Patient Information
Initials: Ms. W Age: 67 Sex: Female Race: White
S (subjective)
CC (chief complaint): Wound up here.
HPI (history of present illness): 67year old white female is experiencing an increase in recent memory loss when having conversations but can recall prior occasions and events. Additionally, she struggles with identifying the appropriate words to use in dialogue and changes the topic. Agitation while being questioned has also been noticed.
Location: Head
Onset: Recently
Character: Disorientation
Associated signs and symptoms: Agitation, forgetfulness, hypertension, hyperlipidemia, osteoporosis.
Timing: While in the middle of conversations and public places like supermarkets.
Exacerbating/relieving factors: Being in unfamiliar territory makes the patient fully disoriented; therefore, having a familiar face around calms her down and makes her regain composure.
Severity: Moderate
Current Medication (no data on the length of time used):
- Amlodipine 10mg dail890[] 4214y: used to help lower blood pressure to control patient’s hypertension.
- HCTZ 12.5mg daily: used to help lower blood pressure to mitigate hyperlipidemia
- Multivitamin daily: used to reduce levels of stress and anxiety
- Atorvastatin 40mg daily: helps increase good cholesterol levels in the patient’s body.
- Alendronate 70mg orally once a week: used to treat osteoporosis
Allergies: 67year old white female has a penicillin allergy, an aberrant immunological response to the antibiotic penicillin, and a Lisinopril allergy, which is a severe allergic reaction to the Lisinopril drug.
PMHx: Chronic Medical Problems: Hypertension, Hyperlipidemia, Osteoporosis
Immunizations: Polio, Tetanus (date of the last one was six months ago), Last PPD, and Cholera
Soc and Substance Hx: Widowed and whose occupation was teaching but is retired. No reports of tobacco, alcohol, or recreational drug usage. Does your house have functional smoke detectors at home? Do you always have a mask on every time you leave the house?
Fam Hx: 67year old white female is diagnosed with hypertension, hyperlipidemia, and osteoporosis. No reports of cancer, coronary stroke, or depression in the family.
Surgical Hx: T&A, Appendectomy, Hysterectomy, Hernia.
Mental Hx: No history of anxiety or depression, or any other mental health problem.
Violence Hx: No reports of personal, home, community, or sexual violence.
Reproductive Hx: Already at menopause; therefore, neither pregnant nor lactating and no engagement in sexual intercourse.
ROS (review of symptoms):
- GENERAL: Alert, cooperative, well appearing, well nourished, clear speech, usual motor movements, and fair eye contact.
- HEENT:
- Head: No lumps, bouts of depression, or visible or tactile scars.
- Eyes: Visual acuity intact, but refutes any claims of visual hallucinations.
- Ears: Hearing is undamaged, but she denies any auditory hallucinations
- Nose: No visible infections, non-inflamed mucous, normal septum, and turbinates.
- Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
- SKIN: Good skin turgor
- Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate
- Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender
- CARDIOVASCULAR: No discomfort, strain, or discomfort in the chest. She has hypertension
- RESPIRATORY: Absence of mucus, cough, or breathing difficulties.
- GASTROINTESTINAL: No vomiting or diarrhea and neither hemorrhage nor stomach pain.
- GENITOURINARY: Smooth Urination and clear discharge. Last menstrual period (LMP), 12/02/Y2007
- NEUROLOGICAL: CN 2-12 regular. Proprioception, touch, and pain perception are all normal. DTRs normal in the upper and lower extremities. No adverse reactions. No pulsating headache, dizzy spells, collapse paralysis, or tingling or numbness in the extremities, but there is a bit of disorientation.
- MUSCULOSKELETAL Typical pose and placement. The head, neck, spine, ribs, pelvis, or extremities are free of displacement, asymmetry, crepitation, abnormalities, stiffness, lumps, pericardial effusion, instability, degeneration, or aberrant strength or tone.
- HEMATOLOGIC: Absence of benign, malignant blood disorders and liver diseases
- LYMPHATICS: No enlarged nodes. No history of splenectomy.
- PSYCHIATRIC: No reports of anxiety or depression.
- ENDOCRINOLOGIC: There have been no reports of cold, heat, or sweating
- REPRODUCTIVE: Vagina and cervix without lesions or discharge. Uterus and adnexa/parametria non-tender without masses.
- Breast: No nipple abnormality, dominant masses, tenderness to palpation, axillary or supraclavicular adenopathy.
- ALLERGIES: History of drug-related allergy, specifically Penicillin allergy and also Lisinopril allergy
O (objective)
Physical exam
General: Ms. Washington appears alert, oriented, and cooperative.
Skin: In terms of appearance, texture, and temperature, it is normal.
HEENT: Scalp normal.
Neck: No abnormal adenopathy, easily retractable without resistance
In the cervical and supraclavicular regions, the Trachea is in the middle.
Moreover, the thyroid gland is typical, with no masses. The carotid artery
The bilateral upstroke is standard, with no bruits. Jugular vein
Pressure is measured at 8 cm with the patient at a 45-degree angle.
Chest: Except for creaks heard in the respiratory system bases bilaterally, the bronchioles are clear to thoracentesis and percussion.
Diagnostic results: Shortness of breath, a chronic cough, a fever, chest pain, or an injury may be identified using a chest x-ray, also known as a CXR, which utilizes a small amount of radiation dose to analyze the lungs, heart, and chest wall but does not reveal any cardiovascular anomalies and it was applied on the patient but indicated no presence of cardiopulmonary findings. When evaluating head injuries, severe headaches, disorientation, and other symptoms of an aneurysm, hemorrhage, stroke, and neurological disorders, computed tomography (CT) of the head is used. Cerebral degeneration, which occurs when brain cells, connectivity between them, and brain volume deteriorate, is employed to diagnose the patient’s head (Marshall & Hale, 2017). The Mini-Mental State Examination (MMSE), the most extensively used psychological assessment diagnostic test of mental function, revealed a patient’s score of 18 out of 30 who already had primary deficiencies in orientation, attention, quantification, and memory. It is used to screen patients for cognitive decline, monitor changes in cognitive working effectively over time, and frequently evaluate the consequences of therapeutic agents on cognitive function. According to this result, Ms. Washington may have moderate dementia.
