Neurology case study

Neurology case study

Case summary

This is a case study of a male patient who is 80 years old who came to see primary care NP complaining of lightheadedness. He had visited the ER 3 days ago and was diagnosed with sinusitis and given antibiotic. The following identified during a full physical exam;

• Low blood pressure while standing
• Fatigue
• Paleness
• Bony deformity
• L knee crepitus
• Right knee midline scar
• Peripheral edema

The patient is on several drugs, and the purpose of this assignment is to come up with a better way to relieve the patient complaints.

Question 1: Please reconcile the medication list by identifying concerns you have, including what could be contributing to his complaints and physical findings

The patient is on the following medications; Norvasc an antihypertensive that lowers but pressure but also causing peripheral edema to the patient. Flomax to aid urinary urgency but also causing rhinitis, Benadryl and Elavil that’s causing anorexia and urinary retention, Augmentin indicated for sinusitis but at the same time causing nausea that may interfere with his appetite. Wellbutrin, Pseudoephedrine and ES APAP causes diminished appetite while Levoxyl causes insomnia while Elavil causes urinary retention as well as constipation.

Question 2: Formulate a problem list from this visit with a focused plan for each problem you identified; take into consideration the abnormal lab values. Please make sure you include all aspects of the plan as outlined in the rubric.

Lab tests

This lab tests shows normal range in against patient’s finding after tests.

From the patient’s physical examination and lab tests, the patient is suffering from knee deformity with knee crepitus which lead to peripheral edema. However, Norvasc, which given to lower patient’s blood pressure increases the peripheral edema as a side effect. He takes ES APAP 1000mg PO q 4 hours to relieve the pain. Patient complains of lightheadedness which is a side effects of HCTZ, Benadryl and Flomax.                                                                                        To solve this problem, alternative medications can be given, or the patient is encouraged to talk a lot of water, fluids with electrolytes or get adequate rest after taking the drugs—Augmentin given to the patient after being diagnosed with sinusitis for treatment. Patient suffered from constipation as a side effect of Benadryl and Elavil given to relieve anxiety, depression and promote sleep to inverse insomnia brought about by Levoxyl, pseudoephedrine and Wellbutrin.                                                                                                                                        Urine retention comes about as a result of the use of Elavil and Benadryl or as a side effect of the use of Ramipril indicated to lower the patient’s blood pressure; thus, Flomax indicated to relieve the condition. Patient’s TSH levels are elevated, which is a sign of hypothyroidism which explains an indication of Levoxyl. Elevated levels of BUN is an indication that the liver and the kidneys are not properly working. To restore or reinforce the functioning ability, Flomax was indicated to enable excretion of urine.

Question 3: Please provide a list of three of differential diagnoses for insomnia for the 80-year-old patient.

Many illnesses can bring about insomnia. These conditions bring about differential diagnoses of the patient. Care and precision should be taken, and especially when dealing with the old age patients; hence all differential diagnoses should not be taken lightly.

Sleeplessness and circadian rhythm disorder– The significant sign of this disorder is lack of sleep due to the interference with the sleep-wake cycle, which could be caused due to an illness. The patient complained of insomnia for the last six three months that could make him be diagnosed with transient disorders as the pattern has lasted less than six months.

Medication-indicated insomnia-In this condition, medications given to a patient have or has the effect of sleeplessness. In this case, Levoxyl, Wellbutrin as well as Pseudoehenedrine harms affecting the sleep pattern hence that could act as part of the differential diagnosis.

Obstructive Sleep Apnea– It is the most common type of sleep-disordered breathing and is characterized by recurrent episodes of upper airway collapse during sleep (Guilleminault C., Tikan A., Dement W.C., 1976).It is characterized by hypertension during the daytime, one of the conditions the patient is being treated for as well as lack of sleep at night. It also brings about depression and anxiety to a patient, and these are signs that the patient has and is being treated for using anti-depressants such as Elavil.

Question 4: Please provide a list three of differential diagnoses for dizziness for the 80-year-old patient

Dizziness is a broad non-specific condition that has many differential diagnosis due to its broad nature. Compared to younger persons, dizziness in older people is not only more common, but it is also more persistent, has more causes, is less likely to be due to a psychological reason, and is more incapacitating (Davis L, 1994).

Cardiomyopathy – This is a condition caused by the weakening of heart muscles leading to insufficient supply of blood. In this patient’s case, the differential condition is chosen as the patient encounters some of its symptoms;

• Lightheadedness
• High blood pressure
• Peripheral edema
• Shortness of breath during exercise.
• Heart palpitations

This symptoms because a differential diagnosis to side with cardiomyopathy as this condition has a risk factor related to long-term hypertension which the patient has as shown in the drug regime prescribed to him earlier.

Anxiety Disorders – This is the body’s natural reaction to stress. It is listed as a differential diagnosis due to the symptoms similar to the patient, which include:

• Lack of sleep
• Dizziness
• Feeling jittery
• Medications that are anti-depressants for example Elavil.

This signs and symptoms pave the way for being diagnosed with anxiety disorders due to the relation seen.

Orthostatic hypotension– This condition characterized by a feeling of dizziness after sudden movement or change in position, which makes the blood pressure drop. This dizziness does not last for long, in the case of this patient, dizziness according to the history of the patient was experienced after excising, and when they sat down, it ended. This is a similar sign to that of the orthostatic hypotension cases. The risk factors of this condition that the patient is associated with are:

• Ageing-patient is 80 years of age.
• Thyroid conditions- TSH levels of patient were elevated than usual.
• Medications used to treat hypertension as well as depression.
• Heart conditions- realized due to irregularity in the physical exam.

Question 5: Polypharmacy in ageing clients is a concern for all primary care providers. As a nurse practitioner, what can you do to safely monitor and promote safe prescribing for your patients in the future? List 5 items

Polypharmacy is when a person is given many two or more drugs at the same period of usage even though at not equal intervals or period within a day. The older people should be well treated and due to their fragile nature, monitoring them closely and promoting safe prescription is done in the following ways:

• Minimizing the drugs prescribed by using non-drug therapies
• Adjusting the dose according to individual response.
• Start remedies slowly with less dosages
• Review patient regularly
• Educate the patient and family on ways to deal with the signs and symptoms that pop-up that can be managed without drug regimes.

References

Davis LE. (1994). Dizziness in Elderly Men. JAGS 42:1184-1188.

Colledge NR, Wilson JA, Macintyre CA, et al. ,(1994). The prevalence and            characteristics of dizziness in an elderly community. Age Aging

Kerber KA, Brown DL, Lisabeth LD, et al. ,(2006). Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a                 population-based study. Stroke

Kroenke K, Hoffman RM, Einstadter D.,(2000). How common are various causes of dizziness? A critical review. South Med.

Staab JP, Ruckenstein MJ.(2005). Chronic dizziness and anxiety: course of illness affects treatment outcome. Arch Otolaryngol Head Neck                                      Surg.

Guilleminault C., Tikan A., Dement W.C.,(1976). The sleep apnea syndromes.