Dr. Horowitz had struggled in his care of Lilly Chui during the first 10 years of their relationship. She dismissed his recommendations regarding the treatment of her uncontrolled hypertension, hypercholesterolemia and type 2 diabetes. Lilly wanted to avoid “pills„ and was adamant that “I just want to do it more naturally.„ Yet her lifestyle changes were minimal, and other than light housework Lilly remained quite sedentary. But Lilly was a ticking time bomb. Concurrent with her own health problems, Lilly’s family history was ominous – both of her parents had suffered debilitating strokes secondary to hypercholesterolemia. Her two elderly brothers had died of pancreatic cancer within six months of each other.
Turning 65 had been a watershed for Lilly. Much to Dr. Horowitz’s amazement, Lilly decided to actively take control of her health. Lilly started walking a little over a mile a day when the weather was fair, and when it became inclement, she took to her treadmill with a vengeance. She attended classes at the Diabetic Education Center, determined to begin cooking healthy meals for her and her husband, Wang.
When Lilly had initially reported her sudden lifestyle changes to improve her health and reduce her risk factors, Dr. Horowitz had been skeptical. What caused this sudden change in Lilly at age 65? He wondered: had it been the sudden death of her two brothers in their early 70s? The increasing care required by her husband, who was 10 years her senior? The birth of her first grandchild? Or all of the above? He might never really know what had motivated Lilly to take charge of her health. What did matter was that Lilly had sustained these lifestyle changes now for five years. Dr. Horowitz was both pleased and impressed.
Now Lilly was complaining of swelling, pain and a burning sensation in her left hand, wrist and forearm for the last two weeks. Lilly had suffered a Colles’ fracture 12 weeks ago secondary to a fall on her outstretched hand while venturing outside for a walk on a less-than-perfect day. She presented to the emergency room, and a temporary cast was put on her forearm. Lilly was later seen in the cast clinic, and a full cast was placed on her forearm for six weeks. The cast had been removed two weeks ago, and since then Lilly had been experiencing severe pain in her left hand, wrist and forearm. In her mind, she had almost recovered from her recent left Colles’ fracture, but now she had this unrelenting pain. The pain was compromising her abilit
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to sleep or do anything with her left hand. Lilly was very worried about this new onset of pain. “What’s causing this?„ she asked, her face red and blotchy from crying.
Lilly had reached a stage in her life where she had taken control of her health. She felt proud of her newfound lease on life – or so she thought. These new symptoms represented a loss of control over her health issues despite her best efforts. “I just feel so helpless,„ Lilly said through her tears. “I worked very hard to take charge of my health and now this happens!„ Dr. Horowitz handed Lilly another tissue and continued to listen. “I’ve been crying nonstop and that’s just not like me – I have always been a fighter,„ she said as the tears flowed down her cheeks, “but right now I can’t fight these feelings of sadness.„ Lilly was unable to differentiate whether the crying spells and loss of sleep were due to the severity of her pain or a result of her feelings of helplessness and present loss of control over her health.
The pain was severely limiting Lilly’s ability to fulfill her day to day role as a homemaker. Her husband, Wang, depended on Lilly for many of his daily needs, both physical and emotional. Lilly was exhausted by her lack of sleep for the last two weeks. This was largely because of the pain, compounded by the anxiety and worry about her health. Lilly had reluctantly tried Tylenol, which had not been of much help to her.
Lilly’s expectations of this visit were very clear to Dr. Horowitz as she rapidly stated, “What’s wrong with my arm? Why has the fracture not healed? It has been three months! Why am I having so much pain now?„ Lilly paused, caught her breath, and through her multiple tears begged, “Please Dr. Horowitz, I need to sleep and to manage at home so I can take care of Wang – and me too!„
Gently, Dr. Horowitz tried to reassure Lilly that he would do whatever he could to understand her problem and help her regain control of her health. “Lilly, I know you have worked very hard to get healthy,„ he said. “You have made some amazing changes in your life, and the improvement in your health has been awesome.„ Lilly smiled with his praise. Dr. Horowitz continued, “So Lilly, this current situation is very distressing and worrisome. I know you are frightened.„ His words appeared to temper Lilly’s sense of desperation.
Dr. Horowitz acknowledged the severity of her pain, and suggested that she could be suffering from complex regional pain syndrome type 1 (CRPS). He explained to her that CRPS is a disease in which the nervous system malfunctions in a way that causes the pain to escalate even the original injury has healed. The symptoms of sadness Lilly was feeling commonly accompanied the diagnosis. Lilly recognized she was feeling sad and anxious but was
not sure whether this was due to her pain and/or her feelings of deep sadness about not being able to engage in her daily activities of healthy living. Also, the fear of the unknown was frightening her. Lilly also expressed grief over the loss of control of her health despite her best efforts in the last five years. She had worked so hard.
Lilly usually refused medications, but in this new situation she willingly agreed to treat the pain, and then slowly taper the medication as the symptoms subsided. A subsequent X-ray of her wrist showed evidence of a healed Colles’ fracture. A bone scan confirmed radiological evidence consistent with the diagnosis of CRPS. Dr. Horowitz offered Lilly a trial of prednisone but also cautioned that her blood sugar levels might be difficult to control while she was taking steroids. Lilly refused the prednisone, as Dr. Horowitz had expected. However, patient and doctor did agree on a plan that included controlling her pain with medications and aggressive physiotherapy, without compromising her diabetic control, which Lilly had worked so diligently to attain.
CRPS is an important diagnosis to make, as the unrelenting pain can cause many patients much physical and emotional misery – as it did for Lilly. Having a diagnosis helped Lilly feel less devastated by her illness experience. It gave her a ray of hope.