NRNP 6540 Week 2 Assignment: Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression
Alzheimer’s Dementia Discussion Example
Nurses and other care providers play vital roles in patient assessment, diagnosis, and management. They utilize clinical findings and additional studies, such as laboratory tests and imaging studies to provide more accurate diagnoses. Alzheimer’s disease and frontotemporal dementia are neurogenerative disorders with similar clinical manifestations but different pathophysiology. This essay focuses on a patient who presents with cognitive changes and is diagnosed with Alzheimer’s disease.
Alzheimer’s Disease and Frontotemporal Dementia Pathophysiology
Alzheimer’s is a neurodegenerative disease with a complex etiology and whose brain changes are irreversible, a vital factor in the disease’s management. The condition stems from changes in the brain caused by cholinergic dysfunction, amyloid/tau toxicity, and oxidative stress/mitochondrial dysfunction (Thakur et al., 2018). These etiologies lead to the progressive deposition of beta-amyloid plaques and neurofibrillary tangles.
These changes interfere with neuronal activity and conduction, leading to brain death in affected areas hence their characteristic brain lesions. The condition is progressive and begins with a decline in cognitive function, and the accumulation of toxic tau proteins causes brain atrophy and inflammation, leading to death.
Frontotemporal dementia is a neurodegenerative disease involving the anterior and temporal brain lobes. In contrast, Alzheimer’s disease begins in the entorhinal cortex and hippocampus and progresses to the cerebral cortex and many other brain regions in later stages. Khan and De Jesus (2022) note that the condition results from the formation of protein aggregates that cause neuronal degeneration.
These proteins differ from Alzheimer’s and include DNA-binding protein TDP-43, microtubule-associated tau proteins, and tumor-associated protein fused in sarcoma. The location of the lesions is also different, and so are some of the clinical presentations depending on the affected areas (Goldman & Van Deerlin, 2018). Alzheimer’s disease also begins in individuals above 60 years, while frontotemporal dementia onset is in earlier years, between 40 and 70.
Clinical Findings from the Case That Supports a Diagnosis of Alzheimer’s Disease.
An Alzheimer’s diagnosis is based on clinical findings, primarily clinical presentations. According to Thakur et al. (2018), patients with Alzheimer’s often present with progressive memory loss, forgetting the names of people and directions. The patient wandered after getting lost in a neighborhood he had lived in for 35 years, which is alarming.
Alzheimer’s patients are also easily irritated and agitated, and these characteristics are often visible when they deny their presentations, as it is with the patient in this case study. The patient also has a positive history of Alzheimer’s disease. According to Cannon-Albright et al. (2019), individuals with a positive family history of Alzheimer’s have a 40-50% chance of getting the disease. The MRI scan reveals hippocampal atrophy, and the Mini-Mental Status Exam shows moderate dementia and clinical signs of Alzheimer’s disease.
A Hypothesis that Explains the Development of Alzheimer’s Disease
The disease stems from changes in the brain caused by “cholinergic dysfunction, amyloid/tau toxicity, and oxidative stress/mitochondrial dysfunction, as mentioned earlier” (Thakur et al., 2018). In oxidative stress/mitochondrial dysfunction, the culprits are reactive oxygen and nitrogen species produced during normal and abnormal mitochondrial activities. The species are responsible for various signaling pathways (normal functions) and have destructive functions, destroying lipids, DNA, and cellular membrane structures (Thakur et al., 2018).
The brain is the largest oxygen consumer and is more prone to oxidative stress than all other tissues. The brain is made of neurons made of fat cells, and reactive oxygen species lead to lipid peroxidation reaction, thus molecular apoptosis. Oxidative stress also promotes Aβ deposition, and tau hyperphosphorylation, leading to the loss of neurons and synapses, which are vital in Alzheimer’s development (Teixeira et al., 2019). Thakur et al. (2018) also note that a glutathione deficiency propagates neuronal injury.
Patient’s likely stage of Alzheimer’s disease.
Alzheimer’s disease is classified into three stages based on clinical findings. The states are “pre-clinical stage, Early-stage Alzheimer’s (mild), Middle-stage Alzheimer’s (moderate), and Late-stage Alzheimer’s (severe)” (Parnetti et al., 2019). The pre-clinical stage occurs when brain changes occur without any clinical manifestations. The early-stage Alzheimer stage is associated with independence, despite the memory loss manifestations.
The symptoms may not be severe but are apparent to the doctor and family members who raise concerns. The next stage is Middle-stage Alzheimer’s (moderate): the patient in the case study is in this stage. The stage is characterized by marked changes in behavior and memory, accompanied by anger, frustration, irritability, agitation, and denial of the symptoms (Parnetti et al., 2019).
