Going 15cm above the patella, on the right side the thigh measured 54cm, on the left side 58cm. Mid-calf circumference on the right was 37cm and on the left was 41 cm. The right ankle measured 28cm and the left ankle measured The right ankle and foot were very cold compared to the left. There was a dearth of hair growth on both feet, the right being worse than the left.
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Reactive hyperemia was noted on skin examination of the upper back. The patient had pain on patellar compression much more so on the right than on the left. The patient was cooperative but appeared somewhat tired and slow moving. There was a well healed scar which was faintly visible on the dorsal aspect of the left foot.
The patient had some chronic venous stasis changes on the bilateral lower calves. No bony ankylosis was noted. This patient had numerous problems. The status of the right ankle—post a bimalleolar fracture—had evolved into reflex sympathetic dystrophy of the right lower leg complex regional pain syndrome, type 1 or CRPS Type 1. Furthermore, he had chronic lumbar strain as a result of the accident and a chronic problem with the left shoulder which started off as a rotator cuff tendinitis diagnosed prior to the accident but made much worse by the accident. I was concerned that he may actually have had a contracture of the left shoulder joint in addition to a severe adhesive capsulitis of the left shoulder.
While he did not fulfill American College of Rheumatology criteria for fibromyalgia6 he certainly had all 18 fibromyalgia tender points. This patient did have an element of diabetic polyneuropathy, but one does not get atrophy of one limb because of diabetic neuropathy. He also had bilateral sacroiliac dysfunction, right worse than left. All of these were the result of the aforementioned accident.
I concluded that this patient was unemployable at his usual job as a tankerman. In fact, it was my professional opinion, to a reasonable degree of medical certainty, that he was totally unemployable for any job in any capacity. He was probably totally and permanently disabled as a result of the injury. I attributed the cognitive problems to depression but also to chronic sleep deprivation.
His memory and concentration problems were severe and likely due to depression, chronic pain, and insomnia.
While I gave him information for this medication, I did not prescribe it for him since he was only seen in my office for an evaluation. I told the patient I would be happy to assume his pain management if he chose to come back and see me. He was not able to sleep. He was very depressed and he told me that he thought that his situation was not going to get any better no matter what he tried.
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I also noted in my letter to his attorney that he looked about 10 years older than his stated age and that I believed that he was truly suffering greatly and required aggressive pain treatment. The patient was only 39 years of age. The physical and emotional stress caused by the injuries he sustained This case serves as a reminder that chronic persistent pain, under-treated and uncontrolled, can result in tragedy.
This patient was 37 years old prior to his accident. He was gainfully employed and enjoying a good quality of life. Chronic pain can be a tremendous stressor and can affect virtually every organ system of the body. One common chronic painful condition, fibromyalgia syndrome FS , 8 for example, has been associated with adult growth hormone deficiency characterized by low levels of somatomedin-C or insulin dependent growth factor one IGF-1 and altered reactivity of the hypothalamic-pituitary-adrenal axis, 9,10 as well as a poor overall quality of life.
His chronic pain went undertreated and thus initiated a cascade of other problems which eventually led to his premature death at the age of thirty-nine. These adverse effects, however, were only confirmed to occur in patients who had been taking the medication for at least eighteen months. This was not the case with the patient who is the subject of this report. A small percentage of the population cannot make this conversion. However, even if the codeine preparation was adequately processed, pain relief would have been of only a short duration. The medical records give no reason for this.
In my community, many physicians avoid prescribing controlled substances for just that reason. Furthermore, more is expected of clinicians in the area of risk management and prevention of diversion of controlled substances. This fear, while palpable in my community, is without foundation if the physician is prescribing opioids for a patient whose painful condition is well documented and the prescriber exercises due diligence in his care of the patient. The fear and embarassment at being manipulated and hoodwinked by drug-seeking addicts may also be a factor in the under-treatment of pain.
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However, this does not relieve the physician of his obligation to ease the suffering of his patient. Every prudent and caring physician has been in the precarious position of balancing patient care and risk prevention. The practitioner must keep in mind state and federal law while, at the same time, fulfill what he believes to be his duty to his patient.
Adequate analgesia can usually be attained. Because chronic pain syndromes are quite common and these medical conditions can cause significant systemic stress and adversely affect the quality of life, the clinician should treat pain aggressively as early as possible. This case report is a reminder of what can happen if chronic pain is not treated successfully.
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Subscribe or renew to PPM. Burning Mouth Syndrome. Chronic Persistent Pain Can Kill. Managing Pain in Intensive Care Units. Oxycodone to Oxymorphone Metabolism. Patulous Eustachian Tube: Part 1. Structuring Opioid Therapy. Case report of a male patient whose death was hastened by chronic pain.
Romano TJ. September, Arlington, Virginia. Tennant F. Complications of Uncontrolled Persistent Pain. Prac Pain Mgmt. Liebeskind JC. Pain Can Kill. Pain May Clin Proc. Am J Pain Mgmt. Report of the Multicenter Criteria Committee. Arthritis and Rheum. J of Musculoskeletal Pain. J Rheumatol. Ann Intern Med. Bengstsson BA. Acta Endocrinol.
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Human Growth Hormone and Human Aging. Andocr Rev. Clin Endocrinol. Swezey RL and Adams J. Fibromyalgia: A Risk Factor for Osteoporosis.