Please Reply to the following 2 Discussion posts:
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DISCUSSION POST # 1 Reply to Reesha
Based on the chief complaints of the patient and his daughter there are a couple of diagnoses that come to my mind that would warrant further investigation or inquiry. It is concerning that the patient has a combination of cognitive impairment and urinary symptoms. However, taking a thorough medical, surgical, social, and family history would give me a better understanding of the patient’s overall health and present condition, so obtaining a HPI is necessary. Was he displaying signs of cognitive impairment long before his urinary symptoms? Does he have a history of BPH? Has he ever had a DRE? What consists of “a lot”? How many times a day is he voiding and what are the characteristics such as color, consistency, and odor. The patient states he “does not like it” but what exactly does that mean, is he having discomfort associated with urination? This is a common complaint relating to a urinary tract infection. UTI’s could cause these symptoms so I would want to initially get a better understanding and ask pertinent questions regarding his urinary symptoms, which include dysuria, urinary frequency, or urinary urgency. Patients with dysuria or UTI also commonly experience burning, stinging, or itching sensation, so I would ask if these are present as well. Obtaining this information, and depending on the outcomes could vary the next steps I would take. Diagnostic tests I would order for his urinary symptoms involve; urine dipstick analysis, urine microscopy, urine culture and sensitivity, and PSA levels to rule out BPH. (Dutta, et, al., 2022). In elderly patients, changes in mental status may be the presenting symptom of a urinary tract infection, manifesting as delirium. It also goes without saying that I would perform a physical exam and since the patient is displaying cognitive decline with trusted family members I would also conduct a Mini-Mental State Examination (MMSE) & MiniCog test that involves three word registration, clock drawing, and three word recall, as I would want to examine him for Dementia. “The Mini-Cog is one such neuropsychological test that has been effective in detecting patients with dementia. It has been shown to yield high sensitivity and specificity for detecting cognitive impairment” (Limpawattana & Manjavong, 2021). Diagnostic tests for Dementia include complete blood count, urinalysis, metabolic panel, Vitamin B12, folic acid, thyroid function tests, and serological tests for certain viral/bacterial infections. (Emmady, et, al., 2022). Brain imaging could be ordered as well if a diagnosis is not able to be placed after history taking and laboratory interpretation. Depending on my laboratory and diagnostic findings and conclusive diagnosis, below are the treatment plans for each differential related to this patient case.
Plan of treatment for UTI: Nitrofurantoin 100 mg capsule course for 5 days. The International Clinical Practice Guidelines, updated in 2010 by the Infectious Disease Society of America and the European Society for Microbiology and Infectious Diseases, recommend nitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days (Rowe, Juthani-Mehta, 2013). Encourage the patient to take medications as prescribed, practice adequate hygiene, promote adequate hydration (etc.)
Plan of treatment for BPH: Alpha blockers cause muscle relaxation and improve flow. Examples include Tamsulosin (400 mcg once daily). Additionally alpha-reductase inhibitors such as finasteride (5mg once daily) can be used conjunctively” (Ng & Baradhi, 2022).
Plan of treatment for Dementia: Two examples of medication classes that have been approved for the treatment for Dementia are cholinesterase inhibitors like Donepezil (Aricept) and N-methyl-D-aspartate (NMDA) receptor antagonists like Memantine (Namenda). Lifestyle modifications such as walking for exercise, balanced diet, adequate hydration, optimal sleep, and adequately managing chronic diseases. Behavioral components should include managing anxiety, agitation, or depression which may involve cognitive therapy or behavioral therapy (Emmady, et, al., 2022).
DISCUSSION POST # 2 Reply to Ella
In the presented case of a 75-year-old male experiencing frequent bathroom visits and memory lapses, a comprehensive diagnostic approach is essential to determine the underlying cause of his symptoms. Given the daughter’s concern about memory issues, one possible concern is the presence of early Alzheimer’s disease or another form of cognitive impairment.
In this case, it is imperative to conduct a more comprehensive assessment due to the concerning findings that may suggest early-stage Alzheimer’s disease as a potential underlying cause. The patient has reported a notable increase in bathroom visits, which raises initial concerns about urinary issues. However, the daughter’s observation of the patient’s occasional inability to remember the bathroom’s location and the repetition of inquiries about it adds a layer of complexity to the clinical presentation.
In light of these observations, it is essential to consider the possibility of cognitive impairment or dementia. To elucidate the nature and extent of these cognitive deficits, I will proceed with a comprehensive cognitive and functional assessment. This assessment will include standardized cognitive screening tests to evaluate memory, reasoning, and executive function. Moreover, I will closely observe the patient’s capacity to carry out essential daily tasks, including independent use of the bathroom.
To reach a diagnosis and establish an appropriate treatment plan, several diagnostic tests and assessments should be considered:
First test that we should consider is to administer a standardized cognitive screening test, such as the Mini-Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA), to evaluate the patient’s cognitive function.
According to (Gallegos et al., 2022), the MMSE, is a test that has become one of the most widely used internationally for the diagnosis and clinical prognosis of cognitive impairment, mainly in elderly patients.
Patient is going to need a detailed medical history, including the onset and progression of symptoms, any relevant family history of cognitive disorders, and any other concurrent medical conditions as well as a detailed physical and neurological examination to assess his overall health.
Blood tests such as a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and an urinalysis should be performed to eliminate the possibility of a Urinary Tract Infection (UTI) or diabetes as contributing factors. UTIs can sometimes lead to confusion, while diabetes may lead to increased frequency of urination.
To gain deeper insights into the patient’s behavior, a careful and continuous monitoring approach is warranted. Specifically, it may be beneficial to closely observe the patient when he goes to the bathroom. This monitoring can help distinguish whether the increased bathroom visits are due to genuine physiological needs or if they are manifestations of repetitive behaviors associated with cognitive impairment. Such meticulous observation is critical for making an accurate differential diagnosis, as it may shed light on whether the patient’s symptoms are primarily related to a cognitive disorder, a urological issue, or a combination of both.
Diagnosis: Early Alzheimer’s Disease
While there is currently no known cure for Alzheimer’s disease, treatment strategies aim to manage symptoms and slow down its progression. The following interventions are recommended:
1. Medication:
Galantamine 8 milligrams (mg) once daily, following the dosage guidelines outlined in Mayo Clinic’s recommendations. This medication is prescribed to enhance cognitive function and alleviate some of the symptoms associated with Alzheimer’s disease.
2. Non-Pharmacological Approaches:
Structured Physical Exercise Program: The patient should be enrolled in a structured physical exercise program tailored to their abilities and preferences. Regular physical activity has shown positive effects in maintaining physical and cognitive health in individuals with Alzheimer’s disease.
Cognitive Stimulation Programs: Participation in cognitive stimulation programs is highly recommended. These programs involve engaging activities and exercises designed to stimulate cognitive functions and improve quality of life for individuals with Alzheimer’s disease. Activities may include puzzles, memory games, and social interactions that help maintain cognitive abilities.
Follow-Up:
A follow-up appointment is scheduled for four weeks from the initial evaluation. During this follow-up, we will closely monitor the patient’s symptoms and assess their response to the current medication regimen. Depending on the evaluation outcomes and the patient’s condition, there may be consideration for an adjustment in medication dosage to 16 mg orally daily.