The individual progressively loses the ability to perform daily activities and often needs help to achieve them. The patient’s wife expresses a need to employ a primary caregiver to cater to her husband’s needs while she is at work. The last stage is late-stage Alzheimers, characterized by extensive brain damage with marked behavioral, motor, and cognitive function changes. It is the final stage in which patients require round-the-clock observation and assistance.
Conclusion
Alzheimer’s is a neurogenerative irreversible disorder that begins with marked cognitive changes such as memory loss. The disease differs from frontotemporal dementia based on the location of lesions (affected areas), proteins, and disease progression. Patients develop behavioral problems such as wandering and forgetting people and routes despite using such routes for long periods. The progressive degeneration leads to a self-care deficit and inability to perform activities of daily living, warranting assistance. Nurses should perform extensive assessments and utilize other clinical findings for definitive diagnosis and proper treatment.
References
Cannon-Albright, L. A., Foster, N. L., Schliep, K., Farnham, J. M., Teerlink, C. C., Kaddas, H., Tschanz, J., Corcoran, C., & Kauwe, J. S. (2019). Relative risk for Alzheimer’s disease based on complete family history. Neurology, 92(15), e1745-e1753. https://doi.org/10.1212/WNL.0000000000007231
Goldman, J. S., & Van Deerlin, V. M. (2018). Alzheimer’s disease and frontotemporal dementia: the current state of genetics and genetic testing since the advent of next-generation sequencing. Molecular Diagnosis & Therapy, 22(5), 505-513. https://doi.org/10.1007/s40291-018-0347-7
Khan, I., & De Jesus, O. (2022). Frontotemporal lobe dementia. In StatPearls [Internet]. StatPearls Publishing.
Parnetti, L., Chipi, E., Salvadori, N., D’Andrea, K., & Eusebi, P. (2019). Prevalence and risk of progression of pre-clinical Alzheimer’s disease stages: a systematic review and meta-analysis. Alzheimer’s Research & Therapy, 11(1), 1-13. https://doi.org/10.1186/s13195-018-0459-7
Teixeira, J. P., de Castro, A. A., Soares, F. V., da Cunha, E. F., & Ramalho, T. C. (2019). Future therapeutic perspectives into the Alzheimer’s disease targeting the oxidative stress hypothesis. Molecules, 24(23), 4410. https://doi.org/10.3390/molecules24234410
Thakur, A. K., Kamboj, P., Goswami, K., & Ahuja, K. (2018). Pathophysiology and management of Alzheimer’s disease: An overview. Journal of Analytical & Pharmaceutical Research, 7(1). https://doi.org/10.15406/japlr.2018.07.00230
NRNP 6540 Week 2: Psychosocial Disorders
In so many countries, to be old is shameful; to be mentally ill as well as old is doubly shameful. In so many countries, people with elderly relatives who are also mentally ill are ashamed and try to hide what they see as a disgrace on the family.
”Dr. Nori Graham, Psychiatrist and Honorary Vice President of Alzheimer’s Disease International
In this quote, Dr. Graham is expressing her observations and experiences in her work with numerous international organizations. Many patients and their families experience feelings of anxiety and shame upon receiving a diagnosis of dementia, delirium, or depression. Among caregivers, 36% report having tried to hide the dementia diagnosis of their family member (Alzheimer’s Disease International, 2019). As an advanced practice nurse providing care to patients presenting with dementia, delirium, and depression, it is critically important to consider the impact of these disorders on patients, caregivers, and their families. A thorough understanding of the health implications of these disorders, as well as each patient’s personal concerns, will aid you in making effective treatment and management decisions.
This week, you explore geriatric patient presentations of dementia, delirium, and depression. You also examine assessment, diagnosis, and treatment for these disorders and complete a SOAP (subjective, objective, assessment, and plan) note.
Reference:
Alzheimer’s Disease International. (2019). World Alzheimer report 2019: Attitudes to dementia. Author. https://www.alz.co.uk/research/world-report-2019
Learning Objectives
Students will:
Evaluate patients presenting with symptoms of dementia, delirium, or depression
Develop differential diagnoses for patients with psychosocial disorders
Develop appropriate treatment plans, including diagnostics and laboratory orders, for patients with psychosocial disorders
Learning Resources
Required Readings (click to expand/reduce)
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Psychosocial disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 428–469). F. A. Davis.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Appendix B: Laboratory values in the older adult. In Advanced practice nursing in the care of older adults (2nd ed., pp. 505-506). F. A. Davis.
Note: See the labs that are relevant to this week’s topics.
