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445 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 6. 13 Insomnia RESOLUTION What is the most likely differential diagnosis and why? Hyperthyroidism: Iris's symptoms of palpitations, tachycardia, insomnia, impaired concentration, fatigue, heat intol-erance, weight loss, and irregular menses all support the diagnosis of hyperthyroidism. Additionally, the exam finding of soft, shiny hair, hyperreflexia, goiter, and thyroid bruit also support the diag-nosis. However, Iris does not yet have some symptoms she might acquire without treatment, such as exophthalmos, lid lag, tremors, and atrial fibrillation. There are many causes of hyperthyroidism, but Graves' disease is the most common. Hypothyroidism would cause other symptoms, such as oversleeping, weight gain, dryness of the skin, hair, or nails, cold intolerance, and dyspnea. The TSH would be high, and the free T4 may be low or normal. Iris could be pregnant, or she could be going through perimenopause. Lab workup should include an HCG and an FSH. A CBC and a CMP will be helpful to rule out additional causes of her symptoms, such as infection, and to provide a baseline prior to treatment. Thyroid disease often affects LDL and HDL levels, so fasting lipid levels should be obtained. Iris may be anxious aside from the thyrotoxicosis, although her history does not appear to support that diagnosis; but screen-ing for depression and anxiety is always helpful. Which diagnostic tests are required in this case and why? A low TSH and elevated T3 and T4 would confirm hyperthyroidism or thyrotoxicosis. The ANA may also be elevated, although the patient does not have systemic lupus erythematosus (if Iris is taking biotin, this could affect laboratory results). Subclinical hyperthyroidism would be indicated by a low TSH and normal free T3 and T4. However, there are other possible causes of these results, including illness unrelated to thyroid disease. If in doubt, retest the patient in 1 or 2 months. If the diagnosis indicates hyperthyroidism but it is not completely clear, such as with Iris, TRab, RAI, or ultrasound can be done to confirm the diagnosis. TRab confirms the diagnosis of Graves' disease. RAI or ultrasound should be performed if TRab is negative. However, if Iris were pregnant, she
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446 Resolutions could not have the RAI test. Iris does not have a thyroid nodule. If she did, provided she was not pregnant, RAI should be performed. What is the plan of treatment? First determine if Iris is pregnant. The choice of drug treatment will depend on whether she is preg-nant. Iris could be given some propranolol or other beta blocker to temporarily relieve her symp-toms of nervousness, tachycardia, diaphoresis, and palpitations. Atenolol or Metoprolol may work better for Iris if she has contraindications to propranolol. Beta blockers are often the initial drug therapy. However, RAI may be initial therapy. The goal is to achieve euthyroidism before surgery if surgery is needed. Beyond beta blockers, there is no consensus as to the best way to treat hyper-thyroidism. Antithyroid drugs, such as Methimazole or PTU, may be used before surgical or radio-active iodine intervention. Methimazoile is the drug of choice, with Propylthiouracil (PTU) used only if patient cannot tolerate Methimazole or is pregnant. As symptoms of hyperthyroidism decrease and the free T4 nears the normal range, drug dosages are reduced. Radioactive iodine is a very common method for destroying the thyroid, and this treatment does not increase the risk for thyroid cancer or other cancers. Methimazole should be stopped for at least 4 days if the patient is to be started on radioactive iodine treatment. Iris smokes, so she runs the risk of increased likelihood of eye problems after iodine treatment. Follow‐up with TSH and free T4 is critical, as the procedure may render the patient hypothyroid requiring thyroid replacement therapy. Thyroid surgery is another option for treatment. These three primary therapeutic options should be discussed with the patient so the best option for the individual patient is chosen. The extent of the disease (mild, moderate, or severe), eye orbit involvement, pregnancy or lactation, age, the extent of symptoms, and general health should all impact the choice of treatment. Iris will need frequent follow‐up as treatment progresses to monitor symptoms and lab results and to check for complications of the disease. Most likely, Iris will need synthetic or natural thyroid replacement following the destruction of the thyroid gland. Table 6. 13. 1 is included to help show the differences between hypo‐ and hyperthyroidism. What is a likely diagnosis if this patient returns with severe tachycardia, confu-sion, vomiting, diarrhea, high fever, and dehydration? If this patient returns with all of these symptoms, suspect thyroid storm. This condition typically requires hospitalization. Methimazole or propranolol is given. Steroids are often used and then tapered as the symptoms improve. What if this patient's lab results return and the TSH is low with normal results for free T4 and T3? If this patient's lab results return and the TSH is low with normal results for free T4 and T3, then the patient most likely has subclinical hyperthyroidism. However, the patient would be asymp-tomatic and does not need treatment. Would the plan be any different if Iris were unemployed? It will be important to find out if Iris is a self‐pay patient and to determine her financial status before ordering a lot of tests. It will be especially important to consider whether you can stage test-ing so cost does not become an undue burden for Iris. Medicine may also be costly for Iris. Referral to a medical social worker might be helpful. Are there any standardized guidelines that should be used to assess and treat this case? The American Association of Clinical Endocrinologists has guidelines that can help the clinician make diagnostic and treatment plan choices (http://www. aace. com/).
Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
Insomnia 447 Table 6. 13. 1. Comparison of Hypo‐ and Hyperthyroidism. Hypothyroidism Hyperthyroidism Can be caused by a rare pituitary gland tumor. Typical presentation: The body cannot make enough thyroid hormone. The body produces less body heat and consumes less oxygen. Other causes: Hashimoto's, surgical removal of the thyroid gland, post Graves' disease (after treatment), thyroid irradiation. Graves disease is most common; caused by Ig G (binds to TSH), initiates production and release of thyroid hormone. Other causes: Toxic adenoma, toxic multinodular goiter, painful subacute or silent thyroiditis, iodine‐induced hyperthyroid (amiodarone treatment), oversecretion of pituitary TSH, excess endogenous thyroid hormone production. TSH is up. Free T4 is down. High lipids. Low sodium. TSH is low. Free T4 is elevated. Radionucleotide uptake and scan with iodine to determine if it is secondary to Graves' disease, thyroid nodule. or thyroiditis. Hyperactivity of thyroid: Increased uptake on RAI. Nodules: Limited areas of uptake on RAI and surrounding hypoactivity. Subacute thyroiditis: RAI uptake is patchy and decreased overall. Treatment: Check pituitary function. Give thyroid hormone (lower dosage for elderly). Initial dose (for anyone): 125-150 mcg (0. 10-0. 15 mg/d). Dose depends on age, weight, cardiac status, duration, and severity of disease. Titrate after 6 weeks and following any change in dose. Use TSH to gauge dose and monitor treatment. Treatment: Radioactive iodine (if not pregnant). Postpone pregnancy for 6 months after scan. Do not use during lactation. PTU may be used to treat condition (prevents conversion of T4 to active T3). Give PTU BID for 7 days (can use in pregnancy) or may use Tapazole daily. Side effect of PTU is agranulocytosis. Post ablation: Follow up 6 weeks after treatment and regularly until evidence of early hypothyroidism (based on TSH); then start treatment for hypothyroidism. REFERENCES AND RESOURCES Barbesino, G., & Tomer, Y. (2013). Clinical utility of TSH receptor antibodies. Journal of Clinical Endocrinology Metabolism, 98, 2247. Hershman, J. M. (2018). Thyroid disorders. In R. S. Porter, J. L. Kaplan, R. B. Lynn, & M. T. Reddy (Eds. ), The Merck manual of diagnosis and therapy (pp. 1346-1349). Kenilworth, NJ: Merck Sharp & Dohme Corp. Ross, D. S. (2019, May). Diagnosis of hyperthyroidism. Up To Date.
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449 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 7. 1 Fatigue RESOLUTION Which diagnostic studies should be considered to assist with or confirm the diagnosis? In order to get a better picture of Fred's status and the reason for his symptoms, it is appropriate to order a CBC, comprehensive metabolic panel, lipid profile, urinalysis with micro albumin and micro-analysis, and serum testosterone levels. The CBC will rule out systemic illness and give a picture of general health. The comprehensive metabolic panel and Hemoglobin A1C will assess Fred's diabetes control, kidney and liver function, and fluid status. The lipid profile will evaluate the status of his hyperlipidemia, while the urine studies will evaluate several aspects of Fred's diabetes control. The serum total and free testosterone levels will evaluate for hypogonadism and may indicate secondary hypogonadism. However, total testosterone is less sensitive in older men. FSH and LH help differen-tiate primary from secondary hypogonadism. If the gonadotropin level is high, the patient has pri-mary hypogonadism. However, given Fred's age, primary hypogonadism should have been apparent long ago and is not the cause of his symptoms. A prolactin level will screen for a pituitary adenoma and transferrin saturation will screen for hemochromatosis. However, a patient over 60 years of age with this profile is unlikely to have a brain mass so imaging is usually unnecessary. Relevant test results for Fred include a free testosterone level of 128 ng/d L. Normal levels for a young adult male are 300-1000 ng/d L. In men older than 60 years with signs or symptoms of androgen deficiency, a total testosterone level below 200 ng/d L is almost always clinically significant. What is the most likely differential diagnosis and why? Secondary hypogonadism: Given the objective report of clinically significant low testosterone, we can conclude that Fred has secondary hypogonadism. This explains his decreased sexual function, along with his lowered concentration and impaired mood. However, looking further into the constellation of Fred's symptoms and conditions, it becomes evident that there is interplay of many factors. Fred's uncontrolled diabetes is a wild card, as it can also contribute to his decline in sexual function. The problem is autonomic neuropathy that results from failure of the small vessels that lead to vasodilation. In addition, it is known that obesity leads to lower free and total testosterone levels. Adding in Fred's probable depressive syndrome completes
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450 Resolutions the clinical picture that shows many overlaps in symptoms. However, an objective diagnosis of hypo-gonadism can be confidently made considering the laboratory results. Diagnosis is made via evalua-tion of serum testosterone levels. It is known that blood concentrations of testosterone and prehormones are significantly lower in older men than younger men, as they begin a gradual decline at midlife. In aging men who have not always had symptoms, hypogonadism is referred to as secondary, since the problem is not a primary dysfunction of the testes. Signs and symptoms of secondary hypogonadism due to aging include decreased muscle mass and strength, decreased bone mass, decreased libido (desire), erec-tile dysfunction, impaired mood, and impaired sense of well‐being. The diagnosis of male sexual dysfunction can include any or all of the following categories: (1) decreased libido, (2) erectile dysfunction, (3) ejaculatory insufficiency, or (4) impaired orgasm. Fred reports both decreased libido and erectile dysfunction, which can have several different etiologies. Decreased libido can occur due to psychogenic factors, medications, androgen deficiency, sub-stance use or abuse, or central nervous system disease. Erectile dysfunction can occur due to psy-chogenic factors, medications, endocrine disorders, aging, or systemic illness. Diagnosis is generally made on subjective reporting, and treatment is symptom based. Fred reports being on antidepressants in the past, which alludes to a previous diagnosis of depressive disorder. Today, Fred's report of altered mood, fatigue, sexual dysfunction, poor concentration, substance use, and personal stressors all suggest the possibility of a depressive syn-drome. In cases of secondary hypogonadism initiated by a systemic illness, it is important to retest FSH and LH 4 to 6 weeks after the illness has resolved. What is the plan of treatment? As an initial approach to Fred's low testosterone, an appropriate treatment is testosterone therapy. There are several different administration modalities, including intramuscular (IM) injections, skin patches, and transdermal gel preparations. IM injection is widely used and is an appropriate choice for Fred. The testosterone transdermal patch delivers 4 mg of testosterone daily but has a high inci-dence of skin irritation. There are other patch preparations that are larger and cause less irritation, but they may have a tendency to fall off with activity. The transdermal testosterone gel is widely used and the dosage is 5-10 mg of 1% testosterone gel applied daily. It causes little skin irritation, though there is a possibility for transfer through direct skin contact. There are also transdermal axil-lary solutions, buccal lozenges, a nasal spray, and subcutaneous implants. Since Fred has difficulty with daily medication compliance, bringing him to the clinic for routine injections is a wise choice. In adjunct to testosterone therapy, Fred should be educated about medication compliance. Explaining to him the importance of diabetes control and the interplay of his numerous symptoms may be an effective approach. What is the plan for referrals and follow‐up? Education about diet and exercise should be reinforced; and, if he is willing, he should be given a referral for nutritional counseling. Since Fred will be coming to the office for routine injections to start, there will be opportunities to reassess his symptoms. There will also be an opportunity to assess whether Fred or his spouse should be instructed in injection administration. Follow‐up intervals should occur between every 4 months in the first year and every 6 months thereafter to evaluate progress, symptoms, and blood levels. Labs should include hematocrit, PSA, and testos-terone. If the hematocrit increases, a reduction in the testosterone therapy should be considered. PSA levels should be monitored carefully. Digital rectal exams should also be performed. Therapy could continue for as long as 3-4 years. What would be relative and absolute contraindications to the treatment plan of testosterone therapy? Testosterone therapy is absolutely contraindicated in those with carcinoma of the prostate or of the male breast, as these cancers require androgens for proliferation. Testosterone therapy should be used with caution in older men with enlarged prostates, with urinary symptoms, or elevated hematocrit.
Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
Fatigue 451 Are there standardized guidelines that would help in this case? The American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Hypogonadism in Adult Male Patients—2002 update (http://www. aace. com/sites/default/files/2019‐06/hypo‐gonadism. pdf” http://www. aace. com/sites/default/files/2019‐06/hypo‐gonadism. pdf), as well as an Endocrine Society Clinical Practice Guideline (Bhasin et al., 2018). REFERENCES AND RESOURCES AACE Hypogonadism Task Force. (2002). American Association of Clinical Endocrinologists medical guide-lines for clinical practice for the evaluation and treatment of hypogonadism in adult male patients—2002 update. Endocrine Practice, 8, 439-456. Bhasin, S., Brito, J. P., Cunningham, G. R., Hayes, F. J., Hodis, H. N., Matsumoto, A. M.,... Yialamas, M. A. (2018). Testosterone therapy in men with hypogonadism: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 103(5), 1715-1744. https://doi. org/10. 1210/jc. 2018‐00229 Hirsch, I. H. (2018). Male hypogonadism. In R. S. Porter, J. L. Kaplan, R. B. Lynn, & M. T. Reddy (Eds. ), The Merck manual of diagnosis and therapy (pp. 2128-2132). Kenilworth, NJ: Merck Sharp & Dohme Corp. NOTE: The author would like to acknowledge the contributions of Geraldine F. Marrocco, Ed D, APRN, CNS, ANP‐BC and Amanda La Manna, RN, ANP to this case in the first edition of this book.
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453 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 7. 2 Testicular Pain RESOLUTION What is the most likely differential diagnosis and why? Epididymitis: As testicular torsion and testicular mass were ruled out via ultrasound and there was no report of trauma, the differential can be narrowed down to a sexually transmitted infection (STI) or epi-didymitis. There was no urethral discharge on exam. Coupled with the patient's report of monogamy, this suggests that the cause of the pain is not an STI. The negative urine tests for gonorrhea and chlamydia confirmed this. The acute pain and positive Phren's sign on exam point strongly toward epididymitis. Commonly, the cremasteric reflex is negative in testicular torsion. Epididymitis is a bacterial infection and inflammation of the epididymis, which is the tube connecting the testicle with the vas deferens. It is the most common cause of acute scrotal pain in all age groups, though it is most common among sexually active men younger than 35. In the younger age group, the infection is most often due to Chlamydia trachomatis or Neisseria gonorrheae. In men who have anal intercourse, epididymitis can be caused by Escherichia coli. In older men, the cause is often a urinary tract infection. On exam, the affected testis will transilluminate, and there will be a positive Phren's sign. While some sexually transmitted infections can lead to epididymitis, it is possible for some infections to affect the ductus deferens and/or the testicles. Those included are chlamydial infec-tion, gonorrheal infection, and syphilis infection. Testicular torsion should be suspected whenever a man complains of scrotal pain, as it is an emergent condition that can, if left untreated, lead to ischemia of the affected testis. It presents acutely as a firm, tender mass, often associated with nausea and vomiting. The cremasteric reflex is typically negative and one testis often rides high (bell clapper deformity). Testicular torsion can occur at any age but occurs more often in men younger than 25 years of age. No exam finding can completely rule out testicular torsion. Therefore, it must be ruled out via a Doppler study due to its emergent nature. A Doppler study will reveal decreased blood flow to the testis in a case of torsion. Testicular malignancy is most prevalent in young men ages 15-35 years. Symptoms include a hard, heavy, firm, nontender mass. There will often be scrotal swelling in the affected testis, and some testicular tumors will cause discomfort or pain. Upon exam, the affected testis where the mass is located will not transilluminate.
Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
454 Resolutions Though uncommon, testicular trauma should be a consideration when presented with a case of scrotal pain. Usually the affected individual will identify a recent injury or trauma. Classifications of disorders due to trauma include blunt trauma, penetrating trauma, degloving trauma, and tes-ticular rupture. Diagnostic testing: To rule out the emergent condition of testicular torsion, it is appropriate to obtain a stat Doppler scrotal ultrasound. In addition, it is appropriate to order obtain a urine sample for a urinalysis, culture, and sensitivity to evaluate for infection and gonorrhea and chlamydia. The results of the Doppler indicated that there was no testicular torsion. A pulse Doppler and a color Doppler were performed, revealing both testicles to be normal in size and to have a homogenous echotexture. The right testicle measured 4. 4 × 2. 2 × 2. 4 cm, and the left testicle measured 2. 98 × 2. 0 cm. There was no intratesticular or extratesticular mass present. No abnormal fluid was noted in bilateral scrotal sacs, and there was no evidence of testicular torsion. The urine tests were negative. What is the plan of treatment? Without knowing the offending bacterial organism, empiric treatment of the infection is appro-priate at this stage. Levofloxacin 500 mg orally daily for 10 days or ofloxacin 300 mg twice a day for 10 days are the most appropriate treatment choices. Bactrim DS twice a day for 10 days is an alternative. If this patient were under age 35, ceftriaxone 250 mg IM (1 dose) plus doxycycline 100 mg twice a day for 10 days would be the first choice of treatment to cover possible gonorrhea or chlamydia. Azithromycin 1 gram orally is an alternative. To address the patient's acute pain, an NSAID, application of ice, and elevation of the scrotum are recommended. Opioids are not recommended. Sitz baths may also provide relief. The patient being treated for epididymitis should be brought back in 2 weeks to evaluate the success of treatment. If treatment is successful in symptom reduction, the antibiotics should be completed. If symptoms still persist, the patient should be further evaluated by a specialist. Are there any referrals or follow‐up care needed? In cases of recurrent infection or failure to respond to treatment, it would be appropriate to consult with or refer the patient to a urologist. REFERENCES AND RESOURCES Eyre, R. C. (2019, May). Evaluation of acute scrotal pain in adults. Up To Date. Shenot, P. J. (2018). Penile and scrotal disorders. In R. S. Porter, J. L. Kaplan, R. B. Lynn, & M. T. Reddy (Eds. ), The Merck manual of diagnosis and therapy (pp. 2141-2142). Kenilworth, NJ: Merck Sharp & Dohme Corp. Trojian, T. H., Lishnak, T. S., & Helman, D. (2009). Epididymitis and orchitis: An overview. American Family Physician, 79, 583. NOTE: The author would like to acknowledge Geraldine F. Marrocco, Ed D, APRN, CNS, ANP‐BC, who wrote the original version of this case in the first edition of this book.
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455 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 7. 3 Prostate Changes RESOLUTION What tool might be useful to evaluate Stanley's symptoms? The American Urological Association symptom index is used to identify the severity and possible impact the symptoms are having on the patient's quality of life. The tool has 7 questions addressing frequency, nocturia, weak urinary stream, hesitancy, intermittence, incomplete emptying, and urgency, each of which is scored on a scale of 0 (not present) to 5 (almost always present). Symptoms are classified as mild (total score 0 to 7), moderate (total score 8 to 19), or severe (total score 20 to 35). The AUA symptom index tool is a validated, self‐administered questionnaire used to assess the severity of the symptoms (O'Leary, 2005). Stanley had an AUA index score of 8. What are the top three differential diagnoses in this case and why? Stanley is having lower urinary tract symptoms (LUTS), including urgency, nocturia, frequency, urge incontinence, and weak stream. The symptoms indicate that he has both obstructive and irri-tative symptoms (Sarma & Wei, 2012). The patient's presentation (obstructive and irritative symp-toms), his age (>60 years), and his race (African American) suggest the following top three differentials. Benign prostatic hyperplasia (BPH): BPH is an enlargement of the prostate gland that is common in older men. It can negatively impact the quality of life. Autopsy studies have shown the prevalence of BPH worldwide to be up to 60% in men over the age of 60 years, reaching up 80% of men by age 80 (Mc Vary, 2006). Some studies have indicated that Black men experience more moderate to severe symptoms compared to White men. Nonmodifiable risk factors for BPH include age, race, genetic susceptibility, and family history of cancer. Modifiable risk factors include metabolic syndrome, beverage consumption, physical inactivity, and alcohol consumption. The enlargement of the prostate can lead to benign prostatic obstruction and bladder outlet obstruction. The most common symptoms are the lower urinary symptoms: LUTS, including frequency, nocturia, urgency, and urinary incontinence, or voiding symptoms, including slow urinary stream, hesitancy, straining, and terminal dribbling. Patients with BPH might also have hematuria; an in‐office digital rectal examination can detect an enlarged prostate (Mc Vary, 2006). The LUTS and digital rectal exam findings might be associ-ated with an increased PSA level.
Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
456 Resolutions Prostate cancer: Prostate cancer is the most common solid cancer in men, and the third most common cause of cancer‐related deaths in 2017. It is most common in Blacks. The PSA test, together with the digital exam and other patient variables including ethnicity, age, and family, would warrant additional follow‐up. A biopsy would be needed to confirm a cancer diagnosis. In this patient, the PSA is elevated at 4. 6ng/DL; however, the digital rectal exam showed a smooth non‐nodular enlarged prostate. The patient presentation and physical exam findings are more in line with BPH than prostate cancer. Urinary tract infection: This a reasonable differential as he presented with LUTS. Urinary tract infections are relatively rare in men under the age of 60 years but increase significantly thereafter due to prostate‐related issues. Patients usually present with dysuria and urethritis. A UTI can be confirmed or ruled out by a urinalysis. A urinalysis would show white blood cells and blood in the urine (Dean & Lee, 2019). If that was the case, urine would be sent for culture and sensitivity identify the bacteria, and the drug it is sensitive to. Which diagnostic tests are required in this case and why? A prostate‐specific antigen testing is indicated because the symptoms of prostate cancer are indis-tinguishable from those of benign prostatic hypertrophy. A PSA test should be done after shared decision‐making. An elevated PSA together with prostate positive physical exam findings will warrant further workup. An elevated PSA with hematuria, asymmetrical nodular prostate, and LUTS would need to be followed up for possible prostate cancer. PSA levels can also be elevated in BPH, infections, and post instrumentation. Stanley's PSA was 4. 6ng/DL. Normal PSA for a man > 60 years < 70 years should be < 4. 5ng/DL (Carter et al., 2013). The PSA test is controversial as a prostate cancer screening tool as there are too many false positives. Urine for urinalysis is needed to rule out a urinary tract infection, with reflex culture and sensi-tivity if positive. This patient had LUTS without hematuria or other signs of infection. If urinalysis did not show any white blood cells, indicating he did not have a UTI, a culture and sensitivity would not be necessary. Bladder scan post void residual: This can be useful, especially in men who have symptoms of obstruction or suspected neurogenic involvement. This can also be useful prior to initiation of treatment. There is no consensus on what is normal PVR; definition on urinary retention in men has ranged from 100 mls to 1000 mls (Kaplan et al., 2008), with most urologists being concerned by a PVR of > 100-200 mls. A high PVR is a possible indicator for BPH, as it is associated with an increased risk for infection (Oeleke et  al., 2013). The amount of PVR is not associated with the severity of BPH, and is not a predictor of surgical outcome. Even though there is no consensus on the amount, Stanley does have a PVR of 100 cc, signaling some type of urinary retention. What are the concerns at this point? The lower urinary symptoms are distressing and can lead to a decreased quality of life. Since Stanley has some retentive symptoms, there is a concern regarding the severity of the symptoms, for if not addressed promptly they can lead to possibly irreversible damage to the kidneys, and severe infection that could become life threatening. What is the likely diagnosis? BPH: This patient has LUTS, an enlarged prostate, a PVR of 100 mls, and an elevated PSA without hematuria or prostate nodules, making it likely that he has BPH with moderate symptoms. What is the plan of treatment? Stanley has BPH with moderate symptoms. The treatment is largely dependent on how bother-some the symptoms are to him. For those with mild symptoms, the treatment can be watchful waiting with reassurance. Stanley has LUTS with nonsuspicious prostate enlargement. With an
Leslie Neal-Boylan - The Family Nurse Practitioner.pdf
Prostate Changes 457 AUA index score of 8, he is in the moderate category. Shared decision making is important in deciding the way forward. If he is unsure of medications, lifestyle modifications and behavior modification will be recommended. The goals for treatment are: 1. Reduce bothersome LUTs symptoms 2. Alter disease progr ession 3. Prevent complications (Mc Connell et  al., 2003). Lifestyle modifications: Lifestyle modifications are the initial recommended treatment for patients with bothersome symptoms. The patient will be encouraged to restrict fluid at night, or, when going out, instructed on double‐voiding techniques to empty the bladder, avoidance of alcohol (he drinks 2 shots of cognac a night), regular physical activity, and avoidance of coffee and other highly seasoned or irritating foods. The lifestyle modifications can improve LUTS and can prevent disease progression; discontinue possibly offending meds, for example, Benadryl (Oelke et al., 2013, Pao‐Hwa & Freedland, 2015). Medications: The AUA symptom index classifies Stanley as having moderately distressing symptoms. He came to seek out treatment because of his discomfort. The symptoms ar e impacting his quality of life. Because of the severity of his symptoms he could decide to start with medica-tions. Alpa‐1‐adrenegic antagonist monotherapy is the recommended treatment for moderate symptoms. Alpha‐1‐adrenegic antagonists relax smooth muscles in the bladder neck, prostate capsule, and the urethra. Curr ently approved alpha‐1‐adrenergic antagonists include terazosin, doxazosin, tamsulosin, alfuzosin, and silodosin. All these drugs have similar efficacy, so which one is prescribed might be based on cost, as well as side effects like hypotension and sexual side effects. Educate Stanley on the side effects, especially orthostatic hypotension and dizziness. Men with scheduled cataract surgery should not start on alpha‐1‐adrenergic antagonists until after surgery (Mc Vary et al., 2010). What are the plans for referral and follow‐up care? Follow up in 2-4 weeks; titrate dose up, if there has been some improvement. If there has been no improvement, refer to urology for further testing and possible combination treatment or surgery if no improvement in 1 to 2 years. What health education should be provided to this patient? Educate on how to take medications and possible side effects, especially orthostatic hypotension and dizziness. Take medication at night to reduce postural lightheadedness. Educate Stanley on the potential for sexual side effects and foods to avoid. Stop taking Benadryl. It might take 1 to 2 weeks before he sees improvement. Does the patient's psychosocial history impact how you might treat him? Avoid prescribing Silodosin, as it is more likely to cause sexual side effects. Are there any standardized guidelines that should be used to treat this case? If so, what are they? American Urologic Association Guidelines (Mc Vary et al., 2010, reviewed and confirmed in 2014). REFERENCES AND RESOURCES Abrams, P., Chapple, C., Khoury, S., Roehrborn, C., de la Rosette, J., & International Consultation on New Developments in Prostate Cancer and Prostate Diseases. (2009). Evaluation and treatment of lower urinary tract symptoms in older men. Journal of Urology, 181, 1779.
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458 Resolutions Brown, C. T., Yap, T., Cromwell, D. A., Rixon, L., Steed, L., Mulligan, K.,... Emberton, M. (2007, January 6). Self‐management for men with lower urinary tract symptoms: Randomised controlled trial. BMJ, 334(7583), 25. Epub November 21, 2006. Carter, H. B., Albertsen, P. C., Barry, M. J., Etzioni, R., Freedland, S. J., Greene, K. L.,... Zietman, A. L. (2013). Early detection of prostate cancer: AUA Guideline. Journal of Urology, 190(2), 419-426. Dean, A. J., & Lee, D. C. (2019). Bedside laboratory and microbiologic procedures. In J. R. Roberts (Ed. ), Roberts and Hedges clinical procedures in emergency medicine and acute care (7th ed., Chapter 67, pp. 1442-1469. Philadelphia: Elsevier. Kaplan, S. A., Wein, A. J., Staskin, D. R., Roehrborn, C. G., & Steers, W. D. (2008). Urinary retention and post‐ void residual urine in men: Separating truth from tradition. Journal of Urology, 180(1), 47-54. Mc Connell, J., Roehrborn, C., Bautista, O., Andriole, G. L. Jr., Dixon, C. M., Kusek, J. W.,... Smith, J. A., for the Medical Therapy of Prostatic Symptoms (MTOPS) Research Group. (2003). The long‐term effect of doxazo-sin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. New England Journal of Medicine, 349, 2387. Mc Vary, K. (2006). BPH: Epidemiology and comorbidities. American Journal of Managed Care, 12(5 Suppl), S122. Mc Vary, K. T., Roehrborn, C. G., Avins, A. L., Barry, M. J., Bruskewitz, R. C., Donnell, R. F.,... Wei, J. T. (2010, validity confirmed 2014). Management of benign prostatic hyperplasia. American Urological Association. https://www. auanet. org/guidelines/benign‐prostatic‐hyperplasia‐(bph)‐guideline/benign‐prostatic‐ hyperplasia‐(2010‐reviewed‐and‐validity‐confirmed‐2014) Oelke, M., Bachmann, A., Descazeaud, A., Emberton, M., Gravas, S., Michel, M. C.,... European Association of Urology. (2013). EAU guidelines on the treatment and follow‐up of non‐neurogenic male lower urinary tract symptoms including benign prostatic obstruction. https://doi. org/10. 1016/j. eururo. 2013. 03. 004 O'Leary, M. P. (2005) Validity of the “bother score” in the evaluation and treatment of symptomatic benign prostatic hyperplasia. Reviews in Urology, 7(1), 1-10. Sarma, A. V., & Wei, J. T. (2012). Benign prostatic hyperplasia and lower urinary tract symptoms. The New England Journal of Medicine, 367, 248-257. doi: 10. 1056/NEJMcp1106637 Pao‐Hwa, L., & Freedland, S. J. (2015). Lifestyle and LUTS: What is the correlation in men? Current Opinion Urology, 25(1):,1-5. doi:10. 1097/MOU. 0000000000000121 Wasson, J. H., Reda, D. J., Bruskewitz, R. C., Elinson, J., Keller, A. M., & Henderson, W. G. (1995). A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. New England Journal of Medicine, 123(1). doi:10. 1056/NEJM199501123320202
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459 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 8. 1 Substance Use Disorder (SUD) RESOLUTION What are the top three differential diagnoses in this case and why? This case describes a patient who expresses the desire to stop using a substance that she and her partner have identified as responsible for contributing to negative health effects. Although there are potentially several other medical and psychiatric issues present in this complex scenario, the most pressing differentials include the following: Opioid withdrawal: The patient reports difficulty in stopping the use of opioids on her own and experiencing severe physical withdrawal symptoms. Withdrawal syndromes (often physical but also psychological or motivational feelings of needing a substance to feel functional) are a key feature within the widely accepted framework of addiction as a chronic, relapsing brain disease (Herron & Brennan, 2019). Opioid use disorder: The features of continued compulsive use (unable to stop despite efforts) despite adverse conse-quences (withdrawal symptoms, social problems like tardiness/job loss, school troubles) point toward this diagnosis. Uncontrolled anxiety/depression/ADHD or other mental health disorder: Several features in this case (e. g., a history of ADHD, a family history of alcoholism/depression/suicide) suggest that a potential contributing factor to Chan Ming's substance use patterns may be comorbid mental health conditions. The prevalence of comorbid mental health diagnoses with substance use disorders is known to be high and, therefore, exploration of mental health diagnoses with an eye toward adequate treatment to mitigate and/or prevent substance use disorder is war-ranted (National Institute on Drug Abuse [NIDA], 2018). What are the top three diagnostic tests or screens required in this case and why? Routinely screening for alcohol, nicotine, and other drug use in general medical settings is consid-ered an important preventive health care measure by the Substance Abuse and Mental Health Services Administration (SAMHSA; 2018). There are a variety of validated screening tools for alcohol, tobacco, and drugs that can be completed via self‐report survey or administered by staff or clinicians during the office visit. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is
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460 Resolutions an evidence‐based approach to universal screening for substance use that can identify those patients who are most at risk for health consequences and allow for early intervention. Detailed resources for SBIRT are available at https://www. integration. samhsa. gov/clinical‐practice/sbirt. In this patient's case, the patient self‐identifies as needing help with opioids. The following screen-ing tools/diagnostic criteria would be useful in this case to more accurately assess this patient: Clinical Opiate W ithdrawal Scale (COWS): This 11‐item scale can be administered by clinicians in inpatient or outpatient settings to determine the severity of withdrawal and assess the level of physical dependence on opioids (Wesson & Ling, 2003). Some signs and symptoms measured with this tool include pulse rate, pupil size, presence of tremor, sweating, gooseflesh, GI upset, and restlessness. This scale can be readministered over time to assess response to withdrawal treatment interventions. Management of physical withdrawal symptoms is a crucial step in maxi-mizing a patient's capacity for further long‐term treatment (Gowing, Ali, White, & Mbewe, 2017). Diagnostic and Statistical Manual 5th edition (DSM‐5) criteria for opioid use disorder: The American Psychiatric Association (APA; 2013) has identified criteria that can be used to confirm and doc-ument a diagnosis of opioid use disorder. OUD is defined as “a problematic pattern of sub-stance use leading to clinically significant impairment or distress” manifested by presence of at least two adverse health effects related to opioid use occurring within a 12‐month period. A clinician can objectively classify and determine severity (mild, moderate, severe) of OUD by applying these criteria. A checklist of the DSM‐5 criteria can be found at: https://www. ncbi. nlm. nih. gov/books/NBK535277/bin/pt2app. p35. pdf Patient Health Questionnaire 9 (PHQ‐9)/Generalized Anxiety Disorder 7 item (GAD‐7): Due to the risk for comorbid mental health issues in any patient who uses substances problematically, these tools serve to identify and assess common mental health conditions that, when ade-quately treated, may synergistically improve OUD treatment. The PHQ‐9 is a valid and reliable 9‐question tool that can be used in an outpatient setting to identify and classify the severity of comorbid depression (Kroenke, Spitzer, and Williams, 2001). Similarly, the GAD‐7 can be used to efficiently identify anxiety disorder (Spitzer, Kroenke, Williams, and Löwe, 2006). Both scales can also be readministered over time to assess changes during therapy. Web‐based versions of both tools can be found at: https://www. hiv. uw. edu/page/mental‐health‐screening/phq‐9 and https://www. hiv. uw. edu/page/mental‐health‐screening/gad‐7. What are the concerns at this point? This case presents several imminent and long‐term health concerns for the family health care pro-vider to address. The potentially life‐threatening effects of opioid use disorder and comorbid mental health crises warrant immediate attention to safety issues such as overdose prevention and suicide screening. Longer‐term issues may require co‐management with specialists but there are several steps an astute primary care nurse practitioner (NP) can take to set the stage for optimal outcomes. The following is a list of priority concerns about this patient: Opioid withdrawal: This patient pr esents with both history and physical exam evidence for acute opioid withdrawal. Appropriate management including medications (see below) will address one of the family's most pressing concerns (severe withdrawal symptoms resulting in continued dangerous use) and can maximize a patient's chance for success at longer‐term treatment approaches. Moreover, although withdrawal from opioids, unlike alcohol or benzo-diazepines, is not associated with acute physiologic life‐threats like seizures, the risk of fatal overdose from the continued use of fentanyl analogues found in the illicit drug supply is high. Therefore, every opportunity to more safely help a patient in opioid withdrawal represents a potentially life‐saving health care encounter. Overdose risk: As mentioned, the use of heroin/fentanyl is extremely concerning given the U. S. opioid crisis and related overdose deaths. In 2017, the Centers for Disease Control (CDC) reported nearly 72,000 overdose deaths, of which over two‐thirds were linked to opioids
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Substance Use Disorder (SUD) 461 (Ahmad, Rossen, Spencer, Warner & Sutton, 2018). Because of the potency and uncertainty of concentrations of illicit fentanyl in the heroin supply in the United States, opioid overdoses have dramatically increased and essentially any person who uses opioids, especially fentanyl, is at risk. Health care providers can mitigate overdose risk by providing education and access to naloxone. In a public health advisory, the U. S. Department of Health and Human Services (2018, April 5) recommends naloxone access for “patients currently taking high doses of opi-oids as prescribed for pain, individuals misusing prescription opioids, individuals using illicit opioids such as heroin or fentanyl, health care practitioners, family and friends of people who have an opioid use disorder, and community members who come into contact with people at risk for opioid overdose. ” NPs should provide education on signs of overdose and the administration of naloxone to patients and families at risk. Naloxone is available in various for-mulations, including an intranasal spray and intramuscular injection. Patients can receive nal-oxone by prescription or in many states by standing order at pharmacies or often for free at community locations. More information on naloxone for overdose prevention can be found at: www. prescribetoprevent. org. Opioid use disorder treatment: This patient's visit, for the express purpose of asking for help with her substance use, offers the NP an important opportunity to rally and coordinate services so that the patient successfully accesses formal treatment for her substance use. According to a 2018 report, only about 1 in 4 people with opioid use disorder received specialty treatment within the past year (U. S. Department of Health and Human Services, 2018, September). Providers in any health care setting should be prepared to reduce this gap by offering initiation of care or by ensuring rapid access to specialty care (i. e., a “warm handoff”; meds/counseling/both/recovery supports). Comorbid mental health issues (i. e. anxiety/depression): As discussed, the prevalence of substance use alongside mental health conditions warrants careful examination of this patient's overall mental health. Prioritizing assessment of possible depression, including a suicide screen, is crucial as a safety concern. In addition to the screening tools mentioned earlier, NPs in general health settings should be familiar with evidence‐based resources such as the Suicide Assessment Five‐Step Evaluation and Triage (SAFE‐T) tool developed by SAMHSA. This resource, including a Suicide Safe mobile app, can be found at: https://store. samhsa. gov/product/SAMHSA‐Suicide‐Safe‐Mobile‐App/PEP15‐SAFEAPP1 What are the options for the medicinal management of acute opioid withdrawal? Options for the medicinal management of acute opioid withdrawal include the following: Methadone: The full opioid agonist action of methadone will ameliorate opioid withdrawal symptoms. Due to the long and variable half‐life of methadone (which ranges fr om 24 to 36 hours or longer), it can take up to 5 half‐lives to reach serum steady state. Slow titration doses of methadone can be given over hours to days until COWS scores improve. Risk of overdosing during induction phase is possible and induction with methadone should be managed only by providers with experience and expertise in a qualified opioid treatment program or inpa-tient setting (ASAM, 2015; SAMHSA, 2018). Research has shown that most patients who go through medically supervised opioid withdrawal return to opioid use, so initiation of mainte-nance treatment with either methadone or buprenorphine is the preferred long‐term treatment for opioid use disorder and results in significantly better morbidity and mortality than detox-ification (SAMHSA, 2018). In general, methadone is restricted to federally designated addic-tion clinics. There is an exception, commonly referred to as the “72‐hour rule,” that allows non‐addiction specialists to administer methadone (no take‐home prescriptions or doses) for the acute management of withdrawal for a period of 72 hours only (U. S. Department of Justice, n. d. ). The federal restrictions, long half‐life, risk for QTc prolongation and arrhythmia (espe-cially in combination with other medicines that prolong the QT interval), and potential for overdose make methadone a challenging medication for non‐addiction specialists to manage.
