Mr. Lane has been going to physical therapy for 2 weeks with minimal change in pain; he is improving in movement and mobility. However, sleeping and pain continue to be a problem for him. He is frustrated, unable to work, worried about cost of physical therapy, cost of surgeries,and his ability to pay for ongoing insurance.
He has been referred to a multidisciplinary pain clinic, which is two hours away from home.
Medical History
Chief Complaint:
- Sharp, dull and achy pain in RUE
- Radiates from elbow to hand
- Cramping in R forearm
- Fatigue – tired all the time
History of Present Illness:
- Pain level high since surgery x 2
- Unable to work, sleep, concerned about finances; lack of sleep and constipation
Review of Symptoms:
- Height/Weight: Height 6'0"; Weight 215 (thirty pound increase)
- Vital Signs: Skin-scar tissue right elbow, forearm, wrist and hand
- Cardiovascular: No deficits, no chest pain.
- Urinary: No deficits
- Vascular: No deficits
- Psychiatric: Concerns from primary care regarding depression and anxiety, further evaluation needed.Sleep-difficulty getting to sleep and staying asleep; averages 4-5 hours per night; unable to lay on the right side
Recommendations:
NCS/EMG Study right neck and upper extremity; Pain Education Class, Medication Modifications; Referral to Outpatient Counseling; UE splint in extension
Medications
- Atorvastatin 10 mg PO daily
- Lisinopril 10 mg PO daily
- Amlodipine 5 mg PO daily
- Docusate sodium 100 mg PO twice daily
- Oxycodone/acetaminophen 5/325 mg 1-2 every 6 hours PRN severe pain.
- NEW Senna-S 2 tablets twice daily
- NEW Doxepin 25 mg HS PRN sleep
- NEW Gabapentin 300 mg PO three times a day
Psychosocial
- Concerns from primary care regarding depression and anxiety, further evaluation needed.
- Sleep: difficulty getting to sleep and staying asleep; averages 4-5 hours per night; unable to lay on the right side
New Diagnoses:
- Situational depression
- Increased anxiety
- told in the hospital he might have to have arm amputated; nightmares from the length of time in combine
Work History
- Minimal use of right arm
- No driving
- Additional bracing in elbow extension
Interventions
Physician/Physician Assistant/Nurse Practitioner:
Completed review of medical record, completed physical exam, consultation with pharmacist regarding medications.
Primary Concern – medications with minimal pain reduction or relief; increasing symptoms of chronic pain with decreased sleep, weight gain, increased concerns from Psychologist and Social work regarding psychosocial issues.
Recommend further diagnostic testing with EMG/NCV for possible ulnar nerve entrapment due to decreased reflex and numbness and tingling in right upper extremity along C8 distal dermatomal distribution.
Pharmacist:
Medications were reviewed with physician and modifications recommended. Patient and patient family education regarding dosing, side effects and questions.
Physical Therapist:
Mr. Lane is being seen in outpatient physical therapy and has made some functional improvement but continued pain, fatigue and difficulty with self care and functional activities with right arm.
Patient very concerned about limited visits, cost of copay per visit and difficulty with home program.
Social Work/Psychologist:
Lane was accompanied by his wife to the initial visit. He demonstrates moderate anxiety, meets the criteria for moderate to severe depression, sleep problems, good social support, no suicidal ideation, hopelessness, and reduced quality of life.
Recommendations for outpatient counselling for pain management and emotional issues; family counseling, guided imagery, monitor for substance abuse/misuse.
Interdisciplinary Meeting
The nurse practitioner, physical therapist, psychologist, and Mr. and Mrs. Lane all meet in a medical office. They discuss Mr. Lane's decreased strength and range of motion at the neck, shoulder, elbow, wrist, and hand.
The psychologist brings up concerns over depression, post-traumatic stress disorder, and chronic pain.
The nurse practitioner adds her concern over compression of the cubital tunnel in Mr. Lane's right arm. She wants to do additional testing to see if this is the case.
Mr. Lane and his wife express their concern over whether that testing will be painful, and whether it will be covered by insurance.
Pain Clinic Team Meeting: Recommendations
The following is the list of recommendations from the pain clinic meeting:
- Referral to Outpatient Counseling
- Modifications to Medications
- Nerve Conduction Velocity Testing (NCV)/Electromyography (EMG) right upper extremity and cervical region
- Bracing of elbow?
- New Diagnoses of:
- Major Depressive Disorder
- Possible Post Traumatic Stress Disorder (PTSD)
- Possible nerve impingement in right arm
- Chronic pain right upper extremity
Additional Info
NCV/EMG Results:
- Negative for compression of the ulnar nerve at the cervical spine.
- Positive for compression of the right ulnar nerve at the elbow
- Right ulnar motor n. distal onset latency; decreased amplitude
- Right ulnar nerve velocity decreased
Final Result:
Moderate entrapment right cubital tunnel
Pharmacy Cost:
$955.00; Insurance paid $573.00; Out of pocket $382.00.
Activity Event
Barriers:
Question: What are some predictor’s Mr. Lane has experienced that are predictors of chronic pain?
