Assignment: NURS 6521 Decision Tree For Neurological And Musculoskeletal

A Sample Answer For the Assignment: Assignment: NURS 6521 Decision Tree for Neurological and Musculoskeletal

Introduction

The most common trigger of dementia in senior individuals, which affects many people worldwide, is Alzheimer’s disease. It is classified as a neurodegenerative condition brought on by the harmful progression of age-dependent cognitive decline. There is accumulation of amyloid plaques made up of abnormal deposits of located in the extracellular brain parenchyma and hippocampus. In AD, neurofibril tangles can also form inside of the neuron.

Alzheimer’s disease is characterized by a progressive memory loss and cognitive abnormalities. The case study of Mr. Akkad, a 76-year-old Iranian man who was brought in by his son, will be covered in this essay. Following a clinical assessment and mini-mental state evaluation, the patient is identified as having a significant neurodegenerative illness caused by Alzheimer’s disease (DementiaCareCentral.com, 2020)

Decision 1 Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2weeks

Rivastigmine is a drug containing a cholinesterase inhibitor with the potential benefit of being pseudo-irreversible. The reversible binding and inactivation of cholinesterase by rivastigmine results in an increase in the level of acetylcholine at cholinergic synapses by blocking acetylcholine’s breakdown. The cholinesterase inhibitor rivastigmine is licensed for use in the treatment of mild to moderate dementia associated with Parkinson’s and Alzheimer’s diseases.

Alzheimer’s disease will develop more slowly as a result of the Exelon. The non-cognitive manifestations of Alzheimer’s disease may be treated with this medication. According to published reports, this medicine improves an Alzheimer’s patient’s cognitive functioning. In the instance of Mr. Akkad, this pharmacological therapy seeks to maximize and uphold the patient’s autonomy, functional capacity, and life quality (Rosenthal & Burchum, 2021).

Struggling to Meet Your Deadline?

Get your assignment on Assignment: NURS 6521 Decision Tree for Neurological and Musculoskeletal done on time by medical experts. Don’t wait – ORDER NOW!

Meet my deadline

In a certain period, the patient will start to show the potential effects of the medication. Exelon will slow the spread of the condition, but the patient won’t notice any effects right away. Therefore, doctors advised patients to report any potential changes in their health within three to six weeks, with or without improvement.

Following the commencement of treatment, doctors should schedule meetings with the patient and family every three to six weeks to assess any changes in cognitive and behavioral issues and to gauge how the patient is responding to the medicine. Mr. Akkad’s patient visited the clinic again after 4 weeks, however there was no improvement in his conduct or cognitive abilities (Kazmierski et al., 2020)

Decision 2 Increase Exelon to 4.5 mg orally BID

The client has returned, and according to his son, neither his father’s cognitive nor behavioral functioning had improved. Additionally, the MMSE test results showed that the drugs’ recommended dosage was not likely to have any positive effects. Mini-mental status examination is a helpful tool for gauging how well a patient is responding to treatment, and family input is crucial for determining the patient’s daily interests.

The second choice is to raise the dosage of rivastigmine in order to reduce symptoms. Exelon lessens the symptoms and slows the disease’s course, although it could take 6 to 8 weeks before memory and behavior start to improve (Kazmierski et al., 2020).

To achieve the best results, the clinical studies advise titrating the Exelon dose to the highest tolerable level. The patient came back with his son after four weeks. According to his son, he is tolerating the medication, attending religious services with family, and everyone is content. One issue is that his dad still finds humor in things that he once found to be serious (Kim et al., 2021).

Decision 3 Maintain current dose of Exelon

The third option is to keep the present dosage of medicine after assessing the condition of the patient by raising the amount in the second choice. Since this patient is responding effectively to the dosage and because there are no negative side effects from this dosage. The patient’s symptoms are reportedly getting better gradually. Behavioral, cognitive, and daily living activity tests have shown that oral Exelon’s effectiveness is dose dependent (Kim et al., 2021).

The suggested course of treatment lessens symptoms while delaying the onset of the illness. It does not, however, completely reverse the disease. Healthcare professionals have a crucial role in educating patients about Alzheimer’s disease, including its signs, problems, treatment options, and positive and negative impacts. They can also help patients and their families find financial and legal resources.

However, it is vital to explain to the client and his kid that this illness is permanent and medications only help to lessen the clinical manifestations and help improve the patient’s cognitive and behavioral functionality. The patient did not report side effects of the medication during the re- visit. Additionally, you have the choice of increasing the dosage or supplementing it with an additional drug such as Namenda (Rosenthal & Burchum, 2021).

