NR-601 Week 6 Janet Riley I Human Case Study, Exams of Nursing

Download NR-601 Week 6 Janet Riley I Human Case Study and more Exams Nursing in PDF only on Docsity! NR-601 Week 6 Janet Riley I Human Case Study a Case Study: Janet Riley VS PC History Choose a person to ask: @ patient {J Janet's daughter Questions you ask now (after evaluation) don't affect your score. Q History Choose a category: Interview Opening > HPI: Constitutional Complaints } HPI: Other Complaints (A - H) } HPI: Other Complaints (I - Z) > HPI: Pain Complaints (A - H) > HPI: Pain Complaints (1 -Z) } HPI: Psychological Complaints > HPI: Sensation & Movement Complaints > Past Medical History (PMH) Family Medical History (FH) > Social Hx (SH) Physical Exam Assessment Janet Riley 79 ylo 5'7" (170 cm) 110.0 Ib (50.0 kg) Chief complaint Confusion and memory loss reported by family member Revie Submitted on 10/12/2020 08:17:15 Case authored by: Alison Reminick, MD Tests Diagnosis Plan Summary Xf Or, ask a question. Complete questions work best. § How can | help you today? What has been happening since your last visit? Do you have any other symptoms or concems we should discuss? Do you have pain anywhere? If so, where? What symptom is the most distressing for you? Has anyone else you know developed these symptoms? Tell me how that makes you feel How does this affect your life? What is your name? Where are you? What time is it? NR-601 Week 6 Janet Riley I Human Case Study History HPI: Confusion HPI: Cough HPI: Coughing up blood (hemoptysis) HPI: Diarrhea HPI: Dizziness HPI: Ears - hearing loss HPI: Ears - tinnitus HPI: Erectile dysfunction HPI: Eye problems HPI: Headache HPI: High blood pressure HPI: Low blood pressure > HPI: Other Complaints (I - Z) HPI: Low blood pressure > HPI: Other Complaints (I - Z) HPI: HPI: HPI: HPI: HPI: HPI: HPI: Memory loss Menstrual irregularities Nausea and/or vomiting Nose complaints Palpitations Pediatric development Skin/Rashes HPI: Sleep HPI: HPI: Sore throat Swallowing problems (dysphagia) HPI: HPI: HPI: Urinary incontinence Urination difficulty Urination - blood (hematuria) Do you feel confused at times? Can you describe the nature of the confusion or the types of memory loss? When did your confusion start? What are the events surrounding the start of your confusion? Does anything make your confusion better or worse? Do you have any other symptoms associated with your confusion? How severe is your confusion? Have you had confusion like this before? Has there been any change in your confusion over time? Does your confusion come and go? How often do you feel confused? Is there any pattern to when your confusion occurs? Does anyone in your family have similar problems with confusion? What treatments have you had for your confusion? u Do you have a problem remembering things? Can you describe the nature of the confusion or the types of memory loss? Do you feel that you have more memory problems than others? When did your memory problems start? What are the events surrounding the start of your memory problems? Does anything make your problem with memory loss better or worse? Do you have any other symptoms associated with your memory loss problem? How severe are your memory problems? Have you had memory problems before? Has there been any change in your memory problems over time? Do your memory problems come and go? How often do you have memory problems? NR-601 Week 6 Janet Riley I Human Case Study ® All Questions Asked ‘You asked 99 questions v¥ suggested by case author as required + never inappropriate - not required by case author x inappropriate Result Question ¥ | How can | help her today? (witness) v What is your name? (patient) wv Where are you? (patient) + | How old are you? (patient) + | Can you tell me about any current or past medical problems you have had? (patient) - Does she have any allergies? (witness) - Are her immunizations up to date? (witness) + ‘Can you tell me about any current or past medical problems she has had? (witness) - How is her overall health? (witness) v Is she taking any over-the-counter or herbal medications? (witness) + Is she taking any prescription medications? (witness) + Is she taking any medications for her symptoms? (witness) - | Is she taking any medications that were prescribed by a different health care provider? (witness) - Does she use any recreational drugs? If so, what? (witness) ¥ Does she have any other symptoms or concerns we should discuss? (witness) - What does she think might be causing her symptoms? (witness) - Does she have any symptoms that occur at the same time as her headache? (witness) + What symptom is the most distressing for her? (witness) - What does she think might be causing her symptoms? (witness) Has she had any significant traumatic injuries or accidents? (witness) Does she have any other symptoms or concerns we should discuss? (witness) - Has anyone else she knows developed these symptoms? (witness) - How long do her periods last? (witness) + Does she have pain anywhere? If so, where? (witness) - Does she have any other symptoms associated with her fatique/tiredness? (witness) - Does she have any pain or other symptoms associated with her walking problems? (witness) - When and what did she last eat? (witness) - When and what did she last drink? (witness) NR- 601 Week 6 Janet Riley I Human Case Study Has she been eating anything out of the ordinary lately? (witness) Can you tell me about her diet? What does she normally eat? (witness) Does she now or has she ever smoked or chewed tobacco? (witness) Is she exposed to secondhand smoke? (witness) Does she use any recreational drugs? If so, what? (witness) Does she have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in her vomit, dark tarry stool, bright red blood in her bowel movements, early satiety, or bloating? (witness) Does she have a problem with depression? (witness) Has she been feeling sad, depressed or hopeless? If so, how often does she feel this way? (witness) Has she lost interest in things that used to give her pleasure? If so, how offen does she feel this way? (witness) Does she have problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor? (witness) What treatments has she had for her depression problem? (witness) Does she have any other symptoms associated with her depression? (witness) Any previous