Assignment: Decision Tree for Neurological and Musculoskeletal Disorder/Complex Regional Pain Disorder

Assignment: Decision Tree for Neurological and Musculoskeletal Disorder/Complex Regional Pain Disorder

Assignment: Decision Tree for Neurological and Musculoskeletal Disorder/Complex Regional Pain Disorder

            The assigned case study demonstrates an adult Caucasian male, at the age of 43 years with pain as the main chief complaint. He reports using crutches as support to promote movement. The patient’s family doctor however claims that the patient’s pain is mental rather than physical. The physician reports that most of the patient’s symptoms are made up, as he is only trying to get narcotics. The patient reports that he started experiencing the pain about 7 years ago when he fell at his work and landed on his right hip. Mental evaluation outcome, in combination with the above presentation, led to a primary diagnosis of complex regional pain disorder (reflex sympathetic dystrophy). Several factors including the patient’s diagnosis, presenting symptoms, age, Caucasian race, and male gender will be utilized in the development of the patient’s care plan.

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Decision Point One

            The initial intervention was to administer 25mg of amitriptyline per oral every night and gradually increase the dose at intervals of 25 mg every week, not exceeding a maximum dose of 200mg/day. Previous evidence reveals the great effectiveness of amitriptyline in the treatment of complex regional pain disorder, with a rating of 6.6/10 (Javed & Abdi, 2021). Neurontin and Savella were inappropriate with this patient given that the former is unable to manage other symptoms of CRPD other than pain, as the latter would result in insomnia (Eldufani et al., 2020). The patient is expected to display complete remission of symptoms and ambulation without support within four weeks, with great compliance and adherence to the prescribed medication (Handa, 2021).

Decision Point Two

            The second intervention was to encourage the patient to continue taking amitriptyline at a dose of 125 mg every night. According to Suer and Sehgal (2021), attaining the optimum therapeutic dose of amitriptyline can take between 4 to 8 weeks, with the patient being able to completely manage their symptoms within 8 to 12 weeks. The patient displayed great tolerance and adherence to the medication, with the only side effect being a groggy feeling in the morning that can be managed by taking the drug at least one hour before going to bed (Handa, 2021). Lowering the dose of amitriptyline, and introducing Bio freeze roll-on therapy was not necessary as the patient needs long-term therapy, rather than a temporary intervention. Adding Neurontin was also inappropriate given that amitriptyline is considered safer (Taylor et al., 2021). The patient’s symptoms are expected to reduce even further with no groggy feeling the following morning for the next four weeks.

Decision Point Three

            The final decision was to advise the patient to continue taking 125mg of amitriptyline every night and refer him to a life coach for appropriate dietary interventions and physical activity/exercise. The patient reported improved pain symptoms, with no groggy feeling the following morning with the previous intervention. This shows the great effectiveness of the drug (Javed & Abdi, 2021). He, however, complained of gaining weight which is a common side effect of the medication that is usually managed with non-pharmacological intervention to promote a positive outcome for the patient (Handa, 2021). Reducing the dose of amitriptyline or introducing a new drug to the patient current regimen would only complicate the adherence and tolerance level of the patient and lead to new side effects with a negative outcome  (Suer & Sehgal, 2021). However, with this intervention, the patient’s body weight is expected to normalize with complete remission of symptoms within the following four weeks (Eldufani et al., 2020).

References

Eldufani, J., Elahmer, N., & Blaise, G. (2020). A medical mystery of complex regional pain syndrome. Heliyon, 6(2), e03329. https://doi.org/10.1016/j.heliyon.2020.e03329

‌Handa, R. (2021). Complex Regional Pain Syndrome. In: Clinical Rheumatology. Springer, Singapore. https://doi.org/10.1007/978-981-33-4885-1_25

Javed, S., & Abdi, S. (2021). Use of anticonvulsants and antidepressants for treatment of complex regional pain syndrome: a literature review. Pain Management, 11(2), 189–199. https://doi.org/10.2217/pmt-2020-0060

Suer, M., Sehgal, N. (2021). Complex Regional Pain Syndrome and Post-herpetic Neuralgia. In: Questions and Answers in Pain Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-68204-0_17

Taylor, S.-S., Noor, N., Urits, I., Paladini, A., Sadhu, M. S., Gibb, C., Carlson, T., Myrcik, D., Varrassi, G., & Viswanath, O. (2021). Complex Regional Pain Syndrome: A Comprehensive Review. Pain and Therapy, 10(2), 875–892. https://doi.org/10.1007/s40122-021-00279-4

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Assignment: Decision Tree for Neurological and Musculoskeletal Disorder.

Decision Point 2: Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day.

interactive media piece assigned by the instructor

Tittle: Complex Regional Pain Disorder

White Male with Hip Pain
Background

This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high”

SUBJECTIVE

The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time.

The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said, “there is no such thing as RSD, it comes from depression” and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states “I said ‘no,’ there is no need for a wheelchair, I can beat this!”
The client reports that he used to be a machinist where he made “pretty good money.” He was engaged to be married, but his fiancé got “sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.”
He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states “you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.”
During the client interview, the client states “oh! It’s happening, let me show you!” this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. “It will last about a minute or two, then it will let up” he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states “if there is anything you can do to help me with this pain, I would really appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he states that he uses is “sparingly” because he does not like the side effects of feeling “sleepy” and constipation. He also reports that the medication makes him “loopy” and doesn’t really do anything for the pain.

MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation and is future oriented.
Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)

Decision Point One
Select what you should do

Decision Point 2: Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day.

RESULTS OF DECISION POINT

Client returns to clinic in four weeks
Client comes to the office still using crutches. He states that the pain has improved but he is a bit groggy in the morning
Client’s pain level is currently a 6 out of 10. You question the client on what would be an acceptable pain level. He states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.” He states that his pain level normally hovers around a 9 out of 10 on most days of the week before the amitriptyline was started. You ask what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 6?” The client states, “I’m able to go to the bathroom or to the kitchen without using my crutches all the time. The achiness is less and my toes do not curl as often as they did before.” The client is also asked what would need to happen to get his pain from a current level of 6 to an acceptable level of 3. He states, “Well, that is kind of hard to answer. I guess I would like the achiness and throbbing in my right leg to not happen every day or at least not several times a day. I also could do without my toes curling in like they do. That really hurts.”
Client denies suicidal/homicidal ideation and is still future oriented

Decision Point two
Select what you should do next.

Reduce dose of Amitriptyline Elavil to 75mg PO at bedtime and add-on Neurontin 300mg PO at bedtime. Schedule follow-up phone call one week to assess pain control.
RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client returns with his crutches. He states that he is still groggy in the morning but now is having trouble staying awake throughout the day. His current pain level is 7 out of 10. He states that his right leg is “killing” him, and he still is dealing with the cramping in his right foot
Client blames all of this on you because “you changed my medication and added the Neurontin which doesn’t help at all”

Decision Point three

Increase the Neurontin to 300mg orally three time a day and Amitriptyline increase to 100mg orally at bedtime

Guidance to Student
Clients in pain want immediate help. Sometimes they get lost in the syndrome and forget that you are trying to help and will blame you for any back steps. Don’t take it personal. It is not the client taking but rather the disease state taking its’ toll on their ability to think rationally. A dose increase with the Neurontin will only worsen the daytime drowsiness, especially if he was only taking it at bedtime and will now take it throughout the day. Referring clients who have pain syndromes to a clinic that specializes in pain is never a bad option and sometimes is the best option. If you do make this referral, then you will need to bridge therapy until the clinic is able to see the client. The amitriptyline seemed to work. Continuing with this medication is a good option. Early morning drowsiness of grogginess can usually be alleviated with a change in administration time. An hour or two earlier usually will give the results you are looking for and should be tried first before a medication change.

Or
Refer the client to a pain specialist since he does not perceive any benefit from what you are doing.
Clients in pain want immediate help. Sometimes they get lost in the syndrome and forget that you are trying to help and will blame you for any back steps. Don’t take it personal. It is not the client taking but rather the disease state taking its’ toll on their ability to think rationally. A dose increase with the Neurontin will only worsen the daytime drowsiness, especially if he was only taking it at bedtime and will now take it throughout the day. Referring clients who have pain syndromes to a clinic that specializes in pain is never a bad option and sometimes is the best option. If you do make this referral, then you will need to bridge therapy until the clinic is able to see the client. The amitriptyline seemed to work. Continuing with this medication is a good option. Early morning drowsiness of grogginess can usually be alleviated with a change in administration time. An hour or two earlier usually will give the results you are looking for and should be tried first before a medication change.

Neurologic and Musculoskeletal Systems and Opioids

Neurologic and Musculoskeletal Systems is a 2-week module, Weeks 6 and 7 of the courses. In this module, you will analyze drugs prescribed to treat neurological and musculoskeletal disorders and explore patient education strategies for treatment and management of these disorders. You will also evaluate the impact of patient factors on the effects of prescribed drugs and drug therapy plans for neurologic and musculoskeletal disorders.
Sabrina is a 26-year-old female who has just been diagnosed with multiple sclerosis. She has scheduled an appointment for a follow up with her physician but has several questions about her diagnosis and is calling the Nurse Helpline for her hospital network. As she talks with the advanced practice nurse, she learns that her diagnosis also impacts her neurologic and musculoskeletal systems. Although multiple sclerosis is an autoimmune disorder, both the neurologic and musculoskeletal systems will be affected by adverse symptoms that Sabrina needs to be aware of and for which specific drug therapy plans and other treatment options need to be decided on.
As an advanced practice nurse, what types of drugs will best address potential neurologic and musculoskeletal symptoms Sabrina might experience?
This week, you will evaluate patients for the treatment of neurologic and musculoskeletal disorders by focusing on specific patient case studies through a decision tree exercise. You will analyze the decisions you will make in the decision tree exercise and reflect on your experiences in proposing the recommended actions to address the health needs in the patient case study.

• Evaluate patients for treatment of neurologic and musculoskeletal disorders
• Analyze decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders
• Justify decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders

For your Assignment, your instructor will assign you one of the decision tree interactive media pieces provided in the Resources. As you examine the patient case studies in this module’s Resources, consider how you might assess and treat patients presenting symptoms of neurological and musculoskeletal disorders