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Case Study: A Caucasian Man With Hip Pain

Case Study: A Caucasian Man With Hip Pain

Case Study: A Caucasian Man With Hip Pain

SAMPLE SOLUTION – Case Study: A Caucasian Man With Hip Pain

The International Association for the Study of Pain (IASP) defines pain as a distressing sensory and emotional experience related to existing or potential tissue damage or expressed as such damage (as cited in NINDS, 2018). Pain alerts us to a problem and prompts us to seek medical attention or take medication; however, pain is a complicated experience that varies greatly between individual patients (NINDS, 2018). Burning pain and a hypersensitivity to heat are symptoms of Complex Regional Pain Syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD) syndrome or causalgia. It is triggered by trauma or nerve damage, causing the skin of the affected area to become characteristically shiny and the limb is swollen (NINDS, 2018).

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The case study for this assignment is on a 43-year-old white male presents at the office with a chief complaint of a right hip pain that began seven years ago after a fall at work. He is asked to seek a psychiatric assessment by his family doctor because the doctor feels that the pain “all in his head.” Also, the family doctor believes he is just making stuff up to get “narcotics to get high.” The purpose of this paper is to show how to assess and treat clients requiring therapy for pain based on the decision concerning the medication to prescribe to the client, the influence of pharmacokinetic and pharmacodynamic, and including ethical and legal implications related to prescribing therapy for clients with pain.

Decision One

Case Study: A Caucasian Man With Hip Pain

The first decision selected is to start the client on Milnacipran (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. Milnacipran, a dual serotonin and norepinephrine reuptake inhibitor (SNRI) that is more selective for norepinephrine reuptake was approved in the 1990s to treat chronic neuropathic pain and fibromyalgia (English, Rey, & Rufin, 2010). Savella is known to cause several side effects such as nausea, vomiting, constipation, increased sweating, headache, and the occurrence of hot flashes (Barbehenn, & Wolfe, 2010). Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day and Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed are not appropriate for the client at this time. Amitriptyline a class of medications called tricyclic antidepressants (TCAs) is used to treat symptoms of depression (MedlinePlus, 2017). Because of the anticholinergic adverse effects (AEs) such as dry mouth, constipation, and drowsiness, also weight gain, headache, anxiety, nervousness, restlessness, it is generally recommended to avoid the use of TCAs (Stahl, 2014b). Neurontin is FDA approved for partial seizures with or without secondary generalization, postherpetic neuralgia, and restless leg syndrome and it in itself is an augmenting agent to numerous other anticonvulsants, SNRIs, and TCAs (Stahl, 2014b).

I hope to achieve a decrease in the client’s pain level within 2- 4 weeks with a report from the client tolerating the medication with fewer side effects and improvement in mood. The expectation is for the client’s pain to reduce as much as possible. The client returns to the clinic in four weeks walking without crutches but limping a bit and reports that the pain is “more manageable since he started taking that drug and has been able to get around more on my own and a pain level of 4 out of 10. Although the client is responding to treatment, the client reports bouts of sweating over the past two weeks, not sleeping good, and having nausea. His vital signs are recorded as blood pressure of 147/92 and pulse is 110 with a feeling of butterflies in his chest. Racing heartbeat, high or low blood pressure, nausea, and vomiting are common side effects of Savella. The actual results indicate the client’s pain level has decreased, although the patient is experiencing the side effects of the medication.

Decision Two

My next decision is to continue with current medication but a lower dose to 25 mg twice a day. Since client showed a decrease in pain level but experiencing the side effects of the medication, it is best to lower the dose at this time; therefore, the client will tolerate the medication while having fewer side effects associated with the medication. It is important as a practitioner to educate the client on the side effects of medications prescribed and instruct to always consult the provider before stopping any medication. To discontinue Savella and start either Lyrica (pregabalin) 50mg orally BID or start Zoloft (sertraline) 50mg daily would not be my recommendation. Even though Lyrica is commonly prescribed for fibromyalgia, the side effect of sedation and dizziness puts the client at more risk for fall along with other side effects such as, ataxia, fatigue, tremor, dysarthria, paresthesia, memory impairment, coordination abnormal, and peripheral edema, I would not choose this medication at this point (Stahl, 2014b). Zoloft is a selective serotonin reuptake inhibitor (SSRI), used in the treatment of major depressive disorder, premenstrual dysphoric disorder (PMDD), panic disorder, posttraumatic stress disorder (PTSD), social anxiety disorder (social phobia), and obsessive-compulsive disorder (OCD) at which there’s no evidence client is experiencing depression at this time (Stahl, 2014b). Case Study: A Caucasian Man With Hip Pain

