Medical report - Case Study Example

MEDICAL CASE STUDY REPORT Department Address THE CASE This is a case of 72 years old married male getting help from a caregiver.He neither smokes nor drink but allergic to codeine and Rosuvastatin. He is inactive with Fluvax (12, 13, 14) immunization with the following medical history; LV, AF, VT, AMI and Mitral valve replacement after AMI in 2006. The recent medical history include; Prostatiem 2011, tiredness+reccurent falls, alzheimer’s, rhabdomyolysis, left frontal lobc CVA, dementia, parkinson but no diabetes, kidney disease, temperature of 36, respiratory rat of 97% and blood pressure of 139/80.

The current medication include; Excelon 4.6mg/day, Warfarin 10/11 night, Ezetrol 10mg evening, Vitamin D 2000IU Daily, Panadol osteo 2x665 mg PRN, Dutasterid 0.5mg and Sinemet (levadopa+carbidopa)100/25  5 pills a day. The patient falls of a chair and x-rays show blood clots on left knee and is administered Warfirm for AF, physiotherapy and dressing of the wound and blisters [1]THERAPEUTIC TREATMENTA. PARKINSON DISEASEVisual Motor symptomsThis disease is characterized by loss vision sharpness, dry eyes as the disease progresses due to changes in the movement of the eyeball, similar to other motor symptoms caused by loss of dopamine neurons.

This result into; trouble reading, the need to blink in order to change eye position, trouble opening the eyes voluntarily, known as apraxia, Eyelid spasms - blepharospasm, and excessive blinking, Dry eyes; people with PD may blink only 1-2 times per minute, leading to itching and burning [2].Changes in Perception includes: decreased sensitivity to contrast due to los of dopamine neurons in retina, color blindness, difficulty judging distance and people’s facial expressions and visual hallucinations due to medications.

Advanced PD could also result into development of delirium due to prolonged medications. People with Parkinson’s may also have bladder problems, the need to urinate, even when the bladder is not full thus there is need to rule out the possibility of urinary infection or any immediate medical issue before administering a medication [3].MedicationsCarbidopa/Levodopa- Smaller doses of levodopa are required to prevent its side effects and being converted into dopamine in the blood stream and reduce nausea and vomiting and prolonged use also cause dyskinesias.

Dopamine Agonists and includes: Pramipexole, Ropinirole, Rotigotine, Bromocriptine. These medications tricks the brain to think that it is receiving the dopamine it requires and is less likely to cause dyskinesias but cause other side effects such as hallucinations, nausea and sedation [4]. Anticholinergics (trihexyphenidyl, benztropine mesylate are very useful for tremor and easing of dystonia associated with wearing off or peak dose effect. This is Prescribed in the earliest stage of Parkinson’s, and has been approved for use in later stages of PD to boost the effects of Sinemet.

Medication reduces the activity of acetylcholine, a neurotransmitter that regulates movement [5]. The use of MAO-B Inhibitors such as selegiline and rasagiline are often prescribed in the early stages of PD and in later stages to boost the effects of Sinemet. It’s also used to block an enzyme in the brain that breaks down levodopa. COMT Inhibitors (entacapone, tolcapone) used to Prolong the effect of levodopa by blocking its metabolism, prevent wearing-off thus the effect of levodopa becomes short-lived [6].

Other medications includes: Amantadine (Symmetrel), mild agent that is used in early PD to help tremor, reducing dyskinesias that occur with dopamine medication. Side effects include dry mouth, constipation, bladder problems, ankle swelling and skin rash and rivastigmine (Exelon) is treatment of dementia in PD [7].B. CARDIAC PROBLEMS: AF, LV, AMI, VTAtrial fibrillation (AF) is the most common sustained cardiac arrhythmia, characterized by irregular ventricular pulse and loss of association between the cardiac apex beat and radial pulsation.

This is due to Stagnation of blood in the atria leading to thrombus formation and a risk of embolism, increasing the risk of stroke. There is also reduction in cardiac output (especially during exercise) which may lead to heart failure [8]. Drug treatment for long-term rhythm controlWhen assessing for long term drug treatment for long-term rhythm control, taking into account the persons preferences, associated comorbidities, and risks of treatment and likelihood of recurrence of AF. Administer beta-blocker other than sotalol as first-line treatment unless there are contra-indications and dose of 139/89 mmHg, a prehypertensive stage.

Dronedarone is an option for the maintenance of sinus rhythm with paroxysmal or persistent AF. Amiodarone also for people with left ventricular impairment or heart failure [9].Assessment of stroke riskCHA2DS2-VASc stroke risk score is used to assess stroke risk in people with symptomatic or asymptomatic paroxysmal, persistent or permanent AF, or a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm. HAS-BLED score is used to assess the risk of bleeding in people who are starting or have started anticoagulation [7].

