Discussion related to the management of chronic pain for the patient in the listed case study.

Case Study Scenario

Rhonda, a 37-year-old white female, states that she transferred her care to you because she is dissatisfied with her previous primary care provider. She describes constant pain in her neck, shoulders, arms, knees, and ankles that started about 5 years ago. Sometimes her skin hurts, and her muscles ache frequently. She recovered from numerous fractures sustained in a motor vehicle accident nearly 8 years ago. She is unable to exercise owing to pain and fatigue. She is employed as a bank teller, but has missed work frequently. She has used up all of her vacation time, and is afraid that she will lose her job if she continues to call in sick. She is unable to keep up with household duties, enlisting the help of her husband. Her teenage daughter has recently been failing in school, adding to her overall stress level. She smokes one pack of cigarettes a day and drinks two glasses of wine after work. She often purchases fast food for dinner. She has frequent heartburn and non-restful, insufficient sleep. She stays in bed up to 20 hours per day on the weekends. She has become isolated from family and friends over the past year. 

Current drugs include amitriptyline (Elavil) 75 mg at bedtime and ibuprofen 400 mg every 8 hours prn pain. Upon review of the patient history form, she had written voluminous notes describing her history, pain, and associated symptoms, filling in all margins of the forms.

Assessment

Physical examination revealed 11/18 pairs of tender points. She was anxious and unable to sit during the interview. She meets the diagnostic criteria for major depression and anxiety. The remainder of the examination was normal. Initial assessment included myofascial pain and anxiety/depression. Amitriptyline, the first-line drug treatment for fibromyalgia is, by her report, failing. Sleep is poor, and she is anxious and depressed. Functional status is poor in physical, psychosocial, social , and vocational.

For the Discussion (Include the corresponding number below as you respond in your initial post):

1. What non-pharmacologic and pharmacologic (controlled and noncontrolled drugs) treatment plan will you prescribe to the scenario? 
2. Give the rationale why you chose certain treatment plans and not others.
3. Provide the follow up plan for the patient and why you made the decision.