medical, surgical or dental procedures? (witness) What does she think might be causing her symptoms? (witness) Does she have a tremor? (witness) When did her memory problems start? (witness) What are the events surrounding the start of her memory problems? (witness) How severe are her memory problems? (witness) Can she describe the nature of the confusion or the types of memory loss? (witness) Do her memory problems come and go? (witness) What treatments has she had for her memory problems? (witness) Has she had memory problems before? (witness) How is her overall health? (witness) When did her memory problems start? (witness) What are the events surrounding the start of her memory problems? (witness) How severe are her memory problems? (witness) Do her memory problems come and go? (witness) What do you think might be causing your symptoms? (patient) What does she think might be causing her symptoms? (witness) What symptom is the most distressing for her? (witness) Does she have any other symptoms or concerns we should discuss? (witness) Does she have any other symptoms associated with her fatique/tiredness? (witness) Does she have any symptoms that occur at the same time as her headache? (witness) Has she lost weight? (witness) Has she gained or lost weight unintentionally, despite normal appetite and exercise? (witness) NR- 601 Week 6 Janet Riley I Human Case Study Has she had weight loss problems like this before? (witness) ¥ Does she have any problems with fatique, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats? (witness) - What are the events surrounding the start of her problem with weight loss? (witness) - Is she having any trouble hearing? (witness) - Does she hear or see things that others say they do not? (witness) - Is she having any trouble hearing? (witness) - Does she hear or see things that others say they do not? (witness) - Does she have any pi in her leg(s)? (witness) What does the pain/discomfort in her chest feel like? (squeezing, pressure, crushing. buming, stabbing, aching, tingling. suffocating, tingling) (witness) - Does she have black tar-like or foul smelling stools? (witness) Does she have problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, or hip pain? (witness) + Does she have pain anywhere? If so, where? (witness) - | Does she think about or feel like hurting others? (witness) - | Has she had any thoughts of hurting or killing herself? (witness) - | Does she often fee! nelpless? (witness) - | Has she been feeling sad, depressed or hopeless? If so, how offen does she feel this way? (witness) V | Does she have trouble with reasoning, planning, or organizing? (witness) - Is she having trouble concentrating or making decisions well? If so, how often? (witness) Vv | Does she sometimes have trouble remembering things or finding the right names or words? (witness) - | Does she have any difficulty performing activities of daily living? (witness) v Does she have any other symptoms or concerns we should discuss? (witness) - Does she have any problems writing? (witness) - Does she feel that she has more memory problems than others? (witness) - Any problem moving her mouth? (witness) - Does she have any pain or difficulty speaking? (witness) - Is she moving or speaking slowly or fidgeting and restless? If so, how often? (witness) - Has she noticed any trouble with her speech? (witness) - Does she ever hear speech but cannot understand it? (witness) - | Tell me about her leisure activities. (witness) - | Has she lost interest in or avoided social activities? (witness) - | Does she prefer to stay at home, rather than going out and doing things? (witness) - Has she had any more stress in her life lately? (witness) - Has her level of activity recently changed? (witness) - Tell me about her work. (witness) NR-601 Week 6 Janet Riley I Human Case Study Neck: palpate neck Hyperthyroidism can impact cognitive function. A normal sized gland without nodules diminishes the risk of hyperthyroidism. o Abdomen: palpate abdomen Abdominal palpation in an older individual that has unintentional weight loss is important. During this procedure you should be looking for organ size (liver and spleen), masses, tenderness, and aortic diameter. 2 Genitourinary: genitourinary female exam In older individuals this exam provides insight into urinary continence and general hygiene. N Extremities: visual inspection extremities Extremity evaluation is a way to look for systemic hypoxia that could contribute to cognitive problems. 0 Musculoskeletal: test range of motion AMSK exam is always an important safety evaluation in older individuals especially if they have reported a previous fall © Neurological: assess cranial nerves © The cranial-nerve exam may identify important abnormalities that can help in differentiating between brainstem and cortical dysfunction © Ofnote: "Because the primary olfactory structures adhere to the ventral frontal lobes and connect to limbic circuits, which involve ventromedial frontal cortex, olfactory perception is often considered a frontal lobe sign [italics added] ..f olfactory acuity is intact (no anosmia), poor olfactory differential identification suggests current or developing Alzheimer's dementia. If olfactory acuity and identification are both intact, depressive pseudodementia or vascular dementia are more likely than Alzheimer's disease.” See: Sanders RD, Gillig PM. Cranial Nerve |: Olfaction. Psychiatry (Edgmont). 