FM PATIENT CASE STUDY: MRS C PATIENT PRESENTATION

Transcription

1 PATIENT PRESENTATION Mrs C is a 42-year-old wife and mother with 3 children. She works 5 days a week in a day care center with 3- to 5-yearolds. Her reason for coming to the office today is severe pain in the neck and shoulder region that she has been experiencing for at least 2 months. You have been her primary care provider for approximately 2 years, and in her chart you quickly peruse a number of chief complaints for which you have seen and treated her, including migraine headaches, chronic interstitial cystitis diagnosed by a urologist, and low back pain. When you see her this morning, Mrs C states that she hasn t been injured but that just touching or gently massaging her neck and shoulders causes much pain and tenderness. In addition to shoulder pain and the low back pain she s had previously, Mrs C reports that she feels more general pain all over in her muscles and joints and that she has felt this way for at least 4 months. When asked how she is sleeping, she reports frequent insomnia and fatigue. Her sleep is not refreshing and she struggles with daytime sleepiness. She wakes up frequently and also snores loudly, according to her husband. With this information, you proceed to the workup for diagnosis. Personal details 42-year-old wife, mother Works 5 days/week in a day care center Medical history Migraine headaches Chronic interstitial cystitis Low back pain Current presentation Severe pain and tenderness in neck/shoulder region for 8+ weeks Pain all over in muscles and joints for 4 months Frequent insomnia, fatigue Sleep is not refreshing Struggles with daytime sleepiness Wakes frequently Snores loudly 1

2 DIAGNOSIS Lab results obtained in the last 6 months were normal, including a complete blood count (CBC), chemistry screen, thyroid-stimulating hormone test (TSH), and tests of antinuclear antibody (ANA) and erythrocyte sedimentation rate (ESR). During a physical examination based on Mrs C s prior history, you identify diffuse mild tenderness throughout the low back that has increased compared with previous visits. You also find moderate tenderness in the suprapubic region upon palpation. To follow up with these results, you follow the 1990 American College of Rheumatology (ACR) classification criteria for FM and you identify tenderness on palpation at multiple sites more specifically, tenderness at 15 of 18 tender point sites.1 You opt to administer the provisional 2010 diagnostic criteria for FM recently released by the ACR, and find that Mrs C has a score of 10 of 19 on the widespread pain index (WPI) and a score of 7 of 12 on the symptom severity (SS) scale.2 Based on the findings of the 1990 and 2010 ACR criteria, you diagnose Mrs C with Fibromyalgia. Laboratory findings CBC and chemistry screen normal TSH normal ANA and ESR normal Physical examination based on prior history Increased diffuse mild tenderness throughout lower back Moderate tenderness on palpation in suprapubic region Physical examination based on current complaints 1990 ACR classification criteria for FM - Tenderness on palpation at 15 of 18 sites 2010 ACR preliminary diagnostic criteria for FM - WPI: 10/19 - SS scale: 7/12 2

3 SETTING TREATMENT GOALS While reviewing Mrs C s history, you ask her to rate her recent levels of pain, sleep quality, and fatigue on a 0-10 (best-worst) scale. She rates pain and sleep quality at 7 and fatigue at 8. You ask, What bothers you the most about the effect FM has had on you? Mrs C becomes emotional and says the worst thing is the impact that the pain and fatigue have had on her ability to care for her children. Her symptoms limit her ability to cook meals, do household chores, and interact with her kids. She states that she still functions reasonably well at work early in the day, but that she drops out at home. Her husband has had to take over many family chores, especially in the evenings, to meet the children s needs. Patient ratings on NRS (0-10) Pain: 7 Sleep quality: 7 Fatigue: 8 Most troubling effect of FM Inability to care for her children You ask Mrs C what she would like to be doing that she cannot do right now. She describes simple things, such as hosting a sleepover for her daughter, cooking, and going to the movies with her husband. When asked, she says the most important thing to her is the sleepover. Based on this dialogue, you and Mrs C decide on 2 goals that she will try to accomplish before her next visit. You suggest that, for now, a play date rather than a sleepover might be more realistic. She agrees. You and she also decide that it is realistic for her to try to cook dinner 2 evenings a week. Pain and fatigue limit her ability to cook meals, do household chores, interact with kids To help Mrs C attain these goals, you and she brainstorm to identify potential barriers to achieving these milestones. Since she functions best in the morning, you suggest that she schedule her daughter s play date for the morning, when her energy levels are highest and her pain is at its lowest. So that she does not feel overwhelmed by the many steps needed to make dinner, you suggest she split up the steps. Mrs C comes up with the idea to prep the ingredients one night and cook the next night as a way to conserve her energy. Host a sleepover for her daughter Effect on daily routine Functions reasonably well at work, early in the day Desired goals discussed Cook meals (dinner 2 nights/week) Go to a movie with her husband 3

4 Although helping Mrs C attain these goals is important to her overall quality of life, as her physician, you will evaluate her treatment success clinically by documenting functional improvement and symptom improvement. Identification of potential barriers Now that you and Mrs C have identified and set some goals, it is time to employ a comprehensive, multimodal treatment plan (ie, pharmacological and nonpharmacological strategies) to better help her attain these goals. Prep dinner ingredients one night, cook the next night to conserve energy Schedule play date for the morning, when she feels best Clinical evaluation of success Functional improvement Symptom improvement 4

