SUD Clinic - Physician Assistant

HPI

Daniel is a 38 year old male with a history of right Symes amputation and chronic severe pain is endorsed to our clinic by podiatry for suspected opioid use disorder. He was last seen by the podiatrist a month ago and has been unable to get to our clinic sooner because his youngest son (who was born prematurely) has been having recurring “chest colds”. It is difficult for him and his wife to take off work, so they have been using their days off to care for their son and take him to his pediatrician appointments. 

Daniel is not sure why he has even been referred the Substance Use Disorder Clinic as he does not think he has a problem. He uses oxycodone and sometimes dilaudid for pain management, not to “get high”. The medication also calms his nerves and helps him get what little sleep he can.

Daniel complains of 10/10 severe pain in his residual limb and where his foot used to be. He describes it as stabbing, shooting, shocking and tingling. He has tried physical therapy, but was only able to make the first appointment. His podiatrist prescribed gabapentin, but that does “absolutely nothing” for his pain. Oxycodone has worked but the dilaudid seems to be a bit more helpful.He last took hydromorphone ~12 hours before coming to the clinic.

ROS (pertinent positivies)

+ “right foot” and distal residual limb pain, severe

+  depressed mood

+ anxiety

+ trouble sleeping due to pain

+ fatigue

+ cramping/twisting of “right toes”

Substance Use Screening Questions

Using larger amounts or more frequently: Yes

Unsucesseful effortrs to cut down or quit: Yes

Craving the drug: Patient gets very irritable when he is due for his next dose. He is constantly thinking about how he will get the next bottle of pills, since he doesn’t have a prescription 

Failure to fufill major obligations: He fell asleep on the couch when he was supposed to be watching the kids while his wife was working. She came home from work and found the 5 year old had turned the stove on to try to cook dinner 

Continued use despite social/interpersonal problems: One of his friends caught him stealing a bottle of dilaudid from his medicine cabinet and they got into a fight about it. They are not friends anymore. 

Recurrent use in physically hazardous situations: Drives to and from work on the pain medications 

Recurrent use despite physical or psychological problem caused by/worsened by use: Yes

Tolerance: Needs at least 2-3 oxycodone tablets to help with the pain, it used to be only 1. He has been switching on and off with hydromorphone 

Withdrawal Symptoms: Rebound pain, anxiety, irritability, insomnia, stomach cramps and diarrhea

Clinical Opioid Withdrawal Score (COWS) = 14

Prescription Drug Monitoring: (6 month review, 6 different prescribers)

Medication                             Fill Date                      Quantity                    Prescriber

Hydromorphone 4mg           1 month ago                    30                         Lisa Hartz, NP

Oxycodone 10mg                    6 weeks ago                    21                         Bruce Levin, DO

Oxycodone 10mg                    3 months ago                  30                         Nancy Lewis, MD

Vicodin 10/325mg                  5 months ago                  60                         Melissa McHenry, PA

Oxycodone 5mg                       6 months ago                  30                         Myles Deserow, MD

Alprazolam 0.5mg                   6 months ago                  30                         Lina Matta,

Physical Exam

Vitals: BP 138/79  HR 90   T 98.8°  BMI 29.6

General: Alert and oriented X 3, somewhat defensive and irritable, restlessness during interview with frequent shifting of legs and arms, yawning twice during interview

HEENT: Pupils  dilated, reactive to light, no scleral icterus, mucus membranes dry

Neck: no lymphadenopathy, no thyromegaly

CVS: regular rate and rhythm, no murmurs

Lungs: clear to auscultation bilaterally

Abdomen: soft, non-tender, no distended. liver not enlarged

Extremities: no clubbing, cyanosis or edema. atrophy of calf on residual limb

Skin: Well healed residual limb with hypertrophic scar 5mm thick. + Callus formation medial aspect of distal residual limb with surrounding erythema. No warmth, no discharge

Neuro: + hyperesthesia along the bottom and sides of distal residual limb. Otherwise, nonfocal