Conclusion

In conclusion, there is no therapy option that can offer a long-term solution for Alzheimer’s disease. The patient’s quality of life, ability to do everyday tasks, and cognitive and behavioral capabilities can all be enhanced by prescribed medications and suggested therapy. It is a neurogenerative condition that develops slowly and places a heavy strain on sufferers and family.

In order to reduce the negative impacts of this condition on patients and their families, it is crucial to create appropriate and effective decisions. Making sure patients with it have enough sleep and rest in between stimulating activities and providing a tranquil environment for these individuals are crucial (DementiaCareCentral.com, 2020).

References

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

Kim, B., Noh, G. O., & Kim, K. (2021). Behavioral and psychological symptoms of dementia in patients with Alzheimer’s disease and family caregiver burden: a path analysis. BMC Geriatrics, 21(1), 160.https://doi-org.ezp.waldenulibrary.org/10.1186/s12877-021-02109 w

DementiaCareCentral.com. (2020, October 7). Mini-mental state exam (MMSE) alzheimer’s /dementia test: Administration, accuracy and scoring. Dementia CareCentral.https://www.dementiacarecentral.com/mini-mental-state-exam/.

Kazmierski, J., Messini-Zachou, C., Gkioka, M., & Tsolaki, M. (2018). The impact of a long- term rivastigmine and donepezil treatment on all-cause mortality in patients with Alzheimer’s disease. American Journal of Alzheimer’s Disease & OtherDementias®,33(6), 385-393

NURS6521 Advanced Pharmacology

Alzheimer’s is one of the most common progressive neurological disorders among the elderly caused by dementia. Patients will present with mild to moderate cognitive signs and symptoms at the onset of the disorder, which will progress to severe memory loss with time, as they grow much older (Li et al., 2019).

However, several treatment options have been proven to be effective in the management of Alzheimer’s disorder among the elderly. The purpose of this discussion is to illustrate the decision process in selecting the most effective drug, based on pharmacokinetic and pharmacodynamic factors, for treating an elderly patient diagnosed with Alzheimer’s disease.

Patient Case Study Summary

The assigned case study demonstrates a 76-year-old Iranian male with symptoms of Alzheimer’s disorder. The patient displays strange behavior upon arrival at the clinic reporting symptoms of memory loss, forgetfulness, confusion, and diminished interest in religious activities for the last 2 years.

Pharmacokinetic and pharmacodynamic patient factors which contributed to the selection of drugs for this patient include his advanced age, male gender, Iranian race, and presenting symptoms in addition to the mini-mental exam results of moderate dementia. the patient’s diagnosis of Alzheimer’s disorder will also be considered.

Treatment Decisions

Based on the patient history and the pharmacokinetic and pharmacodynamic factors mentioned above, the most appropriate intervention is to initiate Exelon 1.5mg twice daily. Exelon (rivastigmine) is an FFDA-approved drug for treating mild to moderate Alzheimer’s disease (Fish et al., 2019). Previous studies support great effectiveness, and safety profile for use of the drug among the elderly diagnosed with Alzheimer’s (Khoury et al., 2018).

The second decision was to increase the dose of Exelon to 4.5 mg twice daily as recommended by most clinical practice guidelines for patients who have displayed great tolerance but with minimal effectiveness. The last decision was to increase the dose further to 6mg twice daily, to promote optimal effectiveness as the patient still displayed limited remission of symptoms with the previous intervention.

Expected Outcome

Studies show that Exelon when administered appropriately takes between 8 to 12 weeks to completely manage symptoms of Alzheimer’s among elderly patients. As such, with the initial intervention of 1.5mg Exelon twice daily, the patient was expected to display approximately 50% remission of symptoms (Nguyen et al., 2021). The dose was however to be titrated to obtain the optimum outcome, not exceeding 6mg twice daily. The same results were expected with the second and third interventions with no side effects expected.

Difference Between Expected Outcome and Actual Outcome

Just like expected, the patient displayed a minimal reduction of symptoms of Alzheimer’s with no side effects reported with the first intervention. After the dose was increased in the second intervention, the patient reported further remission of symptoms, but at a slow rate, hence increasing the dose in the last intervention, which led to optimal remission of Alzheimer’s symptoms just as expected (Huang et al., 2020).

