Differential Diagnosis of the Nervous System - Essay Example

?The Nervous System Introduction This essay will discuss an incident which starts off with a call with our paramedic unit at about 11:30 for assistance on a 72-year old female who is living with her husband. The husband expressed that he called the ambulance because his wife was starting to turn the gas on and off and insisting that she needed to sit in front of it in order to keep warm. He expressed much distress as she seemed not to recognize him; she also kept mumbling to the oven. On arrival, it is observed that she has turned pale and was still in her nightie. She tried to get to her feet but did not appear to be able to get herself up from her chair. Based on the situation, she may be suffering from the early stages of Alzheimer’s disease and manifesting pre-dementia symptoms. The patient is manifesting agitation and memory gaps, and other symptoms which signal a neurological affectation. This essay shall conduct a review of the patient case, including specific pathophysiology and paramedic interventions with their corresponding rationale. Issues which will be discussed would include: causes of the symptoms, possible diagnosis, implications, and rationale of emergency management interventions. Adequate support from literature shall be established for this study, specifically the implemented interventions. Issues which specifically relate to her senility or her memory gaps, her safety, as well as her agitation will be specifically addressed in this study. These issues have been chosen because they are the issues which have the most impact on the patient’s health and the quality of her life. These issues also pose a danger to her safety in general. Differential diagnosis Based on an assessment of the case, symptoms of the patient include: memory gaps, pallor, distress, agitation, inattentiveness, mumbling to herself, feeling cold, unawareness of surroundings, failure to recognize faces and family members, and limited mobility. Based on my initial observation of symptoms, in descending order of possibility, the patient’s disease may be: Alzheimer’s disease, Pick’s disease, and Depression causing pseudo-dementia. The patient shall have to undergo various diagnostic tests, including X-rays, blood work, MRI or CT scans, and ECG tests, as well as the most accurate patient and family history, in order to determine the most possible diagnosis. An analysis of the results of the test and the patient’s history shall help in the establishment of the patient’s diagnosis. Differential diagnosis: Potential Alzheimer’s disease caused by reduced synthesis of neurotransmitter acetylcholine. Pathophysiology of Alzheimer’s disease: Based on the symptoms manifested by the patient, she may be suffering from Alzheimer’s disease. The cause of Alzheimer’s disease is generally unknown, but initial damage includes the loss of neurons and synapses in the cerebral cortex as well as some areas of the subcortical region (Desikan, et.al., 2009). Such loss causes atrophy in these affected areas, including significant degeneration in the temporal and parietal lobe, as well as the cingulated gyrus (Desikan, et.al., 2009). Significant reduction in the size of specific regions of the brain would manifest as the disease progresses. In MRI reports, amyloid plaques and neurofibrillary tangles are visible for Alzheimer’s disease patients, with dense features, as well as insoluble deposits of amyloid-beta peptide and cellular material surrounding the neurons (Tiraboschi, et.al., 2004). These tangles appear as aggregations of protein tau which usually accumulates inside the cells (Tiraboschi, et.al., 2004). These plaques are common among older adults, but are even more numerous among Alzheimer’s disease patients. The exact link between the accumulation of beta amyloid and the manifestation of Alzheimer’s disease symptoms has yet to be established (Van Broeck, et.al., 2007). The amyloid theory refers to the aggregation of beta amyloid peptides which often leads to neuron degeneration (Van Broeck, et.al., 2007). When the amyloid fibrils which has a toxic effect to cell calcium homeostasis would accumulate, cell death would result (Van Broeck, et.al., 2007). Build-up of A? in the mitochondria is also seen among Alzheimer patients, and such build-up leads to the blockage of enzyme functions, as well as the uptake of glucose by the neurons (Chen and Yan, 2006). With the death of the cholinergic neurons, there would also be a deficit in the acetylcholine which is the transmitter for memory (Chen and Yan, 2006). This would help explain the memory issues common among Alzheimer’s disease patients. Mutations in the chromosomes 21, 14, and 1 have also been seen among these patients and can cause a familial and early manifestation of the disease (Waring and Rosenberg, 2008). These mutations represent about 5% of the cases of Alzheimer’s and can lead to the increase and deposit of A?. The mutations in Chromosome 21 are common among Alzheimer’s patients, as well as Down syndrome patients (Evans and Swan, 2012). The Alzheimer’s disease diagnosis is the more likely diagnosis for this disease, not Pick’s disease because the patient manifested the memory loss first before the personality changes (Sadock and Sadock, 2008). The wife did not appear to remember her husband and was acting unfamiliar with her environment. This sets the disease apart from Pick’s disease which usually manifests with personality changes first before any form of memory loss manifests (Sadock and Sadock, 2008). The symptoms also did not indicate signs which relate to depression which may cause pseudo-dementia (Sachdev and Reutens, 2003). Although the patient manifested the possible symptoms of pseudo-dementia, which included loss of memory, vagueness, and slowing of movement, further assessment did not reveal any depression or any major depressive episode (Sachdev and Reutens, 2003). Hence, based on a thorough assessment of her symptoms, as well as the elimination of other possible diagnosis, the patient is suffering from Alzheimer’s disease. Paramedic Clinical Practice Interventions and Rationale According to the South Australia Ambulance Service (2012), the ambulance services provide emergency, non-emergency and support services to individuals who need it. In this case, the case does not appear to be an emergency as none of the issues which require emergency care are present (Airway-Breathing-Circulation). Nevertheless, the patient requires non-emergency care, which may require transport support from her home to the hospital in order to receive medical treatment (SA Ambulance Service, 2012). However, before the patient can be transported, pre-hospital care may be required. Such interventions are discussed below. The pre-hospital interventions that will address the issue of possible Alzheimer’s disease in the patient may be as follows: 1. Establish a supporting and trusting relationship with patient by: speaking calmly and softly, being confident, maintaining eye contact, introducing one’s name and asking the patient her name, and being encouraging, reassuring, and avoiding being critical or frustrated (Industry Skills Council, 2006). 2. Reduce or eliminate risk to patient, to the carer, as well as to the paramedic. 3. Reduce or eliminate stress or situations which can contribute to the patient’s stress. 4. Ensure effective communication (Industry Skills Council, 2006). 5. Ensure that patient’s needs are fulfilled and that the goal of the treatment is based on patient preferences. 6. Ensure continuity of supportive care (Industry Skills Council, 2006) Intervention 1: Establish a supporting and trusting relationship with patient Since the patient is showing signs of agitation, confusion, and anxiety, it is important to speak softly and calmly to her first before any other interventions can be successfully implemented (Wilson, et.al., 2006). In her apparent state of anxiety and agitation, the paramedic workers would not likely be able to approach her without increasing her anxiety. Using more authoritative tones or even loud tones with the patient would likely increase her agitation and even make her uncooperative (Wilson, et.al., 2006). It would be even more difficult to treat uncooperative patients and it would also put the safety of the patient and the carer at risk if the patient would not be sufficiently calmed down for any form of intervention. Speaking softly and calmly is part of the process of promoting and establishing a trusting and supportive relationship with the patient and her carer (Industry Skills Council, 2006). Under these circumstances, it is important for the paramedic to ensure a more positive, controlled and caring attitude towards the patient (Sisman, 2010). Remaining calm can help the paramedics determine secure the cues which can also guide the responses of the patient (Van Amsterdam, et.al., 2012). When the paramedic would portray a calm and supportive demeanour, the patient would also be guided in her responses and would also manifest calm and controlled responses. The calm approach must also be accompanied by a confident approach which is also not loud, arrogant or insensitive to the patient’s situation (Industry Skills Council, 2006). This is because body language is an effective and powerful means of communication and it can be used to portray one’s desire to assist the patient in his health issue (Leckey, 2011). In effect, where a less than therapeutic body language – arrogance, loud tones, and insensitivity – is detected by the patient, she may also become uncooperative and threatened by the paramedics’ demeanour (Leckey, 2011). In order to promote a trusting relationship with the patient, it is important to establish and maintain eye contact whenever appropriate (Industry Skills Council, 2006). Seeking and maintaining eye contact provides an impression of honesty and interest in what the other person is saying. The eye contact must also not be too intimidating or unnecessarily prolonged (Sibson and Mursell, 2010). With proper eye contact, it is possible to ensure that the patient would feel like the paramedics are listening to her, are being honest with her, and are genuinely invested in caring for her (Sibson and Mursell, 2010). It is also