Laske, R. A., & Stephens, B. A. (2018). Confusion states: Sorting out delirium, dementia, and depression. Nursing Made Incredibly Easy!, 16(6), 13-16. https://doi.org/10.1097/01.NME.0000546254.38666.1f
NIH National Institute on Aging. (2017). Basics of Alzheimer’s disease and dementia: What is Alzheimer’s disease? [Multimedia file]. https://www.nia.nih.gov/health/what-alzheimers-disease
Document: Focused SOAP Note Template (Word Document)
Required Media (click to expand/reduce)
Hartford Institute for Geriatric Nursing. (2013, September 24). Elder mistreatment assessment [Video]. YouTube. https://youtu.be/L8jzycu0eTo
Note: The approximate length of this media piece is 39 minutes.
Recommended Media (click to expand/reduce)
Engage-IL (Producer). (2017f). Dementia: Patient-centered dementia care—understanding patient and caregiver expectations [Video]. https://engageil.com/modules/patient-centered-dementia-care-understanding-patient-and-caregiver-experiences/
Note: View the Dementia: Patient-centered Dementia Care” Understanding Patient and Caregiver Experiences video module available in this free course.
Engage-IL (Producer). (2017g). Depression and delirium of the older adult [Video]. https://engageil.com/modules/depression-and-delirium-of-the-older-adult/
Note: View the Depression and Delirium of the Older Adult video module available in this free course.
Engage-IL (Producer). (2017k). Elder abuse and self-neglect [Video]. https://engageil.com/health-professional-ce/psychosocial-needs/elder-abuse/
Note: View the Elder Abuse and Self-Neglect video module available in this free course.
Engage-IL (Producer). (2017z). Sleep quality of the older adult [Video]. https://engageil.com/modules/sleep-quality-of-the-older-adult/
Note: View the Sleep Quality of the Older Adult video module available in this free course.
Assignment: Assessing, Diagnosing, and Treating Dementia, Delirium, and Depression
Photo Credit: Getty Images
With the prevalence of dementia, delirium, and depression in the growing geriatric population, you will likely care for elderly patients with these disorders. While many symptoms of dementia, delirium, and depression are similar, it is important that you are able to identify those that are different and properly diagnose patients. A diagnosis of one of these disorders is often difficult for patients and their families. In your role as an advanced practice nurse, you must help patients and their families manage the disorder by facilitating necessary treatments, assessments, and follow-up care.
To prepare:
Review the case study provided by your Instructor. Reflect on the way the patient presented in the case, including whether the patient might be presenting with dementia, delirium, or depression.
Reflect on the patient’s symptoms and aspects of disorders that may be present. What distinct symptoms or factors would lead you to a diagnosis of dementia, delirium, or depression?
Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? How would you interpret and address the results of the Mini-Mental State Examination (MMSE)?
Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting.
By Day 7
Submit your Assignment.
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Click the Week 2 Assignment Rubric to review the Grading Criteria for the Assignment.
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If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.
Case Study: Week 2 Case 2 (Alzheimer’s )
Dela Cruz, Dedic, Famador, Finefrock, Fritcher, Gallik, Gelegdorj, Go, Joseph, Kabir, Lopez
Ms. Washington is a 67-year-old African American female who is brought to your office by her daughter with concerns about “forgetfulness.” She has lived with her daughter for 4 years now, and her daughter reports noticing she asks the same questions even after they have been answered. She even reports her mom getting lost in Walmart recently. Ms. Washington has lived with her daughter since losing her husband of 57 years about 4 years ago. Her daughter states her mother is a retired teacher and usually very astute but notices more forgetfulness.
According to Ms. Washington’s daughter, Angela, her mom has been demonstrating increased forgetfulness of more recent things but can easily recall historical moments and events. She also reports that sometimes her mom has difficulty “finding the right words” in a conversation and then will shift to an entirely different line of conversation. She also said her mother will “laugh off” things when she forgets important appointments and/or becomes upset or critical of others who try to point these things out.
Note: Be sure to review the Mini-Mental State Exam (MMSE) and how to interpret the results. Use the MMSE in the attached document to determine the patient’s MMSE score in the video. Make sure you document the patient’s score in your SOAP note document: Mental State Assessment Tests.
Ms. Washington is a 67-year-old female who is alert and cooperative with today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert and oriented to person, partially oriented to place, but is disoriented to time and place. (She reported that she thought was headed to work but “wound up here,” referring to your office, at which point she begins to laugh it off.) She denies any falls or pain.
All other Review of System and Physical Exam findings are negative other than stated.
