Week 9 Assignment: Ground Round Practicum
Week 9 Assignment: Ground Round Practicum
Learning Objectives for the Presentation
By the end of this presentation, the learner will be able to:
- Explain three differentials for a patient presenting with memory loss.
- List at least five clinical symptoms of Alzheimer’s disease.
- Differentiate Alzheimer’s dementia and Vascular dementia.
- Explain one medication used to manage Alzheimer’s disease.
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Subjective:
[elementor-template id="165244"]CC (chief complaint): “Forgetful”
HPI: H.L. is an 85-year-old White female who was accompanied by her son to the psychiatric clinic. The son reported that the mother was becoming increasingly forgetful of more recent events. She has been having incidences of forgetting things like where she kept the house keys and her social security number, and doing some house chores. She started exhibiting memory loss more than ten years ago but this has worsened and now concerns the entire family. H.L.’s forgetfulness increasingly became apparent after her husband’s death two years ago. She has difficulties finding the right words in a conversation and shifts to an entirely different conversation line. Besides, she laughs off things when she forgets important appointments and usually gets upset and aggressive when people point out her forgetfulness. Furthermore, she often asks the same questions even after being answered and at times gets lost. The son reports that the patient’s mood often fluctuates and often gets depressed. She might be in a joyful mood and this fluctuates to being sad and tearful.
Substance Current Use: History of smoking 1PPD and taking 3-4 beers. She stopped at 65 years after being diagnosed with HTN and Hyperlipidemia.
Medical History: Medical history of HTN, Hyperlipidemia, Obesity, and Osteoporosis. History of stroke one year ago.
- Current Medications: Enalapril 40 mg OD; Carvedilol 25 mg; Atorvastatin 40 mg OD; Alendronate 5mg OD.
- Allergies: None
- Reproductive Hx: Para 3+0
ROS:
- GENERAL: Denies fever, chills, weight changes, or fatigue.
- HEENT: Denies head trauma, facial tenderness, eye pain, visual disturbances, ear discharge/pain, rhinorrhea, or sore throat.
- SKIN: Denies rash or bruises.
- CARDIOVASCULAR: Denies palpitations, dyspnea, edema, or increased fatigue.
- RESPIRATORY: Denies chest pain, wheezing, cough, or sputum.
- GASTROINTESTINAL: Denies nausea, vomiting, abdominal discomfort, or bowel changes.
- GENITOURINARY: Denies vaginal symptoms or dysuria.
- NEUROLOGICAL: Positive for memory loss, mood changes, confusion, short attention span, and difficulties with language. Denies headaches, dizziness, or tingling sensations.
- MUSCULOSKELETAL: No muscle or joint pain/stiffness.
- HEMATOLOGIC: Denies bruising or bleeding.
- LYMPHATICS: Denies lymph node enlargement.
- ENDOCRINOLOGIC: Denies polyuria, excessive lacrimation, or acute thirst or hunger.
Objective:
Vital signs: Temp- 98.06F; PR- 92; RR- 20; BP- 144/88.
Neurological: Alert and obeys motor commands. Normal balance and posture. CN I-XII intact. Muscle strength 5/5.
Diagnostic results: No tests were requested.
Assessment:
Mental Status Examination:
The patient is an 85-year-old White female. She is alert and cooperative and maintains adequate eye contact. She has clear and coherent speech but is occasionally tangential. No abnormal motor movements or tics. No visual or auditory hallucinations were noted. She also denies any suicidal thoughts or ideations. She is oriented to person, and partially oriented to place but is disoriented to time. The patient laughs off at her disorientation in place. Her recent and recent-past memory is impaired but her long-term memory is intact. She has a fair judgment. Insight is lacking.
Diagnostic Impression:
Alzheimer’s Disease (AD): AD is characterized by changes in function, cognition, and behavior. It has an insidious onset and a slow gradual cognitive decline (Arvanitakis et al., 2019). Clinical symptoms include impairment in short-term memory in the early stage, deficit in word recall, and impaired executive function in later stages (Tahami Monfared et al., 2022). The patient presents with a cognitive decline evidenced by memory loss, confusion, short attention span, and language difficulties. The patient’s cognitive decline has been gradual, making AD the presumptive diagnosis.