Uncontrolled hypertension, Poor control of INR and Concurrent medication - a non-steroidal anti-inflammatory drug (NSAID) are also monitored and medication offered [10].Anticoagulationapixaban, dabigatran etexilate, rivaroxaban(all three contraindicated due to mitral valve replacement and valvular AF) or a vitamin K antagonist (warfarin) CHA2DS2-VASc score of 2 or above needs therapy [11]Therapy with warfarinCertain medicines are not suitable in certain conditions such as; cuts or wounds, Patient falls off relining chair at home.

Efficacy of warfarin is measured by the International Normalized Ratio (INR), which measures the ability of blood to prevent clotting. The aim is to get the right optimal dose to prevent easy clot formation and bleeding problems [12].2. PRIORITIZATION OF CLINICAL INFORMATION.Patient’s medicine therapy can produce side effects like lost of conscious, falling down the chair. For example, Carbidopa/Levodopa controlled release (Sinemet CR®) can cause many side effects when dosage is high thus ensure that it is taken properly, at interval of meal at least 2 hour with a low protein diet.

Rivastigmine tartrate (Exelon®) causes nausea, vomiting, loss of appetite, weight loss. Dutasterid can also cause nausea so we have 2 causes of nausea, both of medicine and therapy [13].A. PARKINSON DISEASE Prescription MedicationsThere are general guidelines that doctors use to choose a treatment regime, however, each person with PD must be individually evaluated to determine which drug or combination of drugs is best for them. For some, a “first choice” drug might be one of the levodopa preparations, and for others, an initial prescription may be given for one of the agonists, an MAO inhibitor or an anticholinergic [14].

Hearing and Vision DeficitsImpaired hearing increases susceptibility to delirium and Inability to communicate and verbal interactions places an older person in a frustrating and isolated state. This can have detrimental effect on mental functions. The brain changes in PD that cause stiffness and slow movement also affect the muscles involved in swallowing and in pushing food through the digestive system. In addition, Parkinson’s can affect the nerves that line the digestive tract, called the enteric nervous system [15]. B. CARDIAC PROBLEMS: AF, LV, AMI, VTThere is no medicine to control or prevent arrhythmia; we only have anticoagulant and lipidic therapy.

AMI complicated with others disease requires special treatment and guide therapy. We need a betablocker52, maybe ACEI to prevent remodelation of myocard and hypertension-small dosage-increase gradually [16].3. RecommendationsA. Parkinson DiseaseManage symptoms and prevent falls by: use walker, use assistance, reduce dosage of Stalevo.Prevent degradation of symptoms of Alzeihmer, add therapy that will both control Parkinson and Alzheimer such as Chilisterace inhibitor (Aricept, Exelon) and memantine to treat the cognitive symptoms like memory loss, confusion, and problems with thinking and reasoning [17].

Bladder problemExamine the abdomen by checking for a palpable bladder which indicate chronic outflow obstruction or a neurogenic bladder. A differential diagnosis is required to eliminate neurogenic bladder, bladder tumor, chronic prostatitis, detrusor instability [18].B. Cardiac problems: AF, LV, AMI, VTManagement includes: control of the arrhythmia and thromboprophylaxis to prevent strokes then treat the associated disease AMI, VT. Metoprolol is added and dosage increased gradually to prevent side effects.

The goal is to optimize function and prevent complication by referral to cardiology and well balance diet [4].Due to AF patient may suffer syncope/dizziness and loss conscience that can lead to fall off chairs/bed. Recommend Watch and monitor blood pressure automatically. WatchBP® Home is recommended device and should be considered for use in people with suspected hypertension and those being screened or monitored for hypertension in primary care [19].Therapy with warfarinOther medical condition that could affect state of mind of the patient, the way he takes the medicines: dementia, Alzheimer’s.

He may forget he had taken warfarin and retake a pill that day. In this case it increases the risk of bleeding. Ask the patient if he had ever forgotten to take a dose and what does if he remembers? Due to his medical condition he may not remember to take medicine and skip and missed [20]. Alarm clock or organizer for medics divided in 7 days a week, morning, noon, evening and before bed time. We have to assure that patient is taking warfarin exactly as doctor or anticoagulant clinic advised [21].

This will help keep the levels of warfarin in your blood steady, and will also help you to avoid missing any doses. INR can suddenly change with diet, especially when beginning to eat more vegetables and salad. Make sure that patient is not in weight-reducing period. Due to patients clinical condition may mean that you need closer monitoring and may need a change in warfarin dose and avoid cranberry juice altogether because it affects INR but use parasetamol as painkiller, but your doctor must know if you need to take it regularly but Keep INR between 3-3.5 [8].THERAPEUTIC PLAN 1.

Excelon 4.6mg patch in the morning2. Warfarin 1pill at 6 o’clock in the evening3. Ezetrol 10mg 1 pill in the evening4. Vitamin D 2000IU Daily5. Panadol osteo 2x665 mg PRN6. Memantine 10mg 1 pill daily, in the morning7. Sinemet (levadopa+carbidopa)100/25  3 pills a day8. Metoprolol 25mg 1 pill a day, divide dosage in two, to avoid side effect 9. WatchBP® HomeREFERENCES1. Buter TC, et al. (2008). Dementia and survival in Parkinson disease: A 12-year population study. Neurology, 70(13): 1017–10222.