2009;6(7):30-35 10. Neurological: reflexes - deep tendon ° Reflex testing assesses the function and interplay of corresponding sensory and motor pathways Intact DTRs indicate the integrity of cutaneous (sensory) innervation, motor pathways, and corticospinal integration at the corresponding spinal segment. Of special note: the palmar grasp, rooting, and glabellar reflexes are primitive CNS responses not seen in the neurologically intact adult. These reflexes may be present in various neurologic disorders, including some dementia variants, Parkinson's disease, and head trauma ° ° 11. Neurological: mini-mental state exam (MMSE) Aull mental status exam is required to assess cognitive functioning and degree of impairment (click here for reference) © AMMSE score between 20 and 26 is associated with mild functional dependency, such as managing finances other instrumental activities of daily living (IADLs) © Moderate impairment (MMSE score between 10 and 20) is associated with more immediate dependency, such as personal care and shopping. gjiy NR-601 Week 6 Janet Riley I Human Case Study © Severe impairment (MMSE score less than 10) correlates with a state of total dependence and the need for constant supervision. Motor impairments, notably gait and balance impairment, incontinence, and myoclonus, develop at this late stage, and presage total debilitation The 15-point geriatric depression scale (GDS) is a practical screening instrument, especially in the setting of mild to moderate neurocognitive disorder with limited attention span © The GDS has 92% sensitivity and 89% specificity, when assessed against prevailing diagnostic criteria © Ascore of five or greater is suggestive of depression. (click here for reference] Mini-Cog should be performed (click here for reference) Clock-draw test is another assessment tool (click here for reference) 12. Musculoskeletal: inspect for muscle bulk and tone Muscle tone is assessed by passive movement of the patient's limbs: © Hypertonia (spasticity, rigidity) is seen with upper motor neuron lesions (e.g., stroke, cerebral palsy, parkinsonism) © Hypotonia (decreased tone) and atonia (loss of tone) are seen with lower motor neuron lesions: genetic (e.g., muscular dystrophy); infectious (e.9., Guillain-Barre syndrome); autoimmune (e.g., myasthenia gravis); and, traumatic injuries © Loss of muscle tone, coordination, and strength (Lucianis triad) suggests cerebellar dysfunction NR-601 Week 6 Janet Riley I Human Case Study 13. Neurological: assess gait & stance Gait abnormalities often precede neurocognitive disorders of any type (Verghese et al., 2002). Elements of the exam should include the following Stance Posture Natural gait (free walking) Heel and toe walking Tandem walking Ability to dual task while walking ©0000 0 For a precise review of gait abnormalities, see: Examination for cerebellar dysfunction. In: DeMyer’s The Neurologic Examination. 6th ed. New York, NY: McGraw-Hill; 2011 14. Neurological: reflexes - plantar/Babinski (L5/S1) © Reflex testing assesses the function and interplay of corresponding sensory and motor pathways. © Dorsifiexion of the great toe with fanning out of the other toes, in response to stroking of the sole of the foot from the heel along the anatomical curve to the metatarsal pads (positive Babinski sign), can indicate an upper motor neuron (UMN) lesion © Apositive Babinski sign may be seen in the following neurocognitive disorders variants: frontotemporal-lobe dementia; HIV dementia; and, other non-Alzheimer's dementias 15. Neck: ask patient to swallow Thyroid glands can be substernal. Thus evaluating the thyroid gland with swallowing helps elucidate this location of the gland wz XIncorrect You performed 22 exams not required by expert. 1. HEENT. examine pupils 2. Skin, Hair, Nails: test capillary refill - fingers 3. Skin, Hair, Nails: test capillary refill - toes 4. HEENT: inspect/palpate scalp 5. Skin, Hair, Nails: Quincke's test 6. HEENT: inspect/palpate head 7. HEENT: inspect eyes 8. HEENT: look in eyes with ophthalmoscope 9. HEENT: inspect ears 10. HEENT: look in ears with otoscope 11. HEENT: inspect nose 12. HEENT: look up nostrils 13. HEENT: smell breath 14. Lymphatic: palpate all lymph nodes 15. Chest Wall & Lungs: visual inspection - anterior & posterior chest 16. Chest Wall & Lungs: palpate - anterior & posterior chest 17. Chest Wall & Lungs: percuss - anterior & posterior chest 18. Abdomen: auscultate fetal heart ae NR-601 Week 6 Janet Riley I Human Case Study Key Findings write Problem Statement Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Key Findings Write Problem Statement Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Differential Diagnoses Rank Differential Diagnoses Select Tests Expert's Problem Statement Janet Riley is a 79-year-old widow with hypertension and coronary artery disease who, according to her adult daughter, has, over the last year, developed progressive cognitive and memory deficits, emotional lability and behavior changes. The daughter also notes a change in her mother’s personality (more argumentative and difficult), deteriorating personal hygiene, and an inability to meet some of her ADLs (activities of daily living) Expert's Problem Statement Janet Riley is a 79-year-old widow with hypertension and coronary artery disease who, according to her adult daughter, has, over the last year, developed progressive cognitive and memory deficits, emotional lability and behavior changes. The daughter also notes a change in her mother’s personality (more argumentative and difficult), deteriorating personal hygiene, and an inability to meet some of her ADLs (activities of daily living) Comparison to Expert @ Correct ® Missing X Incorrect Yours Graded Choice oO Oo oO Cardiovascular ® | Endocrine X | Gastrointestinal Integumentary x Musculoskeletal @ Neurological iG ® | Genitourinary/Renal to Respiratory Tr Hematologic Ei Lymphatic oOo @ Immune @ = Psychologic a oOo Sexual/Reproductive Feedback Altered mental status and confusion can result from conditions involving a variety of body systems, so you need to think broadly. Endocrine A variety of endocrinopathies can result in confusion. Review the physical findings. What endocrine diseases are frequently occult and only found on screening tests? Neurological A variety of central nervous system processes present as confusion. Review the historical and physical findings in order to narrow the list Genitourinary/Renal Confusion is frequently how older individuals present when they have impaired renal function or infections. Does your patient have any physical findings that might narrow the list gay of differentials?" Immune Infection can be occult and present with confusion. Again, look at the history, onset of symptoms and physical findings to narrow the differential list Psychologic Depression can present with lack of interest in daily activities and confusion. Does the history support or refute the involvement of this system? Do you have enough data? NR-601 Week 6 Janet Riley I Human Case Study write Problem Statement Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Student Differential Diagnoses urinary tract infection (UTI) @ dementia, Alzheimer's ® anemia, vitamin B12 deficiency ® pseudodementia ® occult infection ® hypothyroidism ® dementia, frontotemporal ® polypharmacy-induced pseudodementia ® dementia, vascular ® dementia, Lewy body ® toxic encephalopathy ® obstructive sleep apnea (OSA) ® hydrocephalus ® subdural hematoma ® dementia, mixed ® polypharmacy-induced pseudodementia ® dementia, vascular ® dementia, Lewy body ® toxic encephalopathy ® obstructive sleep apnea (OSA) ® hydrocephalus ® subdural hematoma ® dementia, mixed Expert's Feedback Selected Differential Diagnoses @ correct * dementia, Alzheimer's ®Missing You were missing 13 diseases that were specified by the case author R 1. anemia, vitamin B12 deficiency This differential diagnosis should be included because: Signs and symptoms of vitamin B12 anemia may include: Fatigue, weakness Tachycardia, tachypnea Pale skin Easy bruising Unintended weight loss Diarrhea or constipation Vitamin B12 deficiency is a common cause of neuropsychiatric symptoms in elderly persons. Low serum vitamin B12 levels are associated with neurodegenerative disease, cognitive impairment, and mood disorders. There is a small subset of dementias that are reversible with vitamin B12 therapy and this treatment is inexpensive and safe. Vitamin B12 therapy does not improve cognition in patients without pre- existing deficiency. See: Moore E, et al. Cognitive im ent B12: A review. International Psychogeriatrics. 2012;24(4):541-56 Other nutritional deficiencies associated with psychiatric and/or neurological symptoms include folate homocysteine, thiamine and niacin pseudodementia This differential diagnosis should be included because: Pseudodementia is a treatable depressive disorder in older age that presents with many reversible signs and symptoms of neurocognitive disorders © Confusion © Memory impairment NR-601 Week 6 Janet Riley I Human Case Study Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests ® polypharmacy-induced pseudodementia ® dementia, vascular ® dementia, Lewy body ® toxic encephalopathy ® obstructive sleep apnea (OSA) ® hydrocephalus ® subdural hematoma @ aninntia mB ® polypharmacy-induced pseudodementia ® dementia, vascular ® dementia, Lewy body ® toxic encephalopathy ® obstructive sleep apnea (OSA) ® hydrocephalus ® subdural hematoma & polypharmacy induced pseudodementia ® dementia, vascular ® dementia, Lewy body ® toxic encephalopathy ® obstructive sleep apnea (OSA) ® hydrocephalus ® subdural hematoma ® dementia, mixed ® polypharmacy-induced pseudodementia ® dementia, vascular ® dementia, Lewy body ® toxic encephalopathy ® obstructive sleep apnea (OSA) ® hydrocephalus ® subdural hematoma ® dementia, mixed ‘© Mood changes Anhedonia Social withdrawal Sleep disturbance ° ° ° © Weight loss 3. occult infection s o This differential diagnosis should be included because: This differential diagnosis should be included because: Occult urinary tract infection with secondary urosepsis can present in the elderly with impaired cognition, with or without the common GU signs and symptoms: © Urinary urgency, dysuria, frequency © Pelvic pain (in women), rectal pain (in men) © Urine with cloudy appearance and strong odor © Bacteriuria, pyuria, hematuria Other infections that may present with alterations in mental status include HIY, tertiary syphilis, and CNS infections hypothyroidism This differential diagnosis should be included because: ‘Symptoms of hypothyroid usually develop slowly over time; they may not be clinically recognized, or they may be mistaken for features of normal aging. Common symptoms include the following ° ° ° ° ° ° Fatigue, malaise Weakness Depression, Dry skin and brittle nails Cold intolerance Constipation dementia, frontotemporal This differential diagnosis should be included because: Frontotemporal dementia (FTD) is both a clinical and an imaging-based diagnosis. MRI can detect shrinkage in the frontal and temporal lobes of the brain, a hallmark of FTD. FTD has a younger mean age of onset (53 years) than Alzheimer's disease. Frontotemporal dementia is associated with the following clinical findings Changes in personality and behavior that may be mistaken for depression Disinhibition (dysregulated emotions; inappropriate speech and actions) Language impairment, e.g., words convey less and less meaning or specificity (semantic dementia); loss of ability to generate words or sentences (aphasia) Involuntary movements, muscle rigidity, or spasticity Loss of coordination and balance 6. polypharmacy-induced pseudodementia Polypharmacy-induced pseudodementia represents a a NR-601 Week 6 Janet Riley I Human Case Study Statement Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Organize key Findings Write Problem Statement Select Problem Categories Select Differential agnoses Rank Differential Diagnoses Select Tests ® polypharmacy-induced pseudodementia ® dementia, vascular ® dementia, Lewy body ® toxic encephalopathy ® obstructive sleep apnea (OSA) ® hydrocephalus ® subdural hematoma ® dementia, mixed ® polypharmacy-induced pseudodementia ® dementia, vascular ® dementia, Lewy body ® toxic encephalopathy ® obstructive sleep apnea (OSA) ® hydrocephalus ® subdural hematoma ® dementia, mixed This differential diagnosis should be included because: Head injuries are common in the elderly due to balance and gait abnormalities. Subdural hematoma can occur in the elderly after apparently insignificant head trauma that is unrecognized and/or unreported. Chronic subdural hematoma is a common treatable cause of dementia An acute subdural hematoma may be associated with the following: Headache Nausea and vomiting Lethargy, weakness, somnolence Dizziness Confusion Apathy Behavioral changes 13. dementia, mixed This differential diagnosis should be included because: Mixed neurocognitive disorder refers to the coexistence of two or more dementia etiologies © Alzheimer’s disease (AD) and vascular dementia © AD and Neurocognitive Disorder with Lewy bodies © AD, vascular dementia, and Neurocognitive Disorder with Lewy bodies ° Other mixed etiological factors XIncorrect * urinary tract infection (UT!) a Rank the differential diagnoses: Indicate /eading (Lead) or alternative (Alt). Then indicate if the differential diagnosis represents a must-not-miss (MnM) diagnosis or condition aa ALCL 3 Differential Diagnosis dementia, Alzheimer’s anemia, vitamin B12 deficiency pseudodementia occult infection hypothyroidism dementia, frontotemporal polypharmacy-induced pseudodementia dementia, vascular dementia, Lewy body Expert's Feedback Lead or Alt | MnM Diagnosis Ranking: | @ Correct dementia, Alzheimer's anemia, vitamin B12 deficiency pseudodementia occult infection hypothyroidism dementia, frontotemporal polypharmacy-induced pseudodementia dementia, vascular dementia, Lewy body toxic encephalopathy obstructive sleep apnea (OSA) hydrocephalus ® ®@ @®@ XxX x xX @ NR-601 Week 6 Janet Riley I Hu Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Statement Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests Select Problem Categories Select Differential Diagnoses Rank Differential Diagnoses Select Tests cpmmeumunon dementia, frontotemporal polypharmacy-induced pseudodementia dementia, vascular dementia, Lewy body toxic encephalopathy obstructive sleep apnea (OSA) hydrocephalus subdural hematoma dementia mixed Differential Diagnosis Hywouyrenion dementia, frontotemporal polypharmacy-induced pseudodementia dementia, vascular dementia, Lewy body toxic encephalopathy obstructive sleep apnea (OSA) hydrocephalus subdural hematoma hypouryionuiont dementia, frontotemporal polypharmacy-induced pseudodementia dementia, vascular dementia, Lewy body toxic encephalopathy obstructive sleep apnea (OSA) hydrocephalus subdural hematoma Leaa oran | minM man Case Study ® ®@xX X ® @ x * subdural hematoma * dementia, mixed Diagnosis Must-not-Miss: @Missing * anemia, vitamin B12 deficiency * pseudodementia * occult infection * polypharmacy-induced pseudodementia * toxic encephalopathy * obstructive sleep apnea (OSA) * subdural hematoma XIncorrect + dementia, Alzheimer's + dementia, vascular + dementia, Lewy body + dementia, mixed Discussion: Alzheimer's disease (AD) is the leading hypothesis given Ms. Riley's constellation of presenting symptoms and behavioral history, as reported by her daughter. Vascular neurocognitive disorder, the next most frequent dementia etiology following AD, should be considered given Ms. Riley's risk factors: CAD, hypertension, and hyperlipidemia However, her symptoms have been gradual in their progression, not step-wise as is characteristic of vascular dementia; and, she lacks focal-neurologic deficits. A head CT or brain MRI showing evidence of ischemic strokes would support this alternative diagnosis Mixed neurocognitive disorder (AD plus vascular neurocognitive disorder) is a strong alternative hypothesis, as this patient has significant vascular risk factors. Again, neuroimaging studies providing evidence of previous infarctions would support this diagnosis. Major neurocognitive disorder with Lewy bodies is a possible, but less likely, alternative hypothesis, given the patient's lack of gait impairment and/or other Parkinson’s-like features on neurologic exam Pseudodementia, a treatable depressive disorder, should be considered as a must-not-miss, alternative diagnosis in this patient's case, given her mood lability, anhedonia, social withdrawal, weight loss, and sleep disturbance. While pseudodementia and depression, both treatable conditions, may be harbingers of Alzheimer's disease, depression alone is NR-601 Week 6 Janet Riley I Human Case Study aa NR-601 Week 6 Janet Riley I Human Case Stud History Physical Exam Assessment Tests Plan Summary <a What is the correct diagnosis for this patient? @ Correct ® Missing X Incorrect Expert's Feedback \Yours Graded Choice Diagnosis: Alzheimer’s disease, moderate; possible vascular Oo anemia, vitamin B12 deficiency component | © | © _|dementia, Atztieimers Ms. Riley has neuropsychiatric and behavioral manifestations of Oo dementia, Lewy body neurocognitive disorder: ° dementia, frontotemporal © Impaired memory, judgement, and orientation fe) dementia, mixed * Emotional lability, depressive symptomatology : * Delusional symptoms Oo dementia, vascular * Sundowning T * Poor self-insight with regard to disease process and limitations | O hydrocephalus lanosognosia} O° hypothyroidism * Decline in self-care | + Resistance to care-giving Oo obstructive sleep apnea (OSA) °O occult infection There is no current evidence for other etiologic factors. Oo polypharmacy-induced pseudodementia oO pseudodementia Oo subdural hematoma ! Oo toxic encephalopathy a History Physical Exam Assessment Tests Diagnosis Summary ea ys Your Plan Expert's Feedback Tests ordered for Mrs. Riley include bloodwork, a brain MRI, sleep study, urinalysis, an EEG, and CSF analysis. All lab values are The medical-social management of this patient who has been within normal limits: UAis negative, and the sleep study was newly diagnosed with Alzheimer's disease should include the normal. The CSF was normal. The brain MRI shows generalized following components cortical atrophy and a reduced hippocampal volume. The EEG shows cortical dysfunction Brain atrophy is measured on MRI and is a powerful biomarker of the stage and intensity of neurodegenerative aspects of the + Adetermination of the individual's care and safety needs pathology of Alzheimer’s disease. The cerebral cortex plays a key (Activities of Daily Living and Instrumental Activities of Daily Dial inemoly, aifention, thotight. and lanenlaige. Atrophy in the Living). Activities of daily living include are the tasks that are cortex is indicative of AD. An imaging study of medial temporal Fequired to get going in the morning, get from place to place lobe atrophy (MTA), particularly in the hippocampus, the entorhinal using one's body, and then close out the day in the evening cortex, and the amygdala provides evidence of the progression of They invoive caring for and moving the body: walking, AD. Mrs. Riley's test results accompanied by her associated bathing, dressing, toileting, brushing teeth, and eating symptoms indicated that she has Alzheimer’s Disease Instrumental activities of daily living are the activities that people do once they are up, dressed, put together. These tasks support an independent life style. Many people can still live independently even though they need help with one or two of these IADL’s. They include: cooking, driving, using the telephone or computer, shopping, keeping track of finances, managing medication Discussion of placement options; including the option for the patient to remain in her own home with any/all necessary assistance. NR-601 Week 6 Janet Riley I Human Case Study Your Plan Tests ordered for Mrs. Riley include bloodwork, a brain MRI, sleep study, urinalysis, an EEG, and CSF analysis. All lab values are within normal limits, UA is negative, and the sleep study was normal. The CSF was normal. The brain MRI shows generalized cortical atrophy and a reduced hippocampal volume. The EEG shows cortical dysfunction. Brain atrophy is measured on MRI and is a powerful biomarker of the stage and intensity of neurodegenerative aspects of the pathology of Alzheimer's disease. The cerebral cortex plays a key role in memory, attention, thought, and language. Atrophy in the cortex is indicative of AD. An imaging study of medial temporal lobe atrophy (MTA), particularly in the hippocampus, the entorhinal cortex, and the amygdala provides evidence of the progression of AD. Mrs. Riley’s test results accompanied by her associated symptoms indicated that she has Alzheimer’s Disease UCase Summary Learning objectives for this case After completing this case the student should be able to do the following: + Assessment of the patient's support structure and her family's psychosocial and financial abilities to assume primary and/or secondary caregiver responsibilities. Notification of the state DMV, the patient, and the patient's family that the patient's driving privileges are permanently revoked on medical grounds. Question the family regarding pre-existing advanced medical directives and/or durable powers of attorney for healthcare and/or financial matters. Emphasize the role of enrichment activities for those living with neurocognitive disorder (e.g., community-based programs). Continue management of her known cardiovascular risk factors with Aspirin, statin, and antihypertensives. Pharmacologic management of the patient's Alzheimer's disease should be tailored to the individual's stage of disease and behavioral features. Risks and benefits of the following drug classes should be discussed in detail with the patient's family: Cholinesterase inhibitors: e.g., donepezil (Aricept), galantamine (Razadyne ER), rivastigmine (Exelon), NMDA-receptor antagonists: e.g., memantine (Namenda), Antipsychotics (for behavioral disturbances/delusions that pose significant management or safety concerns). Define neurocognitive disorder (formerly referred to as dementia), including the six cognitive domains affected. Perform a comprehensive history to evaluate cognitive impairment. Describe important aspects of the physical examination in evaluating cognitive impairment. List the laboratory work-up of cognitive impairment. Provide a differential diagnosis for neurocognitive disorders. List the risk factors for Alzheimer’s disease. Describe the diagnostic criteria for Alzheimer’s disease. Distinguish Alzheimer’s disease from other forms of dementia. List the treatment options in the management of Alzheimer’s disease. Describe the role of beta-amyloid plaques, neurofibrillary tangles, and acetylcholine in the progression of Alzheimer’s disease. Describe the pathological changes associated with the various forms of neurocognitive disorders. Describe the mechanisms of actions of the medications used to treat Alzheimer's disease. Summarize each of the major theories on the development of the different types of neurocognitive disorders. Epidemiology Dementia, now known as neurocognitive disorder, is a syndrome of acquired, persistent, cognitive and behavioral impairment that significantly impairs daily function, and affects one or more of the following cognitive domains: NR-601 Week 6 Janet Riley I Human Case Study Complex attention Learning and memory Executive function Perpetual motor Language function Social cognition Alzheimer’s disease (AD) is an insidious neurodegenerative disease that is characterized by the gradual/progressive loss of cognitive function. AD disease is the most common cause of neurocognitive disorder (40%), followed by vascular neurocognitive disorder and Lewy body neurocognitive disorder. Rates of neurocognitive disorder increase significantly with age. Neurocognitive disorder affects approximately 5% of the population older than 65, and close to 50% of those age 85 and older. The number of cases of neurocognitive disorder worldwide is estimated at 36 million. Rates of neurocognitive disorder are slightly higher in women than in men at ages 65 and greater. Clinical considerations Differential diagnosis * Hypothyroidism * Occult infection (HIV, tertiary syphilis, other subacute CNS infections) NR-601 Week 6 Janet Riley I Human Case Study Performance Overview The following table summarizes your performance on each section of the case, whether you completed that section or not. Time spent: 1h 34m 54s Status: Submitted eee) er tea Cac) | Cohort Comparison (N=31) aeuceucsr TE Total Score you 7 —=——S ee median History Done you 99 questions asked, 16 correct, 25 oo —=—— SR, «—TSSed relative to the experts list median Physical exams Done you 43 exams performed, 14 correct, 15 . —=—— SE «—SSed relative to the expert's ist median Key findings Done 411 findings listed; 16 listed by expert organization Problem statement Done 109 words long; expert's was 64 words Body system Done you 2 of § correctly picked plus 2 extras classeaton A median Differentials Done you 2 items in the DDx, 1 correct, 13 missed EE eaNeIO Ne exports ist median Differentials ranking Done you 0 OTT He eee (leadvatt score) median i you (must not miss score) oe median Tests Done you 5 tests ordered, § correct, 10 missed 2 ND elie Lo tne experts st median Diagnosis Done You "dementia, Alzheimers" selected; 1% A SSRN | Uementa, Azneimers selected by median ©? Management plan Done 142 words long; expert's was 318 words Exercises Done you 2 of 10 correct (of scored items only) 2 (of scored items only) a median *Status: In progress - the section is incomplete and there's still time to finish it. Incomplete - the section is incomplete and the assignment due date has passed. Done - the section is finished and evaluated. * Exam counts shown here reflect exams performed and certain vitals reviewed, NR-601 Week 6 Janet Riley I Human Case Study Time Spent per Section History Physical Exams Key Findings Organization Problem Statement Differential Tests Diagnosis Selection Management Plan EMR All Exercises History & Physical Exam Key