Conclusion

Alzheimer’s is a common disorder among the elderly compromising their quality of life and well-being. For the patient in the provided case study, it was necessary to administer Exelon at a starting dose of 1.5 mg which was titrated to 4.5mg then 6.5mg twice daily. The patient displayed great effectiveness with this medication in the management of his Alzheimer’s symptoms, with no side effects reported.

References

Fish, P. V., Steadman, D., Bayle, E. D., & Whiting, P. (2019). New approaches for the treatment of Alzheimer’s disease. Bioorganic & medicinal chemistry letters, 29(2), 125-133. https://doi.org/10.1016/j.bmcl.2018.11.034

Huang, L. K., Chao, S. P., & Hu, C. J. (2020). Clinical trials of new drugs for Alzheimer’s disease. Journal of biomedical science, 27(1), 1-13. https://doi.org/10.1186/s12929-019-0609-7

Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic Advances in Drug Safety, 9(3), 171-178. https://doi.org/10.1177/2042098617750555

Li, D. D., Zhang, Y. H., Zhang, W., & Zhao, P. (2019). Meta-analysis of randomized controlled trials on the efficacy and safety of donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease. Frontiers in neuroscience, 13, 472. https://doi.org/10.3389/fnins.2019.00472

Nguyen, K., Hoffman, H., Chakkamparambil, B., & Grossberg, G. T. (2021). Evaluation of rivastigmine in Alzheimer’s disease. Neurodegenerative Disease Management, 11(1), 35-48. https://doi.org/10.2217/nmt-2020-0052

Week 8 Assignment Decision Tree for Neurological and Musculoskeletal

For your Assignment Assignment NURS 6521 Decision Tree for Neurological and Musculoskeletal , your Instructor will assign you one of the decision tree interactive media pieces provided in the Resources. 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.

Photo Credit: Getty Images/Science Photo Library RF

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.

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment: NURS 6521 Decision Tree for Neurological and Musculoskeletal

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.

Alzheimer Disease

The case study is about a 76-year-old male Iranian patient suspected of having Alzheimer’s disease. The conclusion is reports based on his eldest son, and during the test, there were no organic disease processes found. The behavioral changes began two years earlier, which involved changes in personality and apathy, accompanied by memory loss, which challenges in recognizing the appropriate words.

During the speech, self-reported euthymic mood and clinical interview confabulation are often noticed. The patient often has an impairment and a lack of impulse control in his insight and judgment. There is no reported ideation of suicide, and because of Alzheimer’s disease, the patient is diagnosed with neurocognitive disorder.

Donepezil 5 mg at bedtime will be used as the first approach. The donepezil use has been studied for

assignment nurs 6521 decision tree for neurological and musculoskeletal — Assignment NURS 6521 Decision Tree for Neurological and Musculoskeletal

decades by patients who have Alzheimer’s disease. The medication is an inhibitor of acetylcholinesterase, which raises the brain’s acetylcholine levels also makes up for the reduced cholinergic neurons function (Čolović, Krstić, Lazarević-Pašti, Bondžić, & Vasić, 2013). An evaluation of randomized clinical trials analyzes the effect that donepezil has on Alzheimer’s patients utilizing randomized control trials.

The results revealed that there is evidence that donepezil is effective in managing this condition in three main fields, including behavior, functional capacity, and cognition (Knowles, 2006, pp. 195–219). These are the key areas in which the patient affected as well as the aim was to reduce his quality of life effect. As demonstrated in the case, he had major personality changes that had a negative impact on his involvement in activities of interest.

The effects of Donepezil vary as complications may occur along with minimal clinical benefits. The patient-reported side effects documented in patients taking this medication, like appetite, loss of weight, nausea, vomiting, and diarrhea. (Kumar & Sharma., 2019).

The second decision was cognitive behavioral therapy use, that has been shown to have a beneficial effect in early-stage patients of Alzheimer’s disease. In isolated cases, evidence suggesting psychosocial treatments for dementia patients identified (Forstmeier, Maercker, Savaskan, & Roth, 2015). There is also limited empirical information on such approaches, though. Among patients who have neuropsychiatric symptoms, certain researchers have described behavioral treatments as necessary.

This may also be used by the patient to promote behavior, especially directed at reducing apathy & enhancing the patient’s self-control. Mood improvement might have a positive effect on the quality of life as well as the patient’s ability to engage in activities that increase his cognitive status.

