DQ Reply 13 634

Question 1

Benign Prostate Hyperplasia Summarize and discuss the clinical characteristics and identify the appropriate laboratory, imaging, and other diagnostic and screening tools that apply to this condition or disorder. Why did you select these tests or tools as being appropriate to this scenario? Support your summary and recommended plan with a minimum of two peer-reviewed references in addition to the course materials.

Question 2

Imagine a patient comes into your office with your selected condition or disorder. What elements in the patient history and physical exam would indicate the patient has the selected condition or disorder? Select two differential diagnoses that could be applied to this patient. How did you arrive at the two differential diagnoses? Include history and physical examination findings that would support each of the two alternative diagnoses.

DQ-1

Osteoporosis is difficult to diagnose. It is classified as thinning and bone mass reduction that results from depletion of calcium absorption. We can only suspect osteoporosis in an older patient based on age and gender. Clinical characteristics to identify osteoporosis in older adults may be related to assessing the patients risk factors that may make osteoporosis more prevalent. Some risk factors that may put the patient at risk are having a family history of osteoporosis, estrogen deficiency, calcium or vitamin D deficient, use of alcohol and or nicotine. Patients that may be immobilized because of illness or are not able to move more frequently may be at risk. Advance age, female gender, estrogen and or testosterone deficient, cigarette smoking, excessive phosphate ingestion on the diet, sedentary lifestyle (Dymkowska-Malesa, Sterczyńska,2018). Medications such as steroids, thyroid supplements and anticonvulsive medication may decrease calcium reabsorption. Some diagnostic studies that can help me diagnose osteoporosis are bone mineral density measured by dual-energy X-ray absorptiometry scan DXA spine, total hip or femoral neck for all women older than 65. Bone mineral density Z scores and T scores are compared and matched to the patients current age. Osteoporosis is confirmed if there are greater than 2.5 standard deviations below the mean. For these patients, it is good to analyze the fracture risk assessment tool. This will give us a probability of patient may experience a fracture. This tool helps initiate the need for treatment considering the osteoporotic fracture probability and the hip fracture probability. These tests are essential to accurately identify bone density measurements. Patients that are at risk and that fall a little short of the required density allowed in order to be in the preventive stage, I will recommend an exercise program with weight bearing in order to help slow the osteoporosis progression or even stimulate some bone growth to help reverse the disease (Tong,Chen, Zhang,Huang,Shen,Xu,Zou2019). Adequate sun exposure and intake of calcium in foods or multivitamins may help stimulate calcium absorption and bone remodeling. Patients that osteoporosis is identified by using the diagnostics mentioned above, may be started on bisphosphonates 10mg po daily.

 

Dymkowska-Malesa, M., & Sterczyńska, M. (2018). Dietary Behavior and Lifestyle of Women at Risk of Osteoporosis. Carpathian Journal of Food Science & Technology, 10(5), 170–180.

 

Tong, X., Chen, X., Zhang, S., Huang, M., Shen, X., Xu, J., & Zou, J. (2019). The Effect of Exercise on the Prevention of Osteoporosis and Bone Angiogenesis. BioMed Research International, 2019, 8171897. https://doi.org/10.1155/2019/8171897

DQ-2

Dementia is a syndrome of chronic progressive cognitive decline resulting in functional impairment. VD is the second most common cause of dementia after Alzheimer’s disease affecting the elderly of age greater than 65 years with a variable presentation and unpredictable disease progression (Uwagbai, Kalish, 2020). In VD clinical symptoms and signs vary depending on the locations and size of the lesion and are distinguished from other forms of dementia in that, it results from brain ischemia although the event may be subtle or unnoticed (Uwagbai, Kalish, 2020). Approximately 15-17% of all dementia syndrome is vascular in etiology and incidence increases with age, with the risk of doubling approximately every five years and the risk factor of VD, include hyperlipidemia, hypertension, diabetes mellitus, and tobacco use (Uwagbai, Kalish, 2020). The symptoms reported by patients and families may include forgetfulness, including household finances or occupational activities which is commonly expressed as “ forgetting” even non-memory domains are primarily involved confusion or decreased ability to perform cognitive demanding activities, alteration in mood and behavior associated with later-life onset depression, apathy, and psychosis (Smith, 2017).

Diagnosis of VD is obtained by a thorough history from patients that may be limited and hence family/caregiver reports are important any dementia. Physical examination including a measure of cognitive and no-cognitive performance by neuropsychological testing of patients may be challenging and not precise due to many different causes of dementia including the potential for mixed dementia syndrome (Uwagbai, Kalish, 2020). The clinical exam should aim to discover neurological dysfunction in a vascular territory related to prior stroke, signs of motor and sensory dysfunction related to small vessel disease, and a careful history of the setting and circumstances of forgetfulness to anticipate which cognitive domain is involved (Smith, 2017). I will be focusing on neurological, cranial nerves and reflexes after a thorough history and standardized neuropsychological testing, standardized clinical criteria such as ICD -10 (F01 vascular dementia), DSM-5 criteria may be used in the diagnosis (Shaji, Sivakumar, Rao, & Paul, 2018). VD patients have significantly more agitation and sleep disturbances than Alzheimer’s dementia (AD) patients while AD patients have more delusions and have significantly higher white matter hyperdensity volumes in MRI (Anor, O'Connor, Saund, Tang-Wai, Keren, & Tartaglia, 2017). In VD, needed to do a cognitive performance test and rule out other secondary causes of cognitive decline such as depression by Geriatric Depression Scale, thyroid disorder by TSH, medications and alcohol abuse using drug screen tests, infectious and metabolic cause by doing a CBC, Metabolic panel, Vit B12, HIV and syphilis (VDRL test).

