Sample Case Study Mr M

Sample Case Study Mr M

Case Study: Mr. M

Aging is a risk factor for various diseases. According to the World Health Organization’s study on global health and aging, psychiatric illnesses, such as dementia, schizophrenia, and walking impairments, are among the health concerns that develop as people age. Mr. M’s clinical presentation may point out illnesses associated with aging. However, it is necessary to rule out other conditions that may present with similar symptomatology and clinical findings.

Clinical Manifestations

From the case scenario, Mr. M presents with the following subjective clinical manifestations: He has a significant memory impairment (he has difficulty recalling the names of his family members and his room number, and he has been wondering about and frequently found lost due to difficulty finding his way home), an intellectual impairment (he cannot repeat what he has just read), and intermittent emotional outbursts (he becomes excessively agitated and easily aggressive). He also exhibits personality disintegration and a lack of personal care; he is unable to undertake everyday duties on his own and must rely nearly entirely on the support of others.

Mr. M walks with an unsteady gait, although his vital signs are within normal limits. Laboratory blood tests demonstrate significant leukocytosis and lymphocytosis, while urinalysis reveals cloudiness and the presence of leucocytes, pointing towards a urinary tract infection. Proteins are within the normal range, which is usually 6.4-8.8 g/dl (Sack, 2020). He is overweight, with a Body Mass Index (BMI) of 27.8. Additionally, although his liver function tests indicate a normal level of liver enzymes, the aminotransferases are slightly elevated with an AST: ALT ratio of 1.103. This ratio deviates from the normal AST: ALT ratio, which is close to one.

Primary and Secondary Diagnosis

A diagnosis can be primary or secondary. Primary diagnosis refers to the most serious condition upon hospitalization, or rather, the reason for the visit, whilst secondary refers to other diagnoses that require attention.

Primary diagnosis: The symptomatology and diagnostic studies of Mr. M are suggestive of dementia. His advanced age (70 years old) is a risk factor for dementia. In reference to DSM-5, clinical presentations of dementia include impaired memory with clear consciousness (he forgets recent events, the names of his family members and becomes lost in familiar places), personality and behavioral changes, for example, wandering, emotional changes such as increased aggression (he becomes agitated and aggressive quickly), and impaired intellectual functions (having increasing difficulty with communication and needing help with personal care), among others (Bacigalupo et al., 2018).

Secondary diagnosis#1: Viral hepatitis. Laboratory workups reveal leukocytosis with predominantly marked lymphocytosis. Lymphocytosis points towards an infection, particularly viral (Cullen & Lemon, 2019). A slightly elevated AST/ALT ratio depicts hepatocellular injury, which is characteristic of viral hepatitis. The evidence of leucocytes in urine and cloudy urine corroborates the infection. This also suggests a urinary tract infection.

Secondary Diagnosis#2: Systemic Inflammatory Response Syndrome (SIRS). SIRS is typically represented by the following parameters: temperatures greater than 38°C or less than 36°C, heart rate (HR) greater than 90 beats per minute, respiratory rate (RR) greater than 20 breaths per minute, and leucocytes greater than 12000uL or less than 4000uL (Moskowitz et al., 2017). Mr. M’s lab work-up revealed a leukocytosis of 19200/uL, an elevated HR of 93b/min, and an elevated RR of 22 breaths/min. This meets the criteria for diagnosing SIRS. This syndrome presents as an initial response to infection but can also be observed in response to the sterile insult of pancreatitis, aspiration pneumonitis, burns, trauma, and post-surgery. Cloudy urine with a moderate number of leucocytes in the urine may indicate the urinary tract as the source of infection resulting in SIRS. In addition to dementia, Mr. M could have a viral infection that is presenting as a SIRS.

Nursing Assessment, Abnormalities Expected and their Explanation

            Nursing assessment is crucial in gathering patients’ information to aid their diagnosis and management. It involves a physical examination and extensive history-taking. Bearing in mind viral hepatitis as a secondary diagnosis in Mr. M, the nursing assessment may reveal jaundice on the examination of the sclera. The liver plays a vital role in the metabolism of hemoglobin from red cell destruction (Ducamp & Fleming, 2018). In the case of viral hepatitis, hepatocytes are damaged and therefore cannot process and excrete bilirubin adequately, leading to increased bilirubin levels in the blood. This may present as jaundice.

Assessment of psychiatric patients is done using the Mental Status Exam (MSE). Mr. M likely has a clear conscience, a labile affect, sensory disturbances, and mental abnormalities such as perseverations and delusions, which may occur in dementia. According to Arvanitakis et al. (2019), dementia is also associated with disorientation in time, place, and person. Impairment of cognitive function and memory can also be elicited during MSE. Impaired memory and cognitive functions such as thinking in Mr. M meet the ICD-10 (2018) criteria that is important in diagnosing dementia (Astudillo-Garcia et al., 2020).

Physical, Psychological and Emotional Effects of Health Status on Patient and Family.

The health status of Mr. M may pose various physical, psychological, and emotional effects on the patient and the family. Difficulty ambulating due to his unsteady gait may limit his mobility. Immobility may predispose Mr. M to deep venous thrombosis (Ro et al., 2017). Mr. M may also experience physical disturbances due to abdominal distension and pain experienced associated with viral hepatitis. His state of forgetfulness and wandering may place him at risk of being assaulted by thugs. The family may experience changes such as disruption to their social, economic, and leisure activities as they take on the responsibility of caring for Mr. M.