In this case, the third decision will involve family members in the therapeutic process, which will continue to improve behaviors that help the patient. The aim is to improve the patient’s support system and also daily interactions, though it has been shown to have a significant effect on the emotional and cognitive well-being of dementia patients.

References

Čolović, M. B., Krstić, D. Z., Lazarević-Pašti, T. D., Bondžić, A. M., & Vasić, a. V. (2013). Acetylcholinesterase inhibitors: pharmacology and toxicology. Curr Neuropharmacol, 11(3), 315–335. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3648782/

Forstmeier, S., Maercker, A., Savaskan, E., & Roth, a. T. (2015). Cognitive-behavioral treatment for mild Alzheimer’s patients and their caregivers (CBTAC): study protocol for a randomized controlled trial. Trials., 16. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4650298/

Knowles, J. (2006). Donepezil in Alzheimer’s disease: an evidence-based review of its impact on clinical and economic outcomes. Core Evid., 1(3), 195–219. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3321665/

Kumar, A., & Sharma., S. (2019). Donepezil. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK513257/

By Day 7 of Week 8

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.

Goals and Outcomes

The overarching goal was to reduce the patient’s pain levels to an acceptable threshold (around 3 on the scale) and restore his ability to perform daily activities without crutches. The outcomes were remarkably positive; the patient’s pain diminished from a debilitating 9 to a manageable 4. This reduction facilitated enhanced mobility and daily functioning, marking a significant improvement in his overall well-being. Despite minor weight gain, the patient’s improved quality of life underscored the success of the interventions.

Discrepancies Between Expectations and Results

In this case, the outcomes closely mirrored the expectations. The patient experienced a substantial reduction in pain, improved functionality, and minimal side effects, including manageable weight gain. The decisions made successfully struck a delicate balance between therapeutic benefits and potential drawbacks, ensuring the patient’s optimal quality of life. The minor weight gain, while a concern, was overshadowed by the vast improvements in pain control and functionality, aligning with the patient’s stated preferences.

Conclusion

CRPS management necessitates a holistic and individualized approach, integrating evidence-based practices, patient preferences, and vigilant monitoring of outcomes. This case study underscores the pivotal role of healthcare providers in navigating the complexities of CRPS treatment. By employing a comprehensive understanding of available therapies and their potential effects, clinicians can significantly enhance the lives of individuals afflicted with this debilitating condition.

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.

Patient Case Study Summary

Treatment Decisions

Expected Outcome

The dose was however to be titrated to obtain the optimum outcome, not exceeding 6mg twice daily. The same results were expected with the second and third interventions with no side effects expected.

Difference Between Expected Outcome and Actual Outcome

Conclusion

References

Huang, L. K., Chao, S. P., & Hu, C. J. (2020). Clinical trials of new drugs for Alzheimer’s disease. Journal of biomedical science, 27(1), 1-13. https://doi.org/10.1186/s12929-019-0609-7

Multiple sclerosis (MS) is a nervous system disorder affecting the spinal cord and the brain. The myelin sheath is normally destroyed in people diagnosed with MS, slowing down or blocking messages between the body and the brain leading to the associated symptoms. Most people normally start displaying symptoms between the ages of 20 and 40 years (Ferraro et al., 2018).

Such symptoms include muscle weakness, visual disturbances, coordination, and balance problems, numbness, and memory problems among others. However, with appropriate treatment patients’ quality of life and well-being can be improved. The purpose of this paper is to demonstrate appropriate decision-making in selecting the most effective medication for the treatment of a 26-year-old with multiple sclerosis.

Summarize the Patient Case Study

The patient in the provided case study is a 26-year-old female with a diagnosis of multiple sclerosis. She was scheduled for a follow-up appointment with her physician but is still concerned about more knowledge about her MS diagnosis. She also needs to be informed concerning the impact of the disorder on her neurologic and musculoskeletal system in addition to the specific drug therapy plans on which she can decide.

Treatment Decisions

From the available option, the best medication to consider for initial therapy for the patient is 25mg Amitriptyline orally at bedtime. Based on the patient outcome, the drug can be titrated upwards at intervals of 25mg per week, not exceeding 200mg per day. Amitriptyline is a tricyclic antidepressant that has proven to be effective in the management of painful parenthesis in the legs and arms among MS patients (Rae-Grant et al., 2018).