A (assessment)
Differential diagnoses
Dementia
Dementia is the damage of cognitive performance — thinking, recalling, and rationality — to the point where it interferes with routine life and activities. Dementia symptoms occur when previously healthy cells, or nerve fibers, in the nervous system quit functioning, lose interconnection with some other cells in the brain, and start dying (Grande et al., 2020). While everybody loses several neurons as they grow older, people with dementia lose far more. Dementia symptoms include: Memory problems, poor conviction, and confusion. Since Ms. Washington struggles with memory problems and sometimes confusion symptoms, e.g., tangential speech, there is a basis for assigning her a Dementia diagnosis.
Alzheimer
Alzheimer’s is an accelerated disorder in which dementia symptoms worsen gradually over time. Forgetfulness is mild in the early stages of Alzheimer’s, but as the disease progresses, people lose the capacity to communicate and react to their surroundings (Kennedy-Malone & Duffy, 2019). According to a report by Ms. Washington’s daughter, her mother sometimes cannot “find the right words” in discussion and then shifts to a completely different line of conversation, indicating the possible emergence of Alzheimer’s disease. A person with Alzheimer’s disease continues to live 5 to 8 years after a diagnostic test on average but can live up to 20 years depending on other factors.
Delirium
Delirium is a substantial disruption in cognitive capacities that causes confused thinking and decreased awareness of one’s surroundings. The fact that Ms. Washington recently got lost at Walmart suggests she may also be diagnosed with delirium. Delirium usually begins quickly — within a few hours or days (Marshall & Hale, 2017). Delirium is frequently caused by one or more factors, including a devastating or recurrent illness, modifications in physiologic stability (like low carb), medicines, infection, surgical intervention, or drug or alcohol intoxication or withdrawal.
P (plan)
The prevention of dementia diseases would have a significant impact on a significant number of individuals as well as the general public. It seems beneficial to pursue primary preventive tactics to prevent initial pathological alterations or secondary prevention techniques to postpone pathological processes. Early dementia diagnosis could enable secondary preventive strategies and early mobilization of support and assistance. A physical assessment can aid in dementia prevention and detect stroke or other illnesses that may be contributory factors to dementia. It can also spot other diseases that coexist with dementia, like cardiovascular disease or kidney problems (Grande et al., 2020). I would recommend halting or adjusting some drugs this patient is taking because some of the prescriptions could be contributing to or causing her illness. Compared to either technique used alone, a combination of neuropsychological evaluation with neuroimaging enhances the diagnostic accuracy of predicting a mental decline. Nevertheless, the techniques used to identify the early stages of dementias outperform the treatment options. Therefore, the value of such an extremely early “pre-clinical” diagnosis is still controversial.
Similarly, the other two, Alzheimer’s and Delirium, can be healed through regular cognitive and neuropsychological tests that will be used to assess her brain capability and carry out a range of assessments to gauge her mental capabilities. Through this, I will be capable of determining the extent of damage to her brain and seeking out the best strategy to stop dementia from advancing further or slowing down its course. Even though behavioral therapy is not a cure for numerous behavioral issues related to aging, it is an efficient therapeutic strategy that can assist my patient decrease her agitation outbursts. Therapy is generally overseen by a healthcare professional, but behavioral therapy can often be provided by a trained family member or friend (Livingston et al., 2020). In this woman’s situation, her daughter can assume the role of caregiver and help her mother manage her dementia and agitation issues.
Reflection
Overall, this case has taught me that as a physician, I must design a systematic plan for the patient’s curing process. The fact that patients are not always aware of their disease or come to the hospital on their initiative, but at their relatives’ decision, was an “aha” moment for me. It means that the patients might not have the motivation or intent to be cured. If this is the case, I will also need to consider how to keep the patient motivated simultaneously. Further, age reflects a risk factor that should be thoroughly considered while treating Ms. Washington because it dramatically increases the likelihood of dementia with passing years. Hence, traveling outside the home involves a shift in environment, and according to what the patient’s daughter has pointed out, any change in environment can lead to wandering behavior. This prompts me to recommend keeping people with dementia in a familiar environment. Regarding socio-economic factors, Ms. Washington’s past career history as a teacher can also facilitate her healing, providing her with good old memories, and keeping a sense of solidarity with others, which might have been lacking since the death of her husband, making her feel alone.
References
Grande, G., Qiu, C., & Fratiglioni, L. (2020). Prevention of dementia in an aging world: Evidence and biological rationale.Ageing Research Reviews, 64, 101045. Web.
Kennedy-Malone, L., & Duffy, E. G. (2019). Advanced practice nursing in the care of older adults. F.A. Davis Company.
Livingston, G., Huntley, J., Sommerlad, A., Ames, D., Ballard, C., Banerjee, S., Brayne, C., Burns, A., Cohen-Mansfield, J., Cooper, C., Costafreda, S., Dias, A., Fox, N., Gitlin, L., Howard, R., Kales, H., Kivimäki, M., Larson, E., Ogunniyi, A., … Mukadam, N. (2020). Dementia prevention, intervention, and care: 2020 report of The Lancet Commission.The Lancet, 396(10248), 413–446. Web.
Marshall, K., & Hale, D. (2017). Delirium, dementia, and depression.Home Healthcare Now, 35(9), 515–516. Web.