Deep-Seated Injury: Hip Pain, Leg Cramping and Claw Toe

Severe hip pain, episodic leg cramping of the legs and claw toe points at a possible deep-seated injury to the nerves. With all the previous different diagnosis, it is important for the doctor to carry out another x-ray to understand the impact of the injury on the nerves. Assessing the medicines, dosages, and medical history will also be necessary for medication reconciliation. Never the less, based on the current cases study, it is important to understand the client's mental conditions. By examining the case study: A Caucasian Man with Hip Pain, the paper posits that the client's mental condition is attributed to the physical pain and emotional pain he is undergoing.

Savella

Savella is then brand name for Milnacipran. Milnacipran or Savella is a norepinephrine reuptake inhibitor mainly used to treat fibromyalgia. It is informally used to treat major depressive disorders but it has not been approved for that use in some countries. it has often been used to treat a number neuropathic pain especially the chronic pain because it blocks the reuptake pump of serotonin and norepinephrine while boosting the neurotransmitters such as the serotonin and dopamine (Laureate Education, 2016). The client is depressed and has chronic episodic pain which means that the medical intervention should focus on preventing episodes of depression and reducing the pain in the extremities such as the legs (Drugs.com., 2019). Savella is the first line of choice for pain and depression management because its interanion with the serotonin causes an anti-depression effect while its interaction with the norepinephrine helps in reducing the chronic pain at the hips, and episodic cramping in the legs. However, it is contraindicated for people who might experience adverse side effects suchness headache, lack of sleep, anorexia, constipation and in some cases, seizure. The right dosages for the Savella are 100 mg/day. Its peak plasma concentration is in 36 hours. The drug is only eliminated through urine.

Amitriptyline (Elavil)

Elavil is the main tricyclic antidepressant (TCA) in this case and is mainly used to treat patients with fibromyalgia and neuropathic pain. However, it was also approved for the treatment of other unestablished causes of depression. The pharmacodynamics of the Elavil include blocking serotonin production and preventing the reuptake of norepinephrine by interfering with the pumps responsible for pumping the two. The drug has an anticholinergic effect that is why it is the second drug of choice in this case. However, its role in sedating the patient makes it a less preferred drug because the patient already voiced his concern about the drug making him loopy, sleepy and constipated. Other adverse medical reactions include heartburn, weight gain, sedation, dizziness, fatigue, weakness, headache, and anxiety (Drugs.com., 2019). Never the less, suicidal ideation is a major side effect that should be taken into consideration whenever prescript the drug to a patient. The right dosage is between 50mg to 200mb bd.

Gabapentin (Neurontin)

Neurontin is the primary anticonvulsant that can be used in this case because of its antineuralgic properties. It is also useful for treating seizures anxiety, neuropathic pain, and RLS. The drug's mechanism of action includes inhibiting the influx of calcium and prevent the release of the excitatory neurotransmitter (Frettloh, Huppe & Maier, 2006). The absorption rate of the drug is slow after oral administration and can reach its peak plasma concentration within 3 hours of administration (Gerhardt, Eich, Treede & Tesarz, 2017). One of the main advantages of the drug is its absolute bioavailability which remains at more than 90%. the drug does not readily bind to the plasma protein. the recommended dosage for the neuropathic pain is of 450 mg/day. The drug is preferred for its better pharmacodynamic effect.

Decision Point 1

Out of the three options of Savella, Amitriptyline, and Neurontin, the most preferred option is the Amitriptyline at 25 mg, titrating by an additional 25 mg until a dose of 200 mg a day is achieved. The option is chosen because the drug has proven efficacy against Complex regional pain syndrome (CRPS) which is the chronic pain that arises after an injury of the legs of hips (Frettloh, Huppe & Maier, 2006). The drug is also preferred because its side effects are less adverse as compared to the other two options. For example, the side effects of another drug such as dizziness, and loopiness will also be effectively combated by the drugs. The main reason for not recommended Savella as the first option is that it is still not approved to be used for treating CRPS while in this case, the patient was suffering from depression CRPS. On the other hand, Neurontin is not advisable because it is less effective in pain management. To balance between pain reduction and reducing drowsiness, it is important to take a drug that improves on the two. Therefore, amitriptyline is chosen because it does not cause dizziness and improves on the episodic pain.