PMH: Hypertension, Hyperlipidemia, Osteoporosis
Allergies: Penicillin, Lisinopril
Medications:
- Amlodipine 10mg daily
- HCTZ 12.5mg daily
- Multivitamin daily
- Atorvastatin 40mg daily
- Alendronate 70mg orally once a week
Social History: As stated in the Case Study
ROS: As stated in the Case study
Diagnostics/Assessments done:
- CXR—no cardiopulmonary findings. WNL
- CT head—diffuse Cerebral Atrophy
- MMSE—Ms. Washington scores 18 out of 30 with primary deficits in orientation, registration, attention and calculation, and recall. The score suggests moderate dementia.
To prepare:
- Review the case study provided by your Instructor. Reflect on the way the patient presented in the case, including whether the patient might be presenting with dementia, delirium, or depression.
- Reflect on the patient’s symptoms and aspects of disorders that may be present. What distinct symptoms or factors would lead you to a diagnosis of dementia, delirium, or depression?
- Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
- Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
- Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
- Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? How would you interpret and address the results of the Mini-Mental State Examination (MMSE)?
- Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
- Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references.
Mild Neurocognitive Disorder due to Alzheimer’s Disease Example 2
Alzheimer’s disease is the most common neurodegenerative condition in older adults above 65 years. While the slow deterioration of cognition is the key sign of Alzheimer’s disease, it is equally critical to establish actual evidence of cognitive decline (Bello-Lepe et al., 2020). Doctors accomplish this by documenting an individual’s family history, genetic testing, or identifying progressive cognitive decline using periodic standardized neuropsychological examinations. DSM–V diagnostic criteria for mild neurocognitive disorder due to Alzheimer’s disease require meeting the criteria for a mild neurocognitive disorder: an insidious process with gradual progression of at least one of the cognitive domains; meeting the criteria for possible or probable Alzheimer’s disease; and lack of evidence of mixed etiology such as substance abuse or neurocognitive disorder.
The risk assessment tools informing clinical decisions include the General Practioner Assessment of Cognition (GPCOG) for cognitive function determination, Mini-Mental State Examination (MMSE), Alzheimer’s Disease Assessment Scale – cognitive section (ADAS –cog), and activities of daily living (ADL). A Clinical Practice Guideline from the American College of Physicians exists to inform the management of the condition and other FDA recommendations. The paper addresses drug prescription and pharmacologic interventions for Alzheimer’s disease in older adults.
Alzheimer’s Disease FDA-Approved Drug
Aducanumab is currently the only FDA–approved disease-modifying drug for the management of Alzheimer’s disease. The drug is indicated for Alzheimer’s patients with mild dementia or mild cognitive impairment (Silvestro et al., 2022). Aducanumab is an IgG1 monoclonal antibody that crosses the Blood-Brain Barrier to bind to the beta-amyloid protein, reducing the amyloid plaques. The FDA recommends administering the drug as an intravenous infusion over one hour monthly. Doses are titrated upwards after every two infusions with the target of 10mg/kg from the seventh infusion onwards. Aducanumab received an accelerated FDA approval, and some physicians consider its use controversial. Amyloid Related Imaging Abnormalities (ARIA)- inflammation is a common risk with an incidence of 35% during the pre-clinical trials. The EMERGE trial showed that Aducanumab met its primary result of amyloid reduction with benefits on behavior, cognition, and memory. Therefore, there is a need to individualize care for each Alzheimer’s patient by considering the risks against the benefits.
Off – Label Drug for Alzheimer’s disease
Antipsychotics, mood stabilizers, and antidepressants are the commonly used off-label drugs for Alzheimer’s disease. Quetiapine is widely used to manage psychosis and insomnia in dementia patients (Müller et al., 2020). Alzheimer’s patients frequently have sleep disturbances characterized by agitated behavior and increased nocturnal wakefulness. A dose of 50 to 150mg of quetiapine causes a significant decrease in aggression, delusions, and overall patient behavior. The downside is that quetiapine poses a risk of cognitive deterioration, worsening the primary condition. Alternatively, short-term use of risperidone is approved by the Pharmaceutical Benefits Scheme for psychotic symptoms in Alzheimer’s patients.
Non-Pharmacological Management of Alzheimer’s Disease
Some Alzheimer’s disease patients adopt complementary medicine as adjunct or mainstay therapy to delay cognitive decline and improve activities of daily living. Acupuncture is a commonly used non-pharmacological intervention, with clinical studies reporting improvement in cognitive impairment and memory as beneficial effects (Wang et al., 2020). Additionally, it reduces depression risk among the patients and delays disease progression. Acupuncture acts by stimulation of acupoints, causing the increased cholinergic release and reduced amyloid and apoptotic factors. However, unlike drug therapy, the duration of treatment does not modify the condition. Acupuncture single-use may not have higher benefits on global cognition than pharmacologic interventions; therefore, combination therapy is indicated.