The second intervention was to continue with the same medication and increase the dose to 125mg at bedtime given that the patient displayed a minimal reduction of symptoms but great tolerance to the medication. The last intervention was to continue the same drug and dose, 125mg amitryptiline at bedtime, and advise the patient to see a life coach for counseling on good dietary habits and exercise (Mésidor et al., 2021). This decision was based on the great effectiveness displayed by the drug in the management of the patient’s symptoms, with weight gain as the only side effect.

Expected Outcome

With the use of Amitriptyline 25mg once daily, the patient was expected to display at least 50% remission of symptoms, with common side effects such as nausea, vomiting, headache, and dry mouth (Stankiewicz & Weiner, 2020). These side effects were however expected to diminish with time as the patient continues taking the drug. The dose was expected to be titrated upwards at the rate of 25 mg per week to an optimal dose with complete remission of the patient’s symptoms within 8 to 12 weeks.

Difference Between Expected and Actual Outcome

The patient displayed great effectiveness with the medication just as expected. Her pain level reduced gradually with an increased dose with the optimum dose attained at 125mg orally at bedtime (Stamoula et al., 2021). However, she displayed significant weight gain which was not expected. As such, it was necessary to introduce a life coach to help with lifestyle modification that will help the patient maintain healthy body weight.

Conclusion

Multiple sclerosis is a disabling neurological and musculoskeletal disorder that can be managed by the use of several medications. For the 26-year-old patient in the provided case study, the use of 125mg amitriptyline once daily displayed great effectiveness in the management of the MS symptoms.

References

Ferraro, D., Plantone, D., Morselli, F., Dallari, G., Simone, A. M., Vitetta, F., … & Vollono, C. (2018). Systematic assessment and characterization of chronic pain in multiple sclerosis patients. Neurological Sciences, 39(3), 445-453. https://doi.org/10.1007/s10072-017-3217-x
Mésidor, M., Rousseau, M. C., Duquette, P., & Sylvestre, M. P. (2021). Classification and visualization of longitudinal patterns of medication dose: An application to interferon‐beta‐1a and amitriptyline in patients with multiple sclerosis. Pharmacoepidemiology and drug safety, 30(9), 1214-1223. https://doi.org/10.1002/pds.5297
Rae-Grant, A., Day, G. S., Marrie, R. A., Rabinstein, A., Cree, B. A., Gronseth, G. S., … & Pringsheim, T. (2018). Practice guideline recommendations summary: disease-modifying therapies for adults with multiple sclerosis: report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology, 90(17), 777-788. https://doi.org/10.1212/WNL.0000000000005347
Stamoula, E., Siafis, S., Dardalas, I., Ainatzoglou, A., Matsas, A., Athanasiadis, T., … & Papazisis, G. (2021). Antidepressants on multiple sclerosis: a review of in vitro and in vivo models. Frontiers in Immunology, 12. DOI: 10.3389/fimmu.2021.677879
Stankiewicz, J. M., & Weiner, H. L. (2020). An argument for broad use of high efficacy treatments in early multiple sclerosis. Neurology-Neuroimmunology Neuroinflammation, 7(1). https://doi.org/10.1212/NXI.0000000000000636

The case study concerns a 43-year-old man with a history of chronic pain for several years after sustaining a fall and now ambulates with crutches. He has been referred for a psychiatric evaluation by his family physician after suspecting his pain is psychological, and he has been exaggerating the pain to get a narcotic prescription to get high. He complains of cooling and intense cramping in the right leg. He has been diagnosed with complex regional pain syndrome (CRPS). The purpose of this paper is to explain the interventions for each decision and if they are backed by evidence-based literature.

Decisions Recommended For the Patient Case Study

The first decision was to start Amitriptyline 25 mg PO QHS and increase it by 25 mg every week to a maximum of 200 mg daily. The decision is supported by the study by Shim et al. (2019), which found that Amitriptyline is an effective evidence-based treatment for neuropathic pain disorder and peripheral diabetic neuropathic pain.

In decision two, I maintained Amitriptyline and increased the dose to 125 mg with a maximum target of 200 mg. The patient was to take the medication an hour earlier than usual. Increasing the dose is supported by the article by Eldufani et al. (2020), which recommends slow titration of the Amitriptyline dose if a patient exhibits a positive response to the initial dose. It also recommends taking the bedtime dose an hour earlier to minimize morning sleepiness.

In decision three, I continued Amitriptyline at 125 mg and referred the patient to a life coach for counseling on nutrition and exercise. Weight gain is a documented side effect of Amitriptyline. Brueckle (2020) backs this intervention by asserting that patients on medications associated with weight gain should be counseled on lifestyle modification in diet and exercise for a healthy weight.

