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)

The Assignment

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.

At each decision point stop to complete the following:

  • 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.

Complex Regional Pain Disorder
White Male With Hip Pain

Decision Point One

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
� Client returns to clinic in four weeks

� Client comes into the o!ce 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 di”erent 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 butter#ies in his chest. The client denies
suicidal/homicidal ideation and is still future oriented

Decision Point Two

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

RESULTS OF DECISION POINT TWO
� Client returns to clinic in four weeks

� Client comes to o!ce 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

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

Guidance to StudentGuidance 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 th

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Citations (13/13)

1. 1https://www.academicscope.com/assignment-assessing-and-treating-clients-with-pain-essay-help/

2. 2https://www.me-pedia.org/wiki/Neurological

3. 3Another student’s paper

4. 4Another student’s paper

5. 5Another student’s paper

6. 6Another student’s paper

7. 7Another student’s paper

8. 8http://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_07/1.html

9. 9https://thenakedphysio.com/2017/10/08/crps-whats-the-best-treatment/

10. 10https://www.practicalpainmanagement.com/pain/neuropathic/crps/updates-management-complex-regional-pain-syndrome

11. 11Another student’s paper

12. 12https://www.omicsonline.org/author-profile/muehlbauer-tg-190059/

13. 13Another student’s paper

Running head: 1 WHITE MALE WITH HIP PAIN

WHITE M