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.
* THE CASE STUDY IS IN FILE ATTACHMENT. I HAVE HIGHLIGHTED IN YELLOW MY DECISION I CHOOSE FOR EACH POINT
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.Ba
COMPLEX REGIONAL PAIN DISORDER WHITE MALE WITH HIP PAIN BACKGROUND: This week, a 43-year-old white male presents to 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 past years, he has had numerous diagnostics tests done (X-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that his cartilage surrounding his right hip joint was 75% torn (from the 3o’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 extremities (measured by electromyogram). He also reports that he experiences so severe cramping of the extremity. He reports that one of the neurologists diagnosed 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 is what prompt 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 turned out, but empathetically 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 this.” During the client interview, the client states, “oh! It’s happening, let me show you!” this prompted him to stand with assistance of the corner of your desk, he pulls of 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 cramping as the toes are curled inwards 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 2 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 it “sparingly” because he does like the side effects of feeling “sleepy” and constipation. He also reports that the medication makes him feel “loppy” and really does 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. Affects consist to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought process appreciated. Judgement, insight, and reality content are all intact. He denies suicidal/homicidal ideation and is further oriented. DIAGNOSIS: COMPLEX REGIONAL PAIN DISORDER (REFLEX SYMPATHETIC DYSTROPHY) DECISION POINT ONE SELECT WHAT YOU WOULD DO Sevella 12.5mg orally once daily on day one; followed by 12.5mg B.I.D. on day 2 and 3; followed by 25mg B.I.D. on day 4-7; followed by 50mg B.I.D thereafter Amitriptyline 25mg PO QHS and titrate upwards weekly by 25mg to a max dose of 200mg per day Neurontin 300mg PO bedtime with weekly increase of 300mg per day to a max of 2400mg if needed RESULTS OF DECISION POINT ONE Client returns to clinic in 4 weeks Client comes to the office still using crutches Clients pain level is currently a 6 out of 10. You question 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 can live with a pain level of 3.” He states that the pain level normally hovers over around a 9 out of 10 on most days of the week before the amitriptyline was started. You ask what makes the pain on a scale 1 to 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 the kitchen without using my crutched at all times. 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 everyday or at least several times a day. I also could go 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 YOU WOULD DO Continue current medication and increase dose to 125mg BEDTIME this week, continuing towards the goal dose of 200mg daily. Instruct the client to take the medication an hour earlier than normal starting tonight and call the office in 3 days and report how his functioning is in the morning. Reduce the dose of Elavil to 75mg 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 od amitriptyline Elavil to 75mg po orally at BEDTIME and add-on Neurontin (gabapentin) 300mg po orally at BEDTIME. Schedule a follow-up phone call in one week to assess pain control. RESULTS OF DECISION POINT TWO Client returns to clinic in 4 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 pain level is a 4 out of 10. He states he is now taking 125mg of amitriptyline at bedtime. Client has noticed that he is putting on a little weight. When asked, the client states that he has gained 5lbs since he started taking this mediation. He currently weighs in at 162 pounds, He is 5’7’’. He states that his right leg does not bother him nearly as much as it used to, and his toes have only “cramped up” twice in the past month. He states he is able to get around his apartment without his crutches and that he has even started seeing someone he has met at the grocery store. The weight gain seems to be bothering him a lot and he is asking if there is a way to avoid it. DECISION POINT THREE SELECT WHAT YOU WOULD DO Continue with his Elavil with his current 125mg a day dose and start Qsymia (phentermine and topiramate) 3.75mg/23mg tablet once daily and titrate as required by package insert Reduce the dose of Elavil to 100mg a day and follow up in a month Continue the current dose of Elavil of 125mg per day, refer the client to a life coach who can counsel him on good dietary habits and exercise. GUIDENCE TO STUDENT At this point, the client is almost at his goal pain control and increase functionality. Weight gain is a common side effect with amitriptyline and should be a counseling point at 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 to the client at this point. The drug Qsymia contains a product called phentermine which has a history of causing cardiac arrythmias at higher doses. This product is also only approved with a client with obesity defined as a BMI greater than 30kg/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 would be able to accomplish.
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