. Your patient is a 77 year-old woman who has been more socially withdrawn lately and told her daughter she had not been feeling well. While shopping for groceries with her daughter she became separated from daughter in the aisles. She became confused and angry when store employees and others tried to assist her. It is now 30 minutes later.
=Discussion questions part one:
-What is your differential diagnosis based on the information you now have?
-What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.)
The daughter has noticed increased anxiety and confusion in her mother on several occasions
No personal or family history of psychological illness
Problems with abstract thinking
Poor or decreased judgment
Disorientation to time and place
Changes in mood and behavior
Changes in personality
No history of trauma or recent infection
Family history; father and brother have died from stroke and heart disease; mother had Alzheimer disease
Current medications: aspirin, 325 mg. daily; hydrochlorthiazide, 25 mg. bid
No other medical history
No known allergies
Discussion questions part two-1:
Now what do you think about her history?
Alert, elderly woman in no acute distress
T = 37 C orally; P = 85 and regular, RR = 15 and unlabored; B/P 158/88 right arm (sitting)
HEENT, skin, and neck:
Pupils are small, equal, and react to light sluggishly
Ocular fundus is pale; vessels are narrow and attenuated
Dentures present, buccal and pharyngeal membranes are moist without lesions or exudates
Skin pale, dry with senile lentigines
Skin is transparent with decreased turgor
Minor multiple ecchymosis noted on both forearms, no other lesions or abrasions
Trachea is midline, and no lymphadenopathy or thyromegaly noted
Carotid pulses full and equal bilaterally without bruit
No jugular venous distension
Increased anterior/posterior diameter with mild kyphosis
No shortness of breath, lungs clear to auscultation bilaterally
Apical pulse (PMI) at the 5th ICS, left mid-clavicular region
Normal S1, S2; no murmurs, clicks, or rubs
Abdomen, Extremities, Neurological:
Abdomen round, symmetric with no apparent masses, hernias, scars, or lesions
Bowel sounds present and normal; no bruits
Tympanic to percussion in all quadrants with no masses or organomegaly
Extremities symmetric with no swelling, atrophy, redness, cyanosis, or skin lesions, warm bilaterally and all pulses present and equal bilaterally
No lymphadenopathy noted
Orientation to time, person, and place are inconsistent—does not know the day or date
Pinprick, light touch, vibration sensation are intact, and able to identify a key
Motor: no atrophy, weakness or tremor; rapid alternating movements smooth
DTR’s all 2 + with no Babinski noted
Gait slightly wide based and unable to tandem walk
Joints and muscles symmetric; no swelling, masses, deformities, or tenderness
Mild spinal kyphosis
Joints: smooth range of motion; no crepitation or tenderness noted
Extremities: able to maintain flexion and extension against resistance without tenderness
=Discussion questions part two-2:
-What studies would you initiate now while preparing for intervention?
-What therapies would you initiate immediately while awaiting lab work?
Head CT scan showed one small capsular infarction, no mass lesions or edema, and no hydrocephalus
No significant abnormalities noted in chemistry, hematology, and metabolic screens
MMSE findings of impairment of memory and three other cognitive areas
Geriatric Depression scale (GDS) positive for memory difficulty, disrupted sleep-wake cycle, apathy, increased dependence (classic for Alzheimer disease)
=Discussion questions part three-1:
-What does Alzheimer dementia look like on a CT scan?
EMERGENCY ROOM COURSE:
Patient is cooperative with no apparent distress and becomes less confused with repeated explanation of circumstances
No change in physical exam and no repeat lab studies completed
=Discussion questions part three-2:
-What do you think is happening?
-Now what should be done and what can the patient expect?
Responds to therapy; condition stable
Discharged home in the care of daughter after 24 hours
Referred to neurologist for further evaluation of cognitive deficits and treatment
=Discussion questions part three-3:
-What instructions and medications should this patient go home with?
Identify the interprofessional team necessary to care for this patient.
Describe the roles of each team member.
Explain how you as the advanced practice nurse will work with each team member and the patient to provide current evidenced based care.
What steps can she take to prevent further problems?