Conclusion
Alzheimer’s disease is a common neurocognitive disorder among older adults. The condition is progressive, varying from mild to moderate to severe. It is vital to individualize patient care as side effects and disease presentation varies from person to person. Risk assessment tools are essential in gauging the effectiveness of an intervention and informing the next management step. A combination of pharmacologic and nonpharmacologic intervention proves to have additive benefits.
References
Bello-Lepe, S., Alonso-Sánchez, M. F., Ortega, A., Gaete, M., Veliz, M., Lira, J., & Salas, C. P. P. (2020). Montreal cognitive assessment as a screening measure for mild and major neurocognitive disorder in a Chilean population. Dementia and Geriatric Cognitive Disorders Extra, 10(3), 105-114. https://doi.org/10.1159/000506280
Müller, L., Noseda, R., Bertoli, R., Bissig, M., & Ceschi, A. (2020). Off‐label use of quetiapine in nursing homes: Does medical specialty of prescribing physicians play a role? British Journal of Clinical Pharmacology, 86(7), 1444. https://dx.doi.org/10.1111%2Fbcp.14232
Silvestro, S., Valeri, A., & Mazzon, E. (2022). Aducanumab and Its Effects on Tau Pathology: Is This the Turning Point of Amyloid Hypothesis? International Journal of Molecular Sciences, 23(4), 2011. https://doi.org/10.3390/ijms23042011
Wang, Y. Y., Yu, S. F., Xue, H. Y., Li, Y., Zhao, C., & Jin, Y. H. (2020). Effectiveness and safety of acupuncture for the treatment of Alzheimer’s disease: a systematic review and meta-analysis. Frontiers in Aging Neuroscience, 12, 98. https://doi.org/10.3389/fnagi.2020.00098
NRNP 6540 Week 4 Head Neck and Face Case Study
A 76-year-old woman presents today with complaints of nasal drainage, clearing of throat, and occasional nasal congestion, especially on waking in the morning. She has recently moved into an independent living center after living in her home for 40 years. She states that, although she has had these symptoms before, generally, the symptoms appeared in the spring, and she associated the nasal drainage with pollination. Because it is winter, she could not identify the trigger of her symptoms.
Chief complaint: Persistent “runny nose” for the 3-week duration, associated clearing of the throat and nasal congestion on awakening in the morning.
Objective data: Blood pressure (BP) 130/84, temperature 98.6, pulse 78, respiratory rate 20.
What further ROS questions will you want to ask her? List at least three.
What physical exam (PE) will you perform on this patient? List at least three.
What are the differential diagnoses that you are considering? Describe at least four.
What laboratory tests will help you rule out some of the differential diagnoses?
You have determined, by choosing your ROS, PE, and differential diagnosis, that this patient has allergic rhinitis (AR).
Describe the treatment options for your diagnosis, and what specific information about the prescription will you give to this patient?
List at least two treatment options: medications with dose, side effects, and/or cautions in the older adult.
When will you have the patient follow-up? Be specific.
NOTE: Write a focused SOAP note for this case. Choose the ROS, PE, and medications you will use in your SOAP note. Be creative, but do not deviate from the main points of the case study.
Focused SOAP Note Template Example
Patient Information:
GM, 79, Male, White
Subjective: Patient resting in bed quietly, endorses right flank pain, denies nausea/vomiting, or fever.
CC (chief complaint): Patient presents to hospital with right flank pain.
HPI: Patient is a 79 year old male with PMH of AFIB, HTN, HLD, and urinary retention that presents to the hospital with right flank pain. The right flank pain wraps around to the right upper quadrant, patient describes as a dull aching. This pain has been progressing over the last 2-3 days. Patient had nausea and 1-2 episodes of emesis. No fever, chills, diarrhea. Pain started while feeding cattle and has progressively worsened. Patient has taken Tylenol without relief in symptoms. Patient rates pain 10/10.
Current Medications:
- Eliquis 2.5mg PO BID, AFIB
- Aspirin 81mg PO QD, CHF
- Ancef 1G IV Q12H, UTI
- Colace 100mg PO QD, constipation
- Lasix 20mg PO QD, CHF
- Normal Saline 0.9 IV continous 100ml/hr, hydration
- Dilaudid 0.5mg IV q2h PRN, PAIN
- Melatonin 5mg PO PRN nightly, sleep
- Zofran 4mg PO q6h PRN, nausea
- Senna 8.6mg PO BID PRN, constipation
Allergies:
- Tamsulosin – hives
PMHx:
- AFIB
- CHF
- Closed nondisplaced fracture of third metacarpal bone of right hand
- Constipation
- Hypertension
- Mixed Hyperlipidemia
- Traumatic Compression fracture of T9 vertebra
Vaccines
- Tdap 2022
- PPSV23 2022
- FLU 9/1/23
- COVID negative
Soc and Substance Hx: Patient is a cattle farmer and raises them for meat. Patient still currently works on his own farm. Tobacco use: No, Alcohol use: Occasional mixed drink, Substance abuse: No. Patient always uses his seatbelt, has no issues obtaining food, medications, or making it to appointments. Patient lives at home with his wife. Close support from children.
