Decision Tree for Neurologic and Musculoskeletal Disorders

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Assignment
Write a 1- to 2-page summary paper that addresses the following:
• Briefly summarize the patient case study, including each of the three decisions you chose for the patient presented. Support your decisions with evidence-based literature. Be specific and provide examples.
• What were you hoping to achieve with the decisions you recommended for the patient case study? Support your response with evidence and references from outside resources. Decision Tree for Neurologic and Musculoskeletal Disorders
• 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.
Use and cite at least 4 SOURCES / REFERENCES for the assignment.
Please discuss each medication option listed in Decision Point 1. Why did you not chose the alternative options? What is the mechanism of action for each medication? What are first line FDA approved medications for the disease state?
CASE STUDY/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 One
Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max
RESULTS OF DECISION POINT ONE
•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
Continue current medication and increase dose to 125 mg at BEDTIME this week continuing towards the goal dose of 200 mg daily. Instruct the client to take the medication an hour earlier than normal starting tonight and call the office in 3 days to report how his function is in the morning

RESULTS OF DECISION POINT TWO
• Client returns to clinic in four weeks
• The change in administration time seemed to help. The client states he is not as groggy in the morning and is able to start his day sooner than before
•Client\’s current pain level is a 4 out of 10. He states that he is now taking 125 mg of amitriptyline at bedtime.
•Client\’s has noticed that he is putting on a little weight. When asked, the client states that he has gained 5 pounds since he started taking this medication. He currently weighs in at 162 pounds. He is 5’ 7”. He states that his right leg doesn’t bother him nearly as much as it used to and his toes have only “cramped up” twice in the past month. He states that he is able to get around his apartment without his crutches and that he has even started seeing someone he met at the grocery store. The weight gain seems to bother him a lot and he is asking if there is a way to avoid it
Decision Point Three
Continue the current dose of Elavil of 125 mg per day, refer the client to a life coach who can counsel him on good dietary habits and exercise
Guidance to Student
At this point, the client is almost at his goal pain control and increased functionality. Weight gain is a common side effect with amitriptyline and should be a counseling point at the initiation of therapy. He has a small weight gain of 5 pounds in 8 weeks. A reduction in dose may have an effect on the weight gain but at a considerable cost of pain to the client. This would not be in the best interest of the client at this point. Amitriptyline has a side effect of cardiac arrhythmias. He is not experiencing this at this point. The drug, qsymia contains a product called phentermine which has a history of causing cardiac arrhythmias at higher doses. This product is also only approved for a client with obesity defined as a BMI greater than 30 kg/m2. Your client’s BMI is currently 25.5 kg/m2. He does not meet the definition of obesity but is considered overweight. His best course of action would be to continue the same dose of Elavil, counsel him on good dietary and exercise habits and connect him with a life coach who will help him with this problem in a more meaningful way than a 10 minute counseling session will be able to accomplish. Decision Tree for Neurologic and Musculoskeletal Disorders

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Decision Tree for Neurological and Musculoskeletal Disorders

Introduction

Complex regional pain syndrome (CRPS) refers to the chronic pain lasting for over six months and affecting one leg or the arm. CRPS normally develops after an injury but the pain is normally very severe when compared to the initial injury (Shim et al., 2019). The pain normally indicates an injury or damage to the central nervous or peripheral system. Symptoms of CRPS include focal autonomic, sensory, and motor abnormalities. CRPS is characterized by pain, cutaneous vasomotor changes, trophic abnormalities, motor abnormalities, and psychological distress (Shim et al., 2019).

Case Study Summary

The client, a 43-year-old male presented using crutches for ambulation, with the chief complaint of pain. The family referred him for mental assessment because the doctor did not believe the pain was real. According to the client, the pain started about 7 years ago after a fall that tore his right hip joint. Since then, the client has been experiencing a strange constellation of symptoms such as severe cramping or cooling of the extremity. A neurologist once diagnosed him with CRPS. The symptoms of CRPS for this client include chronic pain, the leg changes to purple from the knee, a visible cramp on the foot, and erratic folding of the foot. The assessment indicates that the client is oriented to place, person, event, and time. He is suitably dressed, future-oriented and his mood is euthymic, indicating a normal mental state.