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462 Resolutions Buprenorphine: Buprenorphine is a partial opioid agonist that has been shown to be effective for r educing withdrawal symptoms and is safe to use in both inpatient and outpatient settings. Because of its ceiling effect, buprenorphine is less likely to be associated with respiratory depression (SAMHSA, 2018). To avoid precipitated withdrawal, buprenorphine should not be administered until 12-18 hours after the last dose of a short‐acting agonist such as heroin or oxycodone, and 24-48 hours after the last dose of a long‐acting agonist such as methadone (ASAM, 2015). Titrating doses (4‐16 mg) are administered until withdrawal symptoms abate. NIDA has published a sample algorithm for buprenorphine induction that can be used in emergency room or other ambulatory care settings: https://www. drugabuse. gov/nidamed‐medical‐health‐professionals/discipline‐specific‐resources/initiating‐buprenorphine‐treatment‐in‐emergency‐department/buprenorphine‐treatment‐algorithm. Unlike methadone, current U. S. law allows non‐addiction prescribers to become waivered by the Drug Enforcement Administration (DEA) to prescribe buprenorphine for opioid withdrawal as well as for longer‐term maintenance (see the later section on maintenance therapy). Like methadone, buprenor-phine can be also be administered (but not prescribed/dispensed) for 72 hours for acute withdrawal management by any prescriber even if not waivered. Clonidine: An alpha‐2‐adrenergic agonist has been historically used to ameliorate the sympathetic central nervous system effects of opioid withdrawal and may be helpful if opioid agonist options are not available. Limiting side effects include hypotension. Because clonidine has been found to be less effective than opioid agonists (Gowing et al., 2017), and because most patients who undergo medically supervised full withdrawal return to illicit opioid use, it is recom-mended that opioid agonist maintenance therapy be initiated (SAMHSA, 2018). Other symptom‐specific comfort medications: Although these medications may not be necessary for every patient (especially if using an opioid agonist or partial agonist), secondary medicines targeting specific symptoms such as antiemetics for nausea, dicyclomine for stomach cramp-ing, loperamide for diarrhea, and over‐the‐counter analgesics for mild to moderate pain may be used. As with any medication, the prescriber should consider side effect risks as well as medication interactions that affect the decision to use any drug. What are the three FDA‐approved medicines for maintenance therapy for opioid use disorder (OUD) and which may be prescribed in primary care? It is important to note that there is no single approach to treatment of substance use disorder that is perfectly suited to every patient. Providers must be committed to a patient‐centered approach that considers not only the research evidence on medications but also considers the patient's values, beliefs, and preferences. The following are the three FDA‐approved medications (a detailed treatment improvement protocol for the use of these medications can be found at: https://store. samhsa. gov/product/TIP‐63‐Medications‐for‐Opioid‐Use‐Disorder‐Full‐Document‐Including‐Executive‐Summary‐and‐Parts‐1‐5‐/SMA19‐5063FULLDOC): Buprenorphine: High‐quality research has found buprenorphine to be effective and safe (SAM-HSA, 2018). Buprenorphine has been associated with improved retention in treatment, lower morbidity and mortality compared to treatment without medication, reduced overdose rates, reduced HIV risk behavior, and is effective in primary care settings (SAMHSA, 2018). Under current federal law, buprenorphine is the only opioid‐agonist treatment for OUD that may be prescribed by primary care providers (with special training). Providers are required to take either 8 hours (MDs) or 24 hours (NPs and PAs) of training. Efforts to increase access in the United States to this life‐saving drug are crucial in light of the opioid crisis. Free buprenorphine trainings can be accessed at: https://pcssnow. org/medication‐assisted‐treatment/. If an NP does not yet have a waiver to prescribe buprenorphine, it is important to offer information and arrange for immediate referral and follow‐up to patients who desire it and may benefit from it. Methadone: Methadone has a long (almost‐50‐year) track r ecord as an evidence‐based, effective medicine for treatment of OUD and is used worldwide (SAMHSA, 2018). Proven benefits of
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Substance Use Disorder (SUD) 463 methadone treatment include improved retention in treatment, less illicit opioid use, reduced mortality, reduced crime, and reduced HIV seroconversion rates (SAMHSA, 2018). Current U. S. federal law limits the routine administration/prescribing of methadone for treatment of OUD to federally‐qualified clinics or inpatient settings. Although methadone may not be pre-scribed for OUD in a primary care setting, all providers who take care of patients with OUD should be familiar with it. Methadone may be prescribed for treatment for the explicit indica-tion of pain management but because of the risks and challenges outlined previously, this should ideally only be done by prescribers with specialty training and experience. Naltrexone: Naltrexone is an opioid antagonist that blocks the effect of opioids at receptor sites. The formulation of naltrexone that has been shown in research to be effective for treatment of OUD is an injectable depot extended‐release naltrexone (XR‐NTX). XR‐NTX has been found to improve retention in treatment and reduce illicit opioid use compared to placebo (SAMHSA, 2018). Oral naltrexone has not been shown to be an effective treatment for OUD so is not recom-mended. Primary care providers may prescribe XR‐NTX but must consider that initiation requires a patient to be fully abstinent from opioids for a period long enough (7 to 10 days after last use of short‐acting opioids and 10 to 14 days after last use of long‐acting opioids) to avoid precipitated withdrawal (SAMHSA, 2018). Patients must be willing to return for monthly depot injections and should be counseled about opioid blockade effects, which may complicate treatment of pain should it be necessary. What are health promotion/health prevention/harm reduction topics that should be addressed with this patient? In this case, in addition to addressing the primary concerns of withdrawal and OUD, the NP should strive to attend to the following issues: Overdose education and naloxone provision: With any patient at risk for opioid overdose, naloxone education should be provided to the patient and any family/friends/roommates who may be in the position to witness an overdose. If unable to dispense or provide a take‐home naloxone formulation directly to the patient at the time of the visit, the NP should direct the patient/family to the nearest pharmacy/community resource that can provide it. Resources on where to obtain naloxone should be easily accessed via a web search or through a local/regional/state health department. The NP should convey harm reduction messages such as urging the patient to not use alone and to have naloxone and someone trained on its use nearby in the event of a return to opioid use. Comorbid mental health: If discover ed in the screening recommended earlier, the NP should pri-oritize the need for urgent treatment (i. e., if suicidal ideation is present) and discuss options for treatment of comorbid mental health issues (ranging from medications to counseling across a variety of settings). Involvement of a multidisciplinary team including behavioral health spe-cialists is ideal. General health promotion/pr evention: As with any chronic health condition, the primary care NP should consider the general health needs of the patient and maintain routine screenings, immu-nizations, and reproductive health counseling as indicated by up‐to date guidelines such as the U. S. Preventive Services Task Force (USPSTF; see www. uspreventiveservicestaskforce. org) or other professional organizations/guidelines. What is the plan of treatment? The plan for treatment in this case would involve an informed conversation with the patient and family about available options and preferences. Options for treatment of OUD vary widely and can be delivered in multiple settings ranging from primary care to intensive outpatient programs to inpatient to residential programs (SAMHSA, 2018). Availability of specialized treatment services vary regionally and are often limited by insurance coverage and waiting lists. SAMHSA's Behavioral Health Treatment Services Locator (https://fndtreatment. samhsa. gov) is a national resource that
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464 Resolutions may help patients and providers find available treatment providers if the NP is unfamiliar with local services. A negotiated patient‐centered plan might include the following components for a patient who does not require hospitalization or residential treatment: Praise patient and family for seeking care and provide education about OUD as a chronic health condition that is treatable. Ideally, induce patient on bupr enorphine for withdrawal and begin maintenance therapy. Immediate initiation of buprenorphine reduces the chance a patient will delay or forego access-ing care and return to use (SAMHSA, 2018). Provide naloxone kit or pr escription and overdose education for patient/partner/friends/ family. Consider an antidepressant if PHQ‐9 or GAD‐7 suggests a DSM‐5 diagnosis of anxiety or depression. Ideally, in an integrated car e setting where behavioral health and substance use services are colocated with primary care, conduct a “warm handoff” to addiction and/or mental health counseling. If an integrated setting is not available, the NP should be familiar with community resources and refer urgently. What are the plans for referral and follow‐up care? Referrals and follow‐up for this patient should include the following: Ongoing pharmacotherapy treatment (if not pr ovided by primary care provider). Addiction and/or mental health counseling. Peer recovery supports (r ecovery coaches) may be available in many communities. Trained recovery workers (many with lived experience) provide patients in early recovery important local support. For more details on recovery community centers and their work, see https://www. recoveryanswers. org/resource/recovery‐community‐centers/ Depending on patient prefer ences, referral to self‐help groups like AA, NA, Smart Recovery, and so on may be helpful. The SAMHSA National Helpline serves as a national centralized resource for finding local services (https://www. samhsa. gov/find‐help/national‐helpline). Close follow‐up with primary care (i. e., days to weeks) to maintain therapeutic r elationship and ensure stability in early recovery. Support groups for families dealing with OUD. The SAMHSA National Helpline can assist with these services as well. One example of a group targeting OUD specifically is Learn2Cope (https://www. learn2cope. org/). If OUD progresses to include injection use, referral to a syringe services program (SSP) that can provide life‐saving, health‐preserving harm reduction approaches even if drug use continues. Nearly three decades of quality research have shown SSPs to effectively and safely improve health outcomes such as HIV, hepatitis, and other infection rates and have not been associated with increased drug use or crime (CDC, 2019). To find local services, the North American Syringe Exchange Network maintains a listing of operating SSPs at: https://www. nasen. org/. What health education should be provided to this patient? Education on the following would be important in this case: Education on pathophysiology of OUD as chronic r elapsing disorder/risks of overdose Risks/benefits/potential side effects/interactions of all medicines Naloxone for overdose pr evention as above What are demographic characteristics that might affect this case? Demographic factors such as employment, housing stability, and insurance coverage may greatly affect access to care.
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Substance Use Disorder (SUD) 465 Does the patient's psychosocial history impact how you might treat him? As discussed, the prevalence of substance use disorder with comorbid mental health disorders is high. History of trauma is also associated with higher risk for substance use disorder (SAMHSA, 2018). Sensitive consideration of these factors by the NP is important to enhance efficacy of treatment. Moreover, access to some of the more basic physical social determinants of health (i. e., housing, transportation, a safe living environment) are known to affect the ability for a person to attain their best health (CDC, 2018) and therefore must be considered closely to optimize treatment plans and ongoing care. What if the patient lived in a rural (or urban) setting? Several factors may create differences in the presentation and approach to OUD in a rural versus an urban setting. There may be differences in opioids used based on the illicit market supply (i. e., prescription opioids versus heroin versus fentanyl). Geographic availability of treatment services can vary widely and transportation to treatment becomes an important social factor to consider when planning treatment. NPs should become familiar with the nuances of their community's local available services. Are there any standardized guidelines that should be used to treat this case? If so, what are they? The following guidelines may be useful to the NP for managing care in this case: SAMHSA's “Medications for Opioid Use Disor der. Treatment Improvement Protocol (TIP) Series 63”: Available at: https://store. samhsa. gov/product/TIP‐63‐Medications‐for‐Opioid‐Use‐ Disorder‐Full‐Document‐Including‐Executive‐Summary‐and‐Parts‐1‐5‐/SMA18‐5063FULLDOC American Society of Addiction Medicine's “National Practice Guideline for the Use of Medications in the T reatment of Addiction Involving Opioid Use. ” Available at: https://www. asam. org/docs/default‐source/practice‐support/guidelines‐and‐consensus‐docs/asam‐national‐practice‐guideline‐supplement. pdf Naloxone for overdose pr evention: Guidance for healthcare providers can be found at: https:// prescribetoprevent. org/ What other professionals might you collaborate with to best provide comprehen-sive care for SUD? A collaborative, multidisciplinary approach to treatment of OUD is ideal. The following is a list of other professionals who the NP can collaborate with to provide best care: Addiction specialists if available. NPs should become familiar with locally available experts or if there ar e accessible telemedicine services. Free general mentoring services are provided by the Providers Clinical Support System for any provider who completes buprenorphine waiver training (see: https://pcssnow. org/mentoring/). Mental health/psychiatry providers. Peer recovery coaches (see r eferral information above). Harm reduction or ganizations (see referral information above). If you discovered that the patient were using substances intravenously, what other concerns/testing/treatment would you want to consider? The use of any substance intravenously poses multiple health concerns related to enhanced drug effect (i. e., faster onset of action and high potency increases risk of opioid overdose) and infection risks. If injection use is discovered, the following is a list of potential concerns: Risk for skin infections (especially if needles are r eused, which is common when sterile syringe services are not easily accessible or unavailable) Risk for bacterial endocarditis Risk for HIV/hepatitis and need for screening
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466 Resolutions Education on safer injecting techniques/sterile supplies (referrals to SSPs if available or pr ovi-sion of safe injecting information is crucial). The Harm Reduction Coalition offers a printable manual on safe injection available at: https://harmreduction. org/drugs‐and‐drug‐users/drug‐tools/getting‐off‐right/ Sexual/repr oductive health counseling and provision of condoms and/or birth control as necessary Referrals to local services/social workers as needed for housing instability or other financial concerns such as access to health insurance Risk for trauma and post‐traumatic stress disor der (i. e., witnessing overdoses, violence, sex work) REFERENCES AND RESOURCES Ahmad, F. B., Rossen, L. M., Spencer, M. R., Warner, M., & Sutton, P. (2018). Provisional drug overdose death counts. National Center for Health Statistics. Retrieved from:https://www. cdc. gov/nchs/nvss/vsrr/ drug‐overdose‐data. htm American Psychiatric Association. (2013). Opioid use disorder. In Diagnostic and statistical manual of mental dis-orders (5th ed. ). Arlington, VA: American Psychiatric Publishing. American Society of Addiction Medicine. (2015). National practice guideline for the use of medications in the treatment of addiction involving opioid use. Retrieved from: https://www. asam. org/docs/default‐source/practice‐support/guidelines‐and‐consensus‐docs/asam‐national‐practice‐guideline‐supplement. pdf Centers for Disease Control. (2018, January 29). Social determinants of health: Know what affects health. Retrieved from: https://www. cdc. gov/socialdeterminants/index. htm Centers for Disease Control. (2019, May 23). Syringe services programs (SSPs). Retrieved from: https://www. cdc. gov/ssp/index. html Gowing, L., Ali, R., White, J. M., & Mbewe, D. (2017). Buprenorphine for managing opioid withdrawal. Cochrane Database of Systematic Reviews, 2, CD002025. https://doi‐org. libproxy. unh. edu/10. 1002/14651858. CD002025. pub5 Herron, A. J., & Brennan, T. K. (Eds. ). (2019). The ASAM essentials of addiction medicine (3rd ed. ). Philadelphia: Wolters Kluwer Health. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ‐9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. doi:10. 1046/j. 1525‐1497. 2001. 016009606. x National Institute on Drug Abuse. (2018, August). Comorbidity: Substance use disorders and other mental illnesses. Retrieved from: https://www. drugabuse. gov/publications/drugfacts/comorbidity‐substance‐use‐disorders‐ other‐mental‐illnesses Pew Charitable Trusts. (2019, February). Opioid use disorder: Challenges and opportunities in rural communities. https://www. pewtrusts. org/en/research‐and‐analysis/fact‐sheets/2019/02/opioid‐use‐disorder‐ challenges‐and‐opportunities‐in‐rural‐communities Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anx-iety disorder: The GAD‐7. Archives of Internal Medicine, 166(10), 1092-1097. Substance Abuse and Mental Health Services Administration. (2018). Medications for opioid use disorder. Treatment Improvement Protocol (TIP) Series 63. HHS Publication No. (SMA) 19‐5063FULLDOC. Rockville, MD. https://store. samhsa. gov/system/files/tip63_fulldoc_052919_508. pdf U. S. Department of Health and Human Services. (2018, April 5). U. S. Surgeon General's advisory on naloxone and opioid overdose. Washington, DC: HHS. Retrieved from: https://www. hhs. gov/surgeongeneral/priorities/opioids‐and‐addiction/naloxone‐advisory/index. html U. S. Department of Health and Human Services, Office of the Surgeon General. (2018, September). Facing addiction in America: The Surgeon General's spotlight on opioids. Washington, DC: HHS. https://addiction. surgeongeneral. gov/sites/default/files/Spotlight‐on‐Opioids_09192018. pdf U. S. Department of Justice. (n. d. ) Emergency narcotic addiction treatment. Retrieved from: https://www. deadiversion. usdoj. gov/pubs/advisories/emerg_treat. htm Wesson, D. R., & Ling, W. (2003). The clinical opiate withdrawal scale (COWS). Journal of Psychoactive Drugs, 35(2), 253-259. doi:10. 1080/02791072. 2003. 10400007
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467 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 8. 2 Foot Ulcer RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? A CBC with differential and elevated white count can indicate infection. George is a diabetic so it should be assumed that the foot ulcer is infected. The discharge and increasing discomfort also support a diagnosis of infection. An erythrocyte sedimentation rate (ESR) may also be helpful. Cultures with Gram staining can help determine the cause of the infection. Without signs of infec-tion, a culture is not indicated. It would be helpful to get an HBA1c if George has not had one recently. The test will help determine whether George's diabetes is under control, which seems unlikely. The CMP will reveal his current blood sugar level as well as his kidney function and met-abolic status. An X‐ray will help diagnose osteomyelitis or gout. If osteomyelitis is highly sus-pected, a bone biopsy will be necessary. An MRI would be helpful if osteomyelitis is suspected and is more helpful than an X‐ray. Identify and explain three differential diagnoses. All of the diagnoses listed in the case presentation are possible. George is a diabetic. This ulcer started with a callus, which is a very common early presentation for diabetic foot ulcers. George has a history of both peripheral vascular and peripheral arterial disease. George may also have cel-lulitis with or without osteomyelitis or a secondary infection because his wound has not healed. The presentation could also indicate a MRSA infection. Gout does not typically present with dis-charge but the great toe is the most common location for gout and the affected area typically pres-ents with redness, warmth, and severe pain. In addition, gout usually has an acute onset. See Case 8. 4 (burning leg pain) for more information. The data in this case most likely points to a diabetic ulcer or venous ulcer. The brownish tinge to the skin and the scattered varicosities are hallmark signs.
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468 Resolutions Arterial Ulcers Venous Ulcers Regular borders Irregular borders Base of yellow material or eschar Shallow wound bed Scant or absent granulation tissue No eschar Underlying structure more likely visible No underlying structures visible Absent or decreased pedal pulses Positive palpable pulses Painful Painless Outer sides of ankles, feet, tips of heels, toes Below the knee; around ankle, particularly medial side Waxy skin Brawny skin changes Hair loss on limb Cool to touch What is the plan of treatment? Diabetic foot infections are serious and should be treated promptly. The choice of antibiotic depends on the extent of the infection. Diabetic ulcers are typically caused by more than one organism. Only use antibiotics if the wound is visibly infected. Antibiotic treatment should cover both Gram‐positive and Gram‐negative organisms, especially if the patient has recently been treated with antibiotics. If George had a recently diagnosed MRSA infection or is at high risk (regular hospital-izations or inpatient stays), he should be treated with intravenous vancomycin until the culture and sensitivity test returns. George has a worsening infection, so the best plan of treatment is to start him on IV antibiotics. After stabilization, he can be switched to antibiotics by mouth. Sometimes surgical debridement of the wound is necessary. Choose an antibiotic in consultation with a vascular surgeon and consider George's renal function. Are there any standardized guidelines to consider? Lipsky, B. A., Aragón‐Sánchez, J., Diggle, M., Embil, J., Kono, S., Lavery, L., .  .  .  Peters, E. J. G., on behalf of the International Working Group on the Diabetic Foot, & Peters, E. J. G. (2016). IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metabolism Research and Reviews, 32(Suppl. 1), 45-74. International Diabetes Federation. (2017). Clinical practice recommendation on the diabetic foot: A guide for health care professionals. International Diabetes Federation. What health education should be provided to the patient? George will need health teaching regarding the antibiotic treatment chosen to treat his wound. If he requires debridement, he will need pre‐ and post‐operative teaching. Otherwise, the most important instruction for George concerns getting and keeping his blood sugar under control. He will need to work with his health care providers to maintain tight control. George should also be instructed to inspect his feet daily and report calluses or open wounds, no matter how small. He should use recommend emollients to prevent dryness, scaling, and cracking. George should also report symptoms of neuropathy or nerve damage. He should be referred to a podiatrist for regular nail clipping and foot checks. His podiatrist may need to see him every 3 months. What complicating factors specific to this case should be considered? George has several complicating factors in his health history. He is obese and has both PAD and PVD. He is diabetic. He has hyperlipidemia, heart disease, sleep apnea, and ITP. What collaborative assessment and care might the patient require? Include your rationale. George needs referral to a podiatrist and wound specialist. The podiatrist will check his feet fre-quently, trim his toenails, and teach him how to care for his feet and about the impact of poor glucose control on his feet and skin. The wound specialist will need to evaluate the wound and weigh in on the correct antibiotic and wound treatment. An orthopedic consult will be necessary if
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Foot Ulcer 469 George has osteomyelitis or if the wound is deep enough to affect the bone. George may be hospi-talized while receiving IV treatment or he may receive IV antibiotics at home by a visiting nurse. In any case, he will need follow‐up care by visiting nurses. REFERENCES AND RESOURCES American Association of Clinical Endocrinologists: https://www. aace. com/ American Diabetes Association: www. diabetes. org International Diabetes Federation. (2017). Clinical practice recommendation on the diabetic foot: A guide for health care professionals. International Diabetes Federation. South Australian Expert Advisory Group on Antimicrobial Resistance. (2019, March 20). Diabetic foot infections: Antibiotic management clinical guideline. Clinical guideline no. CG304. Government of South Australia.
