In this paper I will discuss the case of a 43 year old male that complains of persistent
right hip pain after sustaining a fall at work. He has had numerous diagnostic tests done. 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.
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, pull off his shoe, and show
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
Decision Point 1
For decision point 1, I prescribe the patient amitriptyline 25 mg po QHS and titrate
upward weekly by 25 mg to a max dose of 200 mg per day. First‐line therapy of neuropathic pain
consists of tricyclic antidepressants (TCA) like amitriptyline (Eijs et al., 2010). The client returns
to the office still using crutches. The client states that he is able to go to the bathroom and
kitchen without using crutches all of the time. He states that his pain has improved, but that he is
groggy in the morning. He has a pain level of 6/10 and states that a pain level of 3/10 would be
acceptable. He has no suicidal/homicidal ideations.
. Decision Point 2
I decided to continue with the amitriptyline and increased the dose to 125 mg at bedtime,
continuing towards the goal dose of 200 mg daily. Antihistamine side effects secondary to its H1
receptor binding property include sedation, increased appetite, weight gain, confusion, and
delirium (Thour, 2020). I also instruct the client to take the medication an hour earlier than
normal beginning tonight and to call the office in 3 days to follow up on his grogginess. Upon
the 3 day follow up call, the client reports that changing the administration time helped and
reports that his pain is 4/10, currently taking 125 mg daily at bedtime. However, the client states
that he has gained 5 pounds since starting this medication. The client also reported a decrease in
the amount of cramping and that he is able to ambulate around his apartment without crutches.
The client states that the weight bothers him a lot and wants to know if there is a way to avoid it.
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