What I Was Hoping To Achieve With the Decisions I Recommended For the Patient Case Study

By initiating the patient on Amitriptyline, I hoped it would help improve the client’s mood swings, alleviate pain to 4/10, and ambulate without crutches within four weeks. Komoly (2019) established that Amitriptyline helps alleviate pain and autonomic and motor symptoms in CRPS cases. I hoped that increasing Amitriptyline to 125 mg would alleviate the limb to 3/10, and taking the drug an hour earlier would prevent morning sleepiness.

Taking the medication an hour earlier decreases morning sleepiness (Rosenthal & Burchum, 2021). In decision three, I hoped that referring the client for lifestyle modification counseling would guide him in practicing a healthy lifestyle in dietary and physical exercise habits that would prevent unhealthy weight gain. Aguilar-Latorre et al. (2022) recommend counseling on lifestyle modification to enable patients on TCAs to manage their weight and avoid being overweight/obese.

Difference between What You Expected To Achieve With Each of the Decisions and the Results of the Decision in the Exercise

In the first decision, the pain decreased to a 6/10, and the patient ambulated without crutches. The pain severity was not as anticipated, probably because of the low Amitriptyline dose and duration it takes to have maximum effect. In the second decision, the patient’s pain was reduced to 4/10, comparable to the expected outcome of a pain severity of 3/10.

Conclusion

The PMHNP started the patient on an initial dose of Amitriptyline of 25 mg QHS, which was to be increased by 25 mg weekly to 200 mg. The drug led to a positive response and was increased to 125 mg QHS to improve the patient’s pain. The medication led to weight gain, and the PMHNP referred the client to a life coach for counseling on a healthy lifestyle.

References

Aguilar-Latorre, A., Pérez Algorta, G., Navarro-Guzmán, C., Serrano-Ripoll, M. J., & Oliván-Blázquez, B. (2022). Effectiveness of a lifestyle modification programme in the treatment of depression symptoms in primary care. Frontiers in medicine, 9, 954644. https://doi.org/10.3389/fmed.2022.954644

Brueckle, M. S., Thomas, E. T., Seide, S. E., Pilz, M., Gonzalez-Gonzalez, A. I., Nguyen, T. S., … & Muth, C. (2020). Adverse drug reactions associated with Amitriptyline—protocol for a systematic multiple-indication review and meta-analysis. Systematic reviews, 9(1), 1-8. https://doi.org/10.1186/s13643-020-01296-8

Eldufani, J., Elahmer, N., & Blaise, G. (2020). A medical mystery of complex regional pain syndrome. Heliyon, 6(2), e03329. https://doi.org/10.1016/j.heliyon.2020.e03329

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

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

Shim, H., Rose, J., Halle, S., & Shekane, P. (2019). Complex regional pain syndrome: a narrative review for the practicing clinician. British Journal of Anaesthesia, 123(2), e424–e433. https://doi.org/10.1016/j.bja.2019.03.030

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.

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/10.1155/2021/6656863 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

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

Decision Tree For Neurological And Musculoskeletal Disorders

Alzheimer’s disease is defined as a neurological ailment that begins slowly and worsens with time. This health condition is linked to 70% of dementia cases worldwide (Son et al., 2019). The absence of memory relating to current events is the most common first sign. Other signs of the condition include mood swings, confusion, low self-esteem, linguistic problems, and behavioral abnormalities (Iniesta et al., 2022).

All bodily functions gradually deteriorate, finally leading to death. The important thing to remember is that while Alzheimer’s disease cannot be cured, it may be controlled to improve the patient’s quality of life.

Summary of Case Presentation

The media file case study outlines the examination and treatment of Mr. Akkad, a 76-year-old Iranian geriatric man. His eldest son thought he had strange characteristics and was uninterested in religious activities with his family. Furthermore, the patient forgets things, and confabulation was discovered in his case after numerous memory tests. The patient was given the Mini-Mental State Exam, which revealed scores of 18 out of 30 with primary deficiencies in orientation, recognition, attention, and recollection. The result indicates moderate dementia

