Assignment: Decision Tree for Neurological and Musculoskeletal Disorders

Assignment: Decision Tree for Neurological and Musculoskeletal Disorders

Assignment: Decision Tree for Neurological and Musculoskeletal Disorders

The case concerns a 43-year-old white male who presents with pain and uses crutches when walking. He was referred for psychiatric evaluation by his family physician since the physician thinks that he has psychological pain. The client states he has severe cramping of the right extremity and a depressed mood. A neurologist diagnosed him with complex regional pain syndrome (CRPS). The purpose of this paper is to describe the decisions made in each step.

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Decision One

The client was initiated on Amitriptyline 25 mg PO every bedtime with a weekly dose increment of 25mg to a max of 200mg daily. Amitriptyline was selected because it is an antidepressant supported by evidence-based literature as effective in alleviating neuropathic pain and diabetes-related peripheral neuropathic pain (Di Stefano et al., 2021). Its efficacy has been established in alleviating pain and improving motor and autonomic symptoms in CRPS (Shakshuki et al., 2020). It could thus be effective for this client. The clinician expected that amitriptyline would reduce the client’s neuropathic pain enabling him to walk without crutches, and improve mood. After four weeks, the pain had improved and was at 6/10, and he was still walking with crutches. He reported being groggy in the morning. The expected and actual outcomes were similar except for the use of crutches.

Decision Two

The Amitriptyline dose was reduced to 75 mg every bedtime, and Neurontin 300mg PO QHS was added. Amitriptyline was reduced because of the drug-associated grogginess since side effects are usually dose-dependent (Di Stefano et al., 2021). Neurontin was added because evidence shows that it offers adequate levels of pain relief to patients with postherpetic neuralgia and peripheral diabetic neuropathy. Wiffen et al. (2018) found that Neurontin had at least a 50% reduction in pain intensity which is associated with improving other symptoms like sleep disturbance, fatigue, and depression. The PMHNP hoped Neurontin would reduce pain and improve the patient’s depressive symptoms without grogginess. I also hoped that adding. However, the expected outcome was not the same as the actual one since the patient returned still walking in crutches. He reported grogginess, daytime sleepiness, a pain level of 7/10, and increased pain in the right leg with cramping in the right foot.

Decision Three

Neurontin was stopped, and amitriptyline was increased to 100mg. The patient was instructed to take the drug an hour earlier and contact the office in three days to evaluate his pain and ability to stay awake during the day. Instructing the client to take the drug an hour before bed is supported by literature, which shows that it reduces the side effects of morning sleepiness since the sedative effects do not persist after waking up. Komoly (2019) recommends that amitriptyline should be progressively increased if patients achieve a positive response without major side effects to promote maximum drug benefits. The PMHNP hoped that increasing the drug would alleviate the leg pain to below 4/10, and taking the drug an hour before bed would prevent the morning drowsiness.

Conclusion

The client was started on Amitriptyline 25 mg at bedtime, which reduced leg pain to 6/10 but was associated with grogginess. This led to reducing the Amitriptyline dose to 75 mg at bedtime and adding Neurontin 300mg QHS. However, the pain aggravated, and the patient reported leg cramping and daytime drowsiness. The PMHNP stopped Neurontin, increased amitriptyline to 100 mg, and instructed the client to take the dose an hour before bed to reduce morning drowsiness.

References

Di Stefano, G., Di Lionardo, A., Di Pietro, G., Cruccu, G., & Truini, A. (2021). Pharmacotherapeutic Options for Managing Neuropathic Pain: A Systematic Review and Meta-Analysis. Pain research & management, 2021, 6656863. https://doi.org/10.1155/2021/6656863Komoly, S. (2019). Treatment of complex regional pain syndrome with amitriptyline. Ideggyogyaszati szemle, 72(7-8), 279-281. https://doi.org/10.18071/isz.72.0279

Komoly, S. (2019). Treatment of complex regional pain syndrome with amitriptyline. Ideggyogyaszati szemle, 72(7-8), 279-281. https://doi.org/10.18071/isz.72.0279

Shakshuki, A., Yeung, P., & Agu, R. U. (2020). Compounded Topical Amitriptyline for Neuropathic Pain: In Vitro Release from Compounding Bases and Potential Correlation with Clinical Efficacy. The Canadian journal of hospital pharmacy, 73(2), 133–140.

 Wiffen, P. J., Derry, S., Bell, R. F., Rice, A. S., Tölle, T. R., Phillips, T., & Moore, R. A. (2018). Gabapentin for chronic neuropathic pain in adults. The Cochrane database of systematic reviews, 6(6), CD007938. https://doi.org/10.1002/14651858.CD007938.pub4

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Assignment: Decision Tree for Neurological 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.

To Prepare
• Review the interactive media piece assigned by your Instructor.
• Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
• Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
• You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.
By Day 7 of Week 8
Write a summary paper that addresses the following:
• Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
• Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
• What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
• Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.