Major Depression: Depression presents with a depressed mood or diminished interest in activities (Park & Zarate, 2019). The patient often gets into a depressed mood with a sad and tearful mood. However, the patient’s symptoms do not meet the criteria for Major depression, making it an unlikely primary diagnosis.
Vascular dementia: Vascular dementia is also characterized by changes in function, cognition, and behavior similar to AD. However, it has an abrupt or gradual onset. It is associated with cerebrovascular disease like stroke and atherosclerotic conditions, like hypertension and coronary heart disease (McGrath et al., 2022). The patient has a history of HTN and stroke which could have contributed to Vascular dementia. However, the patient’s symptoms have had a gradual onset, ruling out Vascular dementia as the primary diagnosis.
Reflections: If I were to conduct the assessment again, I would assess the patient’s personal and social factors that may deteriorate her condition. I would ask about her caregiver and the challenges they face in caring for her at home and address them. I did not have a chance to follow up on the patient. If I were to follow up, I would assess the patient’s level of cognitive decline to establish if the treatment was successful in reducing cognitive decline.
Case Formulation and Treatment Plan:
The patient was prescribed Donepezil 5 mg P.O. every bedtime. Donepezil is a centrally-acting cholinesterase inhibitor (ChEI). Donepezil is FDA-approved for treating AD symptoms. It improves cholinergic neurotransmission in the brain by delaying the destruction of acetylcholine (ACh) by the enzyme acetylcholinesterase (Yiannopoulou & Papageorgiou, 2020).
The patient was advised to engage in mild physical exercises such as walking and jogging to reduce the progression of dementia by boosting brain health. Arvanitakis et al. (2019) explain that AD patients may benefit from non-pharmacologic approaches, including cognitively engaging activities like reading, physical exercise such as walking, and socialization like family gatherings.
Follow-up: A follow-up was scheduled after four weeks to assess the patient’s progress with treatment and complications related to AD.
Discussion Questions
- What resources may be helpful for this patient and her family or caregiver regarding self-management of Alzheimer disease?
- What should the PMHNP emphasize when counseling the patient and her family following the diagnosis of Alzheimer disease?
- What should be discussed with the patient as symptoms become more pronounced in Alzheimer disease (AD)?
- Which non-pharmacological interventions would you recommend for this patient to prevent further cognitive decline?
PRECEPTOR VERIFICATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek-approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
Arvanitakis, Z., Shah, R. C., & Bennett, D. A. (2019). Diagnosis and Management of Dementia: Review. JAMA, 322(16), 1589–1599. https://doi.org/10.1001/jama.2019.4782Cummings, J. (2019). The National Institute on Aging—Alzheimer’s Association framework on Alzheimer’s disease: Application to clinical trials. Alzheimer’s & Dementia, 15(1), 172-178. https://doi.org/10.1016/j.jalz.2018.05.006
McGrath, E. R., Beiser, A. S., O’Donnell, A., Himali, J. J., Pase, M. P., Satizabal, C. L., & Seshadri, S. (2022). Determining Vascular Risk Factors for Dementia and Dementia Risk Prediction Across Mid- to Later-Life: The Framingham Heart Study. Neurology, 99(2), e142–e153. Advanced online publication. https://doi.org/10.1212/WNL.0000000000200521
Park, L. T., & Zarate, C. A., Jr (2019). Depression in the Primary Care Setting. The New England Journal of Medicine, 380(6), 559–568. https://doi.org/10.1056/NEJMcp1712493
Tahami Monfared, A. A., Byrnes, M. J., White, L. A., & Zhang, Q. (2022). Alzheimer’s Disease: Epidemiology and Clinical Progression. Neurology and therapy, 11(2), 553–569. https://doi.org/10.1007/s40120-022-00338-8
Yiannopoulou, K. G., & Papageorgiou, S. G. (2020). Current and Future Treatments in Alzheimer Disease: An Update. Journal of central nervous system disease, 12, 1179573520907397. https://doi.org/10.1177/1179573520907397
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