NURS 6521 Assignment: Decision Tree for Neurological and Musculoskeletal

NURS 6521 Assignment: Decision Tree for Neurological and Musculoskeletal


Complex regional pain syndrome, CRPS presents with dysfunction of extremities, severe pain, contractions, and swelling (Shim, et al., 2019). The cause of the syndrome is either trauma or surgical procedures. CRPS has three clinical stages, the acute, sub-acute, and chronic phases. The acute phase lasts for approximately three months. The sub-acute phase involves symptoms progression up to nine months, and the chronic phase is over one year. CRPS clinical signs and symptoms are severe pain, usually burning in nature, with vasomotor redness that worsens dependency, hyperhidrosis, and coolness to touch. CRPS is a result of central dysregulation of the nociceptive impulses that cause vasoconstriction. The vasoconstriction causes prolonged ischemia that produces more pain. It also builds a reflex arch that promotes further sympathetic firing and vasospasm. The result is a painful, swollen, and non-functional extremity. Chronic CRPS is the accurate diagnosis for this patient because he presents with severe crampi

NURS 6521 Assignment Decision Tree for Neurological and Musculoskeletal

NURS 6521 Assignment Decision Tree for Neurological and Musculoskeletal

ng of the toes, cooling of extremities, and inability to use the limbs. The patient has suffered pain for seven years. He has a positive history of trauma on his right hip where he sustained a 75% cartilage tear. The patient also has mild depressive mood disorder because he has been presenting with low mood since the onset of the disease, loss of his source of income, and separation from his fiancée. He has been on hydrocodone, which he takes sparingly due to the side effects. Hydrocodone is an opioid used in the treatment of pain. It is also an antitussive used to treat cough in adults. However, the patient does not fully comply with treatment due to its adverse effects such as anxiety, drowsiness, fatigue, and shortness of breath.

The three decisions made in the treatment for this include; Savella, Amitriptyline, and Neurontin. Savella treats depression and complex regional pain syndromes. It is a serotonin and norepinephrine reuptake inhibitor whose effects on regulates dysfunctional noradrenergic and serotonin pathways thus reducing the vasoconstriction that contributes to pain (Zou, et al., 2018). Savella is well tolerated compared to amitriptyline and hydrocodone. In addition to that, it has no side effects compared to the other two drugs.

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Amitriptyline is a tricyclic antidepressant that blocks both serotonin and norepinephrine neurotransmitters. It is

NURS 6521 Assignment Decision Tree for Neurological and Musculoskeletal

NURS 6521 Assignment Decision Tree for Neurological and Musculoskeletal

FDA approved for a major depressive mood disorder. In addition, it is an off-label drug for post-traumatic stress disorder and CRPS. Amitriptyline achieves its therapeutic effects four to six after the initial drug administration. Amitriptyline is not the drug of choice for this patient because of its adverse effects such as hypotension, dizziness, weight gain, and increased risk for bone fractures (Meshalkina, et al., 2018). Neurontin is a GABA mimetic agent that binds to the subunit of voltage-gated calcium channels (Moore, et al., 2018). It is FDA approved for the treatment of convulsive disorders. It is an off-label opioid therapy for neuropathic pain. It is effective in the treatment of CPRS. It has beneficial effects on insomnia, fatigue, depression, and quality of life. However, it relieves 50 % of the pain and has a high chance of addition. Therefore, it is not the drug of choice for this patient because he will not experience worthwhile pain relief. Savella is the drug of choice. The desired effects are to relieve pain and improve the depressive mood.


Meshalkina, D. A., Kysil, E. V., Antonova, K. A., Demin, K. A., Kolesnikova, T. O., Khatsko, S. L., … & Kalueff, A. V. (2018). The effects of chronic amitriptyline on zebrafish behavior and monoamine neurochemistry. Neurochemical research, 43(6), 1191-1199.

Moore, A., Derry, S., & Wiffen, P. (2018). Gabapentin for chronic neuropathic pain. Jama, 319(8), 818-819.

Shim, H., Rose, J., Halle, S., & Shekane, P. (2019). Complex regional pain syndrome: a narrative review for the practising clinician. British journal of anaesthesia, 123(2), e424-e433.

Zou, C. X., Becker, J. E., Phillips, A. T., Garritano, J. M., Krumholz, H. M., Miller, J. E., & Ross, J. S. (2018). Registration, results reporting, and publication bias of clinical trials supporting FDA approval of neuropsychiatric drugs before and after FDAAA: a retrospective cohort study. Trials, 19(1), 1-11.

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).


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.


Fish, P. V., Steadman, D., Bayle, E. D., & Whiting, P. (2019). New approaches for the treatment of Alzheimer’s disease. Bioorganic & medicinal chemistry letters29(2), 125-133.

Huang, L. K., Chao, S. P., & Hu, C. J. (2020). Clinical trials of new drugs for Alzheimer’s disease. Journal of biomedical science27(1), 1-13.

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 Safety9(3), 171-178.

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 neuroscience13, 472.

Nguyen, K., Hoffman, H., Chakkamparambil, B., & Grossberg, G. T. (2021). Evaluation of rivastigmine in Alzheimer’s disease. Neurodegenerative Disease Management11(1), 35-48.