Löhle M, Ramberg C, Reichmann H, Schapira A. Early Versus Delayed Initiation of Pharmacotherapy in Parkinsons Disease. Drugs [serial on the Internet]. (2014, Apr 15), [cited November 20, 2014]; 74(6): 645-657. Available from: Academic Search Premier.3. Chao J, Leung Y, Wang M, Chang R. Nutraceuticals and their preventive or potential therapeutic value in Parkinsons disease. Nutrition Reviews [serial on the Internet]. (2012, July), [cited November 20, 2014]; 70(7): 373-386. Available from: Academic Search Premier.4. Tóth G, Gardai S, Zago W, Bertoncini C, Cremades N, Yednock T, et al.

Targeting the Intrinsically Disordered Structural Ensemble of α-Synuclein by Small Molecules as a Potential Therapeutic Strategy for Parkinson’s Disease. Plos ONE [serial on the Internet]. (2014, Feb), [cited November 20, 2014]; 9(2): 1-11. Available from: Academic Search Premier.5. Hoy S, Keating G. Rasagiline A Review of its Use in the Treatment of Idiopathic Parkinsons Disease. Drugs [serial on the Internet]. (2012, Mar), [cited November 20, 2014]; 72(5): 643-669. Available from: Academic Search Premier.6. Vu T, Nutt J, Holford N.

Disease progress and response to treatment as predictors of survival, disability, cognitive impairment and depression in Parkinsons disease. British Journal Of Clinical Pharmacology [serial on the Internet]. (2012, Aug), [cited November 20, 2014]; 74(2): 284-295. Available from: MEDLINE.7. Aarsland D and Kurz MW. The epidemiology of dementia associated with Parkinson disease. J Neurol Sci. 2010 Feb 15;289(1-2):18-22. Epub 2009 Sep 4.8. Allen NE et al. Balance and falls in Parkinsons disease: A meta-analysis of the effect of exercise and motor training.

Mov Disord. 2011 Aug 1;26(9):1605-15. doi: 10.1002/mds.23790. Epub 2011 Jun 14.9. Djurić-Jovičić M, Jovičić N, Radovanović S, Kresojević N, Kostić V, Popović M. Quantitative and qualitative gait assessments in Parkinsons disease patients. Vojnosanitetski Pregled: Military Medical & Pharmaceutical Journal Of Serbia & Montenegro [serial on the Internet]. (2014, Sep), [cited November 20, 2014]; 71(9): 809-816. Available from: Academic Search Premier.10. Grossi D, Santangelo G, Barbarulo A, Vitale C, Castaldo G, Trojano L, et al.

Apathy and related executive syndromes in dementia associated with Parkinsons disease and in Alzheimers disease. Behavioural Neurology [serial on the Internet]. (2013, Dec), [cited November 20, 2014]; 27(4): 515-522. Available from: Academic Search Premier.11. Kaski D, Dominguez R, Allum J, Islam A, Bronstein A. Combining physical training with transcranial direct current stimulation to improve gait in Parkinson’s disease: a pilot randomized controlled study. Clinical Rehabilitation [serial on the Internet].

(2014, Nov), [cited November 20, 2014]; 28(11): 1115-1124. Available from: Academic Search Premier.12. Tambasco N, Muti M, Chiarini P, Tarducci R, Caproni S, Calabresi P, et al. Entacapone Reduces Cortical Activation in Parkinsons Disease with Wearing-Off: A f-MRI Study. Plos ONE [serial on the Internet]. (2014, May), [cited November 20, 2014]; 9(5): 1-5. Available from: Academic Search Premier.13. Lane DA, et al. (2011). Atrial fibrillation (chronic), search date June 2011. BMJ Clinical Evidence.

Available online: http://www.clinicalevidence.com.14. Treatment of atrial fibrillation (2010). Treatment Guidelines From The Medical Letter, 8(97): 65–70.15. http://content.onlinejacc.org/article.aspx?articleid=112644416. Management of atrial fibrillation; NICE Clinical guideline (June 2014)17. Antithrombotics: indications and management; Scotttish Intercollegiate Guidelines Network - SIGN (updated Jun 2013)18. You JJ, et al. (2012). Antithrombotic therapy for atrial fibrillation: Antithrombotic therapy and prevention of thrombosis, 9th ed.

—American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141(2, Suppl): e531S–e575S.19. http://www.nice.org.uk/guidance/MTG1320. Vu T, Nutt J, Holford N. Disease progress and response to treatment as predictors of survival, disability, cognitive impairment and depression in Parkinsons disease. British Journal Of Clinical Pharmacology [serial on the Internet]. (2012, Aug), [cited November 20, 2014]; 74(2): 284-295. Available from: Academic Search Premier.21.

Rakshit H, Rathi N, Roy D. Construction and Analysis of the Protein-Protein Interaction Networks Based on Gene Expression Profiles of Parkinsons Disease. Plos ONE [serial on the Internet]. (2014, Aug), [cited November 20, 2014]; 9(8): 1-17. Available from: Academic Search Premier.