As a result of his diagnosis, Mr. M may be subjected to stigma and social demotion. He may experience depression and anxiety, which have a detrimental effect on his self-esteem. His family members and caregivers may feel frustrated by the aggression that may be directed towards them by Mr. M. As Cross et al. (2018) note, this may also predispose them to anxiety and depression. Patients with dementia are prone to experiencing a wide range of emotions, such as anger, amazement, and bewilderment. Because some of Mr. M’s factual recollections have vanished, he may react more emotionally than expected. For example, he may become quickly upset and behave with choleric rage. Lack of knowledge about the disease by family members may result in denial. This may result in delayed treatment that may lead to the worsening of Mr. M’s condition. The family members may feel a sense of loss due to their relative condition, experience shock, and even develop depression (Wittenberg et al., 2019). Therefore, besides Mr. M, his family and caregivers should also seek counseling and health care.

Interventions

It is necessary for Mr. M to seek the necessary interventions to relieve his health status. In addition to his current medications, antiviral therapy can be prescribed for his viral hepatitis after a definitive diagnosis is made through a series of serological tests. Similarly, before starting the management of dementia, it is necessary to rule out other possible differential diagnoses by doing baseline investigations. Mr. M should continue with his therapy for hypertension and hypercholesteremia, which may be predisposing factors for vascular dementia. Low-dose, short-acting benzodiazepines (Lorazepam and Oxazepam) can also be indicated for the treatment of anxiety symptoms (Arvanitakis et al., 2019).

Cognitive Stimulation Therapy (CST) is one of the non-pharmacological interventions that can be useful to Mr. M. Cognitive rehabilitation therapy, such as memory training (e.g., puzzles), can also be indicated to support memory retention and strategies to compensate for cognitive and functional decline (Arvanitakis et al., 2019). In addition, supportive care such as lifestyle modifications, maintaining a familiar environment, a regular sleep schedule, and physical activity may also help in relieving symptoms associated with dementia.

Actual or Potential Problems Based on Mr. M’s Condition

Due to his old age and health condition, Mr. M is predisposed to various problems. Firstly, because he is forced to depend on others to carry out his physical activities such as bathing, grooming, moving, walking, and eating. Secondly, Mr. M’s social interactions are limited to caregivers and healthcare providers, as well as the fact that he suffers from severe memory loss. Such patients, as Helm et al. (2018) notes, are likely to suffer from loneliness and isolation. Additionally, his intermittent explosion of extreme emotions, such as aggressiveness and agitation, may, as Wittenberg et al. (2019) observe, result in fierce arguments, striking out, and violent behavior. Finally, adherence to medication may prove problematic for Mr. M. Due to memory impairment, he may forget taking his medication at the specified time. He, therefore, requires holistic care for him to do well.

References

• Arvanitakis, Z., Shah, R. C., & Bennett, D. A. (2019). Diagnosis and management of dementia: Review. JAMA: The Journal of the American Medical Association, 322(16), 1589–1599. https://doi.org/10.1001/jama.2019.4782
• Astudillo-Garcia, C. I., Jaime, B. P. V., Ávila, X. G., Austria-Corrales, F., & Velásquez, J. J. M. (2020). Trends in dementia consultations in two psychiatric hospitals in Mexico City: 2010‐2018: Health services research / Services. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 16(S10). https://doi.org/10.1002/alz.043393
• Bacigalupo, I., Mayer, F., Lacorte, E., Di Pucchio, A., Marzolini, F., Canevelli, M., Di Fiandra, T., & Vanacore, N. (2018). A systematic review and meta-analysis on the prevalence of dementia in Europe: Estimates from the highest-quality studies adopting the DSM IV diagnostic criteria. Journal of Alzheimer’s Disease: JAD, 66(4), 1471–1481. https://doi.org/10.3233/JAD-180416
• Cross, A. J., Garip, G., & Sheffield, D. (2018). The psychosocial impact of caregiving in dementia and quality of life: a systematic review and meta-synthesis of qualitative research. Psychology & Health, 33(11), 1321–1342. https://doi.org/10.1080/08870446.2018.1496250
• Cullen, J. M., & Lemon, S. M. (2019). Comparative pathology of hepatitis A virus and hepatitis E virus infection. Cold Spring Harbor Perspectives in Medicine, 9(4), a033456. https://doi.org/10.1101/cshperspect.a033456
• Ducamp, S., & Fleming, M. D. (2018). The molecular genetics of sideroblastic anemia. Blood, 133(1), 51–58. doi:10.1182/blood-2018-08-815951
• Helm, L., Balzer, K., Behncke, A., Eisemann, N., & Köpke, S. (2018). Patients with dementia in acute care hospitals: A cross-sectional study of physicians’ experiences and attitudes. Zeitschrift Für Gerontologie Und Geriatrie, 51(5), 501–508. https://doi.org/10.1007/s00391-017-1349-5
• Moskowitz, A., Patel, P. V., Grossestreuer, A. V., Chase, M., Shapiro, N. I., Berg, K., Cocchi, M. N., Holmberg, M. J., & Donnino, M. W. (2017). Quick sequential organ failure assessment and systemic inflammatory response syndrome criteria as predictors of critical care intervention among patients with suspected infection. Critical Care Medicine, 45(11), 1813–1819. https://doi.org/10.1097/ccm.0000000000002622
• Ro, A., Kageyama, N., & Mukai, T. (2017). Pathophysiology of venous thromboembolism with respect to the anatomical features of the deep veins of lower limbs: A review. Annals of Vascular Diseases, 10(2), 99–106. https://doi.org/10.3400/avd.ra.17-00035
• Sack, G. H., Jr. (2020). Serum Amyloid A (SAA) proteins. Sub-Cellular Biochemistry, 94, 421–436. https://doi.org/10.1007/978-3-030-41769-7_17
• Wittenberg, E., James, L. P., & Prosser, L. A. (2019). Spillover effects on caregivers’ and family members’ utility: A systematic review of the literature. PharmacoEconomics, 37(4), 475–499. https://doi.org/10.1007/s40273-019-00768-7