Complex Regional Pain Disorder Essay
White Male With Hip Pain
The client presented with a complaint of hip pain that began seven years ago after a fall. The cartilage around the right hip sustained a 75% tear. The client’s mood is euthymic. He was diagnosed with complex regional pain disorder (reflex sympathetic dystrophy). This is a chronic pain condition that mainly affects a single limb following an injury.
The first decision was for the client to begin Savella 12.5 mg and have the dose titrated appropriately. Savella was selected because it is a serotonin-norepinephrine reuptake inhibitor that is effective in the treatment of fibromyalgia (Hayashi et al., 2017). Fibromyalgia affects cartilages, muscles, and other supporting tissues. The medication produces analgesic effects at the nerve endings (Atzeni et al., 2019). The medication also does not have many side effects when compared to the other available options (Neutrotin and amitriptyline). It was expected that the client will report a reduced pain score and stop using crutches when walking. It was also hoped he would report side effects. As anticipated, he reported a reduced pain score. However, he reported side effects like high heart rate, nausea, sweating, and high blood pressure. These are side effects of Savella.
The second decision was for the client to continue with Savella but have the dose reduced to 25 mg twice daily. This is because the medication is effective in pain reduction but the dose was reduced to prevent the side effects (Atzeni et al., 2019). It was expected that the pain score would reduce and the client would not sustain any side effects. The client reported an increased pain score, which affected his mood. However, the side effects were minimized. The increased pain score is due to the reduced efficacy of Savella due to the reduced dose.
The third decision was thus to administer Savella 25 mg in the morning and 50 mg at bedtime. The rationale for this decision is to improve the efficacy of the medication because the efficacy of Savella is dose-dependent (Hayashi et al., 2017). The higher dose was administered at bedtime to minimize side effects during the daytime when the client is awake. The option to discontinue Savella was not chosen because sudden withdrawal of Savella results in withdrawal symptoms (Atzeni et al., 2019). Combining Savella and Citalopram was not chosen because both medications inhibit the reuptake of serotonin and this can lead to serotonin toxicity. By selecting the decision, it was expected that the client would report a further reduction of the pain score, good mood and would not report any side effects.
Atzeni, F., Talotta, R., Masala, I. F., Giacomelli, C., Conversano, C., Nucera, V., … & Bazzichi, L. (2019). One year in review 2019: fibromyalgia. Clin Exp Rheumatol, 37(Suppl 116), S3-10.
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.
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.”
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)
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