CASE STUDY
\nThis 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 \u201call in his head.\u201d He further reports that his physician believes he is just making stuff up to get \u201cnarcotics to get high.\u201d
\nSUBJECTIVE
\nThe 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\u2019clock to 12 o\u2019clock 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, \u201cthere is no such thing as RSD, it comes from depression\u201d 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 \u201cI said \u2018no,\u2019 there is no need for a wheelchair, I can beat this!\u201d
\nThe client reports that he used to be a machinist where he made \u201cpretty good money.\u201d He was engaged to be married, but his fianc\u00e9 got \u201csick and tired of putting up with me and my pain, she thought I was just turning into a junkie.\u201d
\nHe reports that he does get \u201cdown in the dumps\u201d from time to time when he sees how his life has turned out, but emphatically denies depression. He states \u201cyou can\u2019t let yourself get depressed\u2026 you can drive yourself crazy if you do. I\u2019m not sure what\u2019s wrong with me, but I know I can beat it.\u201d
\nDuring the client interview, the client states \u201coh! It\u2019s happening, let me show you!\u201d 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. \u201cIt will last about a minute or two, then it will let up\u201d he reports. Sure “There is no such thing as RSD; it’s caused by depression,” he said, and that’s why he was sent to a psychiatrist. He says that a doctor he saw a few years ago told him to use a wheelchair. The client says, “I told him no, I don’t need a wheelchair, I can beat this!”
\nThe client says he used to work as a machinist and made “pretty good money” at it. He was going to get married, but his fianc\u00e9e said she was “sick and tired of dealing with me and my pain” and thought he was becoming a drug addict.
\nHe says that he sometimes feels “down in the dumps” when he thinks about how his life has turned out, but he denies that he is depressed. He states “you can’t let yourself get depressed\u2026 you can drive yourself crazy if you do. I don’t know what’s wrong with me, but I’m sure I can get over it.”
\nDuring the interview with the client, the client says, “Oh! Let me show you, it’s happening!” This makes him stand up with the help of your desk’s corner. He takes off his shoe and shows you his right leg. From the knee down, his leg is turning purple, and his foot looks like it’s cramping because his toes are curled in and his foot looks like it’s folding in on itself.enough, after about two minutes, the color begins to return and the cramping in the foot\/toes appears to be releasing. The client states \u201cif there is anything you can do to help me with this pain, I would really appreciate it.\u201d He does report that his family doctor has been giving him hydrocodone, but he states that he uses is \u201csparingly\u201d because he does not like the side effects of feeling \u201csleepy\u201d and constipation. He also reports that the medication makes him \u201cloopy\u201d and doesn\u2019t really do anything for the pain.
\nMENTAL STATUS EXAM
\nThe 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.
\nDiagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)<\/p>\n
Decision Tree
\nDecision point 1: I selected the option below;
\nGabapentin 300mg orally at bedtime with weekly increase of 300mg\/day to max of 2400mg if needed.
\nRESULTS OF DECISION POINT ONE
\n\u2022\t Client returns to clinic in four weeks
\n\u2022\t 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, \u201cI would rather have no pain but don\u2019t think that is possible. I could live with a pain level of 3.\u201d 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, \u201cI 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.\u201d
\n\u2022\t Client denies suicidal\/homicidal ideation and is still future oriented. He does seem to be discouraged throughout the interview about his current pain<\/p>\n
Decision point 2: I selected the option below;
\nDiscontinue Neurontin. Start Zoloft (sertraline) 50 mg orally daily and titrate at weekly intervals to a dose of 200 mg
\nRESULTS OF DECISION POINT TWO
\n\u2022\t Client returns to clinic in four weeks
\n\u2022\t 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 \u201camped up\u201d and he cannot seem to control it
\n\u2022\t Client also states that he hasn\u2019t been able to get an erection in over a week and thinks his pain may be causing erectile dysfunction.
\n\u2022\t Although client’s pain is \u201cmore manageable than it has been before\u201d, he thinks it may have gotten the best of him. His new problems really have him discouraged<\/p>\n
Decision point 3: I selected the option below;
\nAdd 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<\/p>\n
Please see feedback I got, bolded in italics below;
\nGuidance to Student
\nAnxiety 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\u2019s and should be a counseling point for men. It happens in roughly 10% of men using SSRI\u2019s. 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).<\/p>\n
ASSIGNMENT QUESTION
\nHomework help – Write a 2-3 page summary paper that addresses the following:
\nBriefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
\nBased 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.
\nWhat 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.
\nExplain 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.<\/p>\n","protected":false},"excerpt":{"rendered":"
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 […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1738,2474,2482,1563,2516,2499],"tags":[2501,2518,2477,2519,2520],"class_list":["post-9928","post","type-post","status-publish","format-standard","hentry","category-help-me-with-social-psychology-assignment","category-psyc-essays","category-psyc-paper-writing-service","category-psychology-case-study-examples","category-sociology-essays","category-write-my-psychology-papers","tag-psy-papers","tag-psych-research-paper-sample","tag-psychology-assignment","tag-psychology-dissertation-writing","tag-psychology-research-paper"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/9928","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/comments?post=9928"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/9928\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/media?parent=9928"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/categories?post=9928"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/tags?post=9928"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}