If the patient demonstrates any focal neurological deficits or acute change in mental status, Then MRI is a preferred imaging modality (Uwagbai, Kalish, 2020). Neuroimaging is crucial to rule out the many differentials in vascular dementia even though it is an expensive one, which is worthwhile and to lessen the anxiety of the patient, family, and an answer to the clinician in challenging cases. Getting the help of a neurologist or neurosurgery depending on the etiology will be planned as well depending on the severity. The management by use of non-pharmacological strategies (psychosocial interventions) over pharmacological agents was preferred in these older population due to the pharmacokinetics and age risk factors of elderly and care setting also needs to be planned as well depending on the resources and patient’s severity of symptoms (Shaji, Sivakumar, Rao, & Paul, 2018).

Reference.

Uwagbai, O., Kalish, V.B. [Updated 2020 Mar 24]. Vascular Dementia. In Statpearls [Internet]. Treasure Island (FL): Statpearls Publishing; Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430817/

Anor, C. J., O'Connor, S., Saund, A., Tang-Wai, D. F., Keren, R., & Tartaglia, M. C. (2017). Neuropsychiatric symptoms in Alzheimer's disease, vascular dementia, and mixed dementia. Neurodegenerative Diseases, 17(4-5), 127-134. Retrieved from https://www.karger.com/Article/Abstract/455127

Smith, E. E. (2017). Clinical presentations and epidemiology of vascular dementia. Clinical Science, 131(11), 1059-1068. Retrieved from https://portlandpress.com/clinsci/article/131/11/1059/71608/Clinical-presentations-and-epidemiology-of

DQ-3

In elderly patients, failure to thrive (FTT) describes a state of gradual decline in physical and/or cognitive function that usually accompanied by weight loss and social withdrawal. FTT is often multifactorial and may be caused by chronic concurrent diseases, drug reactions, and functional impairments or occurs without immediate explanation. Manifestations of this condition include weight loss, malnutrition, impaired physical function, depression, and cognitive impairment. Both age-related and sociodemographic factors predispose the elderly to FTT (Palmer, 2012).

The diagnostic evaluation of patients with FTT includes a targeted history and physical examination, a review of the patient's medications, the impact of existing chronic diseases, cognitive and physical function, mood, and selected laboratory studies. The assessment of physical function would include documentation of a patient’s ability to perform activities of daily living. The Katz ADL scale assesses a patient’s ability to perform six related functions: bathing, dressing, toileting, transferring, continence, and eating. The Lawton IADL scale examines a patient’s ability in such tasks as telephone use, shopping, transportation, budget management, adhering to medication regimens, cooking, housekeeping, and laundry(Robertson & Montagnini, 2014). The “Up & Go” test is a performance-based measure that asks the patient to rise from a sitting position, walk 10 feet, turn, and return to the chair to sit. Patients who complete the test in less than 20 seconds are generally independent for basic transfers, whereas those that take more than 30 seconds to complete the test tend to be more dependent and at a higher risk for falls(Palmer, 2012).

 Assessment of malnutrition involves weight trend and a dietary history that includes daily caloric intake, the availability of food, the number of meals, and the balance of nutrients. Patients also should be assessed for ill-fitting dentures, problems with speech or swallowing, medication use that might cause anorexia or dysgeusia, and financial and social problems that may be contributors to malnutrition. Laboratory evaluations would include a complete blood count, chemistry panel, thyroid panel, urinalysis, vitamin levels such as D and B12. The most accurate evidence of malnutrition in an elderly patient is hypocholesterolemia and hypo-albuminemia. Evaluation of psychosocial function would include an assessment of the patient’s cognitive status, mood, and social setting. The Mini-Mental State Examination is an important screening tool for cognitive disorders in the community and hospital settings. Information on the patient’s social network, relationships, family support, living situation, financial resources, abuse, neglect, and recent loss are also important aspects of the assessment of FTT (Robertson & Montagnini, 2014).

The most common psychiatric condition in older persons is depression, which makes screening for depression necessary for all patients who exhibit characteristics of FTT. Elderly patients who are depressed are more likely to complain of physical problems than to mention conventional depressive symptoms such as mood changes. Useful screening tools for depression include the Geriatric Depression Scale and the Cornell Scale for Depression in Dementia (Palmer, 2012).

 As providers, we should recognize the diagnosis of FTT as a key decision point in the care of an elderly person. Early recognition and management of FTT can reduce the risk of further functional deterioration, hospitalization, or nursing home placement. Interventions should be directed toward easily treatable causes of FTT with the goal of maintaining or improving overall functional status and quality of life (Palmer, 2012).

 

Palmer R. M. (2012). 'Failure to thrive' in the elderly: diagnosis and management. Geriatrics, 45(9), 47–55

Robertson, R. G., & Montagnini, M. (2014). Geriatric failure to thrive. American family physician, 70(2), 343–350.