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)

  Decision Point One

Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day   

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Client comes to the office still using crutches. He states that the pain has improved but he is a bit groggy in the morning  
• Client’s pain level is currently a 6 out of 10. The PMHNP questions  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 could live  with a pain level of 3.” He states that his pain level normally hovers  around a 9 out of 10 on most days of the week before the amitriptyline  was started. 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 6?” The  client states, “I’m able to go to the bathroom or to the kitchen without  using my crutches all the time. 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 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  

Decision Point Two

Continue  current medication and increase dose to 125 mg at BEDTIME this week  continuing towards the goal dose of 200 mg daily. Instruct the client to  take the medication an hour earlier than normal starting tonight and  call the office in 3 days to report how his function is in the morning   

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four 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 current pain level is a 4 out of 10. He states that he is now taking 125 mg of amitriptyline at bedtime. 
• Client’s has noticed that he is putting  on a little weight. When asked, the client states that he has gained 5  pounds since he started taking this medication. He currently weighs in  at 162 pounds. He is 5’ 7”. He states that his right leg doesn’t bother  him nearly as much as it used to and his toes have only “cramped up”  twice in the past month. He states that he is able to get around his  apartment without his crutches and that he has even started seeing  someone he met at the grocery store. The weight gain seems to bother him  a lot and he is asking if there is a way to avoid it 

Decision Point Three

Continue  the current dose of Elavil of 125 mg per day, refer the client to a  life coach who can counsel him on good dietary habits and exercise   

Guidance to Student
 At this point, the client is almost  at his goal pain control and increased functionality. Weight gain is a  common side effect with amitriptyline and should be a counseling point  at the 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 of the client at this point. Amitriptyline has a side  effect of cardiac arrhythmias. He is not experiencing this at this  point. The drug, qsymia contains a product called phentermine which has a  history of causing cardiac arrhythmias at higher doses. This product is  also only approved for a client with obesity defined as a BMI greater  than 30 kg/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 will be able to accomplish. 

Instructions on how to complete 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.