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Case Summary
A 43-year-old white male presents with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. The patient presents for a psychiatric evaluation after a referral by his family doctor, who felt that the pain was imaginary. The patient reports that his physician believes he is faking the pain to get narcotics to get high. He reports that the pain began7 years ago after sustaining a fall at work, landing on his right hip. He notes that the pain has led to the loss of his job and relationship, and he occasionally goes down in the dumps when he sees how the pain has impacted his life. However, he emphatically denies depression. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS).
Decision 1
Start 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
Reasons for Selecting this Decision
In patients with CRPS, changes in the nervous system caused by injuries or trauma cause malfunctioning of peripheral sensory neurons, responsible for transmitting pain signals from the brain and spinal cord to all other parts of the body. As a result, patients with CRPS have a low pain threshold, thus more sensitive to pain. Savella is a selective norepinephrine and serotonin reuptake inhibitor (SNRI) and an NMDA antagonist. Therefore, it inhibits the reuptake of norepinephrine and serotonin neurotransmitters, restoring brain chemical balance and allows more of these neurotransmitters to travel from neuron to neuron. This produces analgesic effects (Stanton-Hicks, 2018).
Although Amitriptyline, a tricyclic anti-depressant, has been established to be effective off-label neuropathic pain management, it could not be prescribed (Benzon, Liu & Buvanendran, 2016). Some of the drug’s significant side effects are drowsiness and dizziness that the client initially stated he didn’t like. Therefore, prescribing this medication for a start might only trigger non-compliance. It is the role of a care provider to prescribe drugs that promote compliance and have fewer side effects. Neurontin, an anticonvulsant, has also been established to be effective in nerve pain relief (Finnerup et al., 2015). However, it also has the side effects of drowsiness and drowsiness; therefore, it wasn’t a viable choice.
Expected Outcome
The expected outcomes of treatment with Savella were significant pain reduction to three on a scale 10 point pain scale, and the ability to walk without support. Additionally, it was expected the patient would resume normal work routine and perform activities of daily life with minimal support and regain a happy mood (Stanton-Hicks, 2018).
Difference between Expected Outcome and Actual Outcome
After four weeks, the patient returned to the facility looking joyous and hopeful. He reports the ability to walk without support, but minimal limping was noticeable. He noted the pain had decreased to four on a ten point pain scale, but it is worse in the morning and gets better as the day progressed. The patient reported occasional sweating, sleep disturbance, and palpations. His physical assessment indicated blood pressure of 147/92mmhg and pulse rate to be 110 beats/ min. He denied depression and suicidal thoughts. The palpitations, sweating, sleep disturbance, and elevated BP and pulse rate are determined to be Savella side effects, which can be addressed by reducing the dosage (Finnerup, et al., 2015).
Decision 2
Reduce the Savella 50 mg oral once-daily dosage to 25 mg twice daily.
Reasons for Selecting this Decision
Although the Savella prescription yielded significant progress, the patient reported unexplained sweats, sleep disturbance, and elevated blood pressure, which were established to be Savella’s side effects. A study has demonstrated that reducing the dosage of Savella can help manage its side effects (Stanton-Hicks, 2018).
Expected Outcome
It was expected that the patient’s pain level would progressively decrease, his limping would disappear, he would increasingly perform more and more daily life activities with minimal support, and that his social, professional, and physical functioning would also improve (Benzon, Liu & Buvanendran, 2016). The Savella side effects were expected to disappear as well, and he was expected to live a near-normal life.
Difference between Expected Outcome and Actual Outcome
The patient returned after four weeks walking with crutches and looking sad and discouraged by his pain management slip. He reported an inability to walk without support and a 7 ou
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