efficacy and Mechanism Evaluation, No. 4.5.) Appendix 3, Research diagnostic criteria (the ‘Budapest Criteria’) for complex regional pain syndrome. https://www.ncbi.nlm.nih.gov/books/NBK464482/

Goh, E. L., Chidambaram, S., & Ma, D. (2021). Treatment algorithm for complex regional pain syndrome. Complex Regional Pain Syndrome, 229-249. https://doi.org/10.1007/978-3-030-75373-3_12

Shin, C., & Cheng, J. (2021). Interventional treatment of complex regional pain syndrome. Complex Regional Pain Syndrome, 179-206. https://doi.org/10.1007/978-3-030-75373-3_9

Walters, J. L. (2017). Complex regional pain syndrome. Oxford Medicine Online. https://doi.org/10.1093/med/9780190217518.003.0025

Xu, J., Sun, Z., Chmiela, M., & Rosenquist, R. (2021). Challenges and controversies in complex regional pain syndrome (CRPS) treatment. Complex Regional Pain Syndrome, 323-344. https://doi.org/10.1007/978-3-030-75373-3_16

Yehya, A., Miles, J. M., & Bhattacharya, R. K. (2019). Savella® (Milnacipran) causing elevated Normetanephrines. Kansas Journal of Medicine, 9(3), 71-73. https://doi.org/10.17161/kjm.v9i3.8618