Fam Hx:
- Heart Attack, Father
Surgical Hx:
- Bilateral Cataract Extraction
- Colonoscopy 2014
- Cardiac Ablation 04/2023
- Hernia Repair
- Kidney Surgery
- Prostate Surgery
- EGD 2014
- Wrist Surgery
Mental Hx: No history of anxiety/depression. No history of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Patient feels safe in home and relationships.
Reproductive Hx: Not currently sexually active
ROS: Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: Shortness of breath, no cough, or sputum.
GASTROINTESTINAL: No anorexia or diarrhea. Nausea and vomiting. No abdominal pain or blood.
GENITOURINARY: No burning on urination. Chronic foley catheter.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness. Right flank pain.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
Objective: BP 113/65, HR 90, Temp 98.9, RR 18, SpO2 94%
Physical exam:
General Appearance: Alert, acutely ill appearing, in mild acute distress
HEENT: Head normocephalic, Eyes-EOMI, sclera anicteric, Throat mucus membranes moist
Cardiovascular: regular rate and rhythm, normal S1, S2, no murmurs, rubs, clicks, gallops, peripheral edema absent
Respiratory: lungs clear to auscultation, without wheezes rales, or rhonchi, on nasal cannula 3L
Abdomen: soft, non-tender, right CVA tenderness, right upper quadrant pain, mildly distended
Genitourinary: chronic foley catheter in place
Neurological: oriented x3, normal speech, no focal findings or movement disorders noted
Musculoskeletal: no significant deformity, or tenderness to palpitation
Skin: normal coloration
Psych: Normal mood and affect
Diagnostic results:
Na 127
Creatinine 1.69
WBC 12.07
Urinalysis: Moderate blood, positive nitrates, large leukocyte esterase, WBC 69, RBC 12, Bacteria few, WBC clumps rare, Mucus rare
Urine Culture: Negative Bacilli
Blood Cultures: Pending
US Abdomen 9/16: No gallstones. Right hydronephrosis.
Chest X-Ray 9/17:
- Lungs: Pulmonary vascular congestion and interstitial prominence has developed. Mild hazy opacities of left perihilar region and right lung base. No definite effusion. No evidence of pneumothorax.
- Heart/mediastinum: Stable contours. Stable enlargement of cardiac silhouette.
- Bones: No acute bony abnormality.
- Impression: Findings are suspicious for pulmonary edema pattern versus mild CHF decompensation. Infiltrate is a secondary consideration.
CT Kidney Stone 9/15:
- Impression:
- Massive right chronic hydronephrosis and hydronephrotic sac, stable, presumably related to chronic UPJ stenosis. However, perinephric fluid is present on today’s examination, suggesting ascending urinary tract infection.
- Short-segment circumferential thickening consistent at hepatic flexure at the distal ascending and proximal transverse colon without secondary bowel obstruction. These findings are likely secondary to inflammation from adjacent ascending urinary tract infection.
- Normal appendix. No adenopathy.
- No urinary tract calculi or hydronephrosis.
- Severe pectus excavatum deformity.
Assessment:
Primary Diagnosis: Right pyelonephritis with hydronephrosis, acute UTI
Secondary Diagnosis: CHF exacerbation due to fluid overload
Differential Diagnoses:
- Cholelithiasis/Cholecystitis: Due to location of pain in right flank and nausea, vomiting this is a potential diagnosis. This was ruled out by abdominal ultrasound (Cleveland Clinic, 2023).
- Renal colic due to kidney stone: Patient presented with flank pain and CVA tenderness. This was ruled out by CT Kidney stone. No stones found on CT (Time of Care, 2023).
- Shingles: shingles can cause deep nerve pain and is often found on the trunk of the body. This was ruled out due to the patient not having a rash (Keck Medicine of USC, 2020).
Plan.
Right pyelonephritis with hydronephrosis/Acute UTI
- CT Kidney Stone-massive right chronic hydronephrosis and hydronephrotic sac, related to chronic UPJ stenosis. Perinephric fluid present suggesting ascending UTI. US abdomen: No gallstones, right hydronephrosis, known UPJ obstruction.
- Consult Urology
- Rocephin started in ER, changed to Ancef 2G q12h (Diaz-Brochero, et al., 2022).
