NURS 6521 Week 6 Discussion Scenario Two Hip Pain

NURS 6521 Week 6 Discussion Scenario Two Hip Pain

NURS 6521 Week 6 Discussion Scenario Two Hip Pain

This is the case study that is assigned.  It is interactive and has three decision points. I have attached the PDF file of the interactive portion. My choices were highlighted in the PDF and the evaluation from that decision is listed below that.

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Scenario Two: White Male 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 has sent him for psychiatric assessment because the doctor felt 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 sever cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CPRS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to this 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 specials 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 for 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 sates that he uses it “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 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 though processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation and is future oriented.

Diagnosis: Title: Complex Regional Pain Disorder (reflex sympathetic dystrophy)

 

Title: Complex Regional Pain Disorder

Pages: 2; References: 8 journal articles

Introduction regarding complex regional pain disorder, expand on reflex sympathetic dystrophy.

High-level summary of patient case

Purpose of the essay statement

Decision 1: see page 3 for details

Decision 2: see page 4 for details

Decision 3: see page 5 for details

Conclusion: include ethical considerations

References: 8 journal articles

Select what the PMHNP should do (a), (b), or (c)?

Decision 1

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

 

Results of Decision 1 (b)

  • 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. 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 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. You ask 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

 

What options were listed
What option did you choose?
Why did you select that option?
Why didn’t you select the other two options?
What was your goal of treatment
Was the outcome what you expected? Why?

Select what the PMHNP should do (a), (b), or (c)?

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Decision 2

  1. 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.

 

  1. Reduce the dose of Elavil to 75 mg at bedtime (dose has been titrated at weekly intervals by 25 mg per week). Add a 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.

  

  1. Reduce dose of amitriptyline Elavil to 75 mg po orally at bedtime and add-on Neuronting (gabapentin) 300 mg po orally at bedtime. Schedule a follow-up phone call in 1 week to assess pain control.

Results of Decision 1 (a)

  • 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

 

What options were listed
What option did you choose?
Why did you select that option?
Why didn’t you select the other two options?
What was your goal of treatment
Was the outcome what you expected? Why?

Select what the PMHNP should do (a), (b), or (c)?

Decision 3

  1. Continue with the Elavil at his current 125 mg a day dose and start Qsymia (phentermine and topiramate) 3.75 mg/23 mg tablet once daily and titrate as required by package insert

 

  1. Reduce the dose of Elavil to 100 mg a day and follow up in a month

 

  1. 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

 

Results of Decision 1 (c) and 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.

 

What options were listed
What option did you choose?
Why did you select that option?
Why didn’t you select the other two options?
What was your goal of treatment
Was the outcome what you expected? Why?

Conclusion

Include ethical considerations

References

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