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471 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 8. 3 Abdominal Pain and Weight Gain RESOLUTION Which diagnostic studies should be considered to assist with or confirm the diagnosis? CBC with differential normal; hemoglobin A1c: 7. 3 (elevated); chemistries normal; LFT normal; H. pylori stool antigen + (abnormal); TSH: 1. 34; LH: 9. 8 (elevated); FSH: 2. 3 (low-normal: 3-20); DHEA: 244; testosterone: 88; bioavailability: 36 (elevated/high normal); HCG: negative; serum prolactin: 102 (elevated); lipids: total cholesterol: 186; triglycerides: 94; LDL: 103; HDL: 46; HIV: negative; vitamin D: 9 (low); urinalysis: normal. To rule PCOS in or out, evaluating androgens is recommended, along with a hemoglobin A1c to evaluate insulin resistance. Hypothyroidism can be diagnosed with a TSH level. Serum prolactin and DHEA are needed to rule in or out the suspicion of hyperprolactinemia. Since Annette reports being sexually active without a form of contraception, getting an HCG is wise. Other labs for rou-tine health maintenance include a vitamin D level, HIV test, and urinalysis. In addition to labora-tory studies, a transvaginal ultrasound is needed to evaluate for the presence of ovarian abnormalities. An abdominal ultrasound can also help pinpoint the cause of the abdominal pain. What are the most likely differential diagnoses and why? Peptic ulcer and PCOS: Peptic ulcers are silent in almost half the cases. Annette does not have nausea, vomiting, heartburn, or radiation of pain. However, she does have abdominal pain. The results of the transvaginal ultra-sound show multiple follicles within the uterus, which are arranged in a peripheral pattern as seen in polycystic ovarian disease. She has a retroverted uterus without any abnormality and multiple cysts on the left ovary indicative of polycystic ovarian syndrome. What is the plan of treatment? Annette should continue to refrain from tobacco use, avoid alcohol and NSAID use, and avoid foods that cause pain. The protocol for eradicating H. pylori includes antibiotics and acid suppres-sion. Antibiotic therapy works to promote ulcer healing, prevent relapse, and decrease the need for long‐term acid suppression. In all cases, combination antibiotic therapy is needed due to the high rates of resistance. To suppress acid, proton pump inhibitors (PPIs) are most often used. It is impor-tant to check regional bacterial resistance to particular antibiotics before treating. An appropriate
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472 Resolutions treatment for Annette would be lansoprazole (30 mg twice daily), amoxicillin (1 g twice daily), and clarithromycin if there is no local resistance (500 mg twice daily) and metronidazole (500 mg twice a day) for 10-14 days. There are several different combination therapy suggestions ranging from 7‐ to 14‐day treatments. The treatment plan for Annette's PCOS should be based mostly on her symptoms. Three reasons for treatment can be considered in her case: (1) regulation of uterine bleeding and reduction in risk for endometrial hyperplasia, (2) the improvement of dermatological complaints including acne and increased dark hair growth, and (3) the correction and prevention of possible metabolic abnor-malities, including DM and cardiovascular disease. To address Annette's irregular menstrual bleeding, a hormonal contraceptive method should be considered based on her individual contra-ceptive needs and comfort level. A common starting place is the combined oral contraceptive pill (COC), but the ring and progestin‐only methods such as the implant or the hormonal IUD could also be considered. To address Annette's complaint of acne and dark hair growth, an androgen receptor blocker could be considered as pharmacotherapy in an extreme circumstance. However, if looking for a more conservative treatment, choosing a combined contraceptive option would improve acne; and a cosmetic route could be chosen for the hair growth (such as bleaching, electrolysis, or laser removal). The correction of any metabolic abnormalities is also of great concern, and the treatment should begin with a discussion of diet and lifestyle modifications. Many studies have shown that weight loss can lower the level of circulating androgens, thus causing the resumption of normal menstrual patterns and a reduction in insulin resistance. Since Annette's lab studies show a high hemoglobin A1c level, indicative of long‐term insulin resistance, starting a hypoglycemic agent would be an acceptable adjunct therapy to lifestyle changes. To address preventive health practices for Annette, starting her on daily calcium, vitamin D, and fish oil supplementation would also be appropriate. Are any referrals or follow‐up needed? It is important to follow up with Annette after her treatment course to see if the H. pylori infection was eradicated. If the infection persists, it is appropriate to continue therapy, most likely changing antibiotics due to suspicion of resistance. If the infection is eradicated but symptoms persist for more than 4 weeks, it would be recommended that Annette be referred to a gastrointestinal spe-cialist for endoscopic evaluation. PCOS is a common condition that can be managed within the realm of primary care, so it is not recommended that Annette be followed by a specialist. However, to evaluate progress on the treatment options discussed today, the time frame for acceptable follow‐up visits is monthly for the first 3 months and then quarterly until specific treatment goals are reached. At the follow‐up visits, diet and exercise journals should be reviewed and blood tests should be done to evaluate insulin resistance (hemoglobin A1c) and androgen levels (FHS, LH, testosterone). Since this is also Annette's establishment of primary care, it is important to encourage follow‐ups for routine gyne-cology care and other routine health maintenance. What if the patient had a positive pregnancy test? If Annette had a positive pregnancy test, the first step would be to establish if this was a planned and/or desired pregnancy. If the pregnancy is either unplanned or undesired, options counseling should be included to discuss keeping the pregnancy, adoption, and termination of the pregnancy. If Annette wanted to continue the pregnancy, she should be offered or referred to prenatal care. Since a common side effect of PCOS is the inability to conceive due to irregular cycles, she would have already overcome a hurdle of the condition. The treatment for irregular menstrual bleeding would be a topic to address postpartum. Metformin is category B in pregnancy, so it would be
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Abdominal Pain and Weight Gain 473 acceptable to treat the insulin resistance concomitantly with the pregnancy. Androgen receptor blockers would be contraindicated during pregnancy. What if the patient were trying to conceive? To treat infertility, a fair trial of treatment should be done to evaluate whether regular menstrual patterns return. If difficulty conceiving persists beyond 9 months or a year, referral to a fertility specialist is acceptable. Are there any standardized guidelines that should be used to assess or treat this case? European Society of Human Reproduction and Embryology. (2018). International evidence‐based guideline for the assessment and management of polycystic ovary syndrome 2018. https://www. eshre. eu/Guidelines‐and‐Legal/Guidelines/Polycystic‐Ovary‐Syndrome Polycystic ovarian syndrome. (2018, June). Obstetrics & Gynecology, 131(6), e157-e171. doi:10. 1097/AOG. 0000000000002656 Randel, A. (2018). H. pylori infection: ACG updates treatment recommendations. American Family Physician, 97(2), 135-137. REFERENCES AND RESOURCES Ferri, F. F. (2019). Ferri's Clinical Advisor. Philadelphia: Elsevier. National Institutes of Health. (2019). Health info: Peptic ulcer. https://www. niddk. nih. gov/health‐information/ digestive‐diseases/peptic‐ulcers‐stomach‐ulcers/definition‐facts NOTE: The author would like to acknowledge Geraldine Marrocco, Ed D, APRN, CNS, ANP‐BC who write the case for the first edition of this book.
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475 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 8. 4 Burning Leg Pain RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm diagnosis? The ankle brachial index (ABI) is a first‐line diagnostic test and would be helpful in diagnosing peripheral arterial disease. If lower extremity vessels are noncompressible, the toe brachial index (TBI) is another option. Exercise ABIs may be performed if the resting ABI is normal and the patient has symptoms of intermittent claudication with walking (but in this case would not be an option since the patient is unable to walk very far). The six‐minute walk test is an alternative to exercise testing to assess functional status. Critical limb ischemia (CLI) is suspected if the patient reports leg pain when reclining (espe-cially at night), relieved by dangling the feet, as is the case here. If critical limb ischemia is sus-pected and the patient has abnormal arterial pressure, the nurse practitioner (NP) should order an arterial duplex ultrasound. Since persons with peripheral artery disease (PAD) have an increased prevalence of abdominal aortic aneurysm (AAA), it is reasonable to screen for AAA with abdom-inal ultrasound in persons with symptomatic PAD, per the AHA/ACC. Vascular specialists may order invasive tests such as computed tomography angiography, magnetic resonance angiography, and angiography. Because these invasive tests confer increased risk for the patient, typically they would only be ordered by a vascular specialist. What is the most likely differential diagnosis and why? The following risk factors support the diagnosis of PAD: hypertension, smoking history, hyperlip-idemia, and diabetes. All patients with these risk factors should be assessed for PAD because of their degree of risk. The findings of dependent rubor, hairless lower extremities, diminished pedal pulses, and a punched‐out appearing ulcer on the heel of the foot also support the diagnosis of PAD. Nocturnal leg pain with reclining, dependent rubor, and hairlessness are characteristic of PAD. Patients with PAD often have ulcers with regular borders that may be slow to heal. In patients who are able to walk some distance, pain in the leg muscles with walking, relieved with rest (inter-mittent claudication) is a hallmark of PAD. However, only 10% of patients with PAD present with
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476 Resolutions intermittent claudication. Approximately 40% of patients do not report leg symptoms, and approximately 50% r eport other types of leg pain. With chronic venous insufficiency the whole leg aches, relieved by elevation. With venous stasis ulcers, patients typically show brawny skin changes; this is not the case here. With spinal stenosis, pain is relieved with lumbar flexion and worsens with standing. With nerve root compression, pain radiates inferiorly and worsens with sitting, standing, and walking; however, it would not cause hairlessness, dependent rubor, and diminished pedal pulses. In the case of neuropathic pain due to diabetes, symptoms progress symmetrically from the extremities superiorly. Negative symptoms include numbness and weakness; positive symptoms include tingling and pain, worse at night. Due to lack of sensation, ulcers occur over weight‐bearing areas, or from abrasion with poorly fitting shoes. What is the plan of treatment? For behavioral therapy, the NP should work with Raymond to follow guideline‐directed medical therapy (GDMT), most recently established in 2016 by the American Heart Association (AHA) and the American College of Cardiology (ACC). First‐line treatment includes supervised exercise therapy; encouraging individual exercise is insufficient. In smokers, smoking cessation is also first‐line therapy. For drug therapy, AHA/ACC guidelines recommend antiplatelet therapy such as either aspirin or clopidogrel alone, or in combination with another anticoagulant, as recommended by the cardi-ologist. Per GDMT, statin therapy is also recommended for all patients with PAD. Also per GDMT, antihypertensive therapy should include either an ACE inhibitor (such as lisinopril) or an angiotensin receptor blocker (such as losartan to reduce the risk of myocardial infarction, stroke, heart failure, and death). For patients with diabetes and PAD, glycemic control of hemoglobin A1C below 6. 5 through diet, exercise, and medication will improve microvascular and cardiovascular outcomes. Are any referrals needed? Since Raymond shows signs of critical limb ischemia, the NP should refer urgently to a vascular surgeon for evaluation (emergent referral for acute limb ischemia, which is not the case here). For management of Raymond's ulcer, referral to specialized wound care is indicated. As Raymond has diabetes, referral to a certified diabetes nurse educator or endocrinologist will help with glycemic control. In all cases Raymond will require a team approach. What are the differences between arterial and venous disease? Arterial Disease Risk Factors Arterial Disease Treatment Venous Disease Risk Factors Venous Disease Treatment Age 65 or older Smoking cessation Prolonged standing Weight loss Hypertension Exercise Increased body weight Exercise Diabetes mellitus Improved diet Failed muscle pump function Compression stockings Hyperlipidemia Glycemic control Trauma Do not massage/rub legs Smoking history ACE/ARB Pregnancy For venous ulcers, Unna boot Family history of PAD Antiplatelet therapy Genetic predisposition Surgical treatment Known atherosclerotic disease in another vascular bed Endovascular surgery Biopsy if nonresponsive to treatment
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Burning Leg Pain 477 How should the clinician differentiate between venous ulcers and arterial ulcers? Arterial Ulcers Venous Ulcers Regular borders Irregular borders Base of yellow material or eschar Shallow wound bed Scant or absent granulation tissue No eschar Underlying structure more likely visible No underlying structures visible Absent or decreased pedal pulses Positive palpable pulses Painful Painless Outer sides of ankles, feet, tips of heels, toes Below the knee; around ankle, particularly medial side Waxy skin Brawny skin changes Hair loss on limb Cool to touch REFERENCES AND RESOURCES Gerhard‐Herman, M. D., Gornik, H. L., Barrett, C., Barhes, N. R., Corriere, M. A., Drachman, D. E., .  .  .  Walsh, M. E. (2017). 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. https://www. ahajournals. org/doi/pdf/10. 1161/CIR. 0000000000000470 Feldman, E. L. (2019). Screening for diabetic polyneuropathy. Up To Date. Retrieved October 2, 2019. Firnhaber, J. M., & Powell, C. S. (2019). Lower extremity peripheral artery disease: Diagnosis and treatment. American Family Physician, 99(6). Guttendorf, Ann. (2017). Peripheral arterial and venous insufficiency. In T. M. Buttaro, J. Trybulski, P. Polgar‐ Bailey, & J. Sandberg‐Cook (Eds. ), Primary care: A collaborative Practice (5th ed. ), 599-610. St. Louis: Elsevier. Kohlman‐Trigoboff, D. (2019). Update: Diagnosis and management of peripheral arterial disease. The Journal for Nurse Practitioners, 15(1), 87-95. American Heart Association. (n. d. ). PAD initial symptom checklist. From Helping your patients with peripheral artery disease: A clinician's guide. Retrieved October 2, 2019, from http://www. ksw‐gtg. com/ahapad/guide/pdfs/PADSymptom Checklist. pdf Walker, C. M., Bunch, F. T., Cavros, N. G., & Dippel, E. J. (2015). Multidisciplinary approach to the diagnosis and management of patients with peripheral arterial disease. Clinical Interventions in Aging, 10, 1147.
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479 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 8. 5 Difficulty Breathing RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Spirometry: FEV1/FVC <. 70; FEV1 50% predicted. Chest X‐ray: Overinflation of lungs; flattened diaphragm; mild cardiomegaly. CBC: Slight elevation of RBCs, all others WNL. ABGs: p H: 7. 36; PCO2: 55; PO2: 60; HCO3: 29; Sa O2: 89. ECG: Sinus tachycardia; fr equent PVCs; no ischemia; right axis deviation. What is the most likely differential diagnosis and why? COPD: Many community‐acquired pneumonias manifest in the right lung due to the right mainstem bron-chus angulation. However, given the absence of infiltrates (evidence for pneumonia) or suspicious lesions on CXR (pulmonary neoplasm), the most likely diagnosis is exacerbation of COPD. The ECG is not suspicious for coronary ischemia although it identifies changes commonly found with pulmonary hypertension, including right axis deviation, often seen with right ventricular enlarge-ment secondary to pulmonary hypertension. The result of the ABG is concerning. Janis is close to acute respiratory failure, requiring hospitalization if the Pa O 2 and Sa O2 fall below their current values. Since Janis is able to perform her metered dose inhaler therapies competently and she has noticeable improvement in her dyspnea with the administration of a nebulizer bronchodilator treatment, with adjustments in her medications, she will likely show improvement. Janis should revisit smoking cessation treatments. She is approaching the point at which home oxygen is needed (pa O 2 less than 55 mm Hg; Sa O2 less than or equal to 88) (Brashers, 2010). What is the plan of treatment? Add beclomethasone dipropionate, 42 mcg/inhalation MDI, 2 puffs 3-4 times per day, and change Janis's inhaled bronchodilator therapy to a long‐acting form: salmeterol, 12 mcg (range 4. 5-12). Oral glucocorticoid therapy may also improve her recovery. Serious discussion about smoking ces-sation and the addition of pulmonary rehabilitation should occur at the time of the visit. She should be seen again in 2-3 days for repeat spirometry and clinical assessment of her lungs.
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480 Resolutions What is the plan for follow‐up care? Janis may improve with pulmonary rehabilitation. Prescription or over‐the‐counter smoking cessa-tion medication should be recommended. She should be instructed to call in the case of increased temperature, dyspnea, or chest pain. Plan to review risk factors with Janis at the next visit, and invite her husband to attend. Working with Janis to improve overall health is essential. Smoking cessation and pulmonary rehabilitation are top evidence‐based treatments for COPD (Rabe et al., 2007; Rabe, 2017). Her current trajectory places her at grave risk for continued decline and early mortality. Are any referrals needed? Annual evaluation by a pulmonologist is recommended. Once Janis's condition has improved, she should also be referred to a cardiologist for further workup to rule out coronary artery disease (CAD). In light of this risk, an assessment of her lipids and an evaluation of her diet are recommended to examine other lifestyle modifications that might slow the development of CAD. With ECG evidence of right axis deviation, it is likely that her right ventricle may be enlarged secondary to pulmonary hypertension. This places her at risk for progression to heart failure (cor pulmonale). These serious effects of her condition require careful discussion so that she is fully aware of her risks and can make informed decisions about her future. Her husband should be invited to meet with the medical team to discuss his risks and how his continued smoking may be contributing to Janis's condition. What additional risk factors are evident for this patient? Janis is at great risk for coronary artery disease and lung cancer. She should also have an annual influenza vaccine, given her progression of disease. A pneumococcal vaccine is also recommended. Are there any standardized guidelines that should be used to treat this patient? Careful review of the progression and treatment recommendations (Rabe et al., 2007) provide evi-dence‐based guidelines for stages of COPD. These highlight the 4 components of management, including assessment and monitoring of the disease and its progression, reduction of risk factors, management of stable disease, and exacerbations. In addition, the Agency for Healthcare Research and Quality (2008) provides guidance for acute respiratory conditions that serve as helpful targets for acute or chronic condition management. REFERENCES AND RESOURCES Agency for Healthcare Research and Quality (2008). ACR Appropriateness criteria acute respiratory illness. National Guideline Clearinghouse. http://www. guideline. gov/summary/summary. aspx?doc_id= 13678 Brashers, V. L. (2010). Alterations of pulmonary function. In K. L. Mc Cance, S. E. Huether, V. L. Brashers, & N. S. Rote (Eds. ), Pathophysiology: The biologic bases for disease in adults and children (6th ed., Chapter 33, pp. 1266-1309). Maryland Heights, MO: Mosby Elsevier. Falk, J. A., Kadiev, S., Criner, G. J., Scharf, S. M., Minai, O. A., & Diaz, P. (2008). Cardiac disease in chronic obstructive pulmonary disease. Proceedings of the American Thoracic Society, 5, 543-548. Global Initiative for Chronic Obstructive Lung Disease. (2019). GOLD report. www. gold‐2019‐v1. 7‐ final‐14Nov2018. WMS. pdf. Kuzma, A. M., Meli, Y., Meldrum, C., Jellen, P., Butler‐Lebair, M., Koczen‐Doyle, D., Rising, P., Stavrolakes, K., & Brogan, F. (2008). Multidisciplinary care of the patient with chronic obstructive pulmonary disease. Proceedings of the American Thoracic Society, 5, 567-571. Rabe, K. F. (2017). Chronic Obstructive Pulmonary Disease. The Lancet, 389(10082), 1931-1940. Rabe, K. F., Hurd, S., Anqueto, A., Barnes, P. J., Buist, S. A., Calverley, P., .  .  .  Zielinski, J. (2007). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD execu-tive summary. American Journal of Respiratory Critical Care Medicine, 176(6), 532-555. http://ajrccm. atsjour-nals. org/cgi/reprint/176/6/532 Sarna, L., Cooley, M. E., Brown, J. K., Chernecky, C., Elashoff, D., & Kotlerman, J. (2008). Symptom severity 1 to 4 months after thoracotomy for lung cancer. American Journal of Critical Care, 17, 455-467.
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481 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 8. 6 Epigastric Pain RESOLUTION What is the most likely differential diagnosis and why? Gastroesophageal reflux disease: This diagnosis is supported by the patient's symptoms of retrosternal burning pain that occurs after meals and is exacerbated by certain foods and heavy meals. The sour taste, coughing, and regurgitation are also relevant symptoms. The fact that Meredith has achieved some relief with Maalox and Tums helps the clinician to validate that the condition is probably related to reflux. A cardiac condition or an ulcer is unlikely to result in relief from an antacid. Which diagnostic studies should be considered to assist with or confirm the diagnosis? Current guidelines recommend that none of these tests be performed if the patient is responsive to acid‐suppressing therapy. However, Meredith's symptoms are severe, so the clinician might order an endoscopy now or after beginning therapy. Possible complications of GERD and ulcers will need to be ruled in or out by an endoscopy. If the endoscopy is normal, 24‐hour p H testing might be considered. For a patient whose symptoms are not severe, the endoscopy can usually wait while the patient is monitored under conservative treatment with medication and diet changes. If the patient has not had a recent ECG or there is immediate concern that this might be cardiovascular in etiology, then she should have an ECG today. Since the guaiac was positive, a follow‐up fecal immunochemical test (FIT) and/or colonoscopy should be done, especially if the patient has not had a colonoscopy done recently. The choice of the initial test should depend on her family and personal medical history. If a FIT is positive, then a colonoscopy must be done regardless of how long it has been since the last one. However, the gastroenterologist should be consulted about this and will need to arrange the colonoscopy. If the suppressive therapy is ineffective or the endoscopy rules out GERD, the clinician should rule out a cardiac condition, pulmonary problem, ulcer, hepatitis, and infection. The other tests listed in the case might then be performed. Meredith's Lipitor dose may be inadequate to treat her hyperlipidemia so lipid values should be checked if they have not been checked recently.
