Nursing

CASE

MD is a 66 years old Female, c/o so much weakness, coldness and inability to sleep for almost 3 months

BP  140/ 80, PR: 86 RR: 20 Temp 97.0 Weight: 128 lbs, Height: 66 in, BMI: 20.7

Last got her blood work done around 2 years ago

she has been having normal bowel and bladder habits,

no chest pain or shortness of breath.

no complaints of headache, dizziness, or loss of consciousness

not in any medication

To prepare:

• Select a patient that you examined during the last three weeks that suffered from any HEENT condition. With this patient in mind, address the following in a Focused Note:

Assignment:

• Subjective: What details did the patient provide regarding her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment:What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan:What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• Reflection notes:What would you do differently in a similar patient evaluation?

ANSWER

Medical Diagnosis

Many people undergo various uncomfortable conditions in their daily lives without really knowing what the discomforts are medical. Some might experience sight difficulties, walking difficulties, waste pains, limb movement difficulties, ear problems, amongst others. A good percentage of the victims typically opt to visit medical facilities for diagnosis, while some people usually ignore the complications, assuming that it is temporary. It is always advisable to see a medical specialist advise on the difficulties rather than guessing, which might later lead to serious medical issues if not taken care of. This paper focuses its discussion on a case study of a patient who visited a medical facility with several complaints that were causing her discomfort; this article analyzes the complaints to determine the illness and finally gives the necessary recommendations.

The patient was a female aged 66 years; she had her blood work done last two years ago, her bowel and bladder habits were regular, no chest pain or shortness of breath noted. She had no complaints of dizziness, headache, or loss of consciousness, and she also had difficulty sleeping for the past three months. Some of the observations made during the physical assessment were so much weakness, coldness, BP of 140/80, PR 86, RR 20, the temperature of 97.0 Fahrenheit, weight of 128 lbs., the height of 66 inches, and BMI of 20.7. From these observations, the first diagnosis would be chronic insomnia, usually characterized by long-term difficulty sleeping. There are two types of chronic insomnia: primary and secondary; primary insomnia is not related to other medical conditions or medications, while secondary insomnia is related to medical issues like stress, trauma, and lifestyle patterns (Abad & Guilleminault 2018).

Patients with this illness usually experience several nights of waking up or waking up early in the morning and finding it difficult to fall back to sleep. The victim patients do experience fatigue during the day, low energy, and poor concentration. This illness’s occurrence is common in older adults due to frequent experience of tiredness in the evening and waking up early in the morning. Some of the common causes of chronic insomnia are changes in sleep patterns common in older people, sleep disorders like apnea or restless leg disorders and health conditions like dementia. Other causes include chronic pain, diabetes or Alzheimer’s, smoking, lack of physical activity, excessive consumption of alcohol or caffeine, depression, anxiety or smoking. Studies have also shown that most elderly individuals experience lighter and shorter sleep periods generally caused by the aging process or medications’ side effects.

The second diagnosis would be anemia; this commonly occurs when a patient does not have sustainable red blood cells in the blood, generally due to the body’s failure to produce sufficient red blood cells. The body destroys them or in worse cases, heavy bleeding from the affected patient. Iron-deficiency anemia typically occurs when the body does not have the required iron to produce sufficient healthy and sustainable red blood cells. Some of the causes of iron-deficiency anemia are blood loss, low diet, inflammatory bowel disease or pregnancy (not applicable in this case). Finally, the third diagnosis would be Vitamin B12 deficiency; vitamin B12 plays a crucial role in producing red blood cells and DNA. The vitamin usually is found in animal foods, poultry, fish, meat, dairy, and eggs; it can also be found in improved products like plant-based milk and bread. Vitamin B12 is usually common in the elderly. High risks of contracting this disease are deficiency of a balanced diet or unable to absorb the vitamin from food consumption. The absorption rate of vitamin B12 gets lower with age; hence the common nature in the elderly. Other causes of Vitamin B12 deficiency are excessive drinking, weight loss surgery, removal of the stomach, atrophic gastritis, pernicious anemia, celiac disease, bacterial growth or Crohn’s disease, and having a consistent vegan diet (Sahin et al., 2016).

The plans that were in place for the diagnostics were; for iron-deficiency anemia, I would recommend consumption of iron supplements and a change of diet. For Vitamin B12 deficiency, I would recommend injections of hydroxocobalamin since it stays in the body for a more extended time than the other injection (cyanocobalamin). The injections would be administered daily for two weeks until improvement of symptoms; the treatment plan would depend on whether the deficiency is diet-dependent or resulting in any neurological problems like behavior, thinking and memory. For the primary diagnosis, chronic insomnia, the treatment would depend on the illness’s cause, with both medication and therapy as critical solutions. Some of the treatment recommendations are Cognitive Behavioral Therapy (CBT), which involves creating awareness on the sleep and good sleeping habits and teaching the patient against the beliefs and behaviors common with sleep interference. Strategies involved in the CBT are cognitive techniques; using journaling to note down areas of concern before going to bed; stimulus control ‘which consists of the changing of habits that conditions the patient’s brain to fight sleep, determination of sleep and wake up times plays a vital role in this strategy (Green 2017).

Other CBT strategies include sleep restriction, relaxation techniques, and paradoxical intention, which involves staying awake in bed instead of falling asleep. There are various medications that I would recommend for the patient to curb the illness. Some of the most effective medications for the treatment are ramelteon, temazepam, doxepin, zolpidem and suvorexant. Over the counter sleep aids would involve absorption of valerian root, chamomile tea, diphenhydramine and melatonin. Management of chronic insomnia conditions can be achieved by consistent consultation with the doctor in charge of changing medications or treatment plans if a prescribed drug is causing insomnia and changes in the treatment plan, thereby either managing or preventing insomnia. Besides, there are several home remedies that I would recommend to be adopted; engagement in regular physical activity, avoiding consumption of large meals in the evening, avoiding caffeine, limiting alcohol and cigarettes before bed and avoiding naps.

One of the things I would do differently in a similar patient evaluation is to admit the patient and monitor her response to the medication for a few days before discharging her and have the patient undergo MRI to evaluate and monitor the body’s physical organ processes. Finally, I would have the patient diagnosed with many other potential illnesses to determine the exact cause of weakness, cold, and lack of sleep. In conclusion, people should visit medical professionals in case of any slight body complications since one might never know its seriousness and the most suitable remedy.

References

Abad, V. C., & Guilleminault, C. (2018). Insomnia in elderly patients: recommendations for pharmacological management. Drugs & aging, 35(9), 791-817.

Green, R. (2017). Vitamin B12 deficiency from the perspective of a practicing hematologist. Blood, 129(19), 2603-2611.

Sahin, S., Tasar, P. T., Simsek, H., Çiçek, Z., Eskiizmirli, H., Aykar, F. S., … & Akcicek, F. (2016). Prevalence of anemia and malnutrition and their association in elderly nursing home residents. Aging clinical and experimental research, 28(5), 857-862.

Ren, Q., Shi, Q., Ma, T., Wang, J., Li, Q., & Li, X. (2019). Quality of life, symptoms, and sleep quality of elderly with end-stage renal disease receiving conservative management: a systematic review. Health and quality of life outcomes, 17(1), 1-9.