I am hoping the client will achieve more decrease in the pain level with a report of a decrease in the side effects of the medication. The expectation with decision two is client will continue with the current treatment plan with a reduction in pain and side effects. The client returned to the clinic four weeks later walking in crutches and complaining of an increase in pain level a 7 out of 10. He seems to be declining due to the lower dose of Savella reporting that he is not feeling as good as he did last month and wakes up frequently at night due to his hip pain. His vital signs this visit are stable with a blood pressure of 124/85 and a pulse of 87, denying any heart palpitations and suicidal/homicidal ideation. The actual results indicate the client’s vitals are stable, no reports of side effects, but the client’s pain increased due to lower doses.

Decision Three

 At this point, my decision is for the client to change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME. With this decision, the client will maintain a stable blood pressure while eliminating the side effect of nausea in the morning/day while the higher dose in the evening will enable the client sleep at the same time his pain will be controlled throughout the night. Discontinuing Savella and starting tramadol 50 mg orally every 6 hours and may increase to 100 mg orally every 6 hours if the pain is not adequately controlled or reducing Savella to 12.5 mg orally BID and starting Celexa (citalopram) 10 mg orally daily are not suitable for the client at this point. Savella is being tolerated by the client; therefore, discontinuing and starting a new medication is not advisable. According to Perez et al. (2010), there is insufficient evidence for the effects of oral opioids in CRPS patients on pain; therefore tramadol is not a suitable decision. Celexa is used to treat depression and both medications inhibit the reuptake of serotonin; therefore can cause a fatal “serotonin syndrome” (Stahl, 2014b).

I am hoping that the client will achieve a tolerable pain level with no further side effects of the medication reported. The expectation is that the client will experience less pain, increased function, and return to everyday life activities. At this point, it is important to educate the client on other non-pharmacological treatment to incorporate such as psychotherapy to help him cope with the problem and physical and occupational therapy to help focus on daily activities to prevent muscle atrophy due to reduction of the use of the affected extremity from severe pain (King, 2006).

Pharmacodynamics and Pharmocokinetic

According to English, Rey, & Rufin, (2010), it is hypothesized that the effects of regulating dysfunctional noradrenergic and serotonergic pathways contribute to its therapeutic properties. Milnacipran does not affect the reuptake of dopamine, and it has no significant affinity for serotonergic (5-HT1–7), dopaminergic (D1–5), opiate, benzodiazepine, and gamma-aminobutyric acid (GABA) receptors and because it lacks affinity for adrenergic, cholinergic, and histaminergic receptors, it does not exhibit many of the expected AEs seen with the TCAs .

Following oral administration, Milnacipran is rapidly absorbed, exhibiting maximal concentrations at two to four hours and a mean peak concentration; therefore, exhibiting a high bioavailability of approximately 85% to 90% (English, Rey, & Rufin, 2010). Because of its low protein binding, milnacipran is free to diffuse, and it is widely distributed in the body with its half-life of between six and eight hours and its inactive metabolites eliminated primarily via renal excretion, with approximately 50% to 60% of the original dose excreted in the urine as unchanged drug (English, Rey, & Rufin, 2010).

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Conclusion with Ethical Considerations

It is important as a PMHNP to involve the client in educating on treatment and treatment plan for a better outcome, discussing the risk and benefits, side effects, and any changes during treatment plan. As mentioned in Laureate (2016a), the client has a complex neuropathic pain syndrome that may never respond to pain medication. It important to explained to the client that he will have some pain but the goal to for a manageable level that will allow him to still function on a daily basis; also explaining that medications are never the final answer but are a part of a complex regimen that includes physical therapy, possible chiropractic care, heat and massage therapy, and medications.