I found your post to be very educational and informative! As most are

aware, gestational diabetes mellitus (GDM) is a condition that may develop

in the second half of pregnancy with increased difficulty in achieving optimal

blood glucose control, leading to hyperglycemia affecting the woman and

her baby (Martis et al., 2018). The GDM is defined as carbohydrate

intolerance developing in hyperglycemia or any other degree of glucose

intolerance with onset during pregnancy, around 24 weeks of gestation, and

beyond (Kilby et al., 2020) and usually resolves following the birth of the

child. This definition excludes women with undiagnosed pre‐existing type I

or type II diabetes initially detected during pregnancy screening. The risk

factors are obesity, advanced age, pregnancy weight gain, diabetes family

history and prior history of GDM, overweight baby, or unexplained stillbirth

(Martis et al., 2018). Women from certain ethnicities with an increased risk

of GDM are Asians, African Americans, Native Americans, Hispanics, and

Pacific Islanders (Martis et al., 2018).

The prevalence of GDM increased globally with significant variation

between 2% to 26% depending on the ethnicity and the diagnostic criteria.

The global obesity epidemic is likely to increase the prevalence of GDM and

the recurrence of diagnosis in successive pregnancies in women previously

diagnosed with GDM; thus, GDM is considered a severe public health

concern (Martis et al., 2018).

Treatments may include dietary and exercise modifications,

subcutaneous insulin, oral hypoglycemic agents, dietary supplements or

nutraceuticals, antenatal breast milk expression, induction of labor, or

cesarean section (Martis et al., 2018).

Lifestyle changes include minimal healthy eating, physical activity, and

self‐monitoring of blood sugar levels. Lifestyle modification may have a

positive effect on the birth weight of the baby.

The primary treatment recommendation for women with GDM is

dietary modification, aimed at preventing maternal hyperglycemia and

ensuring the diet with sufficient energy and nutrients for optimal healthy

fetal growth while avoiding an acceleration in growth patterns and

minimizing excessive maternal weight gain. It is recommended for all women

with GDM to see a diabetic specialized dietitian or experienced nutritionist

to determine the appropriate individualized diet, with the inclusion of

cultural preferences (Martis et al., 2018).

Various diets aimed at GDM include low or moderate glycemic index

diets, high fiber diets, low carbohydrate diets or high complex carbohydrate

diets, and low monounsaturated fat diets. Physical exercise is usually

recommended as low‐impact activities, such as walking, swimming,

stationary cycling, or specific exercise classes for pregnant women (Martis et

al., 2018).

Pharmacological hypoglycemic agents may be considered when

glycemic treatment is inefficient. While customarily, this implied

subcutaneous insulin injection, there has been an increased use of

alternative oral pharmacological hypoglycemic agents. The most utilized oral

agents for GDM are sulphonylureas, including glyburide (glibenclamide),

glipizide and glimepiride (second generation), and biguanide (metformin).

Other less used oral hypoglycemic meds are alpha‐glucosidase

inhibitors (acarbose and miglitol), thiazolidinediones (pioglitazone and

rosiglitazone) and meglitinides (repaglinide and nateglinide). Even though the

use of oral pharmacological hypoglycemics is widespread, there are not

licensed for use in several countries during pregnancy, including the USA,

UK, Australia, and New Zealand, because there is a concern that the first‐

generation oral hypoglycemic agents can cross the placenta. The studies

suggest that glyburide (second‐generation sulphonylureas) and biguanide

(metformin) have not demonstrated short‐term harm to the mother or the

developing fetus, yet there is limited information regarding the long‐term

effects of these drugs. Human insulin does not cross the placenta in clinically

significant amounts and therefore is considered safe for the fetus when

administered subcutaneously in pregnancy. The daily multiple subcutaneous

injections may include rapid‐ (lispro, aspart, glulisine), intermediate‐ (NPH),

and long‐acting (glargine and detemir) insulin. The preferred choice is fast‐

acting and intermediate‐acting insulins because there is limited data for

long‐acting insulin in pregnancy (Martis et al., 2018). Also, oral and nasal

insulins are currently under development for their convenience, quick liver

absorption, less weight gain effects, and hypoglycemia (Martis et al.,

2018).

Other interventions for preventing and treating GDM include dietary

supplements and nutraceuticals. Dietary fiber from psyllium has been used

for glucose control and reducing lipid levels in hyperlipidemia. Omega‐3

fatty acids may reduce glucose tolerance for individuals predisposed to

diabetes as insulin is required to synthesize the long-chain n‐3 fatty acids.