Decision Point 2

The second option is to help reduces the side effect of current medicine. Therefore, the patient will be encouraged to continue taking the drug he is taking by reduce the dosages he in Elavil. This way, the side effect of the drug will be significantly reduced while the same effect on pain management will remain. Upping his dosage to 200mg/day will help reduce the pain (National Institute of Neurological Disorders and Stroke, 2016). The drowsiness is mainly attributed to the time he takes the drugs. he can start taking his drug at least 2 hours earlier every day as the onset of the grogginess is when the drug reaches the peak plasma concentration. By taking the drug earlier, the effect can be felt when he is still within the confines of his home (McCloughen, & Foster, 2011). I did not select the other two options because the client's main issue is pain and therefore introducing another drug will result in more side effect and more interaction between drug (Stahl, Muntner & Ball, 2013). Secondly, it will be premature to reduce the dose of Elavil because it has not shown its full potential and reducing the dose will reduce or stop the groggy feeling with no pain relief. Even though the dosage will be effective in reducing pain, the patient will possibly experience weight gain, he can deal with the weight gain as an isolated case through weight management, physical exercise, and dietary regime.

Decision Point 3

The third option is advising the client to continue with Elavil 125mg/day but add other drugs for weight loss. For example, using a drug such as Qsymia can help the patient reduce weight associated with Elavil (Finkelstein, Kruger & Karnawat, 2014). With Qsymia introduced, the client can continue taking the same dosage as before without faring weight gain. In addition to the drug, the client should be referred to as a nutritional specialist or a life coach to help him manage his depression and diet. The two drugs will help the patient achieve the optimal quality of health as he shall have improved on weight, reduced depression and pain (Stahl, 2013). According to Stahl (2014), the client returned to the clinic in four weeks, the client is not groggy anymore and current pain level is 4 out of 10 and is able to get around his apartment without the use of crutches. However, the client is concern about a weight gain of 5 pounds and wonder if that could be avoided.

Impact of Ethical Consideration on Treatment Plan

Considering the client's gender, the general societal pressure to be a man, the client may be hiding a lot from his history. Therefore, when developing a care plan, it is important to understand the possibility of some other underlying causative factors to his depression that should be addressed. Probably, issues such as marriage, family, and joblessness are the main factors that should also be addressed (Stahl, Muntner, & Ball, 2013). As a Psychiatric-mental health nurse practitioner (PMHNP), I would recommend weekly meetings to discuss other issues that might have a bearing on the client's condition.

Conclusion

The clients psychiatric and mental health needs should be given primacy even though the pain is episodic. Addressing the physical pains alone will not adequately address the client's problems, in the long run, it is, therefore, important to take into consideration the whole person including his mental, emotional, spiritual and physical needs and problems. Talking to the client might help expose some other underlying problems that might not be visible to the physical eye. Additionally, when prescribing drugs, the Psychiatric-mental health nurse practitioner (PMHNP) has adequately compared the effectiveness and efficacy of the drug as well as the side effects of the drug. The drug interaction has also been taken into consideration when choosing the drug of choice.

Reference

Drugs.com. (2019). Amitriptyline - Search results. Page 1 of about 12233 results. Retrieved from https://www.drugs.com/search.php?searchterm=Amitriptyline

Finkelstein, E., Kruger, E., & Karnawat, S. (2014). Cost-Effectiveness Analysis of Qsymia for Weight Loss. Pharmacoeconomics, 33(7), 699-706. doi: 10.1007/s40273-014-0182-6

Frettloh, J., Huppe, M., & Maier, C. (2006). Severity and specificity of neglect-like symptoms in patients with complex regional pain syndrome (CRPS) compared to chronic limb pain of other origins. Pain, 124(1), 184-189. doi: 10.1016/j.pain.2006.04.010

Gerhardt, A., Eich, W., Treede, R., & Tesarz, J. (2017). Conditioned pain modulation in patients with nonspecific chronic back pain with chronic local pain, chronic widespread pain, and fibromyalgia. PAIN, 158(3), 430-439. doi: 10.1097/j.pain.0000000000000777

Laureate Education. (2016). Case study: White Male with hip pain [Interactive media file]. Baltimore, MD: Author.

McCloughen, A., & Foster, K. (2011). Weight gain associated with taking psychotropic medication: an integrative review. International Journal of Mental Health Nursing, 20(3), 202-222. doi: 10.1111/j.1447-0349.2010.00721.x

National Institute of Neurological Disorders and Stroke. (2016). Pain: Hope through research. Retrieved from http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#3084_2

Stahl, S. M. (2013). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

Stahl, S. M. (2014b). The prescriber's guide (5th ed.). New York, NY: Cambridge University Press.

Stahl, S.M., Muntner, N., & Ball, S. (2013). Chronic Pain and Fibromyalgia. Cambridge University Press.