Decision Tree for Neurological and Musculoskeletal Disorders

Summary of the Clinical Decision Steps

This scenario is about a 43-year-old white man who complains of right-sided hip pain that started seven years ago after a fall at work. Over the past seven-year she has received various workups that have revealed cartilage tears. She has had symptoms such as cooling of the extremity and severe cramping of the extremity. He has been seen by a neurologist and psychiatrist over his symptoms, and various impressions have been made over his presentation. Complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD), was a diagnosis given by his neurologist.

Decision Tree for Neurological and Musculoskeletal Disorders

His mental state examination is unremarkable, and his mood is euthymic, ruling out the possibility of depression as a cause of his pain. Physical inspection showed that he still uses his crutches to walk, has curly right toes, and intermittent cramping and purpling of the right leg. He had tried hydrocodone from his general practitioner, but this did not help with the pain. Therefore, a final diagnosis of complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD), was made (Kessler et al., 2020). This summary paper describes the journey of this patient during his pain management and the justification of the decisions made.

Decision Point #1

In my decision point one, I decided to prescribe amitriptyline 25 mg per oral taken at bedtime. Amitriptyline is commonly used as an antidepressant but can also manage neuropathic pain (Luthi et al., 2019; Urits et al., 2018; Rosenthal & Burchum, 2020). Therefore, I expected to improve the patient’s pain while hoping for fewer side effects. This was to be titrated upwards every week by 25 mg.

After four weeks, the patient returned to the clinic, the pain had improved, but he still used his crutches to walk. He feels a bit groggy in the morning, and his pain scale has improved to 6/10, but the target was 3/10. The patient reports no suicidal or homicidal ideations. At this point, this medication has shown effectiveness in achieving pharmacological and clinical effects. I expected to achieve pain control and reduce the risk of suicidal ideations associated with this medication (Thour & Marwaha, 2022). Fortunately, these goals were achieved, but the former was not achieved optimally.

Decision Point # 2

I decided to retain the medication but increased the dosage to 125 mg NOCTE and instructed the patient to take the dosage an hour earlier before bed. Due to dose increase, the risk of side effects is higher; thus, the patient was also instructed to call the office after three days to report side effects. He returns four weeks later with improvement in the pain to 4/10 – still not achieved the pain target but tolerable. He can ambulate without crutches and no longer feels groggy in the morning. However, he is bothered by the recent 6-pound weight gain and seeks alternative ways to avoid it.

Decision Point # 3

I decided to retain the amitriptyline and its dosage but refer the patient to a life coach for counseling on weight management. This is because the benefits of using this medication have outweighed the side effects and the debilitation due to the pain he had earlier. His current body mass index shows he is not obese, and a reduction in the medication would increase the pain. Therefore, this decision was evidence-based and in the best interest of the patient quality of life. Primary treatment goals were achieved but at the cost of weight problems.

Conclusion

This patient has a complex regional pain disorder that required a multidisciplinary approach in the end. The decision to start amitriptyline was evidence-based and worked to achieve the significant two goals at the beginning – achieve pain control and minimize side effects. Holistic management necessitated the involvement of a life coach to counsel the patient on weight-related issues that resulted from therapy.

References

  • Kessler, A., Yoo, M., & Calisoff, R. (2020). Complex regional pain syndrome: An updated comprehensive review. NeuroRehabilitation47(3), 253–264. https://doi.org/10.3233/NRE-208001
  • Luthi, F., Buchard, P.-A., Cardenas, A., Favre, C., Fédou, M., Foli, M., Savoy, J., Turlan, J.-L., & Konzelmann, M. (2019). Complex regional pain syndrome. Revue medicale suisse15(640), 495–502. https://doi.org/10.1016/j.cps.2019.12.009
  • Rosenthal, L. D., & Burchum, J. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Saunders.
  • Thour, A., & Marwaha, R. (2022). Amitriptyline. In StatPearls [Internet]. StatPearls Publishing.
  • Urits, I., Shen, A. H., Jones, M. R., Viswanath, O., & Kaye, A. D. (2018). Complex regional pain syndrome, current concepts, and treatment options. Current Pain and Headache Reports22(2). https://doi.org/10.1007/s11916-018-0667-7

Decision Tree for Neurological and Musculoskeletal Disorders Instructions

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.