Decision Tree for Neurological and Musculoskeletal Disorders
The patient’s chief complaint is pain. The onset of the pain presents with purpling of the leg and curled toes. The pain lasts for approximately two minutes before it subsides. According to him, his family doctor believes that the problem is psychological and referred him for psychiatric evaluation. The patient attributes the pain to a fall he sustained seven years ago. Past diagnostic tests done four years ago revealed that three-quarters of the cartilage covering his right hip was torn. Thereafter, the patient reports that he has experienced multifaceted symptoms ranging from cool extremities to severe cramping. According to him, he was diagnosed with a complex regional pain disorder and referred to his family doctor for management. However, the family doctor ruled out the diagnosis and referred the patient for psychiatric review. Currently, the patient is taking hydrocodone but reports non-adherence due to drowsiness, constipation, and limited pain control. Mental examination reveals that the patient is oriented to place and time, has an organized speech and thought process, has a euthymic mood, and lacks suicidal ideations.
I made three sequential decisions for the patient. I believe that these decisions are backed by evidence. Firstly, I initiated Savella 12.5 mg on the first day, increased the dosing frequency to twice daily on the second and third day, and increased the dose to 25 mg twice daily from day four to seven, followed by 50 mg twice daily after that. Savella is used to manage fibromyalgia (Gupta et al., 2021). This is relevant because the patient has musculoskeletal pain. Additionally, initiation of the drug is accomplished via sequential titration. Secondly, I discontinued Savella and initiated Zoloft 50 mg daily. This is relevant because Zoloft can be used to manage neuropathic pain (Szok et al., 2019). Additionally, it would reduce the incidence of elevated blood pressure, pulse rate, perspiration, and nausea caused by Savella. Thirdly, I increased the dose of Zoloft to 100mg daily and added 150 mg of Wellbutrin XL every morning. I added Wellbutrin to manage erectile dysfunction caused by Zoloft and to control neuropathic pain (Rothmore, 2020).
My first decision point aims to manage the patient’s pain. Savella is a serotonin and norepinephrine reuptake inhibitor that is indicated for the management of fibromyalgia (Siracusa et al., 2021). Fibromyalgia presents with diffuse musculoskeletal pain (Siracusa et al., 2021). As such, Savella would help to manage the patient’s severe cramping. The second decision point aimed at addressing Savella’s side effects (elevated blood pressure and pulse, nausea, and perspiration) (Siracusa et al., 2021). Also, Zoloft is used in the management of neuropathic pain (Szok et al., 2019). As such, this decision point would provide pertinent analgesia for the patient and control side effects. The third decision point is aimed at increasing medication adherence. Counselling would enable the patient to cope with Zoloft-induced anxiety and erectile dysfunction. Rothmore (2020) reports that Wellbutrin is a dopamine reuptake inhibitor used to manage Zoloft-induced erectile dysfunction and to manage neuropathic pain.
The outcomes of the first decision point are consistent with the initial expectation. In this context, the patient reported that his pain has been manageable since he started taking Savella. However, this medication elevated the patient’s blood pressure, causing nausea and unexpected perspiration. The outcomes of the second decision point are consistent with the expected outcomes. His blood pressure and pulse have normalized, and he denies nausea and perspiration. Also, the patient notes that the severity of pain in his right leg has reduced.
References
Gupta, H., Girma, B., Jenkins, J. S., Kaufman, S. E., Lee, C. A., & Kaye, A. D. (2021). Milnacipran for the Treatment of Fibromyalgia. Health Psychology Research, 9(1), 1–13. https://doi.org/10.52965/001C.25532
Rothmore, J. (2020). Antidepressant-induced sexual dysfunction. Medical Journal of Australia, 212(7), 329–334. https://doi.org/10.5694/mja2.50522
Siracusa, R., Di Paola, R., Cuzzocrea, S., & Impellizzeri, D. (2021). Fibromyalgia: Pathogenesis, mechanisms, diagnosis and treatment options update. In International Journal of Molecular Sciences (Vol. 22, Issue 8). https://doi.org/10.3390/ijms22083891
Szok, D., Tajti, J., Nyári, A., & Vécsei, L. (2019). Therapeutic Approaches for Peripheral and Central Neuropathic Pain. Behavioural Neurology, 2019. https://doi.org/10.1155/2019/8685954
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Question 
To Prepare
Review the interactive media piece assigned by your Instructor
Walden University, LLC. (Producer). (2019e). Complex regional pain disorder Links to an external site. Links to an external site. Links to an external site.[Interactive media file]. Baltimore, MD: Author.
http://cdn-media.waldenu.edu/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_07/index.html
Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
Decision Tree for Neurological and Musculoskeletal Disorders
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.
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.
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.
Decision 1 – Savella 12.5mg once daily on day 1…….
Decision 2 – Discontinue Savella and start Zoloft 50mg daily
Decision 3 – Increase the dose of Zoloft to 100mg po day. Add on Wellbutrin…..