Diagnosis

Complex regional pain disorder (reflex sympathetic dystrophy)

Decision Point One

The first decision is to administer the client with Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a maximum dose. Amitriptyline was selected because it is a tricyclic antidepressant used in treating chronic neuropathic pain caused by nerve damage (Moore et al., 2015). Therefore, this medication would relieve the pain the client is experiencing. The other options were not selected because the client’s pain is due to neuropathic pain and the traditional analgesics and opioids are not effective in treating neuropathic pain (Cisewski & Motov, 2018).

The results of the first decision indicated that after starting Amitriptyline, there was a notable improvement as the pain score dropped from 9/10 to 6/10. However, the client reported drowsiness, a common side effect of Amitriptyline. The client also reported that with the medication he was able to go to the kitchen and bathroom without using crutches, achiness reduced, and the curling of the toes reduced. This was due to the efficacy of Amitriptyline in treating neuropathic pain (Moore et al., 2015).

Decision Point Two

The second decision is for the client to continue with Amitriptyline and increase the dose to 125 mg at BEDTIME and continue titrating upwards. The dose is being titrated upwards because the client is responding to the treatment and also, he reported minimal side effects, indicating that he is tolerating the medication. The client will be instructed to take the medication at bedtime due to its sedative properties (Kamble et al., 2017). The client will be reviewed after 4 weeks.

The results of the second decision indicated significant symptom remission as the pain score further reduced to 4. The client’s mobility also improved and the toe cramping reduced. The improvement is attributable to the efficacy of Amitriptyline in treating neuropathic pain (Moore et al., 2015). The client also reported that he was no longer feeling unsteady. This is attributable to the medication being administered at bedtime. However, the client reported significant weight gain since he began taking Amitriptyline. The weight gain is among the common side effects of Amitriptyline (Wharton et al., 2018).

Decision Point Three

The third decision is for the client to continue with the current dose of Amitriptyline 125 mg per day and refer him to a life coach to be counseling regarding exercise and good dietary habits. With the current dose, the pain has been controlled adequately and thus the dose should be maintained. The exercises and diet modifications will help the client to lose weight and this addresses the issue of weight gain.

Conclusion

The first decision is to administer the client with Amitriptyline 25 mg. Amitriptyline is effective in treating chronic neuropathic pain caused by nerve damage and therefore it is expected that the medication would be effective in reducing the pain for the client. The second decision is for the client to continue with Amitriptyline and increase the dose to 125 mg at BEDTIME. The pain score reduced to 3 and thus the third decision is to maintain the current dose of Amitriptyline 125 mg and refer the client to a life coach for counseling on exercise and good dietary habits.

READING/RESOURCES

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 6, “Vital Signs and Pain Assessment”
This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.
Chapter 18, “Abdomen”
In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 3, “Abdominal Pain”
This chapter outlines how to collect a focused history on abdominal pain. This is followed by what to look for in a physical examination in order to make an accurate diagnosis.

Chapter 10, “Constipation”
The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests.

Chapter 12, “Diarrhea”
In this chapter, the authors focus on diagnosing the cause of diarrhea. The chapter includes questions to ask patients about the condition, things to look for in a physical exam, and suggested laboratory or diagnostic studies to perform.

Chapter 29, “Rectal Pain, Itching, and Bleeding”
This chapter focuses on how to diagnose rectal bleeding and pain. It includes a table containing possible diagnoses, the accompanying physical signs, and suggested diagnostic studies. Decision Tree for Neurologic and Musculoskeletal Disorders

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

These sections below explain the procedural knowledge needed to perform gastrointestinal procedures.

Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)

Chapter 115, “X-Ray Interpretation of Abdomen” (pp. 514–520)

Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

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RUBRIC

The response accurately and thoroughly summarizes in detail the patient case study assigned, including specific and complete details on each of the three decisions made for the patient presented.
The response accurately and thoroughly explains in detail how the decisions recommended for the patient case study are supported by the evidence-based literature.
“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.”
The response includes specific and relevant outside reference examples that fully support the explanation provided.
The response accurately and thorough explains in detail what they were hoping to achieve with the decisions recommend for the patient case study assigned.
“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.”
The response includes specific and relevant outside reference examples that fully support the explanation provided.
The response accurately and clearly explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise.
“Explain any difference between what you expected to achieve with each of the decisions and the results of the decisions in the exercise. Describe whether they were different. Be specific and provide examples.”
The response provides specific, accurate, and relevant examples that fully support whether there were differences between the decisions made and the decisions available in the exercise.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance.

Decision Tree for Neurologic and Musculoskeletal Disorders