Assessing and Treating Patients with Pain


Introduction

Complex regional pain disorder also called reflex sympathetic dystrophy refers to a long-lasting pain illness which affects mostly one limb (leg, arm, hand, or foot) usually following an injury. Studies reveal that the disorder is as a result of damage to or breakdown of the peripheral and central nervous systems (Lohnberg & Altmaier, 2013). The ailment is characterized by prolonged or excessive pain and alterations in skin color, body temperature, and inflammation in the affected area (Marinus, Moseley, & Birklein et al., 2011). This particular case study is an assessment and treatment of a 43-year old white male who has been diagnosed with complex regional pain disorder. Three decision points are being explored to explain the reason for selecting the decision, expected results, and how the actual results differ from the expected results.

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Decision Point One
Selected Decision
Amitriptyline 25 mg po QHS and titrate upwards weekly by 25 mg to a max dose of 200 mg per day.
Reason for Selection
The patient is has chronic neuropathic pain as a result of nerve damage. Amitriptyline is a good prescription for patients who suffer pain as a result of damages in the nerves. The drug is also a tricyclic antidepressant and can serve to enhance mood and feelings of well-being, get rid of anxiety and tension, abate insomnia, and boost one’s level of energy. This particular patient reports that the family doctor also suggested he had depression. The progressive increment in the dosage of the drug is to ensure that the patient adapts to the effect of the drug progressively and hence eliminating the potential side effects (Schwartzman, Erwin & Alexander, 2009). Other medications are available for this ailment. However, their side effects are far beyond the ones a patient taking amitriptyline experienced.
Expected Results
The doctor expects that the patient will experience reduced pain and even walk short distances without his crutches within the first week of medication. Toes curling should also decline and leg throbs should also minimize. Due to the progressive increment, it is also expected that with time, the patient will adapt to the drug with few or no side effects (Yu, 2004).
Difference between Expected Results and Actual Results
After four weeks, the patient has reported reduced pain through it has not reduced to the level he want and that he can now manage moving around short distances without crutches. He seems to have adapted well to the medication with the only unexpected result being feeling groggy in the morning.
The patient appears to have adapted to the drug fairly well since the only side effect is feeling groggy in the morning. He is clear of any suicidal or homicidal ideations. This improvement is symptoms are coherent to the expectations. There is no much of a difference between the results and the expectations besides the groggy feeling in the morning.
Decision Point Two
Selected Decision
Reduce the dose of Elavil to 75 mg 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
Reason for Selection
Elavil was reduced to 75 mg at bedtime to reduce pain and Biofreeze added to ease muscle cramping. Additionally, reducing Elavil to 75 mg could remedy the groggy feeling in the morning but could reduce the pain further. The patient’s main problem is pain and so it is the focus of medication.
Expected Results
It is expected that reducing Elavil to 75 mg at bedtime will could both reduce pain and remedy the foggy feeling in the morning (Shah & Kirchner, 2011). Furthermore, ease muscle cramping is also expected to decline with addition of Elavil.
Difference between Expected Results and Actual Results
After four weeks the patient is still complaining of pain though feeling grogginess in the morning has changed. Besides, the functionality has improved to an extent that he can make it around his apartment without the crutches but still needs them when he ventures outside. He complains that muscle cramping is still a problem and he is asking if there is a long-term solution.
Decision Point Three
Selected Decision
Continue same dose of Elavil. Continue the BioFreeze on an as-needed basis. Add on lidocaine patches applied to the areas of pain for 12 hours on and 12 hours off
Reason for Selection
The patient is still experiencing pain hence the same medication would be appropriate as well as adding lidocaine patches applied to the areas of pain. Lidocaine is a local anesthetic or a numbing medication (Pawelka, Fialka & Ernst, 1993). It functions by blocking nerve signals in one’s body. It is used to reduce pain.
Difference between Expected Results and Actual Results
The only result that was not expected was the escalation of pain as was evidenced by continued use of oxycodone due to in-efficiency as a result of continued usage. The in-effectiveness of opioids on neuropathic pain results to dose escalation. Before long, the client is escalating the dose on his own and there is a risk of inducting an addictive disorder in the client which will need treatment (O'Connell et al., 2013).
Ethical Consideration
All the medication used to treat complex regional pain disorder (reflex sympathetic dystrophy) seem to have side effects. These side effects should be communicated to the patient prior to admission of the drug.

References


1. Lohnberg, J. A., and Altmaier, E. M (2013). A review of psychosocial factors in complex regional pain syndrome. Journal of Clinical Psychology in Medical Settings, 20(2): 247–254.
2. Marinus, J., Moseley, G. L. and Birklein, F. et al. (2011). Clinical features and pathophysiology of complex regional pain syndrome. Lancet Neurology, 10(7), 637–648.
3. Moseley, G; Zalucki, N; Wiech, K (2008). Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain. Pain, 137 (3), 600–608.
4. O'Connell, N. E., Wand, B. M., McAuley, J., Marston, L. and Moseley, G. L. (2013). Interventions for treating pain and disability in adults with complex regional pain syndrome. The Cochrane Database of Systematic Reviews, 4, CD009416.
5. Pawelka, S., Fialka, V, and Ernst, E. (1993). Reflex sympathetic dystrophy and cigarette smoking. The Journal of Hand Surgery, 18(1), 168–169.
6. Schwartzman, R. J., Erwin, K. L. and Alexander, G. M. (2009). The natural history of complex regional pain syndrome. The Clinical Journal of Pain, 25(4), 273–280.
7. Shah, A. and Kirchner, J. S. (2011). Complex regional pain syndrome. Foot and Ankle Clinics, 16 (2), 351–66.
8. Yu, D. (2004). Shoulder pain in hemiplegia. Physical Medicine and Rehabilitation Clinics of North America, 15 (3), 683–697.

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