- Pain Management PRN
- UA- Large leukocytes, positive nitrates
- Urine Culture: Negative Bacilli
- Blood Culture Pending
- Care Management
Leukocytosis
- WBC 13.04>10.9
- Trend CBC
- No fevers
Chronic Kidney Disease
- Creatinine 1.62>1.6
- Baseline 1.7
- IV hydration-stopped due to fluid overload
Hyponatremia
- Na 127>128>122
- Monitor
Chronic AFIB s/p ablation 4/13/23
- Continue Eliquis
- Rate Controlled
- Keep K+>4, Mag >2
Hypertension Hyperlipidemia
- No current home medications
- Continue to monitor
HFrEF-CHF
- BNP-pending
- Echo 1/25/23 EF 67%
- Change Lasix to 40mg IV x1, then 20mg IV BID (Yoshioka, et al., 2022).
- Daily Weights
- Strict I&O
- Repeat Echocardiogram
- Weight up 8# since admission
- Chest Xray suspicious for pulmonary edema pattern vs mild CHF decompensation
Chronic Urinary Retention
- Chronic Indwelling Catheter
- Follows with Dr. Peck
- Consult Urology
Reflection
This patient was a truly unique case. He originally came in with right flank pain and ended up being fluid overloaded. The admitting doctor started the patient on IV hydration due to AKI on CKD and the acute urinary tract infection. Orders were not placed to keep a watch on the patient’s intake and output and daily weight. The patient did not have bilateral lower extremity edema and he only had diminished lung sounds. His main symptoms of fluid overload were a distended belly and shortness of breath. This patient needed his IV fluids stopped and his Lasix transitioned to IV. Once the patient started to put more out his shortness of breath resolved.
Objectives:
After viewing the presentation:
- You will be able to explain why the patient became fluid overloaded.
- Explain two ways to facilitate diuresis of the patient.
- Explain what was still pending that could narrow done the antibiotic choices.
Discussion Questions:
- The patient was initially started on Rocephin, and then switched to Ancef. The urine culture was not fully resulted and only showed negative bacilli. What additional information would you need to make sure that you have chosen the appropriate antibiotic therapy?
- What labs are important to monitor while a patient is receiving IV Lasix and why?
- What are the risks involved with having a chronic indwelling catheter? What education can you provide the patient?
References
Cleveland Clinic. (2023). Flank pain. Retrieved from https://my.clevelandclinic.org/health/symptoms/21541-flank-pain
Diaz-Brochero, C., Valderrama-Rios, M. C., Nocua-Baez, L. C., & Cortes, J. A. (2022). First-generation cephalosporins for the treatment of complicated upper urinary tract infections in adults: A systematic literature review. International Journal of Infectious Disease, 116, 403-410. Retrieved from https://www.sciencedirect.com/science/article/pii/S1201971221012613
Keck Medicine of USC. (2020). 5 reasons you might have flank pain. Retrieved from https://www.keckmedicine.org/blog/5-reasons-you-might-have-flank-pain/
Time of Care. (2023). Flank pain. Retrieved from https://www.timeofcare.com/flank- pain-ddx/
Yoshioka, K., Maeda, D., Okumura, T., Kida, K., Oishi, S., Akiyama, E., Suzuki, S., Yamamoto, M., Mizukami, A., Kuroda, S., Kagiyama, N., Yamaguchi, T., Sasano, T., Matsumura, A., Kitai, T., & Matsue, Y. (2022). Clinical implications of initial intravenous diuretic dose for acute decompensated heart failure. Scientific Reports, 12, 2127. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8825846/
NRNP 6540 Week 5 Case Assignment
Case Title: A 67-year-old With Tachycardia and Coughing
Ms. Jones is a 67-year-old female who is brought to your office today by her daughter Susan. Ms. Jones lives with her daughter and is able to perform all activities of daily living (ADLs) independently. Her daughter reports that her mother’s heart rate has been quite elevated, and she has been coughing a lot over the last 2 days. Ms. Jones has a 30-pack per year history of smoking cigarettes but quit smoking 3 years ago. Other known history includes chronic obstructive pulmonary disease (COPD), hypertension,
vitamin D deficiency, and hyperlipidemia. She also reports some complaints of intermittent pain/cramping in her bilateral lower extremities when walking, and has to stop walking at times for the pain to subside. She also reports some pain to the left side of her back, and some pain with aspiration.
Ms. Jones reports she has been coughing a lot lately, and notices some thick, brown-tinged sputum. She states she has COPD and has been using her albuterol inhaler more than usual. She says it helps her “get the cold up.” Her legs feel tired but denies any worsening shortness of breath. She admits that she has some weakness and fatigue but is still able to carry out her daily routine.
