Further relevant information and examination
During his first consultation, Mr S reported the above history. He expressed despair about the fact that despite undergoing multiple surgical procedures including losing a limb he remained in severe pain. He was reporting pain in the stump itself and also the same pain he used to experience in his foot and ankle before it was removed. He reported flashbacks about the accident and although he was not in anyway culpable for the accident, he felt guilty that another person had died. He could not drive and found being a passenger in a car very difficult. He could not face being driven down the road where the accident occurred, which meant that travelling from home for hospital or other appointments required long detours. Prior to the accident he had no significant past medical history. He was happily married with a grown-up family. He had been working as a manager within a warehouse. He had not returned back to work since the accident.
Mr S was on a significant amount of medication including Morphine Sustained Release tablets 50mg twice daily, Pregabalin 150mg twice daily, and Fluoxetine 40mg once daily. The latter had been started in the first three months following the accident as his mood had not surprisingly dipped. He had previously tried Amitriptyline 50mg nocte, Co-Codamol 30/500mg up to eight tablets per day, Tramadol 100mg qid, Naproxen 500mg twice daily. These medications had not helped and had been discontinued. He continued to be supported by the rehabilitation physiotherapy team, but had been unable to tolerate a prosthesis due to pain.
During his first consultation he completed the following measurement tools:
- Verbal Rating Scale: 8/10 average, 10/10 especially re phantom pain (worst)
- Patient Self Efficacy Questionnaire: 18/60
- HADS: Depression (Moderately severe): 19, Anxiety: 21 (severe)
The consultation was lengthy and used to address the multifaceted presentation of stump pain, phantom pain, post traumatic stress disorder, compounded by anxiety and depression, and deconditioning associated with the multiple trauma and enforced inactivity.