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482 Resolutions What is the plan of treatment? The first‐line treatment for GERD includes antacids, H2 blockers, or proton pump inhibitors (PPI) (see Table 8. 6. 1). PPIs are the drug of choice because H2 blockers are less effective. However, they may be used in combination with PPIs. Meredith has already tried antacids but they are only providing minimal relief. At this point, Meredith should be started on a PPI once each day (with the possibility of increasing to twice each day if once a day is insufficient to control symptoms) for 4-8 weeks to see if that helps her symptoms to resolve. If her symptoms continue or if she develops dysphagia, weight loss, anemia, or odynophagia, and she has not yet had an endoscopy, she should be sent for one. If the endoscopy reveals abnormal results, such as an ulcer or Barrett's esophagus, the patient should be referred to a gastroenterologist. She may require surgery. Lifestyle modification (diet, weight loss, reduction or elimination of coffee intake, smoking ces-sation, reduction or cessation of alcohol intake, sitting up after meals and in bed at night) might be sufficient for patients with mild cases of GERD. Patients should avoid anticholinergics if possible and fatty foods and chocolate. Most people can come off of the PPI after 8-12 weeks or just change to an as‐needed basis However, Meredith has some troublesome symptoms that are affecting her quality of life. These modifications should still be recommended, but she should use the PPI therapy for 8-12 weeks. If she continues to have symptoms and requires twice‐daily treatment after 12 weeks, she should be placed on the lowest dose possible with awareness of the possible adverse effects of long‐term use (increased risk of Clostridium difficile and hip fractures). Surgery may be preferable to long‐term treatment. Meredith also has high blood pressure. The HCTZ 25 mg appears to be inadequate. The clinician should add an ACEI or ARB to her regimen. What is the plan for referrals and follow‐up? Most patients are treated based on a clinical diagnosis but some may need to be referred to a gastro-enterologist for further testing and treatment. However, Meredith may need referral for an endos-copy because her symptoms are severe and long lasting. She should see the gastroenterologist if 12 weeks of a PPI is insufficient to resolve her symptoms. Intractable disease may require surgical treatment via fundoplication. Meredith should monitor her blood pressure, keep a record and return for follow‐up in 2 weeks. She also needs follow‐up for her diet, weight loss, smoking, and alcohol reduction/cessation and to review her lipids and whether she needs an increased statin dosage. What are the patient's risk factors for this condition? The risk factors that Meredith has include obesity, alcohol consumption, and smoking. What are the possible complications of this condition? Possible complications of GERD include adenocarcinoma, Barrett's esophagus, aspiration pneu-monia, severe esophagitis that results in odynophagia and dysphagia, esophageal hemorrhage, laryngitis, reflux‐induced asthma, unexplained wheezing, chronic cough, dental erosions, and a feeling of a lump in the throat. Table 8. 6. 1. Medications Used to Treat GERD. Antacids: Quick Onset, Short Duration H2 blockers: OTC Dose Is Half the Prescription Dose. Longer Onset, Longer Duration Proton Pump Inhibitors: Take 30 Minutes before Breakfast Tums Baking soda Maalox Mylanta Gaviscon (to buffer antacid)Cimetidine Ranitidine Famotidine Nizatidine Omeprazole (also available with sodium bicarbonate) Rabeprazole Lansoprazole Pantoprazole Esomeprazole Dexlansoprazole
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Epigastric Pain 483 REFERENCES AND RESOURCES Ferri, F. F. (2019). Gastroesophageal reflux disease. Ferri's clinical advisor 2019 (pp. 569-571). Philadelphia: Elsevier. Lynch, K. L. (2018). Gastroesophageal reflux disease. In R. S. Porter, J. L. Kaplan, R. B. Lynn, & M. T. Reddy (Eds. ), The Merck manual of diagnosis and therapy (pp. 113-114). Kenilworth, NJ: Merck Sharp & Dohme Corp.
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485 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Measure blood pressure for pulsus paradoxus. This is done by initially taking the BP and then retesting systolic BP during inspiration to see if it is lower with inspiratory effort. With pericardial tamponade, cardiac compression causes lowering of the systolic BP as the inspiratory mechanics increase venous return, increasing ventricular preload, placing strain on the left ventricular capacity to pump. Repeat the ECG. Arrange for the following tests: echocardiogram, CBC, electrolytes, sed-imentation rate, and serial troponins (stat, 12 and 24 hours). Measuring lipids, blood glucose, elec-trolytes, hemoglobin, liver function tests, and TSH can help rule out other causes. The BUN, creatinine, and urinalysis can help rule out kidney disease. What is the most likely differential diagnosis and why? Pericarditis: The most likely diagnosis is acute pericarditis. The chest pain, ECG findings, and pattern of symp-toms, including elevated temperature, point to this diagnosis. Due to the complaints of chest pain over several days, an acute MI must be ruled out. Although the pattern of pain does not point to MI, especially since there is relief with leaning forward, this condition must still be ruled out, espe-cially given this patient's age and family history. While troponin I elevations are common in peri-carditis (Brandt, Filzmaier, & Hanrath, 2001), the combination of serial ECG changes and echocardiographic findings will generally allow diagnostic specificity. Troponin levels are not con-sidered a negative prognostic indicator in pericarditis (Rahman & Broadley, 2014). Infectious car-diomyopathy can be ruled out with the echocardiogram. Zachary's recent history of an upper respiratory infection and his pattern of dyspnea bring this condition into the realm of possibility. Generally, the onset is abrupt; and progressive heart failure, including all chamber enlargement, jugular venous distention, and severe dyspnea, ensues. These symptoms are similar to those seen with severe pericardial effusion/tamponade. What is the plan of treatment? The patient should be hospitalized for further diagnostic testing and treatment. Once myocar-dial infarction is ruled out, Zachary should be started on an anti‐inflammatory drug such as Case 8. 7 Chest Pain and Dyspnea without Radiation
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486 Resolutions indomethacin. Echocardiography will quantify the degree of pericardial effusion and guide further therapy. If the pericardial effusion is small, observation is indicated. If the pericardial effusion is moderate to large, pericardiocentesis or a pericardial window will be considered based on the patient's progression of symptoms. If his blood pressure remains elevated, he will need to begin an anti‐hypertension regimen. You should also instruct him regarding continued regular use of ibuprofen, Ecotrin, and glucosamine. The patient should be instructed to decrease alcohol use, improve diet, lose weight, and reduce stress. Once permitted, Zachary should increase his exercise. What is the plan for follow‐up care? Following hospitalization, the patient should be seen in 2 weeks. A repeat echocardiograph is indi-cated to ensure resolution of the effusion. A careful review of Zachary's management of gout is also indicated, and serum uric acid levels should be checked (goal 5-6 mg/d L). Are any referrals needed? Yes, the patient needs a cardiology consultation for definitive diagnosis and treatment. Admit the patient to the hospital, order a cardiology consult, and order the following upon admission: tro-ponin, CBC, electrolytes, and sedimentation rate. What if this patient had recently sustained an acute myocardial infarction? Dressler's syndrome, or post‐MI pericarditis, would be the suspected diagnosis if the patient had recently sustained an acute myocardial infarction. Generally, the pericardial sac has approximately 15-30 m L of fluid between the pericardial layer and the epicardial layer to allow for smooth filling and contraction. When inflammation develops, the fluid in this layer may increase considerably, compress-ing the ventricular muscle and preventing filling, reducing cardiac output and raising central venous pressure. Symptoms of dyspnea and discomfort are common. If the onset of fluid accumulation occurs rapidly, severe symptoms may develop and emergent treatment by pericardiocentesis may be required. Are there any standardized guidelines that should be used to assess/treat this case? The Imazio, Spodick, Brucato, Trinchero, and Adler (2010) article offers excellent summaries of med-ical therapy for pericarditis, including a strong overview of anti‐inflammatory drugs, tapering regi-mens if prednisone is used, and an overview of treatment patterns, incorporating the latest published standards. In addition, Choi (2010) provides a wonderful summary of lifestyle changes that help reduce the incidence of gout. These are helpful in reducing overall cardiac risk factors as well. REFERENCES AND RESOURCES Brandt, R. R., Filzmaier, K., & Hanrath, P. (2001). Circulating cardiac troponin I in acute pericarditis. American Journal of Cardiology, 87, 1326-1328. Choi, H. K. (2010). A prescription for lifestyle change in patients with hyperuricemia and gout. Current Opinion in Rheumatology, 22, 165-172. Hilaire, M. L., & Wozniak, J. R. (2010). Gout: Overview and newer therapeutic developments. Formulary, 45, 84-90. Imazio, M., Spodick, D. H., Brucato, A., Trinchero, R., & Adler, Y. (2010). Controversial issues in the management of pericardial diseases. Circulation, 121, 916-928. Imazio, M., Spodick, D. H., Brucato, A., Trinchero, R., Markel, G., & Adler, Y. (2010). Diagnostic issues in the clinical management of pericarditis. The International Journal of Clinical Practice, 10, 1-9. Khandaker, M. H., Espinosa, R. E., Nishimura, R. A., Sinak, L. J., Hayes, S. N., Meiduni, R. M., & Oh, J. K. (2010). Pericardial disease: Diagnosis and management. Mayo Clinic Proceedings, 85, 572-593. Punja, M., Mark, D. G., Mc Coy, J. V., Javan, R., Pines, J. M., & Brady, W. (2010). Electrocardiographic manifes-tations of cardiac infectious‐inflammatory disorders. American Journal of Emergency Medicine, 28, 364-377. Rahman, A., & Broadley, S. A. (2014). Elevated troponin: Diagnostic gold or fool's gold? Emergency Medicine Australasia, 26, 125-130.
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487 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What is the most likely differential diagnosis and why? Acute coronary syndrome (ACS): probable non‐ST elevation myocardial infarction (NSTEMI): The patient has a positive family history, a history of diabetes mellitus, and a long smoking history—all risk factors for ACS. The symptoms ar e consistent with ACS and the ECG changes are reflective of myocardial ischemia in the inferior (II, III, and a VF) lateral (V5 and V6) leads. The sudden onset of chest pain is a hallmark sign of pulmonary embolism (PE). Oliver also demonstrates tachypnea, hypertension, and neck vein distention, all of which may be seen with PE. Pulmonary embolism is generally associated with mor e dyspnea and seldom presents with epigastric distress. The patient should be screened for other risk factors associated with PE, such as prolonged immobility or history of hypercoagulable state, or a history of deep vein thrombosis (DVT). Oliver reports feeling a need to belch. Gastroesophageal reflux can often cause symptoms of chest pain or pressure. A positive smoking history and being overweight are risk factors for gastroesoph-ageal reflux. However, the presence of ischemia on the ECG makes a diagnosis of GERD unlikely. Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Within 2 hours of arrival to care: ECG: Inferior wall myocardial ischemia; troponin: 6 ng/d L; chem panel: Na: 138 m Eq/L, K: 4. 2 m Eq/L, Mg: 1. 7 mg/d L; BUN: 20; creatinine: 0. 8; serum glucose: 189 (Figure 8. 8. 1). What is the plan of treatment? Urgent transport by the EMS system to nearest interventional cardiology service is required. The ECG demonstrates myocardial ischemia and, coupled with the serious symptoms, is a medical emergency. Since Oliver is tachypneic and has chest discomfort, pulmonary embolism is likely the top differential diagnosis. However, the preponderance of history and symptoms point to acute MI. Pain onset in early morning hours is common with AMI symptoms; Oliver's pain began at 7:00 a. m. He did not report pain consistent with PE, which often is accompanied by deep vein throm-bosis. In addition, PE is generally associated with more severe dyspnea and oxygen desaturation. Coronary artery catheterization will dictate the intervention and plan, with possible angioplasty Case 8. 8 Chest Pain with Radiation
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488 Resolutions and stent placement. Calling the hospital and faxing the office ECG would allow for more rapid definitive care for this patient. Oliver will need a number of lifestyle changes in light of his diagnosis. Management of his mul-tiple risk factors will be attempted with the addition of medications to prevent recurrence. Lifestyle changes include the addition of exercise, smoking cessation, dietary changes to reduce his intake of saturated and trans fats, and secondary prevention measures to improve his risk profile and reduce the risk of a second cardiac event. Despite his family history, Oliver has continued a number of risky behaviors that will be very difficult to change all at once. Supportive education and reinforce-ment of small gains will be needed as he seeks to implement changes in his lifestyle. He and his wife need education about activating the emergency medical system, and he needs to be advised against driving independently to the office or hospital in the event of future chest pain episodes. Are any referrals needed? Oliver will be followed by a cardiologist. He will undergo cardiac catheterization, which will allow for assessment of his coronary artery perfusion, interventions such as angioplasty and stent placement, and ventriculography, which will provide an estimated ejection fraction. If acute MI is confirmed, the most definitive treatment will be completed. If stents are possible to stabilize the coronary lesions, they will be placed; if coronary artery bypass is required, Oliver will be hospital-ized for approximately 4-5 days. If CAD is confirmed, he will be discharged on additional medica-tions, including a beta blocker, ACE inhibitor, IIb/IIIa inhibitor, daily aspirin, and a statin. He will be referred to cardiac rehabilitation post‐intervention so that he may be monitored during recovery as he increases his exercise capacity. His blood pressure will need to be controlled with an ACE inhibitor and beta‐blocker, given his comorbidities of cardiovascular disease and diabetes mellitus. Does the patient's family history impact how you might treat him? Oliver will be placed on similar treatments as any patient following an AMI. However, his family history requires a more aggressive approach to management of lipids, hypertension, and diabetes. What are the primary health education issues? Smoking cessation is the top priority. Smoking is a primary risk factor. A full cholesterol panel should also be ordered and a healthy diet begun. Exercise and risk factor reduction are key ele-ments in the educational process. Educational efforts with diabetes management should be reinforced, with tighter control of blood glucose. Figure 8. 8. 1. Oliver's ECG.
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Chest Pain with Radiation 489 What if this patient were female? Women often present with symptoms that differ from men. Common symptoms in women include chest discomfort with radiation to the jaw, nausea, and fatigue. Radiation of pain to the back, sim-ilar to one of Oliver's symptoms, is also a primary presenting symptom in women. Women may also present with dyspnea more often than men. What if the patient lived in a rural, isolated setting? Anticipatory education would be strongly recommended for anyone with the family history presented in this scenario. Since Oliver had both a father and a brother who died early with cardio-vascular disease—and particularly if he lived in a rural area—he should be counseled to become familiar with the emergency medical services in his area, taught to keep chewable aspirin on hand and to take one immediately with the onset of chest pressure or pain that might resemble cardiac symptoms, and be given detailed steps to take for recognition and early intervention to prevent a heart attack. Nitroglycerin PRN will be prescribed and the patient should be advised to take one sublingual tablet at the onset of chest pain and to call 911 immediately. Family members would benefit from learning CPR, especially since Oliver lives in a rural, isolated setting. Are there any standardized guidelines that should be used to assess/treat this case? The American Heart Association has published standards for care in both NSTEMI and STEMI; nurse practitioners should be familiar with these standards. REFERENCES AND RESOURCES Anderson, J. L., Adams, C. D., Antman, E. M., Bridges, C. R., Califf, R. M., Casey, D. E. Jr., .  .  .  Wright, R. S. (2007). ACC/AHA 2007 guidelines for the management of patients with unstable angina/non‐ST‐elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non‐ST‐Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons, endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Journal of the American College of Cardiology, 50, 1-157. Krumholz, H. M., Anderson, J. L., Bachelder, B. L., Fesmire, F. M., Fihn, S. D., Foody, J. M., .  .  .  Nallamothu, B. K. (2008). ACC/AHA 2008 performance measures for adults with ST‐elevation and non‐ST‐elevation myo-cardial infarction: A report of the American College of Cardiology/American Heart Association task force on performance measures. Circulation, 118, 2596-2648. Lieberman, K. (2008). Interpreting 12‐lead ECGs: A piece by piece analysis. Nurse Practitioner, 33(10), 28-35. Wasylyshyn, S. M., & El‐Masri, M. M. (2009). Alternative coping strategies and decision delay in seeking care for acute myocardial infarction. Journal of CV Nursing, 24, 151-155. NOTE: The author would like to acknowledge the contribution of Kathy J. Booker, Ph D, RN to this chapter in the first edition of this book.
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491 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 8. 9 Persistent Cough and Joint Tender ness RESOLUTION Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? The chest X‐ray showed a right upper lobe mass and diffuse right infiltrates. CBC results: Marked elevations in WBC, eosinophils, and segmented neutrophils. ABGs: p H: 7. 34; Pa O2: 55; PCO2: 48; HCO3: 26; Sa O2: 89. What is the most likely differential diagnosis and why? Blastomycoses dermatitidis (BD): BD is a fungal infection identified in the yeast form from sputum or tissue culture. It may present as a pulmonary mass or a head/neck mass. BD may mimic histoplasmosis or tuberculosis. The spores are generally inhaled and transmitted through the lymphatic system. Presenting symptoms are often similar to influenza, accompanied by a dry, hacking cough. Diagnosis requires micro-scopic visualization of spores from a tissue or sputum sample. In this patient, the combination of dry cough, hypoxemia, and CBC changes point to the potential for BD. What is the plan of treatment? Alice is admitted to the hospital for further workup and treatment of her tachypnea and hypox-emia. A pulmonary consult is ordered. Given her history, an urgent bronchoscopy is scheduled. She is started on supplemental oxygen by venti‐mask at 40%. BD infections are generally treated with amphotericin, followed by oral antifungal therapy. When fulminant fungal infections develop in the lungs, a restrictive pattern of respiratory failure is the general trajectory. As the infection spreads, inflammation and injury to alveolar tissue results in ventilation‐perfusion mismatching and true shunting develop, with resultant hypoxemia. At the peak of the infection, respiratory failure may require continuous positive airway pressure or total ventilator support. Pulmonary neoplasm is a distinct possibility, especially given her history of breast cancer. However, the prodromal and admitting symptoms do not align with malignancy. Untreated, BD manifests in joint pain, which explains Alice's joint pain.
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492 Resolutions What further diagnostic tests are needed? Bronchoscopy will allow for direct evaluation of the mass and cytology analysis of tissue or sputum sample. What is the plan for follow‐up care? Completion of the full therapy is essential to prevent recurrence of BD. Supplemental oxygen may be necessary. Pulmonary function testing will be required to follow resumption of function. Unlike obstructive disorders associated with air trapping, restrictive pattern pulmonary disorders gener-ally cause severe restrictions in total lung capacity, reduced tidal volumes and potentially severe hypoxemia. Amphotericin B (Am B) is toxic to the liver and kidneys and is difficult to tolerate, caus-ing a number of side effects. Baseline renal and liver function tests should be measured prior to starting therapy. During therapy with Am B, electrolytes should be measured every 48-72 hours and renal function and liver enzymes measured at least weekly, if not more often, during therapy. Are any referrals needed? Alice should be followed by pulmonary medicine for at least 1 year. Are there any standardized guidelines that should be used to assess/treat this case? The Infectious Diseases Society of America issued a clinical practice update in 2008 (Chapman et al., 2008). This published guideline makes recommendations for treatment based on age, clinical status, and severity of symptoms. Drug therapy guidelines for pulmonary and extrapulmonary treatment include intravenous amphotericin for those with severe infections, followed by oral itra-conazole. The practice guidelines also review monitoring parameters. REFERENCES AND RESOURCES Chapman, S. W., Dismukes, W. E., Proia, L. A., Bradsher, R. W., Pappas, P. G., Threlkeld, M. G., & Kauffman, C. A. (2008). Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 46(12), 1801-1812. Saccente, M., & Woods, G. L. (2010). Clinical and laboratory update on blastomycosis. Clinical Microbiology Reviews, 23(2), 367-381. Wheat, L. J., Freifeld, A. G., Kleiman, M. B., Baddley, J. W., Mc Kinsey, D. S., Loyd, J. E., & Kauffman, C. A. (2007). Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 45, 807-825. NOTE: The author would like to acknowledge Kathy J. Booker, Ph D, RN for her contribution to this case in the first edition of this book.
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493 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 8. 10 Morning Headache RESOLUTION Which diagnostic studies should be considered to assist with or confirm the diagnosis? ECG: The ECG shows nonspecific T wave changes; no evidence of acute ischemia. Troponin: <0. 4. CBC: slightly elevated RBCs, otherwise, WNL. Electrolytes: WNL. Total cholesterol: 240; HDL: 58; LDL: 166; triglycerides: 196. What is the most likely differential diagnosis and why? Hypertension: Morning headaches and the development of hypertension may also suggest obstructive sleep apnea. Daytime sleepiness and patterns of snoring should be explored. If either is present, Andrew should be referred for a sleep study. With this patient's strong family history of early congenital heart disease, immediate treatment of his hypertension is indicated. Close monitoring of his altered cholesterol panel values is also indicated. If he is able to improve his exercise and diet and reduces weight subsequent to these changes, cholesterol levels may improve. Since he had nonspecific T wave changes, a repeat ECG in 6 months would be important. Teaching for signs and symptoms of acute coronary syndrome is extremely important. What is the plan of treatment? Start the patient on antihypertensive therapy to include a thiazide diuretic with a calcium channel blocker (CCB). Begin with lower daily dosages with incr eases of baseline dosages if BP targets less than 130/80 is not reached. URGENT—stop smoking. Prescribe nicotine substitute patch and discuss plans for smoking cessation. Assess pt's risk and need for aspirin supplementation using the ASCVD Risk Calculato Recommend low‐fat, low‐salt diet (DASH) high in fruits and vegetables; pr ovide a referral to a dietitian. Encourage walking a minimum of 3-5 days per week. Schedule gradual increases in length and time after a 2‐week initiation.
