Advanced Pharmacology. 6521.

Assignment: Decision Tree for Neurological and Musculoskeletal Disorders

Complex regional pain disorder

Decision Point 1:

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

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

Select what you should do:

RESULTS OF DECISION POINT ONE

· 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

·  Client returns to clinic in four weeks

·  Client comes into the office 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

DCISION POINT TWO

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

RESULTS OF DECISION POINT TWO

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 THREE

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.

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. Provide at least 3 citations and references in APA. No plagiarism.

RUBRIC

Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. Be specific.	18 (18%) – 20 (20%) 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.	16 (16%) – 17 (17%) The response accurately summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented.	14 (14%) – 15 (15%) The response inaccurately or vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented.	0 (0%) – 13 (13%) The response inaccurately and vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented, or is missing.
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.	23 (23%) – 25 (25%) The response accurately and thoroughly explains in detail how the decisions recommended for the patient case study are supported by the evidence-based literature. The response includes specific and relevant outside reference examples that fully support the explanation provided.	20 (20%) – 22 (22%) The response accurately explains how the decisions recommended for the patient case study are supported by the evidence-based literature. The response includes relevant outside reference examples that lend support for the explanation provided that are accurate.	18 (18%) – 19 (19%) The response inaccurately or vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature. The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided.	0 (0%) – 17 (17%) The response inaccurately and vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature, or is missing. The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing.
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.	18 (18%) – 20 (20%) The response accurately and thorough explains in detail what they were hoping to achieve with the decisions recommend for the patient case study assigned. The response includes specific and relevant outside reference examples that fully support the explanation provided.	16 (16%) – 17 (17%) The response accurately explains what they were hoping to achieve with the decisions recommended for the patient case study assigned. The response includes relevant outside reference examples that lend support for the explanation provided that are accurate.	14 (14%) – 15 (15%) The response inaccurately or vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned. The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided.	0 (0%) – 13 (13%) The response inaccurately and vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned, or is missing. The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing.
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.	18 (18%) – 20 (20%) 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. 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.	16 (16%) – 17 (17%) The response accurately explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. The response provides accurate examples that support whether there were differences between the decisions made and the decisions available in the exercise.	14 (14%) – 15 (15%) The response inaccurately or vaguely explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. The response provides inaccurate or vague examples that may or may not support whether there were differences between the decisions made and the decisions available in the exercise.	0 (0%) – 13 (13%) vaguely 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, or is missing. The response provides inaccurate and vague examples that do not support whether there were differences between the decisions made and the decisions available in the exercise, or is missing.
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.	5 (5%) – 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity.	4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.	3.5 (3.5%) – 3.5 (3.5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.	0 (0%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation	5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors	4 (4%) – 4 (4%) Contains a few (1–2) grammar, spelling, and punctuation errors	3.5 (3.5%) – 3.5 (3.5%) Contains several (3–4) grammar, spelling, and punctuation errors	0 (0%) – 3 (3%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.	5 (5%) – 5 (5%) Uses correct APA format with no errors	4 (4%) – 4 (4%) Contains a few (1–2) APA format errors	3.5 (3.5%) – 3.5 (3.5%) Contains several (3–4) APA format errors	0 (0%) – 3 (3%) Contains many (≥ 5) APA format errors
Total Points: 100

12.5 mg orally once daily on day 1; followed by 12.5 mg BID on day 2 and 3; followed by READINGSdays 4-7; followed by 50 mg BID thereafter

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: