Case study: Alzheimer’s Disease| Answered

Case study: Alzheimer’s Disease

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:

  1. CXR—no cardiopulmonary findings. WNL
  2. CT head—diffuse Cerebral Atrophy
  3. 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. 

Answer

Focused SOAP Note Template

 

Patient Information:

C.W. 67-year-old, African American female

S: (subjective)

CC: client is brought to the clinic with concerns of “forgetfulness” of more recent things but easily recalls historical moments and events.

HPI: 67-year-old African American female, has been demonstrating forgetfulness for the last four years. She forgets more recent events but easily recalls historical events. She also has a challenge finding the right words in a conversation and shifts entirely to a different conversation. The Patient also laughs off important things she has forgotten and is upset when someone points them out.

Current Medications: Amlodipine 10mg daily- for hypertension

HCTZ 12.5mg daily- For hypertension

Multivitamin daily- used to boost immunity and promote bone health

Atorvastatin 40mg daily- prescribed for hyperlipidemia

Alendronate 70mg once per week- prescribed for osteoporosis

The American Geriatrics Society Beers Criteria lists the medication that should not be used in older adults or Potentially Inappropriate Medication (PIM) use, due to increased risk factors and other drug-drug reactions (2019 American Geriatrics Society Beers Criteria, 2019). None of the medications listed above is in the American Geriatrics Society Beers Criteria list of PIM, thus safe for this client. Therefore, there is no need to recommend alternative drugs.

Allergies: Allergic to penicillin and Lisinopril. Both medications cause anaphylaxis allergic reactions, presenting symptoms such as hives, difficulty breathing, swelling, and severe skin reactions.

PMHx: All immunizations are up to date. Major illnesses are hypertension, hyperlipidemia, and osteoporosis. No history of past major surgeries.

Soc and Substance Hx: The client is a retired teacher. She has been living with her daughter for the last four years. Her husband passed on four years ago. She does not use tobacco, alcohol, or other drugs/substances. She enjoys meeting her friends at the local community center. She also has strong friendship ties. The client’s house has working smoke detectors to enhance safety.

Fam Hx: Both parents are deceased; father had dementia. Her sister, 71, is hypertensive. Has two children: the son is diabetic, the daughter is healthy. No family history of other major illnesses. with possible genetic predisposition, contagious, or chronic illnesses.

Surgical Hx: No history of major surgical procedures.

Mental Hx: Has not been diagnosed or treated of any mental illness. No concerns of anxiety or depression. No history of self-harm practices or suicidal or homicidal ideations.

Violence Hx: No history of personal, home, or community violence cases compromising safety.

Reproductive Hx: LMP at 44 years. Used oral contraceptives. Heterosexual. No sexual concerns.

ROS

GENERAL: denies weight loss, fever, chills, general weakness, or fatigue.

HEENT:

  • Eyes: denies visual loss, blurred vision, double vision, or yellow sclerae.
  • Ears, Nose, Throat: denies hearing loss. Denies sneezing, congestion, runny nose, or sore throat.

SKIN: denies rash or itching.

CARDIOVASCULAR: denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: denies nausea, anorexia, vomiting, or diarrhea. Reports no abdominal pain or blood.

GENITOURINARY: Reports no burning sensation on urination.

NEUROLOGICAL: denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Reports no change in bowel or bladder control.

MUSCULOSKELETAL: reports no muscle pain, back pain, joint pain, or stiffness. Denies muscle swelling

HEMATOLOGIC: reports no anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. Denies history of splenectomy.

PSYCHIATRIC: No history of depression. Reports feeling anxious occasionally

ENDOCRINOLOGIC: Reports no excessive sweating. Denies cold or heat intolerance. Denies polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O (objective)

Physical exam:

Vital signs: BP 186/84 HR 74 RR 16. Weight 79kg Height 5’ 6” BMI 28.1

General: Client is A&O, appears relaxed with no apparent distress

HEENT: Head normocephalic, no masses, normal scalp hair distribution. PERRLA bilaterally, EOMI. Eyelids conjunctiva pink, no lesions, white sclera. TM intact and pearly gray. Oral mucosa moist, no lesions. No sinus tenderness. Full ROM without clicks. No lymphadenopathy. Thyroid smooth.

Musculoskeletal: No swelling, masses, or deformities on the neck and upper extremities. Fingernails have no ridges or abnormalities. Pink nailbeds. No lesions or deformities in the lower extremities. Full ROM on the neck and extremities. Neck and extremities strength 5/5.

Neurological: steady gait. Movement and coordination smooth and accurate, poor concentration. Deep tendon reflexes 2+. Disorientation and confusion present. Primitive reflexes present.

Based on the mini-mental status exam, the client is cooperative, alert and maintains fair eye contact. She has a clear speech, but occasionally tangential. No unusual movements demonstrated. She denies hallucinations, suicidal thoughts and ideations, and she is disoriented to time and place. The overall mental status exam score is 18/30, with deficits in attention, recall, orientation, and registration, suggesting moderate dementia.

Diagnostic results:

The diagnostic assessments done include CXR, head CT scan, and a mini-mental status exam. Hemmy et al. (2020) note that other diagnostic assessments required to develop differential diagnoses in patients with cognitive impairment include a psychiatric mood assessment and blood tests. The CXR shows no cardiopulmonary findings, while the head CT scan shows diffuse cerebral atrophy. The mental status exam score is 18/30, with deficits in attention, recall, orientation, and registration. The psychiatric mood assessment would assist rule out conditions such as depression, which also mimics cognitive impairment. The blood tests would also help identify the cause of cognitive impairment.

A (assessment)

Differential diagnoses:

1. Dementia. The primary diagnosis is dementia. Dementia is a chronic, progressive neurodegenerative condition that generally affects cognitive function and memory loss (Weintraub, 2022). The disorder is characterized by gradual decline of cognitive function that worsens with age. Its symptoms include forgetfulness, disorientation of time and place, and personality changes. The patient, in this case, presents with all the symptoms mentioned, thus considering the disorder as the primary diagnosis.

2. Mild cognitive impairment. According to Dunne et al. (2021), mild cognitive impairment is a disorder characterized by cognitive function changes, which are noticed but do not necessarily interfere with daily activities. The condition may be associated with age-related cognitive decline. Common symptoms include forgetting recent events/conversations and poor attention. Language, executive functions, and mood changes. In this case, the patient presents with memory loss of recent events, thus including the condition as a differential diagnosis. However, it is ruled out due to absence of mood changes, and the patient can manage daily activities.

3. Delirium. Delirium is an acute condition that develops rapidly over a short time and affects cognitive function. The condition is characterized by cognitive impairment, disorientation, hallucinations, inability to focus/sustain attention (Fong & Inouye, 2022). The patient, in this case, presents with disorientation to time and place, inability to focus and sustain attention, and cognitive impairment, therefore, delirium is a differential. The disorder is ruled out considering the patient’s condition does not have a sudden onset, and the patient reports no hallucinations.

P (plan)

After diagnosis, it is crucial to identify the therapeutic interventions that will work best for the client and the education required to reduce dementia progression and improve the quality of life. It is important to educate the patient and the caregiver on the disease, its symptoms and management. In this case, dementia cannot be cured, but its progression can be slowed, and symptoms managed. According to Kumar et al. (2022), medication therapy to manage dementia entails cholinesterase inhibitors such as galantamine and Partial N-Methyl D-Aspartate (NMDA) memantine. The patient should also be encouraged to continue adhering to the current medications to manage current conditions, including multivitamins for immunity support. A follow-up after four weeks will be required to assess the patient’s progress and determine if any changes should be made. The caregiver will be informed to consider getting the patient enrolled in art, speech and language therapy, and behavioral management to effectively manage dementia symptoms. Interacting with the case study, I have learned the essence of including health promotion and disease prevention in common patient education. For instance, for this patient, considering the age and past medical history, it is crucial to educate the patient on medication adherence, safety at home, and the necessary immunizations for this population/age. Therefore, the patient will receive holistic care, thus improving outcomes and the quality of life.

 

References

By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society67(4), 674–694. https://doi.org/10.1111/jgs.15767

Dunne, R. A., Aarsland, D., O’Brien, J. T., Ballard, C., Banerjee, S., Fox, N. C., Isaacs, J. D., Underwood, B. R., Perry, R. J., Chan, D., Dening, T., Thomas, A. J., Schryer, J., Jones, A. M., Evans, A. R., Alessi, C., Coulthard, E. J., Pickett, J., Elton, P., Jones, R. W. & Burns, A. (2021). Mild cognitive impairment: the Manchester consensus. Age and Ageing50(1), 72–80. https://doi.org/10.1093/ageing/afaa228

Fong, T. G., & Inouye, S. K. (2022). The inter-relationship between delirium and dementia: the importance of delirium prevention. Nature Reviews. Neurology18(10), 579–596. https://doi.org/10.1038/s41582-022-00698-7

Hemmy, L. S., Linskens, E. J., Silverman, P. C., Miller, M. A., Talley, K. M. C., Taylor, B. C., Ouellette, J. M., Greer, N. L., Wilt, T. J., Butler, M., & Fink, H. A. (2020). Brief Cognitive Tests for Distinguishing Clinical Alzheimer-Type Dementia from Mild Cognitive Impairment or Normal Cognition in Older Adults with Suspected Cognitive Impairment. Annals of internal medicine172(10), 678–687. https://doi.org/10.7326/M19-3889

Kumar, A., Sidhu, J., Goyal, A. &Tsao, J. W. (2022) Alzheimer Disease. In: StatPearls [Internet]. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK499922/

Weintraub S. (2022). Neuropsychological Assessment in Dementia Diagnosis. Continuum (Minneapolis, Minn.)28(3), 781–799. https://doi.org/10.1212/CON.0000000000001135

 

Get the best expert writers with just a few clicks. At online nursing paper writers we offer quality and original nursing papers at an affordable cost. Contact us today!