Findings / cree Prob Statement ©@® Assessment Process The following is a summary of all the tasks you performed dur © All History Questions Time spent: 46m 36s ee Performed: 16 of 41 required @@ (40%), ee 8 not required, not ws inappropriate cc 55 not required by c¢ case author Performed @ Performed Extraneous X Incorrect © Not required, not inappropriate [] Duplicate Time spent: 3m 25s ee Performed: 14 of 29 required ee (48%) 5 not required, not inappropriate 22 not required by case author Accuracy: 5 performance errors 46m 36s 3m 25s 4m 3s 4m 37s 5m 16s im 44s 53s 3m 6s 3m 34s 19m 20s 10m 20m 30m 40m 50m Differential Summary Management Plan bein! Tests Summary Exercises ing the history and physical exams portion of your patient encounter. & & & @ ®@ @ ane o@ ann AC8e® An ® nnee noee aAnR® anee anee anee@ anee ANG® ann Anne Anne an Anan AR Annee AnC8e Not performed @ Missing @eeeeee0000 @@eecccc cece a Exam counts shown here reflect exams performed and certain vitals reviewed. Performed @ Performed C Extraneous X Incorrect 1] Duplicate @ Not required, not inappropriate Not performed @ Missing NR-601 Week 6 Janet Riley I Human Case Study Documentation Score: VY Correct = Missing association © Incorrect Pee ey See me cl) Performance Errors a boa e 1 temperature e 2 Vitals: blood pressure = “systolic 142 = = “Diastolic 86 = “Assessment elevated = ‘Pressure normal ® 3 orthostatic blood pressure (BP) e 4 Vitals: respiration — ‘Rate 14 = “Rhythm regular ® 5 Sp02 ® 6 skin vital sign ® 7 Spco ® 8 eTCO2 © 9 Skin, Hair, Nails: inspect skin overall e 10 Skin, Hair, Nails: inspect hair color, distribution, thickness e 11 Skin, Hai, Nails: inspect nails C 12 Skin, Hair, Nails: test capillary refill - fingers Cc 13 Skin, Hair, Nails: test capillary refill - toes Cc 14 HEENT: inspect/palpate scalp Cc 15 Skin, Hair, Nails: Quincke's test Cc 16 HEENT: inspectipalpate scalp Cc 7 HEENT: inspect/palpate head Cc 18 HEENT: inspect eyes e 19 HEENT: test visual acuity Cc 20 HEENT: examine pupils + did not fully examine left pupil Left normal reactive ‘= did not fully examine right pupil ri ee Cc 24 HEENT: look in eyes with ophthalmoscope Cc 22 HEENT: inspect ears. 23 HEENT: look in ears with otoscope 4 NR-601 Week 6 Janet Riley I Human Case Study has lost weight recently wears hearing aids thinks people are taking things from her Unable to organize things, house is a mess Trouble paying attention; trouble remembering things NKA, PMH, HTN, high cholesterol, stent placed 15 ys ago, CAD fell 4 weeks ago hit head Related Related Related Related Unknown Unknown Unknown interest in previously enjoyed activities) Impaired performance of activities of daily living (ADL) Oriented X 2 only Geriatric depressive possible symptomatology Weight loss - unintended 8 pound loss over last 3 months Coronary artery disease Hypertension Hyperlipidemia Related Related Unknown Unknown Unknown Unknown Unknown NR-601 Week 6 Janet Riley I Human Case Study History of head trauma Unknown Hearing loss Unknown Expert: Key Findings Feedback The medical key findings list you have compiled should be a list that includes everything that is out of the ordinary about this patient, even when it is not a problem’ in the true sense of the word. In this 79-year-old female, the most significant active problem (MSAP) is impaired memory and related behavioral changes. Look through the list of problems identified. What medical conditions frequently found in the geriatric population has this list: + Personality change * Confusion + Poor concentration + Impaired judgment + Paranoid ideation + Disengagement/loss of interest in valued acti + Decline in performance of ADLs + Unintended weight loss ‘Some problems could be grouped as potential risk factors for behavioral changes: + Hypertension + Hyperlipidemia + History of head trauma + Newly widowed status (despite low but somewhat ambiguous geriatric depression score) Next look for specific physical findings identified during your examination of the patient. Hearing loss is a common, non-specific finding but the loss of orientation to time is significant. In what medical conditions is this a prominent finding? In developing your differential diagnosis, keep in mind that there not only may be cross-over findings between various hypotheses, but that some conditions that may explain Ms. Riley's presentation may actually coexist as mixed etiologies, or as comorbidities. Also remember that the geriatric population frequently does not exhibit the same degree of physical findings for some medical conditions, thus more generic screening for common conditions that can result in the above list of problems needs to be considered. Problem Statement Use this section to compare your problem statement with the one created by the case expert. Time spent: 4m 37s User: Problem Statement Janet Riley is a 79-year-old Caucasian female that presents with her daughter, Ann, who has concems about Janet's progressive cognitive and memory deficits, ‘emotional lability, and behavioral changes over the past year. She has noticed changes in Mrs. Riley's personality, inability to complete her activities of daily living, and lack of interest in previous activities and friends. Does not answer any questions, and denies the need to be at the doctor. She presents as unkempt and has obvious malodorous body odor. She has a recent history of head trauma related to a trip and fall four weeks ago. Mrs. Riley has a history of htn, high cholesterol, and CAD. Expert: Problem Statement Janet Riley is a 79-year-old widow with hypertension and coronary artery disease who, according to her adult daughter, has, over the last year, developed progressive cognitive and memory deficits, emotional lability and behavior changes. The daughter also notes a change in her mother's personality (more argumentative and difficult), deteriorating personal hygiene, and an inability to meet some of her ADLs (activities of daily living). NR-601 Week 6 Janet Riley I Human Case Study Body System Categorization Use this section to compare your problem body systems with the list selected by the case author. Time spent: 41s User: Body System List Correctly selected Neurological Psychologie Ig Endocrine Genitourinary/Renal Immune Incorrectly selected Gastrointestinal Muscul loskeletal Differential Summary Expert: Body System List