5 APPLYING MULTIMODAL THERAPY: Part 1 You decide to start Mrs C on an approved pharmacotherapy for FM, based on her symptom profile. When you prescribe this medication, you discuss her expectations, explaining that medications used in FM management are not cures, but they can help reduce FM pain and improve function. You explain that every person is different and that it may take some trial and error to determine if the chosen medication works and at which dose. You describe possible side effects and explain that at first she may feel these effects before she experi-ences relief which may take several weeks. You encourage her to stick with it through this initial period because she needs to give the therapy time to work, and side effects may resolve as her body gets used to the drug. You start at a low dose to minimize side effects, with a plan to slowly titrate upward as needed to achieve therapeutic efficacy. Mrs C s pretreatment pain score was 7. Slight decreases in this score are observed after the initiation of therapy (eg, pain score of 6 after 2 months), but more reductions may require upward dose titration. You assess Mrs C s fitness level, ask what activities she prefers, and together come up with a plan for her to walk minutes a day and to gradually increase the time as she feels able. You write all this clearly on a prescription pad to emphasize its importance as part of the treatment plan to reach the first goal she has set (hosting a play date). You also decide to refer Mrs C to a sleep specialist to determine whether she has sleep apnea. You explain to Mrs C that if she has sleep apnea, it can be treated and may help with her sleep and fatigue, which are major problems for her. Meanwhile, you discuss sleep hygiene and provide a handout with tips for her to take home. To help build Mrs C s self-management skills you talk with her about the importance of activity pacing. You stress that the key to living with any chronic condition is to learn ways Treatment plan Patient started on approved pharmacotherapy for FM Review of expectations Discussion of possible side effects Need to titrate dose Prescription for physical activity (eg, walk minutes/day) Referral to a sleep specialist for possible sleep apnea Build self-management skills Stress importance of activity pacing Refer to online self-management program for FM Reinforce goals Sleep specialist outcomes Sleep apnea diagnosed CPAP trial completed, some improvement noted 5

6 that one can control it and suggest she visit a website that offers a self-management program for people with FM, which she agrees to do. You remind her of the goals she has agreed to and ask her to schedule a follow-up visit. In the interim, Mrs C schedules an appointment with a sleep specialist, who diagnoses her with sleep apnea after a sleep study. Mrs C uses a continuous positive airway pressure (CPAP) device for a week and notes that, after getting used to the device, she seems to be sleeping more soundly and waking up feeling more refreshed. Urologist outcome Ongoing management of interstitial cystitis In addition to being seen by a sleep specialist, Mrs C continues to have her interstitial cystitis managed by a urologist. 6

7 APPLYING MULTIMODAL THERAPY: Part 2 It is now several weeks later, and Mrs C is in the office for her scheduled follow-up visit. She reports improved pain, which is a 4 on a 10-point scale. However, her fatigue is only slightly better, decreasing from an 8 previously to a 7. You remark on all the good progress and ask how she s doing with increasing her physical activity and caring for her children. Mrs C notes that she is tolerating her medication well and believes that much of her improvement is related to medication use. In general, she feels better but admits that she has not been exercising because she has been experiencing fatigue. At this point, you emphasize that there is not an expectation for her to exercise excessively; she should start with gentle physical activity and then increase her activity level as she feels able. You also mention that she may want to consider a buddy system for exercise. She may find it enjoyable to exercise with a friend. Also, if she knows that someone is depending on her, she may be more motivated to keep the exercise appointment. You also talk with her about what types of physical activities would be fun for her. Mrs C notes that her functional abilities at work have extended beyond just the morning. She now feels that her energy levels persist through the middle of the day, at which time they start to wane. During all subsequent visits, it will be very important to track all aspects of Mrs C s progress to determine whether her condition is improving. Improvements on NRS (0-10) at follow-up Pain: 4 Sleep quality: 4 Fatigue: 7 Pharmacotherapy Well tolerated Patient s perception is that much of her improvement is related to her medication Functional improvement Functions well at work through midday Physical activity status at follow-up Patient feels better, but admits to not exercising because of fatigue

8 TRACKING PROGRESS It s been 6 months since you began treating Mrs C for FM, and she has made gradual improvement. In that time, you have adjusted the dosing of the medication you prescribed to manage her symptoms. There have been some setbacks, namely that her symptoms flared with the onset of winter and it affected her mood. At one point, you invited her husband to accompany her to an appointment to reinforce for both of them how important it is for Mrs C to engage in gentle physical activity, and you helped them brainstorm together about ways of doing so. You also invited her husband to join his wife during her next appointment to help him feel included and invested in his wife s care. In 6 months since diagnosis Gradual improvement observed Medication titrated to manage symptoms Occasional setbacks - Symptoms flared with onset of winter, affecting her mood Mrs C has made use of the self-management information she has found on the Internet. Your follow-up visits have tracked progress in the specific areas she has worked on. At her most recent visit, she showed marked improvement in pain, sleep, fatigue, and overall well-being, which you have encouraged by reviewing her 0-10 scores over time. You have also encouraged Mrs C by reinforcing the progress she has made toward her goals. She was able to host her daughter s play date during the third month post-diagnosis, and she currently cooks dinner 2-3 nights per week. She still has good and bad days, but with pacing and scheduling Mrs C does more with her family and is now focused on ensuring that she and her husband have a date night every 2 or 3 weeks. Husband invited to attend an appointment to reinforce importance of physical activity Given Mrs C s progress, you have scaled back your follow-up visits from monthly to every 3 months, unless issues arise. Pain: 4 - Brainstormed during visit on ways to achieve this goal - Husband invited to join wife at next appointment Patient uses online self-management program to facilitate progress Current ratings on NRS (0-10) Sleep quality: 4 Fatigue: 5

9 References: 1. Wolfe F. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum. 1990;33(2): Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. 2010;62(5): Goals attained Hosted daughter s play date during third month postdiagnosis Cooks dinner 2-3 nights/week Goals attainedm Visits scaled back from monthly to every 3 months