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494 Resolutions What is the plan for referrals and follow‐up care? Return for BP check in 1 week. Encourage patient to monitor BP at home twice daily and keep a log. Encourage a log of daily walking activity with BP. Recheck serum cholester ol in 3 months. Referral for stress testing. Explore need for grief counseling. Refer to dietitian for dietary assistance. Refer to stop smoking clinic or web‐guided smoking cessation program What if this patient were female? The initial treatments and counseling would be the same in females. In educating about the signs of acute coronary syndrome, women should be told about atypical symptoms including dyspnea and pain radiating to the jaw and back. What if this patient were also diabetic? Diabetes increases the risk of coronary artery disease (CAD), and additional teaching for glycemic control and risk factors associated with diabetes would be required. BP targets are set at a lower point (<130/80) in patients with diabetes to reduce CAD risk. Are there any standardized guidelines that should be used to assess or treat this case? Bakris, G., Ali, W., & Parati, G. (2019). ACC/AHA versus ESC/ESH on hypertension guidelines: JACC guideline comparison. Journal of the American College of Cardiology, 73(23). doi:10. 1016/j. jacc. 2019. 03. 507 REFERENCES AND RESOURCES Bakris, G., Ali, W., & Parati, G. (2019). ACC/AHA versus ESC/ESH on hypertension guidelines: JACC guide-line comparison. Journal of the American College of Cardiology, 73(23). doi:10. 1016/j. jacc. 2019. 03. 507 Whelton, P., & Williams, B. (2018). The 2018 European Society of Cardiology/European Society of Hypertension and 2017 American College of Cardiology/American Heart Association blood pressure guidelines more similar than different. JAMA, 320(17), 1749-1750. doi:10. 1001/jama. 2018. 16755 NOTE: The author would like to acknowledge Kathy J. Booker, Ph D, RN for her contribution to this case in the first edition of this book.
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495 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic studies should be considered to assist with or confirm the diagnosis? None are necessary at this time. However, repeated sinus infections or episodes of sinusitis may warrant a CT scan of the sinuses. What is the most likely differential diagnosis and why? Acute sinus infection: The headache, sinus pain and pressure, and dental pain all support this diagnosis. It is not uncommon for patients to experience blood‐streaked rhinorrhea. A typical course toward the development of sinusitis includes a cold or upper respiratory infection followed by the patient feeling improved or well. However, symptoms return, and they tend to be worse and include sinus pressure and pain. A sinus infection needs time to develop and typically follows a cold, URI, or allergies, as mucus and drainage accumulates in the sinus, allowing bacteria or viruses to grow and fester. Henry may also have allergic rhinitis, which is characterized by cobblestoning in the throat, pale boggy mucosa, clear drainage, scratchy throat, itchy eyes, and an initial presentation after age 8 years old. However, any evidence of Henry's allergies would be superseded by his sinusitis symptoms. Children may have an obvious crease in their noses called an allergic salute that is caused by constantly rubbing the nose. People with allergies may also have epistaxis and frequent throat clearing accompa-nied by a cough. Mouth breathing, snoring, and creases beneath the lower eyelids (Dennie lines) are sometimes also present. It is not unusual to also have sinus pressure, tenderness, and headache. Vasomotor rhinitis is a type of nonallergic rhinitis. It is unrelated to an allergic hypersensitivity, infection, structural lesions, systemic disease, or drug use. One can also have atrophic sinusitis (from normal aging), rhinitis medicamentosa (overuse of some over‐the‐counter medication), or rhinitis related to the hormonal changes of pregnancy. Nonallergic rhinitis may also be caused by foreign bodies in the nose, nasal polyps, neoplasms, cocaine use, hypothyroidism, anatomic variations, and NARES (nonallergic rhinitis with eosinophilia syndrome). In NARES, there is eosinophilia in the nasal drainage, but skin and in vitro tests for allergens are negative. Case 8. 11 Facial Pain
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496 Resolutions What is the plan of treatment? Treat patient for rhinosinusitis and allergic rhinitis. See Table 8. 11. 1. What is the plan for referrals and follow‐up treatment? There is no need for a scheduled follow‐up unless the patient reports that symptoms have persisted beyond treatment or have worsened. No referrals are needed at this time. However, a referral to an Table 8. 11. 1. Plan of Treatment. Illness Pathophysiology Signs/Symptoms Treatment Common cold: URIAntigen, inflammatory response: edema, WBCs, congestion. Airborne, direct contact. Rhinovirus, coronavirus, parainfluenza virus, coxsackie, RSV. Incubation 1-5 days, virus shedding up to 3 weeks. Mild fever possible, chills, body aches, rhinorrhea (possibly purulent), and ear congestion, HA. ≤7-10 days, peak 5 days. Rest, fluids, analgesic, antipyretic. Atrovent nasal spray (anticholinergics), nasal spray. Afrin (watch for rebound): vasoconstriction. Dextromethorphan: Cough suppressant, may cause serotonin syndrome. Allergic rhinitis Ig E mediated: Allergen‐specific Ig E after T cell release. RXN is from subsequent exposure to allergen. Early phase: Prompt, lasts 1 hour. Late: Begins in 3-6 hours, gone in 12-24 hours. Early mediated by histamine. Late mediated by chemokines, cytokines, eosinophils, basophils. Eosinophils release leukotrienes. Sneezing, pruritus, congestion, drainage, sometimes conjunctivitis. Pale, boggy nasal mucosa, allergic shiners, nasal salute, watery eyes, cobblestoning throat and nose. Avoidance, antihistamines (Zyrtec, Allegra, Claritin), decongestants: oral or topical (watch for rhinitis medicamentosa), intranasal steroids, antileukotrienes (Singulair), intranasal cromolyn (prevention), allergy shots (prevention). Rhinosinusitis Cause is usually viral URI. Sinus inflammation should resolve in <14 days. If symptoms worsen after 3-5 days or last >10 days, then probably bacterial infection. Nasal mucosa produces drainage, then congestion and swelling into sinus cavity. Hypoxia and mucus retention promote bacterial growth. Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis. Chronic: Staphylococcus aureus and anaerobic bacteria. Can also have fungal sinusitis. >7 days of congestion, purulent rhinorrhea, PND, facial pain, pressure, ear/teeth pain, maybe cough, fever, nausea, fatigue, halitosis, impaired smell, taste. Chronic: Congestion, cough, and PND, worse at night. PE: Mucosal edema (nasal), purulent nasal secretions, sinus TTP (not specific or sensitive). Nose: Deviated septum, polyps, epistaxis, foreign bodies, tumors. Nasal vasoconstrictors such as phenylephrine 0. 25% or 0. 5% (use only 3-5 days). Systemic decongestants. Nasal or systemic corticosteroids such as beclomethasone. Nasal irrigation with saline. Analgesics/antipyretics. Do not prescribe antibiotics for mild to moderate sinusitis. Most sinusitis is viral. Give antibiotics if: symptoms > 10 days, high fever, purulent nasal drainage or facial pain > 3 consecutive days or symptoms that worsen after a viral illness lasting > 5 days that improved initially First line: Augmentin (XR bid × 2 weeks) or Doxycycline Second line: Levofloxacin or moxifloxacin, clarithromycin, oral cephalosporins
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Facial Pain 497 EENT may be warranted for repeated episodes. An allergist might be worth a visit if it is deduced that allergies are the inciting causes of each episode of sinusitis. Is the family history of migraines relevant? Migraine headaches often appear in families. They tend to be more common in women than in men. The symptoms of migraine and sinusitis are often mistaken for each other, and each condition may be misdiagnosed as the other. REFERENCES AND RESOURCES Ferri, F. F. (2019). Sinusitis. Ferri's clinical advisor 2019 (pp. 1268-1269). Philadelphia: Elsevier.
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499 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic studies should be considered to assist with or confirm the diagnosis? CBC: Hemoglobin and hematocrit were 10. 1/29. 5; FBS: 149; potassium 4. 8; BUN: 42; creatinine 1. 44 (estimated glomerular filtration rate [GFR] was 35). What is the most likely differential diagnosis and why? Chronic kidney disease (CKD), stage 3: The GFR of 35 points directly to CKD, stage 3. The low hemoglobin clearly suggests anemia, though the specific etiology is unknown. There are several mainstays of CKD management, which include blood pressure control, volume management, anemia management, and sodium/potassium management. The target blood pressure should be < 130/80 if albumin excretion is >30 mg/24 hours. Otherwise, the target blood pressure should be </= 140/90. ACE‐I and ARBs are pharmaco-therapy options that have been proven to be renoprotective, so switching to one of these agents for blood pressure control is wise. In addition, chlorthalidone should be added if the blood pressure remains high. Avoid loop diuretics if there is a concern about hypokalemia. Since individuals with CKD can be at risk for hyperkalemia and hypernatremia, particularly if they are also diabetic, management of sodium, phosphorous, and potassium levels is crucial. Fluid intake should be restricted if the patient has significant edema or is hyponatremic. Maryanne also has anemia secondary to CKD, stage 3. The BUN and creatinine lab values lead us to evaluate Maryanne's kidney function. The general health of an individual's kidney is deter-mined by the glomerular filtration rate, 35 in this case. A decrease in GFR correlates with a change in histology secondary to kidney disease. The stages of CKD are as follows: CKD is defined as kidney damage or GFR < 60 m L/min/1. 73 m 2 for at least 3 months with or without kidney damage. Kidney damage is defined is abnormal pathology, abnormal blood values, abnormal urine studies, or abnormal imaging. Stage 1: Normal or increased GFR, some evidence of kidney damage Stage 2: Kidney damage with mild decrease in GFR (89-60 ml/min per 1. 73 m2 Stage 3: Moderate decrease in GFR (30-59)Case 8. 12 Fatigue, Confusion, and Weight Loss
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500 Resolutions Stage 3A: GFR 59-45 ml/min per 1. 73m2 Stage 3B: GFR 44-30 ml/min per 1. 73m2 Stage 4: Severe decr ease in GFR (15-29) Stage 5: Kidney failure (GFR < 15 or dialysis) The workup for anemia of CKD is initiated when the hemoglobin value is less than 12 g/d L in a post-menopausal female. Anemia of CKD can be most commonly attributed to decreased production in erythropoietin by the kidneys or to iron deficiency. Other causes of anemia of CKD include blood loss, hypothyroidism, acute and chronic inflammatory conditions, and hemoglobinopathies. Maryanne also appears to have dementia, a condition that is characterized by a progressive decline in intellectual functioning. The functional decline tends to involve the memory, cognitive capacities, and adaptive behavior. Dementia does not involve alteration in consciousness. Dementia may start as mild cognitive impairment in its earliest stages, which refers to an isolated loss of memory without difficulty in other cognitive functions. Alzheimer's disease is the leading cause of dementia, though depression in the older adult can also present similarly. Other symptoms of depression in the older adult include hopelessness, anhedonia, and fatigue. Assessment of dementia is further evaluated with a mental status examination. When evaluating chronic fatigue, malignancy must always be on the differential. The clinical picture often also includes severe involuntary weight loss, depression, and apathy. Laboratory studies (CBC) are paramount for ruling out a cancer. Obstructive sleep apnea (OSA) might be considered as a differential diagnosis. It occurs when the nasopharyngeal airway patency is compromised during sleep. Risk factors include obesity, increased neck circumference, deviated septum, nasal polyps, and enlarged tonsils. Presentation includes snoring, disturbed sleep, daytime sleepiness, chronic fatigue, and personality change. The easiest way to determine whether OSA is appropriately on the differential is to have the patient observed by another during sleep to evaluate for snoring. COPD is known as an irreversible and progressive decline in lung function due to obstruction of airflow, airway inflammation, and reduction in the expiratory flow rate. Individuals with COPD often have a history of smoking, asthma, or environmental/work exposure to irritants. COPD refers to chronic bronchitis or emphysema. Symptoms include shortness of breath, wheezing, and increased work of breathing. On examination, lung sounds can include fine or coarse crackles and wheezes. In emphysema, the AP diameter of the chest is increased, and lung sounds can be distant. What is the plan of treatment? To manage and further evaluate the anemia secondary to CKD, it is necessary to order further lab tests, particularly iron studies. Maryanne's hemoglobin is within the range of 9-11g/d L, so she does not need erythropoietin at this time. The iron studies to be ordered are CBC, indices, reticulo-cytes, serum iron, TIBC, and ferritin and rule out thalassemia. Her transferrin saturation should be >/= 20% and ferritin >100 mg/ml before starting erythropoietin therapy to avoid cardiovascular complications. If the iron studies reveal iron deficiency, Maryanne may need iron replacement. If iron studies are normal, it means that the deficiency is in fact due to the damaged kidneys pro-ducing less than normal erythropoietin. Specific changes to Maryanne's medication regimen should be as follows: Discontinue glucophage Discontinue Avandia Begin Actos, 30 mg daily (for glycemia contr ol) Discontinue Lasix Begin chlorthalidone daily for hypertension Continue Actonel 35 mg weekly
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Fatigue, Confusion, and Weight Loss 501 The following lab studies should also be ordered at this time and discussed as soon as the results become available: LFTs; chemistry panel; BUN/creatinine; Hgb A1C; micro urinalysis. The nephrol-ogist may order a CT scan of the chest, abdomen, and pelvis with contrast (if not contraindicated), a mammogram, and a transvaginal ultrasound of the uterus. Continue statin and Zetia treatment. Normalize serum phosphate and calcium levels. Monitor salt, potassium, and fluid balance. Vitamin D supplementation may be appropriate. Maryanne may need nutritional supplementation and counseling to cope with the disease. Recommend annual influenza vaccination and a polyvalent pneumococcal vaccine. Consider vaccination with the hepatitis B series. What is the plan for referrals and follow‐up care? Referrals should be initiated to hematology and nephrology. Are there standardized guidelines that should be used to assess or treat this case? International Society of Nephrology. (2013). KDIGO 2012 clinical practice guideline for the evalua-tion and management of chronic kidney disease. Kidney International Supplement, 3(1), 136-150. REFERENCES AND RESOURCES Ferri, F. F. (2019). Chronic kidney disease. Ferri's clinical advisor 2019 (pp. 322-325). Philadelphia: Elsevier. International Society of Nephrology. (2013). KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney International Supplement, 3(1), 136-150. NOTE: The author would like to acknowledge Geraldine F. Marrocco, Ed D, APRN, CNS, ANP‐BC for her contribution to this case in the first edition of this book.
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503 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What are the three most likely differential diagnoses and why? Carpal tunnel syndrome: Carpal tunnel syndrome (CTS) is the most likely diagnosis. Though it is more common in females than males, males may be afflicted with the condition, especially with a history of repetitive motion. In 50% of the cases, it will affect both wrists (Werner & Andary, 2011). The gradual onset of numb-ness, pain, and even burning are typical. Symptoms can worsen at night because individuals may sleep with a flexed wrist (Mc Clure, 2003). It is typical for patients to describe that shaking their hand helps to relieve the numbness (Werner & Andary, 2011). This is known as the flick sign (Scanlon & Maffei, 2009). The median nerve is a mixed nerve and transmits both sensory and motor neurons. The median nerve supplies sensation to the ventral aspect of the thumb, first 2 fingers, and half of the third and to the tips of the fingers on the dorsal aspect of the same digits (Walker, 2010). Since it is a mixed nerve, it also supplies motor movement to the muscles of the thenar eminence, which abducts, flexes, adducts, and medially rotates the thumb (Walker, 2010). It first affects sensation and then motor movement. The dropping of his hammer can represent the beginning of motor weakness. Pronator syndrome: Pronator syndrome occurs with entrapment of the median nerve at the elbow. Pronator syndrome can mimic symptoms of CTS (Neal & Fields, 2010) and pain often occurs with repetitive motion of the forearm. It affects sensation, but not motor. Therefore, you would not see weakness or thenar atrophy. With pronator syndrome, the Tinel's and Phalen's tests are negative. Cervical radiculopathy: When dealing with nerve symptoms, you must always eliminate the possibility of circulation prob-lems and determine whether the origin is from an upper motor neuron or lower motor neuron. When dealing with upper motor neuron entrapment syndromes, pain typically is not limited to the hand. According to Scanlon and Maffei (2009), if pain is located in the shoulder, upper arm, or neck, a cervical problem is suspected. With cervical radiculopathy, there may be point tenderness on vertebral palpation or percussion or pain with neck movement. Pain, weakness, or numbness or paresthesias when the C 6/7 nerve root is compressed is indicative of a spinal cord problem (Walker, 2010). Cervical problems usually present bilaterally or shift from right to left. If spinal cord injury Case 8. 13 Hand Numbness
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504 Resolutions is suspected, this mandates immobilization, radiologic evaluation, and repeated neurological exams as motor symptoms may occur hours to days later (Neal & Fields, 2010). Which diagnostic or imaging studies should be considered to assist with or con-firm the diagnosis? See Table 8. 13. 1. What is the plan of treatment? Prescribe a wrist splint for Timothy to wear at night. Advise careful use of topical and/or oral NSAIDs for pain relief. Advise avoidance of repetitive activities. Suggest a break, if possible, from his work. Consider a corticosteroid injection at this visit or in the future for pain relief. Combined treatments may be most effective. What is the plan for referrals and follow‐up? Refer for electrodiagnostic studies. Refer for surgical evaluation in cases of severe median nerve injury. If treating with nonsurgical interventions, follow up in 4-6 weeks to assess effectiveness. Also follow up after electrodiagnostic studies to determine next steps. What specific activities do you want to ask about? Peripheral nerve injuries commonly occur in individuals who participate in recreational sports or specific occupational activities. Ask about repetitive motion activities, use of keyboard, hammer-ing, knitting, and piano playing, which constantly flex the wrist. However, repetitive motion as causal for CTS is controversial. What other important history questions must you ask so as not to miss an impor-tant differential diagnosis? When deciding on a cause for median nerve compression, think about internal causes from a decrease in tunnel space or external causes from edema or inflammation. This will narrow down whether the nerve compression is from repetitive motion; trauma; congenital malformations; med-ications that can increase edema; or metabolic, infectious, or inflammatory diseases/conditions such as rheumatoid arthritis, systemic lupus erythematosus, gout or obesity. Table 8. 13. 1. Diagnostic Testing. Complete blood count Not necessary for diagnosis. Chemistry profile Not necessary for diagnosis. Fasting plasma glucose Yes, because of the family history and to rule out as a differential diagnosis. There is some controversy whether to obtain this lab test without suspicion of diabetes mellitus. TSH Yes, because of the family history and to rule out as a differential diagnosis. There is some controversy whether to obtain this lab test without suspicion of hypothyroidism. X‐ray of wrists No. Conditions that you would obtain X‐ray:History of trauma or suspicion of a tumor or bone spurs (history of a fracture or dislocation of carpal bone or distal radius and concern about malunion, wrist arthritis, or mass). Ultrasound if you suspect a structural abnormality. Electrodiagnostic studies:Nerve conduction velocity studies (NCV) Electromyography (EMG)Diagnosis is usually based on history and physical exam. May treat conservatively first prior to obtaining. Neal & Fields (2010) recommend obtaining NCF studies if no improvement occurs after 6 weeks after initiating conservative treatment. It is also acceptable to initiate these tests at the time of diagnosis. MRI Not ordered unless the following are present:Only in unusual cases, to rule out a mass or lesion or evaluate cervical radiculopathy. X‐ray of elbows No, not necessary unless a history of trauma. X‐ray of neck No, not necessary unless there is a history of trauma.
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Hand Numbness 505 Since rheumatoid arthritis, systemic lupus erythematosus, and gout can mimic CTS, asking about pain, swelling, and erythema in other joints is important. Pain and swelling may indicate osteoarthritis. Other conditions that can cause swelling include hypothyroidism, heart failure, pregnancy, and any use of steroids. Also, conditions that can cause neuropathy, such as diabetes mellitus, should be ruled out. Why do you inspect for thenar atrophy? The motor aspect of the thumb is innervated by the median nerve. The abductor pollicus brevis is only innervated by the median nerve and is responsible for abduction of the thumb. The opponeus pollicus flexes, adducts, and medially rotates the thumb. With a lower motor neuron entrapment injury, the nerve innervating the muscle is compromised causing decreased movement, resulting in muscular atrophy. Would your diagnosis change if Timothy complained of acute onset of paresthe-sias of the upper arm? Yes. Acute CTS is uncommon; and, if it does occur, it is typically caused by a radial fracture or carpal injury. Other considerations for nontraumatic acute CTS can develop secondarily from infec-tive tenosynovitis, coagulopathies, false aneurysm, gout, or rheumatoid disorders. Why would you be concerned if Timothy's pain were past his elbows? CTS pain may present as shooting pains radiating up to the elbow. If pain radiates past the elbow toward the shoulder or neck, consider a cervical cord problem (Scanlon & Maffei, 2009). What significance does thumb strength have? The motor aspect of the thumb is only innervated by the median nerve. Muscle weakness of the thumb is a strong indicator of median nerve entrapment. What would you do if this patient were female and pregnant? Pregnancy or any condition that increases estrogen may cause fluid retention, causing increasing pressure on the median nerve. Avoiding noxious stimuli, wrist splinting, ergonomic modification, and ultrasound treatment are the courses of treatment for pregnancy. Are there any standardized guidelines available to be used to assess or treat this case? The National Guideline Clearing House published the American Academy of Orthopedic Surgeons evidence‐based practice guidelines for the diagnosis and treatment of carpal tunnel syndrome. REFERENCES AND RESOURCES American Academy of Orthopaedic Surgeons (2016). Clinical practice guideline on the diagnosis of carpal tunnel syndrome. https://www. guidelinecentral. com/summaries/american‐academy‐of‐orthopaedic‐surgeons‐ clinical‐practice‐guideline‐on‐management‐of‐carpal‐tunnel‐syndrome/#section‐society Chesterton, L. S., Blagojevic‐Bucknall, M., Burton, C., Dziedzic, K. S., Davenport, G., Jowett, S. M., .  .  .  Roddy, E. (2018). The clinical and cost‐effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): An open‐label, parallel group, randomised controlled trial. Lancet, 392, 1423. Fernández‐de‐Las Peñas, C., Ortega‐Santiago, R., de la Llave‐Rincón, A. I., Martínez‐Perez, A., Díaz, H. F. ‐S., Martínez‐Martín, J., .  .  .  Cuadrado‐Pérez, M. L. (2015). Manual physical therapy versus surgery for carpal tunnel syndrome: A randomized parallel‐group trial. Journal of Pain, 16, 1087. Kothari, M. J., Shefner, J. M., & Eichler, A. F. ( 2018). Carpal tunnel syndrome. Up To Date. Mc Clure, P. (2003). Evidence‐based practice: An example related to the use of splinting in a patient with carpal tunnel syndrome. Journal of Hand Therapy, 16, 256.
