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Decision Tree for Neurological and Musculoskeletal Disorders...

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Assignment: Decision Tree for Neurological and Musculoskeletal Disorders

Mary Hampton Walden University NURS 6521: Advanced Pharmacology Dr. Austin Resop, PharmD January 21, 2021

2 Assignment: Decision Tree for Neurological and Musculoskeletal Disorders

Case Summary

3 In this paper I will discuss the case of a 43 year old male that complains of persistent right hip pain after sustaining a fall at work. He has had numerous diagnostic tests done. 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. 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, pull off his shoe, and show 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.

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Decision Point 1 For decision point 1, I prescribe the patient amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day. First‐line therapy of neuropathic pain consists of tricyclic antidepressants (TCA) like amitriptyline (Eijs et al., 2010). The client returns to the office still using crutches. The client states that he is able to go to the bathroom and kitchen without using crutches all of the time. He states that his pain has improved, but that he is groggy in the morning. He has a pain level of 6/10 and states that a pain level of 3/10 would be acceptable. He has no suicidal/homicidal ideations.

. Decision Point 2 I decided to continue with the amitriptyline and increased the dose to 125 mg at bedtime, continuing towards the goal dose of 200 mg daily. Antihistamine side effects secondary to its H1 receptor binding property include sedation, increased appetite, weight gain, confusion, and delirium (Thour, 2020). I also instruct the client to take the medication an hour earlier than normal beginning tonight and to call the office in 3 days to follow up on his grogginess. Upon the 3 day follow up call, the client reports that changing the administration time helped and reports that his pain is 4/10, currently taking 125 mg daily at bedtime. However, the client states that he has gained 5 pounds since starting this medication. The client also reported a decrease in the amount of cramping and that he is able to ambulate around his apartment without crutches. The client states that the weight bothers him a lot and wants to know if there is a way to avoid it.

Decision Point 3

5 I decided to continue with the amitriptyline 125 mg at bedtime, continuing towards the goal dose of 200 mg daily and refer the client to a life coach for counseling on good dietary habits and exercise. Utilization of antidepressants may contribute to long term increased risk of weight gain. The potential for weight gain should be considered when antidepressant treatment is indicated (Gafoor, Booth, & Gulliford, 2018).

Summary Since this patient is very near to his pain control goal I would not decrease the dose of amitriptyline. Weight gain is a well-known side effect of this medication. Reducing the dose of the medication may have an effect on the weight gain, but may have detrimental effects to the patient in respect to his pain level. The risk is not worth the benefit. This patient would benefit most from good dietary and exercise habits for weight gain prevention. This patient will most likely reach his pain control level as the dosage of amitriptyline is increased to the goal dose of 200 mg per day. I was hoping to achieve the patient’s acceptable pain level goal of 3/10. I was not able to achieve the goal during the short time that this patient was observed, but believe that it will be achieved in the next few weeks as the dosage of amitriptyline is increased.

References

Eijs, F. V., Stanton-Hicks, M., Zundert, J. V., Faber, C. G., Lubenow, T. R., Mekhail, N., . . . Huygen, F. (2010). 16. Complex Regional Pain Syndrome. Pain Practice, 11(1), 70-87. doi:10.1111/j.1533-2500.2010.00388.x

6 Gafoor, R., Booth, H., & Gulliford, M. (2018, May 23). Antidepressant utilisation and incidence of weight gain during 10 years' follow-up: Population based cohort study. Retrieved January 21, 2021, from https://www.bmj.com/content/361/bmj.k1951.abstract

Thour, A. (2020, November 29). Amitriptyline. Retrieved January 21, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK537225/...