Discussion w2 650

DQ-1

Gait dysfunction in older adults.

Symptom- Gait Dysfunction or gait disorder (GD). GD is the result of the complex interplay of major parts of the nervous, musculoskeletal, and cardiorespiratory systems and influenced by age, personality, mood, and sociocultural factors. Gait disorders lead to a loss of personal freedom, falls, and injuries and result in a marked reduction in quality. GD may indicate cerebrovascular or other acute lesions in the nervous system, and also systemic diseases or adverse effects of medication including sedatives (polypharmacy). One-third of the population between age 60 and 97 years had a GD with a marked increase in prevalence with age and two-thirds of those have a neurological and one half has a non-neurological cause (Pirker, & Katzenschlager (2017). It can be Rule out with a careful history and physical examination which direct further diagnostic tests.

Vascular- Hemorrhagic stroke can be ruled out CT and ischemic stroke by MRI.

Infection- Meningitis shows up with nuchal rigidity (neck pain) and lumbar puncture for CSF culture and analysis may rule out the cause.

Neoplasm. Brain tumors manifested by acting indifferent, CT head, and more detail study with MRI.

Drugs- Altered mental status can be ruled out by urine drug screen and careful history from the caregiver/significant other on a medication history of sedating or blood pressure lowering effects such as tricyclic antidepressants, sedatives, anxiolytics, neuroleptics, poisons, opioid pain medications, antidiabetic drugs, antihypertensives, and alcohol intoxication and polypharmacy.

Inflammatory/idiopathic: Hip osteoarthritis cause antalgic gait with Trendelenburg sign according to Pirker, & Katzenschlager (2017), and maybe ruled out by CT.

Congenital: muscular dystrophy may be ruled out by EMG studies.

Autoimmune: cerebral ataxia from cerebellar vasculitis by tested by Romberg’s and rule out CT head. (Caffarelli, Kimia, & Torres, 2016).

Trauma: intracerebral bleed or bleeding in the meningeal layers maybe rule out by any trauma history and CT head.

Endocrine/metabolic: Hypoglycemia with metabolic derangement occurs with electrolyte imbalance that may be ruled out by doing a BMP.

Social/psych: dementia maybe rule out by cognitive screening tests and MRI may show brain encephalopathy and microvascular changes.

Reference.

Caffarelli, M., Kimia, A. A., & Torres, A. R. (2016). Acute ataxia in children: a review of the differential diagnosis and evaluation in the emergency department. Pediatric Neurology, 65, 14-30. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0887899415302757

Pirker, W., & Katzenschlager, R. (2017). Gait disorders in adults and the elderly: A clinical guide. Wiener klinische Wochenschrift, 129(3-4), 81–95. Retreived from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5318488/

DQ-2

Experiencing cold hands and feet, even when not in a cold environment, is quite common and usually not a cause for concern. However, constantly experiencing cold hands and feet, particularly if accompanied by color changes, can be a result of many conditions, such as tissue damage, poor nerve function, and blood circulation (Wollina et al., 2018).

Vascular- Buerger’s disease, Atherosclerosis

Atherosclerosis is diagnosed based on patient risk factors such as having a high-fat diet, tobacco smoker, alcohol use, hypertension, and diabetes. In addition to a physical exam, which may reveal carotid bruits, an ankle-brachial index, stress test, cardiac catheterization, and magnetic resonance angiography will confirm the diagnosis (Bae et al., 2018).

Infection-sepsis, gangrene

Septic patients may present with hypothermia as a result of decreased blood flow and the body’s inability to maintain homeostasis.

- In addition, to abnormal vital signs, serial lactic acid, C Reactive Protein, d-dimer, and procalcitonin can be elevated in patients with invasive bacterial infections and part of the systemic response in severe sepsis (Drewry, Fuller, Skrupky, & Hotchkiss, 2015).