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506 Resolutions Muller, M., Tsui, D., Schnurr, R., Biddulph‐Deisroth, L., Hard, J., & Mac Dermid, J. C. (2004). Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: A systematic review. Journal of Hand Therapy, 17, 210. Neal, S. L., & Fields, K. B. (2010). Peripheral nerve entrapment and injury in the upper extremity. American Family Physician, 81, 147-155. Page, M. J., Massy‐Westropp, N., O'Connor, D., & Pitt, V. (2012). Splinting for carpal tunnel syndrome. Cochrane Database Systematic Review, CD010003. Premoselli, S., Sioli, P., Grossi, A., & Cerri, C. (2006). Neutral wrist splinting in carpal tunnel syndrome: A 3‐ and 6‐months clinical and neurophysiologic follow‐up evaluation of night‐only splint therapy. Europa Medicophysica, 42, 121. Scanlon, A., & Maffei, J. (2009). Carpal tunnel syndrome. Journal of Neuroscience Nursing, 41, 140-147. Walker, J. A. (2010). Management of patients with carpal tunnel syndrome. Nursing Standard, 24, 44-48. Werner, R. A., & Andary, M. (2011). Electrodiagnostic evaluation of carpal tunnel syndrome. Muscle Nerve, 44, 597. Wu, Y. T., Ho, T. Y., Chou, Y. C., Ke, M. ‐J., Li, T. ‐Y., Tsai, C. ‐K., & Chen, L. ‐C. (2017). Six‐month efficacy of peri-neural dextrose for carpal tunnel syndrome: A prospective, randomized, double‐blind, controlled trial. Mayo Clinic Proceedings, 92, 1179.
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507 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic studies should be considered to assist with or confirm the diagnosis? Serologic testing is done while the patient remains on a gluten‐containing diet. t TG‐Ig A antibody: This is a serological test for immunoglobulin A (Ig A) antibodies against tissue transglutaminase (t TG). The test has a sensitivity of more than 90% and a specificity of more than 95%. This is considered the first‐line screening test for celiac disease. EMA‐Ig A test: This test is moderately sensitive and highly specific for untreated celiac disease with 85-98% sensitivity and a specificity of 97-100%. CBC: This is used to look for nutritional deficiencies. Patients with celiac disease have malab-sorption, which can result in iron‐deficiency anemia. Total Ig A: This would rule out Ig A deficiency. Ig A deficiency decreases the sensitivity of t TG‐Ig A, resulting in false negative serologies. Negative t TG‐Ig A serologies in a symptomatic patient would warrant a total Ig A to help explain the negative serologies. If there is a positive t TG-Ig A, the patient should be referred to Gastroenterology for a celiac dis-ease confirmatory small bowel biopsy. Dermatitis herpertiformis biopsy: In patients with biopsy‐proven dermatitis hepertiformis, celiac disease can be diagnosed by serology alone (Cichewicz et  al., 2019; Rubio‐Tapia, Hill, Kelly, Calderwood, & Murray, 2013). It is also appropriate to order a CBC, comprehensive metabolic panel, TSH, Ig A antiendomysial antibody (EMA), and Ig A antitissue transglutaminase antibody (anti‐t TG). It would not be appro-priate to order a duodenal biopsy at this time, though it may be part of a diagnostic workup after the results of the current screening lab work are received. The CBC will show whether Amelia has iron deficiency anemia, as this would be a crucial part of the clinical picture. It will also rule out systemic illness and give a picture of general health. The CMP will show Amelia's kidney and liver function, as well as her fluid status. The TSH will show thyroid function, and the Ig A studies are part of the autoimmune workup for celiac disease. The lab results are as follows: hemoglobin: 11. 7; HCT: 32; MCV: 80; ferritin: 100; LFTs: normal; TSH: 2. 08. The Ig A antitissue transglutaminase (anti‐t TG) antibody was positive. The Ig A antibody was positive. The skin biopsy was positive. Case 8. 14 Chronic Diarrhea
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508 Resolutions What is the most likely differential diagnosis and why? Celiac disease: Celiac disease is a chronic, multiorgan autoimmune disease affecting the gastrointestinal tract; it affects about 1% of the population is often underdiagnosed due to similar symptom presentation to other conditions, such as IBS and IBD. It is triggered by exposure to gluten, a storage protein found in wheat, rye, and barley (American Gastroenterological Association [AGA], 2006). Gluten triggers an autoimmune reaction that causes chronic inflammation of the intestinal mucosa, which leads to malabsorption. It is common in persons with European ancestry and in those of Middle Eastern, Indian, South American, and North African descent (Green & Cellier, 2007; Setty, Hormaza, & Guandalini, 2008). The most common symptoms are diarrhea and flatulence. Other intestinal symptoms include abdominal pain, weight loss, and poor appetite. Extraintestinal symptoms include dermatitis herpetiformis, fatigue, headaches, metabolic bone disease, and others (Pelkowski & Viera, 2014). Amelia's presentation, including diarrhea and weight loss over a long period of time, findings of rash on the elbows and extensor surface of the arms (likely dermatitis herpetifor-mis), and family history of Type 1 diabetes, point to celiac disease. Confirmation of the diagnosis is based on the lab results and biopsy findings. Diagnostic criteria include a minimum of 4 out of 5 or 3 out of 4 of the following (if the HLA genotype test is not done to confirm): symptoms as described in this case, positive Ig A class auto-antibodies with high titer, celiac enteropathy if a biopsy is done of the small intestine, and response to a gluten‐free diet. The average age of diagnosis is during one's 50s. Celiac disease is an inflammatory condition of the small bowel that manifests due to an allergy or sensitivity to foods containing gluten. Foods that contain gluten include wheat, barley, and rye. Other classic symp-toms of typical celiac disease include steatorrhea and weight loss. Atypical celiac disease presents without gastrointestinal symptoms, but may present with osteoporosis, anemia, infertility, sei-zures, and other neurologic symptoms. Screening for celiac disease should be done whenever an individual presents with chronic symptoms of abdominal pain and bloating, diarrhea, and weight loss. Initial screening can be done via bloodwork, and the Ig A antiendomysial antibody and Ig A antitissue transglutaminase antibody tests are over 95% sensitive and specific when done together. A capsule endoscopy of the small intestine is recommended initially followed by another biopsy after treatment. The biopsy can also identify small bowel lymphoma, which has a higher risk for patients with celiac disease. Celiac disease is difficult to diagnose due to its similar presentation to other gastrointes-tinal disorders. What are other possible differential diagnoses? Irritable bowel syndrome: Irritable bowel syndrome, a functional and highly prevalent disorder, is characterized by severe disturbance in bowel functions. The Rome III diagnostic criteria describe IBS as “recurrent abdom-inal pain or discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following: (1) improvement with defecation, (2) onset associated with a change in frequency of stool, and (3) onset associated with a change in form of stool” (Rome Foundation, 2006). It can be noted that Amelia's symptoms fall into the criteria of IBS. However, since approximately 10% of those diagnosed with IBS have celiac disease, the 2 conditions are not mutually exclusive and must both be considered in a workup. Inflammatory bowel disease: Another diagnosis to consider with individuals presenting with chronic loose stools is inflammatory bowel disease, which includes ulcerative colitis and Crohn's disease. IBD hallmarks include bloody diarrhea, urgency, steatorrhea, fever, abdominal pain, and weight loss. Both disease processes of IBD must be diagnosed via endoscopy. While Amelia's symptoms do not fit perfectly into this pattern, it is a differential to be considered if our initial diagnosis proves to be incorrect.
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Chronic Diarrhea 509 Viral gastroenteritis: Viral gastroenteritis is not a likely diagnosis as this patient does not have nausea, vomiting, or abdominal cramps. What is the plan of treatment? If there is a positive t TG-Ig A, the patient should be referred to Gastroenterology. Individuals with positive serology require a GI endoscopy with small bowel biopsy to confirm the diagnosis. Treatment for celiac disease is a lifelong commitment to a gluten‐free diet. Foods that contain wheat, barley, or rye must be omitted. In most individuals with gluten sensitivity, oats are well tolerated. Such a diet can be a challenge, as many foods today contain gluten derivatives. There are, however, many support networks, grocery stores, and restaurants that make a gluten‐free life much easier. Lifelong gluten‐free diet Referral to a dietician for education on gluten‐free diet Tr eatment of nutritional deficiencies Referral to an advocacy group Nutritional supplements (Bai & Ciacci, 2017; Rubio‐Tapia et al., 2013) What is the plan for referrals and follow‐up? Amelia will be instructed to follow a gluten‐free diet and will be scheduled for an endoscopy and duodenal biopsy. After 1 month, Amelia should return to the clinic for reevaluation. A diagnosis of celiac disease involves lifelong management of one's diet, which is why routine meetings with a dietician should be strongly encouraged. If Amelia's symptoms are not alleviated by a gluten‐free diet, it is appropriate to consider referral to a GI specialist. Amelia should be sent for a bone min-eral density test that should then be used as a baseline. Repeat serologies (Ig A‐t TG) in 6-12 months to check response, then annually. Perform a follow‐up CBC (Rubio‐Tapia et al., 2013). Are there standardized guidelines or resources that would help in this case? The Celiac Disease Foundation (https://celiac. org/) is an excellent resource for both the health care professional and the consumer. The American Gastroenterological Association (https://gastro. org) has published guidelines and position statements for many GI diseases and syndromes. The Rome Foundation (https://theromefoundation. org/) criteria for IBS is an excellent resource. What demographic characteristics might affect this case? Serologic tests have decreased sensitivity in children under 2. Deamidated gliadin peptides (DGPs) have better sensitivity. If this patient had no insurance or lived in a rural area without access to health care (difficult to get to a clinic), how would that change management, or would it change management? If the patient lived in a rural area with few or no gastroenterologists, treatment could be started without confirmatory small bowel biopsy. A gluten‐free diet would still be the mainstay of treatment.
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510 Resolutions REFERENCES AND RESOURCES American Gastroenterological Association. (2016). AGA Institute medical position statement on the diagnosis and management of celiac disease. Gastroenterology,131(6), 1977-1980. Bai, J. C., & Ciacci, C. (2017). World Gastroenterology Organisation global guidelines: Celiac disease. Journal of Clinical Gastroenterology, 51(9), 755-768. Cichewicz, A. B., Mearns, E. S., Taylor, A., Boulanger, T., Gerber, M., Leffler, D. A., .  .  .  Lebwohl, B. (2019). Diagnosis and treatment patterns in celiac disease. Digestive Diseases and Sciences, 64, 2095-2210. https:// doi. org/10. 1007/s10620‐019‐05528‐3 Ferri, F. F. (2019). Celiac disease. Ferri's clinical advisor 2019 (pp. 293-295). Philadelphia: Elsevier. Green, P. H., & Cellier, C. (2007). Celiac disease. New England Journal of Medicine, 357(17), 1731-1743. Pelkowski, T. D., & Viera, A. J. (2014). Celiac disease: Diagnosis and management. American Family Physician, 89(2), 99-105. Rome Foundation. (2006). Guidelines—Rome III diagnostic criteria for functional gastrointestinal disorders. Journal of Gastrointestinal & Liver Diseases, 15(3), 307-312. Retrieved from Ovid (MEDLINE). Rubio‐Tapia, A., Hill, I. D., Kelly, C. P., Calderwood, A. H., & Murray, J. A. (2013). ACG clinical guidelines: Diagnosis and management of celiac disease. American College of Gastroenterology, 108(5), 656-676; quiz 677. doi:10. 1038/ajg. 2013. 79 Simren, M., Palsson, O. S., & Whitehead, W. E. (2017). Update on Rome IV criteria for colorectal disorders: Implications for clinical practice. Current Gastroenterology Reports, 19(4), 15. doi: 10. 1007/s11894‐017‐0554‐0 Setty, M., Hormaza, L., & Guandalini, S. (2008). Celiac disease: Risk assessment, diagnosis, and monitoring. Molecular Diagnosis & Therapy, 12(5), 289-298. NOTE: The author would like to acknowledge the contribution to this case of Geraldine F. Marrocco, Ed D, APRN, CNS, ANP‐BC in the first edition of this book.
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511 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION Which diagnostic studies should be considered to assist with or confirm the diag-nosis? If you choose imaging studies, state what part of the body you will image. No testing is needed at this time. What is the most likely differential diagnosis and why? Phantom limb pain (PLP): PLP can be caused by a skin infection, pressure points, skin breakdown, ischemia in the remaining limb, a neuroma, hetereotopic ossification, or deep tissue infection. It is important to rule out med-ical causes of the pain and not automatically assume it is PLP. When evaluating a chief complaint of pain, it is important to look at a detailed history to identify the possible source of the pain, if there is one. Roger's trauma history points strongly to PLP, as he describes pain in the limb that is no longer present. His description of pain is congruent with PLP, which is often described as tin-gling, burning, or pins and needles. PLP is common in amputees and should always be part of the follow‐up assessment. Phantom pain is loosely defined as pain that is associated with nerve injury or as pain in a limb that is either no longer present due to trauma/amputation or completely numb due to major injury. The source of PLP is unknown; discussion suggests it either derives from the peripheral nervous system activity or changes in the spinal/supraspinal body surface representations. The difficulty in knowing the source of the pain results in difficulty treating it. The evidence suggests that PLP can be prevented preoperatively via regional anesthesia such as an epidural. There are several risk factors for developing PLP: stump pain, older age, repeated limb surgeries, and postoperative pain that is severe. What is the plan of treatment? Opioids are not recommended and have limited value. Perineural blockade via a catheter for a minimum of 80 hours following the amputation can prevent PLP. Clonidine is sometimes added in cases at risk for severe PLP. There is emerging evidence that gabapentin and pregabalin are effec-tive in treating PLP. Ketamine given intravenously is the most frequently used treatment for severe PLP. Nonpharmacologic methods are sometimes used, such as TENS (transcutaneous electrical nerve stimulation) and biofeedback. Tricyclics are no longer recommended. Case 8. 15 Intractable Pain
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512 Resolutions There are no definitive guidelines for the treatment of phantom limb pain; however, several sources outline the different options. The consensus seems to be to either treat with pharmaco-therapy, combined with adjunct symptom management, or with the procedural options of TENS or biofeedback. If neither of those treatment modality pathways leads to alleviation of pain, specialty care should be sought out in or by a pain clinic, rehabilitation care, or an orthopedic specialist. Several adjuvant therapy options should be considered, such as mental relaxation, wrapping, heat, massage, pressure, and mirror box therapy. One of these methods that has been studied and shows considerable promise is mirror box therapy. This technique allows the amputee to perceive the missing limb through strategically placed mirrors. Focusing on the reflection of the limb can allow reconfiguration of the sensory cortex, thus leading to a reduction in PLP (Black et al., 2009). Acupuncture and repetitive transcranial magnetic stimulation (r TMS) may provide relief. Since Roger's pain is severe and untouched by over‐the‐counter pain medications, it is appro-priate to consider a combination of medications. Roger can start taking pregabalin (Lyrica), an anti‐seizure medication used often for neuropathic pain. He should receive a prescription for 100 mg in the morning, 50 mg at noon, and 50 mg at bedtime. In adjunct to pharmacotherapy, Roger can consider the adjuvant therapies listed above, including hypnotherapy, mirror box therapy, and acupuncture. In the meantime, the clinician should tell Roger to try heat, massage, and pressure on the affected limb if he finds himself in pain between now and his follow‐up visit. Roger will be asked to follow up in 10 days, at which point his old records will be transferred and first assess-ments can be made regarding his pain control. What is the plan for referrals and follow‐up? At this time, it is appropriate to manage Roger's phantom pain in the primary care clinic setting. If pharmacotherapy does not work, or if he is interested in specific adjuvant or procedural therapies, referrals can be made to the appropriate specialist. If the therapies tried are unsuccessful, the patient should be referred to the pain clinic, orthopedics, or rehabilitation. Are there standardized guidelines or resources that would help in this case? There are no universal guidelines for the treatment of phantom limb pain. However, the Department of Veterans Affairs has a published set of guidelines that are widely referenced. Particularly insightful organizations include the Amputee Coalition of America (https://www. amputee‐coalition. org/) and the American Society of Regional Anesthesia and Pain Medicine (https://www. asra. com/page/44/the‐specialty‐of‐chronic‐pain‐management). REFERENCES AND RESOURCES Baird, J. C. (2018). Pain in the residual limb. In R. S. Porter, J. L. Kaplan, R. B. Lynn, & M. T. Reddy (Eds. ), The Merck manual of diagnosis and therapy (p. 3205). Kenilworth, NJ: Merck Sharp & Dohme Corp. Black, L. M., Pearsons, R. K., & Jamieson, B. (2009). What is the best way to manage phantom limb pain? The Journal of Family Practice, 58(3), 155-158. Neil, M. J. E. (2016). Pain after amputation. BJA Education, 16(3), 107-112, https://doi. org/10. 1093/bjaed/ mkv028 NOTE: The author would like to acknowledge the contribution of Geraldine F. Marrocco, Ed D, APRN, CNS, ANP‐BC to this case in the first edition of this book.
