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This week a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches

This week a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches

Decision Tree for Neurological and Musculoskeletal

BACKGROUND

This week a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high.”

SUBJECTIVE

The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). 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. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states “I said ‘no,’ there is no need for a wheelchair, I can beat this!”

The client reports that he used to be a machinist where he made “pretty good money.” He was engaged to be married, but his fiancé got “sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.”

He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states “you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.”

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, he pulls off his shoe and shows 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.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented.

Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)

  • Review the interactive media piece assigned by your Instructor.
  • Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
  • Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
  • You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.

Write a 1- to 2-page summary paper that addresses the following:

  • Briefly summarize the patient case study you were assigned including each of the three decisions you took for the patient presented.
  • Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
  • What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
  • Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.
Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. Be specific. 18 (18%) – 20 (20%)

The response accurately and thoroughly summarizes in detail the patient case study assigned, including specific and complete details on each of the three decisions made for the patient presented.

16 (16%) – 17 (17%)

The response accurately summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented.

14 (14%) – 15 (15%)

The response inaccurately or vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented.

0 (0%) – 13 (13%)

The response inaccurately and vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented, or is missing.

Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources. 23 (23%) – 25 (25%)

The response accurately and thoroughly explains in detail how the decisions recommended for the patient case study are supported by the evidence-based literature.

The response includes specific and relevant outside reference examples that fully support the explanation provided.

20 (20%) – 22 (22%)

The response accurately explains how the decisions recommended for the patient case study are supported by the evidence-based literature.

The response includes relevant outside reference examples that lend support for the explanation provided that are accurate.

18 (18%) – 19 (19%)

The response inaccurately or vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature.

The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided.

0 (0%) – 17 (17%)

The response inaccurately and vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature, or is missing.

The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing.

What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources. 18 (18%) – 20 (20%)

The response accurately and thorough explains in detail what they were hoping to achieve with the decisions recommend for the patient case study assigned.

The response includes specific and relevant outside reference examples that fully support the explanation provided.

16 (16%) – 17 (17%)

The response accurately explains what they were hoping to achieve with the decisions recommended for the patient case study assigned.

The response includes relevant outside reference examples that lend support for the explanation provided that are accurate.

14 (14%) – 15 (15%)

The response inaccurately or vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned.

The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided.

0 (0%) – 13 (13%)

The response inaccurately and vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned, or is missing.

The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing.

Explain any difference between what you expected to achieve with each of the decisions and the results of the decisions in the exercise. Describe whether they were different. Be specific and provide examples. 18 (18%) – 20 (20%)

The response accurately and clearly explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise.

The response provides specific, accurate, and relevant examples that fully support whether there were differences between the decisions made and the decisions available in the exercise.

16 (16%) – 17 (17%)

The response accurately explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise.

The response provides accurate examples that support whether there were differences between the decisions made and the decisions available in the exercise.

14 (14%) – 15 (15%)

The response inaccurately or vaguely explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise.

The response provides inaccurate or vague examples that may or may not support whether there were differences between the decisions made and the decisions available in the exercise.

0 (0%) – 13 (13%)

vaguely explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise, or is missing.

The response provides inaccurate and vague examples that do not support whether there were differences between the decisions made and the decisions available in the exercise, or is missing.

Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance.
5 (5%) – 5 (5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

4 (4%) – 4 (4%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

3.5 (3.5%) – 3.5 (3.5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.

0 (0%) – 3 (3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors

4 (4%) – 4 (4%)

Contains a few (1–2) grammar, spelling, and punctuation errors

3.5 (3.5%) – 3.5 (3.5%)

Contains several (3–4) grammar, spelling, and punctuation errors

0 (0%) – 3 (3%)

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list. 5 (5%) – 5 (5%)

Uses correct APA format with no errors

4 (4%) – 4 (4%)

Contains a few (1–2) APA format errors

3.5 (3.5%) – 3.5 (3.5%)

Contains several (3–4) APA format errors

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