Event 4: Follow Up

Nurse Manager

Mrs. Johnson meets with the nurse manager for a follow up appointment.

Individualization of Treatment Course

  • Listen to the patient
  • Draw on patient's past experience
  • Address psychosocial issues
  • Use a multidiscipline approach
  • Have ongoing reassessment

Re-assess / Revise Treatment

  • Identify which pain scale to use consistently for reassessment & associated symptom parameters to evaluate (eg. Sleep, mood)
  • Evaluate for changes in frequency and intensity
  • Try to make treatment changes sequentially unless at critical point
  • Re-evaluate AGAIN!

Follow Up with Dr. Kent

Test Your Knowledge

What treatments below would be appropriate at this point?

Incorrect. There is little to suggest addiction
Correct. This is a reasonable approach.
Correct. This is reasonable given that her depression has not responded to Citalopram and an SNRI may also help her musculoskeletal pain.
Incorrect. This is inappropriate given the high anticholinergic effects and elevated fall risk associated with this agent.
Incorrect. Mrs. Johnson has found that she needs less opioids over the past several weeks, so it is inappropriate to escalate the opioid therapy at this juncture.
Correct. This is appropriate, acupuncture has proven analgesic efficacy and patients can find it supportive and complimentary to ongoing allopathic medical care.

Mrs. Johnson is willing to see the psychologist but is reluctant to leave this visit with Dr. Kent without further consideration of medication.

Follow Up - Tramadol Issue

The patient provided some additional information regarding the “reaction” she had to tramadol; her symptoms included:

  • Feeling hot (she did not check her temperature)
  • Flushed in the face
  • Mild tremulousness
  • Felt like her heart was racing

These symptoms lasted for several hours after a single dose of tramadol.

Test Your Knowledge

What is the most likely explanation for Mrs. Johnson's reaction to tramadol?

Correct. Her symptoms were consistent with serotonin syndrome and the combination of tramadol with her SSRI could induce this syndrome.

Serotonin Syndrome

  • Our patient reported feeling “hot and anxious” after taking a few tramadol tablets from her neighbor.  
  • Potential causative agents
    • Citalopram and tramadol
  • Serotonin syndrome signs and symptoms
    • Agitation and possible hyperthermia
    • Occurred within an hour of taking tramadol
  • Instruct patient to not take any additional tramadol
    • Hospitalization not indicated at this time
    • Given tramadol’s half-life, symptoms should improve within 24-48 hours
  • Avoid future tramadol use in this patient if she continues antidepressant therapy

Medical History Questionnaires

Mrs. Johnson has completed a series of questionnaires about her medical history:

  • Body drawing
  • Brief Pain Inventory
  • Questionnaire containing multiple details regarding HPI (OLD CART-P)
  • Personal Medical Hx, Family Hx, Social Hx and Review of Systems
  • Patient Health Questionnaire -9 Depression Screen

PHQ - 9 Depression Scale

Mrs. Johnson scores a 14 on the PHQ - 9 depression scale.

Mrs. Johnson's responses on the PHQ -9 Depression scale for a total of 14.
PHQ -9 Depression Scale

Scoring and Interpreting the Personal Health Questionnaire-9

  • Sum each item (0-3 points)
  • Cut points for depression severity:
    • greater than or equal to 5: mild
    • greater than or equal to 10: moderate
    • greater than or equal to 15: moderately severe
    • greater than or equal to 20: severe

Mrs. Johnson’s Personal Health Questionnaire-9: score = 14; moderate depression symptom severity

Suicide Risk

  • Mrs. Johnson denies any active suicidal ideation, intent or plan
    • Some concerns about future risk should her symptoms worsen, suggesting on going monitoring is indicated
  • Given her moderate depression symptom severity, withdrawal from usual activities, concerns about burdening others, and potential future risk for suicidality, psychotherapy referral is recommended

Mrs. Johnson's Mood

Mrs. Johnson's Mood, Part 2

How Mrs. Johnson Feels About Herself

Next: Event 5: Second Follow Up

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