References

The Assignment: Case Study: A Caucasian Man With Hip Pain

Examine Case Study: A Caucasian Man With Hip Pain. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

Decision #1

  • Which decision did you select?
  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

Decision #2

  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

Decision #3

  • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
  • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
  • Also include how ethical considerations might impact your treatment plan and communication with clients.

Finally: 1. Complete the decision tree (keep track of what you selected. come up with a rational reason why you chose it. Come up with patient specific rational reason behind not choosing the other two options not chosen).

Write paper addressing all section listed based on the decision tree.

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Case Study: A Caucasian Man with Hip Pain

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)

Decisions Made and Outcomes (Needed to formulate the paper)

Choices for Decision 1: Select what the PMHNP should do:

  1. 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
  2.  Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day
  3.  Neurontin 300 mg po BEDTIME with weekly increases of 300 mg per day to a max of 2400 mg if needed.

My decision: 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

Outcome: 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 complains 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

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Choices for Decision 2: Select what the PMHNP should do:

  1. Continue with current medication (Savella) but lower dose to 25 mg twice a day
  2.  Discontinue Savella and start Lyrica (pregabalin) 50 mg orally BID
  3.  Discontinue Savella and start Zoloft (sertraline) 50 mg

My decision: Continue with current medication (Savella) but lower dose to 25 mg twice a day.

Outcome: RESULTS OF DECISION POINT TWO:

  • 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.

Choices for Decision 3: Decision Point Three Select what the PMHNP should do next:

  1.  Change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME
  2.  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
  3.  Reduce Savella to 12.5 mg orally BID and start Celexa (citalopram) 10 mg orally

Outcome: Guidance to Student

RESULT FROM CHOOSING TO CHANGE SAVELLA TO 25 MG ORALLY IN THE MORNING AND 50 MG ORALLY AT BEDTIME:

Guidance to Student

The client has a complex neuropathic pain syndrome that may never respond to pain medication. Once that is understood, the next task is to explain to the client that pain level expectations need to realistic in nature and understand that he will always have some level of pain on a daily basis. The key is to manage it in a manner that allows him to continue his activities of daily living with as little discomfort as possible. Next, it is important to explain that medications are never the final answer but a part of a complex regimen that includes physical therapy, possible chiropractic care, heat and massage therapy, and medications. Savella is a SNRI that also possesses NMDA antagonist activity which helps in producing analgesia at the site of nerve endings. It is specifically marketed for fibromyalgia and has a place in therapy for this gentleman. Tramadol is never a good option along with other opioid-similar analgesics. Agonists at the Mu receptors does not provide adequate pain control in these types of neuropathic pain syndromes and therefore is never a good idea. It also has addictive properties which can lead to secondary drug abuse. Reductions in Savella can help control side effects but at a cost of uncontrolled pain. It is always a good idea to start with dose reductions during parts of the day that pain is most under control. The addition of Celexa with Savella needs to be done cautiously. Both medications inhibit the reuptake of serotonin and can, therefore, lead to serotonin toxicity or serotonin syndrome

***Write on each decision. Make sure that in each decision choice that you explain why the other two decisions were not good choices. Use cited sources to validate points. Make sure that this paper has at least 7 ReferencesPlease use in-text citations for each section of each decision. Don’t forget the ethical considerations for this assignment. Make it a section by itself.***

***Also please make sure when looking at the ethical consideration for this assignment that you look at how the Caucasian (male) ethnicity and pain medications interact.***

Please use the following format when formulating the paragraphs for each section. Don’t forget the intext citations. Remember to use at least 7 references.

Introduction

Decision #1

  1. Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)
  2. Anticipated Results (of Chosen Decision)
  3. Difference in Results (Anticipated VS Actual)

Decision #2

  1. Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)
  2. Anticipated Results (of Chosen Decision)
  3. Difference in Results (Anticipated VS Actual)

Decision #3

  1. Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)
  2. Anticipated Results (of Chosen Decision)
  3. Difference in Results (Anticipated VS Actual)
  4. Ethical Considerations

Conclusion

References

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