Decision Tree for Neurological and Musculoskeletal Disorders Essay

Decision Tree for Neurological and Musculoskeletal Disorders Essay

Decision Tree for Neurological and Musculoskeletal Disorders Essay

Healthcare providers are expected to decide the diagnosis of their patients, considering the presenting symptoms and the potential comorbid and physical patient factors. The decisions should be supported by evidence from the literature (Portney, 2020). This discussion summarizes a case study on a patient with neurological and musculoskeletal symptoms and the decisions made using a decision tree. The summary will include the case study and the decisions made at each point, a discussion on whether the decision was based on evidence, the expected outcomes from the decisions, and the difference between the actual results and the expected outcomes.

The case study entails a 43-year-old white male who presents to the clinic complaining f pain. He has been referred to the clinic by his family doctor for a psychiatric assessment, citing that the pain is all in his head. He reports that the pain started seven years ago, after sustaining a fall at work, after which he developed cooling of the extremities and often experiences severe cramping on the extremity. The mental status exam reveals that the patient is oriented to place and time. His judgment and insight are intact, and he denies hallucinations and delusions. The diagnosis is Complex regional pain disorder (reflex sympathetic dystrophy). 

The first decision was to begin Savella 12.5 mg once daily on day 1; followed by 12.5 mg BID on days 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter, followed by continuing the current medication, but at a lower dose of 25mg BID. The third decision was to change Savella to 25 mg orally in the morning and 50 mg orally at bedtime. The decisions provided are supported by literature evidence. According to Harden et al. (2022), Milnacipran (Savella) is an effective medication for treating complex regional pain disorders. Gurba and Haroutounian (2022) also note that Savella should be started using a low dose and increased later, based on the patient’s reaction, as recommended in the decisions.

The expected outcomes I hoped to achieve by making the abovementioned decisions include managing the patient’s chronic pain to a place where he will comfortably go n with his daily activities. According to Miller et al. (2019), it is impossible to address chronic pain from RSD completely; the pharmacological interventions aim to reduce the pain to a manageable scale. In addition, reducing the dose aimed at dealing with the side effects, such as sweating and sleep disturbance.

However, some of the expected outcomes differed from the actual case study results. In the second visit, the client noted that the pain had reduced but was not manageable. After the dosage reduction, the client reported that the pain had increased, as opposed to the expected outcome, which was further pain reduction. However, the current dose managed to deal with the side effect of sleep disturbance.   

The decisions identified above were, to some extent, effective in reducing pain to a manageable level. However, since the patient has a complex neuropathic pain syndrome, pharmacological therapy may never be completely effective in total symptom remission. Therefore, using the intervention alongside physical therapy, possible chiropractic care, and heat and massage therapy is essential.

References

Gurba, K. N., & Haroutounian, S. (2022). Antidepressant analgesics in the management of chronic pain. Clinical Pain Management: A Practical Guide, 171-180. https://doi.org/10.1002/9781119701170.ch16

Harden, R. N., McCabe, C. S., Goebel, A., Massey, M., Suvar, T., Grieve, S., & Bruehl, S. (2022). Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition. Pain Medicine (Malden, Mass.), 23(Suppl 1), S1–S53. https://doi.org/10.1093/pm/pnac046

Miller, G. F., Guy, G. P., Zhang, K., Mikosz, C. A., & Xu, L. (2019). Prevalence of Nonopioid and Opioid Prescriptions Among Commercially Insured Patients with Chronic Pain. Pain Medicine (Malden, Mass.), 20(10), 1948–1954. https://doi.org/10.1093/pm/pny247

 Portney, L. G. (2020). Foundations of clinical research: applications to evidence-based practice. FA Davis. https://fadavispt.mhmedical.com/content.aspx?

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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.

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.

Write a 1- to 2-page 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.

Below results from the interactive video

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. 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 1:

Start patient on Savella 12.5 mg once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by 25 mg BID on days 4-7; followed by 50 mg BID thereafter.

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks

Client comes into the office to without crutches but is limping a bit. The client states that the pain is “more manageable since I started taking that drug. I have been able to get around more on my own. The pain is bad in the morning though and gets better throughout the day”. On a pain scale of 1-10; the client states that his pain is currently a 4. When asked what pain level would be tolerable on a daily basis, the client states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.”. When questioned further, you ask what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 4?”. The client states that since using this drug, I can get to a point on most days where I do not need the crutches. ” The client is also asked what would need to happen to get his pain from a current level of 4 to an acceptable level of 3. He states, “If I could get to the point everyday where I do not need the crutches for most of my day, I would be happy.”

Client states that he has noticed that he frequently (over the past 2 weeks) gets bouts of sweating for no apparent reason. He also states that his sleep has “not been so good as of lately.” He does complain of nausea today

Client’s blood pressure and pulse are recorded as 147/92 and 110 respectively. He also admits to experiencing butterflies in his chest. The client denies suicidal/homicidal ideation and is still future oriented

Decision Point 2

Continue with current medication but lower dose to 25 mg twice a day

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Client comes to office today with use of crutches. He states that his current pain is a 7 out of 10. “I do not feel as good as I did last month.”

Client states that he is sleeping at night but woken frequently from pain down his right leg and into his foot

Client’s blood pressure and heart rate recorded today are 124/85 and 87 respectively. He denies any heart palpitations today

Client denies suicidal/homicidal ideation but he is discouraged about the recent slip in his pain management and looks sad

Decision Point 3

Change Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIME

Guidance to Student

The client has a complex neuropathic pain syndrome that may never respond to pain medication. Once that is understood, the next task is to explain to the client that pain level expectations need to be realistic in nature and understand that he will always have some level of pain on a daily basis. The key is to manage it in a manner that allows him to continue his activities of daily living with as little discomfort as possible. Next, it is important to explain that medications are never the final answer but a part of a complex regimen that includes physical therapy, possible chiropractic care, heat and massage therapy, and medications. Savella is a SNRI that also possesses NMDA antagonist activity which helps in producing analgesia at the site of nerve endings. It is specifically marketed for fibromyalgia and has a place in therapy for this gentleman. Tramadol is never a good option along with other opioid type analgesics. Agonists at the Mu receptors does not provide adequate pain control in these types of neuropathic pain syndromes and therefore is never a good idea. It also has addictive properties which can lead to secondary drug abuse. Reductions in Savella can help control side effects but at a cost of uncontrolled pain. It is always a good idea to start with dose reductions during parts of the day that pain is most under control. The addition of Celexa with Savella needs to be done cautiously. Both medications inhibit the reuptake of serotonin and can, therefore, lead to serotonin toxicity or serotonin syndrome.