The omega‐3 fatty acid docosahexaenoic acid (DHA) involved with

regulating insulin resistance has been suggested for managing GDM. Also,

magnesium, chromium picolinate, calcium, and vitamin D use demonstrated

improvement in insulin sensitivity in non‐diabetic individuals. Additionally, a

co-treatment of cinnamon and extracts of bitter melon might have some

beneficial effects in preventing diabetes (Martis et al., 2018).

References

Kilby, M. D., Johnson, A., & Oepkes, D. (2020). Fetal therapy: Scientific basis

and crucial appraisal of clinical benefits. (2^nd ed.). Cambridge University

Press.

Martis, R., Crowther, C. A., Shepherd, E., Alsweiler, J., Downie, M. R., Brown,

J. (2018). Treatments for women with gestational diabetes mellitus: An

overview of Cochrane systematic reviews. Cochrane Database of

Systematic Review, 8(8). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513179/

Hi Diandra! Your SOAP note is very creative with your outside information you brought in. As I thought about the differential diagnosis you chose I agreed with some and thought others were easily ruled out. This I think is so easy to do when we have to come up with more of the story to collaborate with diagnosis than what was given to us. I thought you did a great job though. There was one diagnosis I thought of that was not listed. I placed it last in my thoughts, it may be worth looking up and seeing what you think.

A differential diagnosis of Soft Tissue Knee Injury is a safe diagnosis that covers many different diagnosis including contusions, sprains, tendonitis, bursitis, stress injuries and strains. Soft tissue damage can lead to pain and swelling as is seen in this case (John Hopkins Medicine, 2020). I agree with this diagnosis as without obvious deformity of bone it is safe to assume that soft tissue damage has occurred.

The diagnosis of Patellar Dislocation is a diagnosis that can be ruled out as the patient is able to straighten the knee and is able to walk. Patient’s history does not show immediate reports of these symptoms after injury. This injury is also frequently caused by a standing injury such as dancing or during sports, not as a fall injury as this patient reports he sustained (NHS Choices, 2019).

Juvenile Idiopathic Arthritis (JIA) is a diagnosis that of a chronic rheumatological condition in children. This diagnosis can be ruled out as this patient is experiencing an acute process following a fall just six days ago. This diagnosis may be one that would be looked at should the patient continue to have trouble walking after six weeks along with other diagnosis such as Leukemia (Thatayatikom & De Leucio, 2020).

Patellar Tendinopathy is a condition caused by overuse and is often found in persons with a history of playing sports that involve jumping such as volleyball and basketball. This diagnosis is not one of inflammatory nature but one of degenerative nature (Figueroa et al., 2016). Although this diagnosis is one involving sports, our patient is a swimmer and does not have repetitive ‘jamming’ motions and is also not caused by an acute fall.

Bursitis is a diagnosis that is also included in Soft Tissue Injury, it may be as a result of direct trauma such as a fall like the patient reports. This diagnosis would have evidence of swelling and inflammation of the bursa sac (Mayo Clinic, 2019). This diagnosis may be appropriate dependent on imaging.

A differential diagnosis that I believe could also be given for this patient is infrapatellar fat pad (IFP) impingement, or Hoffa’s fat pad impingement. This condition involves the anterior knee where the patient has specified pain and can be caused by a direct blow to the knee such as a fall onto the knees. A decrease in ROM can be seen and pain can be elicited by the Hoffa Test. With this diagnosis an MRI can confirm and treatment would begin with taping of the knee to help tilt the patella in order to allow release and relaxation of the fat pad (Dragoo et al., 2012).

References

Dragoo, J. L., Johnson, C., & McConnell, J. (2012). Evaluation and Treatment of Disorders of the Infrapatellar Fat Pad. Sports Medicine, 42(1), 51–67. https://doi.org/10.2165/11595680-000000000-00000

Figueroa, D., Figueroa, F., & Calvo, R. (2016). Patellar Tendinopathy. Journal of the American Academy of Orthopaedic Surgeons, 24(12), e184–e192. https://doi.org/10.5435/jaaos-d-15-00703

John Hopkins Medicine. (2020). Soft-Tissue Injuries. John Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/softtissue-injuries

Mayo Clinic. (2019). Knee bursitis – Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/knee-bursitis/symptoms-causes/syc-20355501

NHS Choices. (2019). Dislocated kneecap. NHS. https://www.nhs.uk/conditions/dislocated-kneecap/

Thatayatikom, A., & De Leucio, A. (2020). Juvenile Idiopathic Arthritis (JIA). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554605/