DECISION TREE FOR NEUROLOGICAL AND MUSCULOSKELETAL DISORDERS
Order Instructions
Reminder: All papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center offers an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm Links to an external site.). All papers submitted must use this formatting.
DECISION TREE FOR NEUROLOGICAL AND MUSCULOSKELETAL DISORDERS
For your Assignment, 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.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
LEARNING RESOURCES
Required Readings
• Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
o Chapter 11, “Basic Principles of Neuropharmacology” (pp. 67–71)
o Chapter 12, “Physiology of the Peripheral Nervous System” (pp. 72–81)
o Chapter 12, “Muscarinic Agonists and Cholinesterase Inhibitors” (pp. 82–89)
o Chapter 14, “Muscarinic Antagonists” (pp. 90-98)
o Chapter 15, “Adrenergic Agonists” (pp. 99–107)
o Chapter 16, “Adrenergic Antagonists” (pp. 108–119)
o Chapter 17, “Indirect-Acting Antiadrenergic Agents” (pp. 120–124)
o Chapter 18, “Introduction to Central Nervous System Pharmacology” (pp. 125–126)
o Chapter 19, “Drugs for Parkinson Disease” (pp. 127–142)
o Chapter 20, “Drugs for Alzheimer Disease” (pp. 159–166)
o Chapter 21, “Drugs for Seizure Disorders” (pp. 150–170)
o Chapter 22, “Drugs for Muscle Spasm and Spasticity” (pp. 171–178)
o Chapter 24, “Opioid Analgesics, Opioid Antagonists, and Nonopioid Centrally Acting Analgesics” (pp. 183–194)
o Chapter 59, “Drug Therapy of Rheumatoid Arthritis” (pp. 513–527)
o Chapter 60, “Drug Therapy of Gout” (pp. 528–536)
o Chapter 61, “Drugs Affecting Calcium Levels and Bone Mineralization” (pp. 537–556)
• American Academy of Family Physicians. (2019). Dementia Links to an external site.. Retrieved from http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=5
This website provides information relating to the diagnosis, treatment, and patient education of dementia. It also presents information on complications and special cases of dementia.
• Linn, B. S., Mahvan, T., Smith, B. E. Y., Oung, A. B., Aschenbrenner, H., & Berg, J. M. (2020). Tips and tools for safe opioid prescribing: This review–with tables summarizing opioid options, dosing considerations, and recommendations for tapering–will help you provide rigorous Tx for noncancer pain while ensuring patient safety Links to an external site.. Journal of Family Practice, 69(6), 280–292.
• Document: Mid-Term Summary & Study Guide (PDF)Download Mid-Term Summary & Study Guide (PDF)
Required Media
• Walden University, LLC. (Producer). (2019b). Alzheimer’s disease Links to an external site.[Interactive media file]. Baltimore, MD: Author.
In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat Alzheimer’s disease.
• Walden University, LLC. (Producer). (2019e). Complex regional pain disorder Links to an external site.[Interactive media file]. Baltimore, MD: Author.
In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat complex regional pain disorders.
Disorders of The Nervous System
• Reflect on the comprehensive review of disorders of the nervous system and think about how you might recommend or prescribe pharmacotherapeutics to treat these disorders. (15m)
• Speed Pharmacology. (2019). Drugs for Parkinson’s Disease (Made Easy) Links to an external site.[Video]. https://www.youtube.com/watch?v=Z84iypHdftQ&t=13s
Note: This media program is approximately 9 minutes.
• Speed Pharmacology. (2019). Pharmacology- Drugs for Alzheimer’s Disease (Made Easy) Links to an external site.[Video]. https://www.youtube.com/watch?v=euzRPrvrwj0&t=31s
Note: This media program is approximately 7 minutes.
To Prepare:
• Review the interactive media piece assigned. (Walden University, LLC. (Producer). (2019b). Alzheimer’s disease Links to an external site.[Interactive media file]. Baltimore, MD: Author.) – DECISION POINTs One-Two-Three are all done and its located below.
• 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 an ESSAY of 2-page summary paper that addresses the following:
1. Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
a. Review the interactive media piece assigned. (Walden University, LLC. (Producer). (2019b). Alzheimer’s disease Links to an external site.[Interactive media file]. Baltimore, MD: Author.) – DECISION POINTs One-Two-Three are all done and its located below.
2. 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.
3. 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.
4. 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 STUDY CASE
BACKGROUND
Alzheimer’s Disease
76-year-old Iranian Male
Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including CT-scan of the head) were normal.
According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”
Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficult “finding the right words” in a conversation and then will shift to an entirely different line of conversation.
SUBJECTIVE
During the clinical interview, Mr. Akkad is pleasant, cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so you perform a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia.
MENTAL STATUS EXAM
Mr. Akkad is 76 year old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear, coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic. Self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh]. Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When you asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.
Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)
RESOURCES
§ Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources.
Review the interactive media piece assigned. (Walden University, LLC. (Producer). (2019b). Alzheimer’s disease Links to an external site.[Interactive media file]. Baltimore, MD: Author.) – DECISION POINTs One-Two-Three are all done and its located below.
Alzheimer’s Disease
76-year-old Iranian Male
Decision Point One
: Begin Aricept (donepezil) 5 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
• Client returns to clinic in four weeks
• The client is accompanied by his son who reports that his father is “no better” from this medication
• He reports that his father is still disinterested in attending religious services/activities, and continues to exhibit disinhibited behaviors
• You continue to note confabulation and decide to administer the MMSE again. Mr. Akkad again scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall
Decision Point Two
Increase Aricept to 10 mg orally at BEDTIME
RESULTS OF DECISION POINT TWO
• Client returns to clinic in four weeks
• Client’s son reports that the client is tolerating the medication well, but is still concerned that his father is no better
• He states that his father is attending religious services with the family, which the son and the rest of the family is happy about. He reports that his father is still easily amused by things he once found serious
Decision Point Three
Continue Aricept 10 mg orally at BEDTIME
Guidance to Student
At this point, it would be prudent to continue Aricept at 10 mg orally at bedtime. Recall that this medication can take several months before stabilization of deterioration is noted. At this point, the client is attending religious services with the family, which has made the family happy. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that you should review with the son.
There is no evidence that Aricept given at doses greater than 10 mg per day has any therapeutic benefit. It can, however, cause side effects. Increasing to 15 and 20 mg per day would not be appropriate.
There is nothing in the clinical presentation to suggest that the Aricept should be discontinued. Whereas it may be appropriate to add Namenda to the current drug profile, there is no need to discontinue Aricept. In fact, NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease. The key to using both medications is slow titration upward toward therapeutic doses to minimize negative side effects.
Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.
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