important for the paramedic/s to introduce himself/herself to the patient, and to also ask the patient what her name is (Snyder and Christmas, 2003). The reciprocal knowledge of each other’s names establishes a more personal relationship between the paramedic/s and the patient, and also helps promote a feeling of trust, security, and care on the part of the patient (Snyder and Christmas, 2003). Knowing the patient’s name also supports a more personal investment on the part of the paramedic in regard to his/her patient’s recovery. The patient now becomes a name, a person, not just a ‘patient’; and for the patient, the paramedic becomes more than a health worker responding to an emergency call, instead, the paramedic now becomes a lifeline, someone who can help ease her symptoms and health concerns. Under these conditions, the care process becomes faster and more efficient. It is also important for the paramedic to be encouraging and reassuring to the patient, and to avoid manifesting a critical or frustrated demeanour (Industry Skills Council, 2006). Being supportive and reassuring can also help calm the patient down. It can also help her open up about what and how she is feeling. Under the encouragement of the paramedic, a feeling of safety and trust can develop in the patient and consequently, she can be more cooperative, less fearful, and less disorientated (O’Meara, 2005). Intervention 2. Reduce or eliminate risk to patient, to the carer, as well as to the paramedic. Due to the mental state of the patient, it is also important to secure her safety, as well as the safety of the husband and of the paramedic. In order to ensure the safety, the paramedic must first assess the situation and evaluate if there are any safety issues with the patient (O’Meara, et.al., 2012). The patient turning on and off the gas is one risk. Another risk would be knives or any deadly weapons she can get her hands on. Since she does not recognize her husband, she may think he is an intruder, or think that the paramedics are intruders and such scenario may prompt her to defend herself. It is therefore important to neutralize the scene, remove any sharp objects, and to make sure the stove is turned off (O’Meara, et.al., 2012). It is also important to avoid any quick or threatening movements towards the patient which may prompt her to physically attack her husband, family members, or paramedics (O’Meara, et.al., 2012). Avoiding any sudden or threatening movements would also prevent the patient from acting in ways which may cause her further injury (like running and falling down steps, jumping off the window, locking herself in the closet, etc.). The patient’s agitation and confusion can also be defused when the husband is asked to leave the scene momentarily (Mason, et.al., 2007). Sometimes, the patient’s memory lapses may also trigger their agitation and anxiety. It may be possible to make the situation more neutral to the patient and make her calmer and less anxious by removing triggers to their anxiety (Industry Skills Council, 2006). Triggers for agitated behaviour among Alzheimer’s disease patients may also relate to requests to do something (Mason, et.al., 2007). For example, asking to take the patient’s blood pressure or temperature may increase the patient’s aggression or agitation. In this case, it is often best to delay the order or request until such time that the patient has calmed down or her memory gap has lapsed. Intervention 3. Reduce or eliminate stress or situations which may cause stress. In order to reduce stress or situations which may cause stress, it is important for the paramedic to avoid placing the patient in unfamiliar situations, or situations where they would feel out of control (Haskell, 2005). It is therefore ill-advised to bring the patient immediately to the ambulance or the emergency room without calming her down because this would cause her more stress. Instead, staying with her in her room or in a place familiar to her, and then trying to treat and manage her symptoms would make her feel in control of her situation (Haskell, 2005). It would also validate the presence of the paramedic and helps convince the patient that the paramedics do want to help her (Haskell, 2005). Once she recognizes that fact, it may then be possible to convince her to cooperate with the paramedics; and she may then agree to be brought to the hospital for further care. It is also vital for the paramedic to explain intentions and actions. This would help ensure and protect empathy and trust, as well as reduce anxiety (Industry Skills Council, 2006). By making an effort to explain, the patient would be more aware and more ready about what is going to be done to them. Explaining paramedic intentions would make him/her a less threatening presence or person to the patient (Griffith, 2009). It would put across the message that the paramedics do want to help her, not harm her, and that as soon as she lets them help her, she may be relieved of her symptoms. Intervention 4. Ensure effective communication Effective communication is one of the most important interventions for Alzheimer’s disease patients