PLAN:
1. Trial TENS.
2. Encourage him to increase the gabapentin dosage slowly by 300 mg every three days. If excessive drowsiness occurs he should stay at a dosage lower until tolerance to this side effect occurs (usually 1-2 weeks)
3. Congratulate him on stopping his alcohol intake.
4. Encourage finger exercises.
5. Consider referral to Occupational therapist for hand exercises and to commence the process of a plan to return to the work force.
6. Increase nortriptyline to75mg.
7. See in one week.
He returned in one week stating he sleeping had improved on 75 mg nortriptyline at night. His dry mouth was not as troublesome if he chewed gum to relieve it. His constipation had been effectively treated by adding more roughage and prune juice to his diet.
The TENS worked well when it was on, decreasing the pain to 5/10, which was the best it had been since the accident. The pain relief only lasted a few minutes after turning the device off.
He was still off his alcohol and taking 6-8 analgesics per day. He was taking gabapentin 300 mg morning and noon and 600 mg at night.
His average pain was 6-7/10, but he was beginning to use his hand more. His wife also stated he was beginning to take more interest in the family and do more things around the house.
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