Endocrine Neurological Genitourinary/Renal Psychologic Immune The following shows how you did in developing your differential. Please observe the correct diseases, thelr order and appropriate ranking. You may also compare this to the order and diseases on your final list. Selected Not Selected @ Performed @ Missing X Incorrect © Differential Selection/Ranking ‘Time spent: 1m 5s in differential selection 4m ‘1s in differential ranking 53s in selecting final diagnosis Selection 1 of 14 correct (7%) Score: Ranking Score: 1 incorrect 100% ranked correctly 21% categorized must not miss correctly Diagnosis 100% Score: Cord isease dementia, Alzheimer's anemia, vitamin B12 deficiency pseudodementia occult infection hypothyroidism dementia, frontotemporal polypharmacy-induced pseudodementia dementia, vascular ©8988 G88G8BO9SBOX Ranking Score: Y Correct — Missing © Incorrect ee) v ard . es a A ee « ig ° Derr v Result Partially Correct: dementia, Alzheimer's is not a must-not-miss. Missing: anemia, vitamin 812 deficiency is a differential, and is a must-not-miss. Missing: pseudodementia is a differential, and is a must-not-miss. Missing: occult infection is a differential, and is a must-not-miss. Missing: hypothyroidism is a differential Missing: dementia, frontotemporal is a differential. Missing: polypharmacy-induced pseudodementia is a differential, and is a must-not-miss. Missing: dementia, vascular is a differential, and is not a must-not- miss. NR-601 Week 6 Janet Riley I Human Case Study electroencephalogram (EEG) complete blood count (CBC) human immunodeficiency virus (HIV) antibody rapid plasma reagin (RPR) free thyroxine (FT4) polysomnography/sleep study comprehensive metabolic panel (CMP) folate, serum homocysteine homocysteine thyroid-stimulating hormone (TSH) erythrocyte sedimentation rate (ESR) urinalysis (UA) dementia, Lewy body dementia, vascular dementia, frontotemporal dementia, mixed dementia, Alzheimer's Other Tests toxic encephalopathy Other Tests occult infection Other Tests Other Tests hypothyroidism obstructive sleep apnea (OSA) Other Tests toxic encephalopathy Other Tests anemia, vitamin B12 deficiency Other Tests anemia, vitamin B12 deficiency Other Tests hypothyroidism Other Tests occult infection Indicated Indicated Indicated Indicated Indicated Indicated Indicated Indicated Indicated Indicated Indicated Indicated Indicated NR-601 Week 6 Janet Riley I Human Case Study Management Plan Time spent: 3m 6s This report shows a comparison of your management plan compared to the expert's User: Management Plan Tests ordered for Mrs. Riley include bloodwork, a brain MRI, sleep study, urinalysis, an EEG, and CSF analysis. All lab values are within normal limits, UA Is negative, and the sleep study was normal. The CSF was normal. The brain MRI shows generalized cortical atrophy and a reduced hippocampal volume. The EEG shows cortical dysfunction. Brain atrophy Is measured on MRI and is a powerful biomarker of the stage and intensity of neurodegenerative aspects of the pathology of Alzheimer's disease. ‘The cerebral cortex plays a key role in memory, attention, thought, and language. Atrophy in the cortex is indicative of AD. An imaging study of medial temporal lobe atrophy (MTA), particularly in the hippocampus, the entorhinal cortex, and the amygdala provides evidence of the progression of AD. Mrs. Riley's test results accompanied by her associated symptoms indicated that she has Alzheimer's Disease. Expert: Management Plan The medical-social management of this patient who has been newly diagnosed vith Alzheimer's disease should include the following components: + Adetermination of the individual's care and safety needs (Activities of Daily Living and Instrumental Activities of Daily Living). Activities of daily living include are the tasks that are required to get going in the morning, get from place to place using one's body, and then close out the day in the evening. They involve caring for and moving the body: walking, bathing, dressing, tolleting, brushing teeth, and eating. Instrumental activities of daily living are the activities that people do once they are up, dressed, put together. These tasks support an independent life style. Many people can still live independently even though they need help with one or two of these IADL's. They include: cooking, driving, using the telephone or computer, shopping, keeping track of finances, managing medication. + Discussion of placement options; including the option for the patient to remain in her own home with any/all necessary assistance. + Assessment of the patient's support structure and her family's psychosocial and financial abilities to assume primary and/or secondary caregiver responsibilities. + Notification of the state DMY, the patient, and the patient's family that the patient's driving privileges are permanently revoked on medical grounds. + Question the family regarding pre-existing advanced medical directives and/or durable powers of attorney for healthcare and/or financial matters. Emphasize the role of enrichment activities for those living with. neurocognitive disorder (e.g., community-based programs). Continue management of her known cardiovascular risk factors with Aspirin, statin, and antihypertensives. Pharmacologic management of the patient's Alzheimer's disease should be tailored to the individual's stage of disease and behavioral features. Risks and benefits of the following drug classes should be discussed in detail with the patient's family: Cholinesterase inhibitors: e.g., donepezil (Aricept), galantamine (Razadyne ER), rivastigmine (Exelon), NMDA- receptor antagonists: e.g., memantine (Namenda), Antipsychotics (for behavioral disturbances/delusions that pose significant management or safety concerns). NR-601 Week 6 Janet Riley I Human Case Study Electronic Medical Record Time spent: 3m 34s This report shows your documentation in the patient's electronic medical record. User: History of Present Illness Chief complaint confusion and memory loss History of present illness User: Past Medical History Other active problems Medical, surgical, obstetric, hospitalizations User: Medications Rx (medications) User: Allergies Allergies User: Preventive Health Preventive health Immunizations User: Family History FHx (family history) User: Social History SHx (social history)