because it can help ensure that the other interventions would be adequately and effectively implemented (Madhu, 2009). Questions asked of the patient must however be short and simple and must be issued in a calm and casual conversational manner. These simple and short questions are important because more often than not, Alzheimer’s patients cannot sufficiently process complex questions, and their inability to process complicated, interrogatory, or pressing questions may sometimes cause them more anxiety and agitation (Industry Skills Council, 2006). It is also important to identify the feelings being expressed by the patient and to reflect them back to the patient (Industry Skills Council, 2006). Although the specific words of the patient may be unclear, her body language, tone, as well as her expressions still expresses her feelings and when these feelings are validated, a more trusting scenario between the patient and the paramedic can be established (Fostino, 2007). In effect, as the patient appears confused, anxious, and agitated, it is important to acknowledge these feelings, and echo them back to the patient, even when she does not actually say that she is feeling anxious or confused (Industry Skills Council, 2006). Where these feelings are acknowledged, the patient will not feel as disconnected from the paramedic, nor will she feel as helpless or misunderstood in her overall state of mind (Fostino, 2007). Intervention 5. Ensure that patient’s needs are fulfilled and that the goal of the treatment is based on patient preferences. In order to implement such intervention, it is important to observe and evaluate the domestic environment of the patient and to apply management intelligence in order to understand and deduce patient’s condition (Bursack, 2011). Information which is gained from the observations made on the patient’s domestic environment would give accurate clues on the patient’s needs and the effective patient interventions (Bursack, 2011). Making such observations may also reveal possible elderly abuse. Elderly adults are often victims of abuse, and it is important to evaluate the patient’s overall condition, as well as her domestic environment to establish possible signs of abuse (Bursack, 2011). Viewing a domestic environment which is for example full of the patient’s personal touches would also guide the paramedics on the preferred interventions. For example, playing old music or showing her pictures of her family may help calm her down, and may prompt her to be more cooperative with the paramedics (Gibson, et.al., 2007). During the patient’s most vulnerable moments, having familiar and comforting objects or people at her side can help ensure effective management of her symptoms. Intervention 6. Ensure continuity of supportive care The handover process to the emergency hospital staff is also a delicate stage in the patient’s care. Improperly handling such a stage may cause further agitation and stress to the patient, and set back whatever gains and progress already made in the management of patient’s condition (Evans, et.al., 2009). It is therefore important for the paramedic to ensure continuity of care by turning over the patient to a competent health care professional in the hospital setting. The paramedic may need to explain to the patient that she is being handed to a nurse or a doctor; the paramedic may then need to introduce such nurse or doctor to the patient and assure the patient that she would be properly cared for by such nurse or doctor (Evans, et.al., 2009). Ensuring the continuity of care will further promote confidence in the patient’s care and eliminate any unforeseen setbacks in her recovery. Conclusion The discussion above presents the management of a patient with a possible diagnosis of Alzheimer’s disease. Based on her presenting symptoms, she may be in the early stages of her disease and her anxiety and agitation may further be presenting a danger to herself and to her husband. The pathophysiology of the disease presents with possible defects in the activity of the acetylcholine causing the further progression of her illness. This diagnosis can be addressed through the implementation of paramedic interventions which include: establishing a trusting relationship with the patient, reducing or eliminate risk to the patient, to the husband, and to the paramedic, reducing stress, ensuring person-centred care, ensuring effective communication, making sure that patient’s needs are met, and ensuring the continuity of the patient’s care. There may be other interventions which could have been carried out for the patient, including the monitoring of her vital signs, administration of oxygen, and assessment of her mental status. However these interventions cannot be administered until some of the interventions above are carried out. The patient’s mental status or vital signs cannot be checked while she is agitated, confused, and anxious. Hence, it is important to implement the other interventions mentioned above first before any other interventions are implemented. References Bursack, C., 2011. 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