CASE STUDY
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 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 Tree
Decision point 1: I selected the option below;
Gabapentin 300mg orally at bedtime with weekly increase of 300mg/day to max of 2400mg 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. You question the client on what an acceptable pain level would be. 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.”
Client denies suicidal/homicidal ideation and is still future oriented. He does seem to be discouraged throughout the interview about his current pain
Decision point 2: I selected the option below;
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.
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: I selected the option below;
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
Please see feedback I got, bolded in italics below;
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).
ASSIGNMENT QUESTION
Write a 2-3 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.