Neoplasm-Myelodysplastic syndrome, leukemia

Multiple tests are needed to confirm a diagnosis, and subsequently, to stage leukemia. Helpful initial studies include a complete blood count (CBC), complete metabolic panel, and coagulation panel, which are often followed by a peripheral blood smear and a bone marrow specimen. A bone marrow aspiration and biopsy are often required for the diagnosis of acute leukemias and would be diagnosed based on observing greater than 5 percent blasts. For chronic leukemias, peripheral blood evaluation is often enough, and an invasive bone marrow biopsy may not be needed (Hollier, 2018).

Drugs- Propanolol, Lithium, Amoxapine, chemotherapy

Discussion of the patient’s past and current medications will help determine if the patient’s symptoms are related to their medications.

Inflammatory/Idiopathic- Iron deficiency anemia secondary to inadequate dietary iron, frequent blood donations, or heavy menstruation.

Peripheral smear would show hypochromic, microcytic red blood cells (MCV less than 80 fL), an increased total iron-binding capacity, low transferrin saturation, low serum ferritin, and decreased reticulocyte count. The CBC would also show a hemoglobin level of less than 12 g/dL in adults (Hollier, 2018).

Congenital- Perniosis

Rett's syndrome is a rare genetic mutation affecting brain development in girls. Infants seem healthy during their first six months, but over time, rapidly lose coordination and the inability to walk or use their hands. Additional symptoms include seizures, the inability to talk, and cold extremities.

Diagnosis involves careful observation of your child's growth and development and a genetic test that searches for the MECP2 mutation on the child's X chromosome (Wollina et al., 2018).

Autoimmune- Raynaud's phenomenon/syndrome, scleroderma, rheumatoid arthritis, lupus

Raynaud's phenomenon/syndrome (secondary Raynaud's), caused by autoimmune or connective tissue diseases such as lupus or rheumatoid arthritis.

-The cold stimulation test for Raynaud’s disease is a test that measures the temperature of each finger after they are placed in an ice-water bath (Wollina et al., 2018).

Trauma- frostbite

During the early stage of frostbite, patients may experience "pins and needles," throbbing or aching in the affected area, which may become cold, numb, and white.

-The diagnosis of frostbite is usually made based on your signs and symptoms, the appearance of the skin, and a review of recent activities in which the patient had been exposed to cold. Additional tests may include an X-ray, a bone scan, or an MRI (Bae et al., 2018).

Endocrine/Metabolic- Hypothyroidism

-A low level of thyroxine and a high level of TSH indicate an underactive thyroid (Hollier, 2018).

Social/Psych- anorexia, bulimia, post-traumatic stress disorder

-Diagnosing anorexia nervosa includes a careful history, mental and physical exam, noting the patient’s preoccupation about weight loss, having a disturbance in body image, participates in strenuous exercise, amenorrhea, swelling of parotid and submandibular glands, and evidence of osteopenia or osteoporosis (Hollier, 2018).

 

Bae, K. H., Jeong, Y. S., Go, H. Y., Sun, S. H., Kim, T. H., Jung, K. Y., Song, Y. K., Ko, S. G., Choi, Y. K., Park, J. H., Lee, S., Lee, Y., & Jeon, C. Y. (2018). The definition and diagnosis of cold hypersensitivity in the hands and feet: Finding from the experts survey. Integrative medicine research, 7(1), 61–67. https://doi.org/10.1016/j.imr.2017.11.001

Drewry, A. M., Fuller, B. M., Skrupky, L. P., & Hotchkiss, R. S. (2015). The presence of hypothermia within 24 hours of sepsis diagnosis predicts persistent lymphopenia. Critical care medicine, 43(6), 1165–1169. https://doi.org/10.1097/CCM.0000000000000940

Hollier, A. (2018). Clinical guidelines in primary care. LA: Advanced practice education associates.

Wollina, U., Koch, A., Langner, D., Hansel, G., Heinig, B., Lotti, T., & Tchernev, G. (2018). Acrocyanosis - A Symptom with Many Facettes. Open access Macedonian journal of medical sciences, 6(1), 208–212. https://doi.org/10.3889/oamjms.2018.035

DQ-3

Joint pain can be involved in a number and a variety of diseases all with different etiologies (Ahmed Saad et al., 2018). Each disease process usually can be ruled in or out with at least one diagnostic test that reveals surrounding tissue or bone involvement and is most likely the cause of the joint pain (Ahmed Saad et al., 2018). 