Vital Signs: 99.2, 126/78, 96, RR 22
Labs: Complete Metabolic Panel and CBC done and were within normal limits
CMP Component Value CBC Component Value
Glucose, Serum 86 mg/dL White blood cell count 5.0 x 10E3/uL
BUN 17 mg/dL RBC 4.71 x10E6/uL
Creatinine, Serum 0.63 mg/dL Hemoglobin 10.9 g/dL
EGFR 120 mL/min Hematocrit 36.4%
Sodium, Serum 141 mmol/L Mean Corpuscular Volume 79 fL
Potassium, Serum 4.0 mmol/L Mean Corpus HgB 28.9 pg
Chloride, Serum 100 mmol/L Mean Corpus HgB Conc 32.5 g/dL
Carbon Dioxide 26 mmol/L RBC Distribution Width 12.3%
Calcium 8.7 mg/dL Platelet Count 178 x 10E3/uL
Protein, Total, Serum 6.0 g/dL
Albumin 4.8 g/dL
Globulin 2.4 g/dL
Bilirubin 1.0 mg/dL
AST 17 IU/L
ALT 15 IU/L
Allergies: Penicillin
Current Medications:
ï‚· Atorvastatin 40mg p.o. daily
ï‚· Multivitamin 1 tablet daily
ï‚· Losartan 50mg p.o. daily
ï‚· ProAir HFA 90mcg 2 puffs q4–6 hrs. prn
ï‚· Caltrate 600mg+ D3 1 tablet daily
Diagnosis: Pneumonia
Directions: Answer the following 10 questions directly on this template.
Question 1: What findings would you expect to be reported or seen on her chest X-ray results, given the diagnosis of pneumonia?
Question 2: Define further what type of pneumonia Ms. Jones has, HAP (hospital-acquired pneumonia) or CAP (community-acquired pneumonia)? What’s the difference/criteria?
Question 3:
ï‚· 3A) What assessment tool should be used to determine the severity of pneumonia and treatment options?
ï‚· 3B) Based on Ms. Jones’ subjective and objective findings, apply that tool and elaborate on each clinical factor for this patient.
Question 4: Ms. Jones was diagnosed with left lower lobe pneumonia. What would your treatment be for her based on her diagnosis, case scenario, and evidence-based guidelines?
Question 5: Ms. Jones has a known history of COPD. What is the gold standard for measuring airflow limitation?
Question 6: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain/cramps. Which choice below would be the best choice for a potential diagnosis for this? Explain your reasoning.
a. DVT (Deep Vein Thrombosis)
b. Intermittent Claudication
c. Cellulitis
d. Electrolyte Imbalance
Question 7: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain. What test could be ordered to further evaluate this?
Question 8: Name three (3) differentials for Ms. Jones’ initial presentation.
Question 9: What patient education would you give Ms. Jones and her daughter? What would be your follow-up instructions?
Question 10: Would amoxicillin/clavulanate plus a macrolide have been an option to treat Ms. Jones’ Pneumonia? Explain why or why not.
NRNP 6540 Week 7 Assignment
R.B.is a 95-year-old white male, currently living in a skilled nursing facility (SNF)
Chief complaint: “My urine is really red.”
HPI: On Wednesday (2 days ago), the patient was brought to your clinic by his son and complained that his urine appeared to be bright red in color. You ordered labs, urinalysis, culture, and sensitivity, and the results are below.
Allergies: Penicillin: Hives
Medications: Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily, Atorvastatin 10 mg 1 tablet daily, Donepezil 10 mg 1 tablet PO QHS, Metoprolol 25 mg 0.5 mg tablet every 12 hours, Acetaminophen 500 mg 1 tablet BID
Code status: DNR
Diet: Regular diet, pureed texture, honey-thickened liquids
Vitals: BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98%
PMH: Cognitive communication deficit, pneumonitis due to inhalation of food and vomit, dysphagia, R-sided hemiplegia and hemiparesis from a previous ischemic CVA, moderate vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on the left lower extremity, gross hematuria
Labs:
RBC 3.53 (L)
Hemoglobin 10.2 (L)
Microscopic Analysis, Urine, straight cath
Component:
WBC UA 42 (H) (0-5/ HPF)
RBC, UA >900 (H) (0-5/HPF)
Epithelial cells, urine 2 (0-4 /HPF)
Hyaline casts, UA 0 (0-2 /LPF)
Urinalysis
Color Red
Appearance (Urine) Clear
Ketones, UA Trace
Specific gravity 1.020 (1.005-1.025)
Blood, UA Large
PH, Urine 7.0 (5.0-8.0)
Leukocytes Small
Nitrites Positive
C&S results were not available yet.
Please include differential diagnosis with explanation and citation.