Vascular- Avascular Necrosis- Can be associated with localized breaks that are not seen on initial x-rays, also associated with long term steroid use with alcohol consumption, the most common location is the hip (Ahmed Saad et al., 2018). Tests include an X-ray, CT scan, MRI, Bone Scan to quickly rule in or out (Joint Pain, 2018). 

Infection- Septic Arthritis- Infection of the joint that causes joint inflammation, pain, and swelling (Joint Pain, 2018). This can be diagnosed by a thorough assessment of the joint looking for hallmark signs of inflammation such as lesions involvement, redness, tenderness, pain, and elevated temperature (Joint Pain, 2018). 

Neoplasm- Tumors rarely affect the joint itself, but tumors of surrounding tissues can invade the joint and cause damage to the structure (Ahmed Saad et al., 2018). Two rare tumors of the synovial lining-synovial chondromatosis and pigmented villonodular synovitis can occur and are found by Xray CT or MRI of the affected joint (Joint Pain, 2018). 

Drugs- There are drugs that can cause joint pain and swelling, the top three are levofloxacin, statins, and Actonel for osteoporosis (Ahmed Saad et al., 2018). 

Inflammatory/Idiopathic- The most common cause of inflammatory joint pain is actually Gout, and diagnosis includes lab work of WBCs, ESR, Xray and Serum uric acid levels but compared against the patient's presenting signs and symptoms (Joint Pain, 2018). 

Congenital-Arthrogryposis multiplex congenital- is a congenital defect that affects joints, whose etiology actually lies in the surrounding musculature not forming properly leading to muscle weakness and improper formation and growth of the involved joints (Joint Pain, 2018). This disease is usually found on the assessment of the child's joints, and the findings that one or two joints are asymmetrical, or the long bones attached are asymmetrical (Joint Pain, 2018). 

Autoimmune- Rheumatoid Arthritis is the number one joint involved autoimmune disease and is diagnosed by the patient's presenting signs and symptoms compared to the Rheumatoid Arthritis Classification along with Xrays and Autoimmune studies (Joint Pain, 2018). 

Trauma- Initial trauma can cause pain and inflammation to the affected joint, but Post Traumatic Osteoarthritis results from the scarring and healing process of the traumatic joint (Joint Pain, 2018). Usually, highly active people or athletes experience this and are diagnosed upon assessment with comparison to the patient's presenting signs and symptoms (Joint Pain, 2018). 

Endocrine/Metabolic- Hypothyroid Arthritis- caused by hypothyroidism leading to protein storage in connective tissues, however, if the connected tissue is a joint area, proteins could be stored there leading to painful joints without inflammation (Joint Pain, 2018). This diagnosis is based on an assessment of the patient's presenting signs and symptoms against their health history and the unique flag of no inflammation in the affected joint (Joint Pain 2018). 

Social/Psych - A classic social joint pain usually involves the knees and is experienced by males ages 40-50 after an extreme activity that they do not normally perform (Joint Pain, 2018). An example is someone joining a pick-up football game over a weekend and experience post-exercise joint pain (Joint Pain, 2018). A  diagnosis is made after a comparison of the patients presenting signs and symptoms against their recent social history (Joint Pain, 2018). 

References:

Ahmed Saad, A. A. E., Al-Ashkar, A. M. A., Mohamed Fahmy, A. M. A., Hassan, N. F. I., & Abdulkhaliq, M. S. A. (2018). Role of Ultrasound in Assessment of Joint Pain among Hemodialysis Patients. Egyptian Journal of Hospital Medicine, 72(5), 4523–4526.

Joint Pain. (2018). Care On Point. APEA. Retrieved October 29, 2020, from https://app.careonpoint.com/Search.aspx