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513 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. RESOLUTION What is the most likely differential diagnosis and why? Rheumatoid arthritis (RA): The patient most likely has rheumatoid arthritis (RA). There are several findings that support this diagnosis: wrist and foot pain and swelling, more than 1 hour of morning stiffness, fatigue, and weakness. According to the American College of Rheumatology 1987 criteria for a diagnosis of rheumatoid arthritis, the patient must have 4 of the following 7 criteria for at least 6 weeks: 1. Morning stiffness lasting mor e than 1 hour. 2. Arthritis pain in 3 or more joints. 3. Swelling in the hand joints. 4. Symmetrical joint swelling. 5. Erosions or decalcifications on X‐rays of the hands. 6. Rheumatoid nodules. 7. Abnormal rheumatoid factor. Rosa has had the symptoms mentioned in the first 4 criteria for 3 months. Her diagnostic workup will include a rheumatoid factor and X‐rays of the hands and feet. Rosa is an unlikely candidate for osteoarthritis because of her youth. She may have systemic lupus erythematosus (SLE), as it is present in her family and the symptoms of SLE are similar to those in RA and also occur most often in young women. Which diagnostic studies should be considered to assist with or confirm the diagnosis? Her diagnostics should include tests for SLE, which include at this time: ANA (antinuclear anti-body), C3, C4, and DS DNA (double stranded DNA). Sjögren's disease can also be ruled out— although the patient denies dry eyes or dry mouth—by testing her SS‐A and SS‐B levels. A rheumatoid factor, CRP (c‐reactive protein), ESR, or CCP should be done to confirm inflammatory disease. In addition, a CBC can rule out anemia that often accompanies RA, and a CMP should be done to check the status of blood sugar, electrolytes, and liver function. Several treatments for RA require normal liver function. Carpal tunnel syndrome (CTS) often accompanies or follows a diag-nosis of RA. In addition, the patient does perform repetitive movements in her job. Consider an Case 8. 16 Wrist Pain and Swelling
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514 Resolutions ultrasound of the hand because the patient has swelling. Hand and wrist X‐rays will be helpful in assessing whether there are erosions in the wrists, but a nerve conduction test might be done in the future on each wrist to evaluate for the loss of nerve function. This is not urgent at this point because tests during the physical exam were negative for CTS. What is the plan of treatment? The lab work and imaging studies described above should be performed, and the results should be evaluated and discussed with the patient at the follow‐up visit. Treatment in the meantime should consist of NSAIDs such as ibuprofen or naproxen sodium. The patient can be provided with wrist splints and be encouraged to alternate ice and heat to the painful joints. What is the plan for referrals and follow‐up? A referral to a rheumatologist is appropriate at this time. However, if an appointment is not pos-sible for several months, it is important to consult with the rheumatologist by phone regarding starting the patient on methotrexate. Further, it may be advisable to give the patient a short course of prednisone during this time if symptoms flare. Would the primary diagnosis be different if the patient were 55 years old? If the patient were 55 years old, the diagnosis of RA would still be the most likely diagnosis, given the same history and presentation. Would there be treatment considerations if the patient had a history of tuberculosis? If the patient had a history of tuberculosis, the treatment might differ in that the rheumatologist would be likely to steer away from the use of TNF alpha inhibitors, which are often used to treat RA if methotrexate does not work sufficiently to control symptoms. REFERENCES AND RESOURCES American College of Rheumatology. (2020). Rheumatoid arthritis. Guidelines. Retrieved from https://www. rheumatology. org/Practice‐Quality/Clinical‐Support/Clinical‐Practice‐Guidelines/Rheumatoid‐ Arthritis Imboden, J., Hellman, D., & Stone, J. (2007). Current diagnosis and treatment: Rheumatology (2nd ed. ). New York: Mc Graw‐Hill Lange. Singh, J. A., Saag, K. G., Bridges, J. R. Jr., Akl, E. A., Bannuru, R. R., Sullivan, M. C., .  .  .  Mc Alindon, T. (2015). 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care & Research. doi10. 1002/acr. 22783
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515 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 9. 1 Sad Mood RESOLUTION What are the top three differential diagnoses in this case and why? Adjustment disorder with depressed mood: To meet the criteria for adjustment disorder with depressed mood, symptoms must emerge in response to an identifiable stressor that occurred within the prior 3 months. In Julia's case, the stressor could be her transition to college and the subsequent loss of direct family support and structure of home life. Major depressive disorder: Julia reports a constellation of symptoms that meet the criteria for a major depressive episode, including sad mood, low energy and motivation, difficulty concentrating, increased appetite, and hypersomnia. These symptoms have been present for more than 2 weeks and are causing impair-ments in academic and social functioning. Further, they cannot be attributed to substance use or an underlying medical condition. Bipolar depression: Bipolar depression is frequently misdiagnosed as unipolar depression due to the clinical challenge of accurately identifying a history of (hypo)mania, a criterion that must be met to fulfill the diag-nostic criteria for bipolar disorder. This happens, in part, because patients are more likely to seek treatment during depressive episodes and do not necessarily view hypomanic symptoms as prob-lematic or disruptive to functioning and, as such, they frequently go unreported. Which diagnostic tests are required in this case and why? Diagnostic tests, including TSH, CBC with differential, basic metabolic panel, B12 and folic acid, should be obtained to rule out any underlying medical conditions, including hypothyroidism, anemia, vitamin deficiency. The PHQ-9 should be completed to assess both the severity of depres-sive symptoms and their impact on daily functioning. What are the concerns at this point? It is important to distinguish between unipolar and bipolar depression. A thorough psychiatric his-tory should be obtained to determine whether Julia has ever experienced a manic or hypomanic episode. Understanding the impact of depressive symptoms on Julia's functioning can serve to inform the development an appropriate and comprehensive treatment plan. The possibility that
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516 Resolutions Julia's symptoms could worsen before beneficial effects of pharmacological treatment are realized makes her vulnerable to self-neglect and/or suicidal ideation. Social support can be a protective factor in patients with depression, so encouraging social engagement should be a behavioral treatment strategy in Julia's case. What are 3-5 case-specific questions to ask? Is the patient experiencing suicidal ideation? Is there a history of hypomania or mania?Is the patient using alcohol, marijuana, or other substances?Has the patient confided about how she is feeling to family or friends? What type of support is being provided? What is the plan of treatment? First, it is important to treat any underlying medical condition. In the absence of an underlying medical condition, determine the severity of depressive symptoms based on PHQ-9 score. Julia's PHQ-9 score is 19, which indicates moderately severe depression. Appropriate treatment includes medication, and SSRIs are typically the first-line pharmacological treatment. It would be helpful to know which, if any, antidepressant Julia's mother is taking for her depression. A medication that works effectively for Julia's mother may be a good first choice for Julia. In the absence of this information, fluoxetine is a good choice because of its long half-life. Most SSRIs have a half-life of approximately 24 hours and missed doses can lead to discontinuation syndrome. Fluoxetine has a half-life of 2-4 days and its active metabolite has a half-life of 7-15 days. Occasional missed doses are less likely to cause withdrawal symptoms. It is important to review the risks, benefits, and common side effects of fluoxetine with the patient. This includes warning the patient about the link between the use of these medications and a small increased risk of suicidal thinking and behavior in adolescents and young adults. Any worsening of symptoms should be reported immediately. It is important for the patient to under-stand that fluoxetine needs to be taken daily and that beneficial effects may not be fully realized for 6-8 weeks. It is generally recommended that medication be continued for 6-9 months to reduce the risk of depression recurrence and discontinuing medication should be done under the supervision of the prescribing clinician. Treatment may also include psychotherapy. Cognitive behavioral therapy (CBT) is an effective treatment for mild to moderate depression, alone or in combination with pharmacological inter-ventions. Educate the patient on how exercise, adequate sleep, relaxation, and other behavioral strategies may also help to relieve depressive symptoms. What are the plans for referral and follow-up care? Julia should return for follow-up in 2 weeks to assess her depressive symptoms and how well she is tolerating the medication. Although beneficial effects may require more time, it is important to assess for any worsening of symptoms, including the presence of suicidal ideation. A referral for cognitive behavioral therapy is indicated. Julia could benefit from engaging in this evidence-based intervention and, in doing so, be followed closely and supported by a clinician with an expertise in treating depression. Since Julia's mother has a history of depression, Julia's risk of recurrence is higher than that of the general population. What health education should be provided to this patient? It is important to educate Julia about what to expect of treatment, including how long it may take to feel better, and that symptom improvement will be gradual. Lifestyle strategies that can help relieve depressive symptoms, including exercise, social interaction, and stress management, as well as behaviors that may worsen symptoms, including poor sleep hygiene, social isolation, and the use of alcohol and substances, should also be shared.
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Sad Mood 517 What demographic characteristics might affect this case? Men are less likely than women to seek treatment for depression and may be underdiagnosed in health care settings because they often present with anger and irritability versus sadness. In gen-eral, non-white Americans are less likely to engage in mental health treatment, so a culturally sensitive approach is critical to ensure participation. Does the patient's psychosocial history impact how you might treat her? Patients with few psychosocial supports may not respond as robustly to pharmacological interven-tions as patients with strong supports. They are also at a higher risk of depression recurrence. It is important to educate and assist patients in identifying strategies to improve functioning in this area. What if the patient lived in a rural (or urban) setting? If a patient lives in an area with inadequate health services, it may be more difficult to engage in treatment for depression without traveling a significant distance. The use of telemedicine is one way to address this issue. Urban settings are more likely to have adequate treatment resources; however, access to these resources may be delayed due to a scarcity of mental health clinicians. Are there any standardized guidelines that should be used to treat this case? The American Psychiatric Association has published guidelines for the treatment of depression in adults. Up To Date also provides treatment guidelines for depression in both adults and children. REFERENCES AND RESOURCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed. ). Arlington, VA: Author. Dixon, L. B., Holoshitz, Y., & Nossel, I. (2016). Treatment engagement of individuals experiencing mental ill-ness: Review and update. World Psychiatry, 15(1), 13-20. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. Miller, G. E., & Noel, R. L. (2019) Unipolar vs bipolar depression: A clinician's perspective. Current Psychiatry, 18(6), 10-18. National Institute for Mental Health. (2017). Men and depression. Retrieved September 9, 2019 from https:// www. nimh. nih. gov/health/publications/men-and-depression/index. shtml National Institute for Mental Health. (2018). Depression. Retrieved September 9, 2019 from https://www. nimh. nih. gov/health/topics/depression/index. shtml#part_145396 Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559-568. Roohafza, H. R., Afshar, H., Keshteli, A. H., Mohammadi, N., Feizi, A., Taslimi, M., & Adibi, P. (2014). What's the role of perceived social support and coping styles in depression and anxiety? Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences, 19(10), 944-949. Simon, G. (2017). Unipolar major depression in adults: Choosing initial treatment. In Roy-Byrne, P. P. (Ed. ), Up To Date. Waltham, MA: Up To Date Inc. https://www. uptodate. com (accessed September 9, 2019. ) Warner, C. H., Bobo, W., Warner, C., Reid, S., & Rachal, J. (2006). Antidepressant discontinuation syndrome. American Family Physician, 74(3), 449-456.
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519 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 9. 2 More Than Depression RESOLUTION What are the top three differential diagnoses in this case and why? In order for a patient to meet criteria for any mental health disorder there is a diagnostic require-ment that the patient be currently experiencing a significant distress in multiple domains including in their social life, work or school, or in other activities resulting in a decrease in functioning (American Psychiatric Association [APA], 2013). The top three differential diagnoses in this case are: Major depressive disorder (MDD): The patient presents with symptoms congruent with depression related problems, given the nor-mative findings on vitals and in review of symptoms (APA, 2013). Depression symptoms include lethargy, difficulty falling asleep and staying asleep, slow response and movements, difficulties feeling motivated, and reduced functioning in grades over a period of months “during this mark-ing period,” in addition to reduced work attendance. Further assessment is needed to refine a diag-nosis of MDD, including the use of tools, including Patient Health Questionnaire (PHQ) 9, given that only the PHQ-2 has been administered thus far. The level of depression and potential of sui-cidality require additional clinical assessments, such as the Columbia Suicide Severity Rating Scale (C-SSRS) (Mundt et al., 2013). The patient meets criteria for major depressive disorder, unspecified currently. Other specified depressive disorder: The patient presentation includes recurrent experiences of depressed mood, over a period of months, more often than not; additionally, the frequent presence of negative affect has affected sleep, level of psychomotor and physical activity, and work/ school functioning. The patient dem-onstrates decreased interest in activities once found enjoyable and fulfilling, including work and school, evidenced by reduced attendance to work and slipping grades. Additionally, symptoms of lethargy, a marked decrease in energy level, also with changes in sleep with onset and intermittent insomnia, taken together with the previously mentioned presentation are indicative of a depres-sion disorder. However, this diagnosis is less refined than major depressive disorder, and given that the MDD diagnosis is warranted, this otherspecified depressive disorder is not given, even though the criteria are met (APA, 2013).
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520 Resolutions Personal history of self-harm: The patient presents with history of self-injurious behavior (SIB) including presence of several thin linear scars approximately 2 inches long and 2 centimeters thick that were visible. Some scars appeared white; silvery in tone; one mark was pink in tone with minimal scabbing, indicative of probable reemergence of SIB s. While it is likely given the pattern of these wounds, various degrees of healing are in fact a result of SIB, further inquiry with the patient is required prior to making the diagnosis. Assessment in accordance with psychometric tools such as the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) can aid a clinician to rule in this provisional diagnosis (Whitlock et al., under review). Hypothyroidism: When diagnosing depression, organic causes should also be considered in the differential. Hypothyroidism (a sluggish or underactive thyroid) is linked to depression, as a thyroid deficiency can cause fatigue, weight gain, and a lack of energy, all of which Marc is also experiencing in his presentation. Other symptoms include bloating, memory loss, and difficulty processing information. Conversely, hyperthyroidism (overactive thyroid) can cause insomnia, anxiety, elevated heart rate, high blood pressure, mood swings, and irritability. A diagnosis of hypothyroidism does not mean that Marc does not also have a mental health condition, but often when diagnosing mental health conditions, the ruling out of organic causes or contribution(s) to clinical symptoms may be inad-vertently overlooked. What diagnostic tests are required in this case and why? Further screening questionnaires and assessment are indicated at this time. At this point, the PHQ-2 is positive and so a full Patient Health Questionnaire-9 (PHQ-9) is required and will yield further areas of potential concern related to depression and anxiety. The PHQ-9 is a specific screening tool designed to assess for symptoms of depression in teenagers. The Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) is useful at this point to guide the assessment in terms of standardized self-injury questions. Further assessment for suicidality and safety is essential in any initial presentation of self-injury. The Columbia Suicide Severity Rating Scale (C-SSRS) is recommended by the American Academy of Child and Adolescent Psychiatrists for use in suicide assessment in primary care. A blood panel that includes thyroid-stimulating hormone (TSH) and T3 and T4 hormone levels for specific indicators of a thyroid condition contributing to the patient's mood stability. What are the concerns at this point? It is important to assess the patient's risk for self-harm or suicide. It is necessary to obtain a Suicide Risk Assessment and a Self-Harm Risk Assessment. Is the patient motivated to engage in a safety plan to reduce the risk of self-harm and suicide? Marc is the oldest of 4 children, his father is unknown to him, and he had early childhood exposure to domestic violence. He has experienced episodes of housing insecurity and his mother works 3 jobs to provide for the family so Marc supervises his younger siblings. The psychosocial factors and family dynamics that influence this case are of concern and should be explored. What is the plan of treatment? Treatment should include an immediate assessment for suicidal risk. In accordance with the Patient Health Questionnair e (PHQ) 9 (Kroenke & Spitzer, 2002) and the Columbia Suicide Severity Rating Scale (C-SSRS) (Mundt et al., 2013), assessment of suicidal risk should include the following questions stated directly in age-appropriate language:1. Do you ever wish you were dead? 2. Do you think about killing yourself? 3. Do you have a plan to kill yourself? 4. Do you have means to carry out that plan? 5. Do you intend to carry out the plan to kill yourself?
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More Than Depression 521 A “No” response to Question 1 or Question 2 means that the remaining questions are not mandatory. A “Yes” response to Question 1 or Question 2 mandates that ALL the questions be asked (Questions 1 - 5). ◾ If all subsequent answers are “No” (Question 3, 4, or 5) and an ef fective safety plan is not already in place, then the provider must create a safety plan with the patient (and caregiver, if applicable). An inability to execute a safety plan by the patient or caregiver requires further assessment from a mental health professional for possible hospitalization. Example safety plan: List of coping skills to use to remain safe (e. g., distraction activities, deep br eathing, etc. ) List of triggers to avoid (e. g., caregiver will lock up sharp knives). List of supportive people to utilize when triggered (all people named must be awar e they are part of the safety plan). Emergency contact information (e. g., suicide hotline phone number). “Y es” responses to Question 3, 4, or 5 needs to result in an immediate assessment from a mental health professional for possible hospitalization. Calling emergency services (911) or having the patient safely transported to the Emergency Department (ED) are indicated treatment with expressed suicidality. Assessment for self-injurious behavior (SIB) follows a similar trajectory to suicidality assessment but with notable differ ences. Clinical best practices for SIB assessment falls in line with the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) (Whitlock et  al., under review) and should include the following questions in age-appropriate language: 1. Do you ever intentionally hurt yourself? 2. When you hurt yourself, what function does it serve? (e. g., to no longer feel numb) 3. How recent/ How fr equent do you hurt yourself? 4. How old were you when you first started to self-harm? 5. When you self-harm where on your body do you hurt yourself? 6. How severe ar e the wounds? (i. e., any wounds in need of medical care) “Yes” to Question 1 requires all questions for patient to respond to (Questions 2 -  6) and requires a safety plan (see the previous example safety plan). “No” to Question 1 results in no further questions being mandatory. However, use good clinical judgment, a “No” with visible wounds requires additional investigation. Ask the patient if they have ever been to a therapist for counseling and assess where, with whom, and for long, as well as the patient's feelings about engaging in therapy. Referral for mental health care including psychotherapy and subsequent psychopharmacology are necessary given the clinical presentation. However, asking the patient's possible previous experience with therapy may help in the referral process. Evidence-based treatment interventions such as cognitive behavioral therapy (CBT) have demonstrated efficacious treatment for depression and their comorbid disorders, such as anxiety disorder (Hofmann et al., 2012). Further inquiry and psychoeducation on sleep hygiene are of benefit in this case, but may best be saved for a futur e visit. Disrupted sleep can be a symptom of a mental disorder but also can exacerbate a mental disorder. Assess inadequate levels of sleep including the quantity, quality, and satisfaction with sleep, as well as sleep hygiene (caffeine consumption later in the day, bedtime routine, etc. ), and sleep schedule. Inability to sleep (as opposed to poor sleep hygiene) is more likely psychiatric in origin. If sleep is a concern, ask the patient to complete a 2-week sleep diary (see an example at www. brightfutures. org/mentalhealth/pdf/families/ec/diary. pdf). Incorporation of ongoing education on the importance of sleep as it relates to depression is appropriate for the treatment plan.
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522 Resolutions An accurate and refined diagnosis is needed prior to advent of psychopharmacology into the tr eatment plan. There is no standard (specific or sensitive) way to determine if a child/adolescent will respond to medication or if a patient will experience side effects. The Diagnostic and Statistical Manual of Mental Disorders (5th ed. ; DSM-5; APA, 2013) recom-mends that the following is assessed first in determination of the appropriateness of psycho-tropic medication: 1. The patient has sufficient symptoms to support a mental health disor der; 2. Symptoms are pr esent for a sufficient period; 3. There is significant impairment or distr ess from the symptoms; 4. The mental health disorder is dif ferent from normal levels of activity, worry and concern, or grief; 5. The patient has utilized evidence-based therapies (including cognitive-behavioral therapy for depression) been done suf ficient in quality and duration. The U. S. Food and Drug Administration has approved fluoxetine or escitalopram in the psy-chopharmacological treatment for treatment of MDD in youth and teens. Fluoxetine and escita-lopram are selective serotonin reuptake inhibitors (SSRIs) and are indicated for MDD for patients 8-17 years of age (fluoxetine) and 12-17 years of age (escitalopram). The initial dose for fluoxetine in a teen is 10-20 mg with the max daily dose of 60 mg (and supplied in 10, 20, or 40 mg capsules). The initial dose for escitalopram is 10 mg with the max daily dose of 20 mg (sup-plied in 5, 10, and 20 mg scored tablets or 1 mg/ml oral solution). The most common adverse reactions for SSRIs include nausea, diarrhea, insomnia, somnolence, fatigue, sexual dysfunction, increased sweating, agitation, and tremors. Safety monitoring is required with drug administration of the psychotherapeutic medica-tions, especially in youth. Monitoring for contraindications, adverse effects, and potential drug interactions are to occur no less than every 30 days with closer monitoring on initiation of SSRI prescribing. All SSRIs have a boxed warning of suicidal thoughts and behaviors and suicidal assessment should remain a priority in follow-up care. Beyond suicide risk, other precautions to be aware of include: Serotonin syndr ome, which may occur with co administration of other serotonergic agents (such as triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspi-rone, and St. John's wort). Activation of mania, which occurs with misdiagnosis of MDD and actual diagnosis of bipolar disorder. Seizures, which occur with conditions that potentially lower the seizur e threshold in patients who have a history of seizures. Abnormal bleeding may occur with use of nonsteroidal anti-inflammatory dr ugs, aspirin, warfarin, or other drugs that affect coagulation. Hyponatremia in patients with syndr ome of inappropriate antidiuretic hormone. Cognitive or motor impairment may occur. Be cautious in use with patients who have disorders that pr oduce altered metabolism or hemodynamic reactions. Weight loss or gain may occur and r equires close monitoring. Routine weight, height, and BMI are to be included as a part of follow-ups with medication management. Anxiety or insomnia may occur with fluoxetine. Fluoxetine has been associated with QT prolongation and is pr escribed only with caution in patients with conditions that predispose to arrhythmias. What health education should be provided to this patient? Self-harm/risk for infection: Patients with SIB often are nonsuicidal in their injurious behavior but can end up with complications from infections, poor wound care, or unclean instruments used for self-
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More Than Depression 523 harming. Education about wound care while the patient is seeking mental health care is helpful in reducing possible confounding medical conditions until the SIB subsides with appropriate care. Neurobiology of depression: Psychoeducation is a well-established practice in the mental health field, often found to be the first step on a gradual exposure treatment, such as cognitive behavioral therapy (CBT), for patients with anxiety, depression, and trauma disorders, among many others (Hofmann et al., 2012). The simple learning process that their brains and bodies are functioning in a particular pattern due to neurobiology can be very anchoring to people whom often feel unsure of why they have “lost control” over their thoughts, behaviors and mood. Sleep: The regenerative processes involved in sleep are essential for healthy functioning minds and bodies. Depression can affect sleep and vice versa. Sleep hygiene education and establishing healthy sleep habits would be essential in the holistic treatment of this patient. Nutrition: The quality of the food ingested by each patient directly affects the ability for the brain to produce healthy thoughts. In addition, nutrition counseling about the impact food has on blood sugar and mood would aid greatly in helping to reduce the depressive symptoms, or at least not exacerbate the negative mood. What demographic characteristics might affect this case? Cultural considerations are important when evaluating this case. While it is essential not to stereo-type, it is also important to be reflective that patients of nonmajority cultures can feel marginalized or have their symptoms inappropriately viewed through the majority culture lens. Given that this patient is Hispanic in America, it is important to acknowledge family systems of interdependence that include childcare for younger siblings is not taboo. Whereas, majority culture standards in America tend towards prioritizing individuality and independence this is not universal values across all cultures. Additionally, discussions of topics such as depression, SIB, or suicidality in medical or religious framework are more tolerable to most individuals of Hispanic culture than mental health terms (Baruth & Manning, 2002). Does the patient's psychosocial history impact how you might treat him? Family systems resulting in this patient being required to provide a primary caretaker role for younger siblings when not at school or work is a likely stressor, but also a potential source of pride and accomplishment for the patient, depending on his perspective. Maternal history of depression can be an indicator of a genetic predisposition toward depressive mood. Finally, if onset of depres-sion and reduced functioning symptoms had occurred more immediately following exposure in childhood to domestic violence, then a trauma or adjustment diagnosis would also be an appro-priate differential. What if the patient were elderly or under age 13? Should the patient's age be different, practitioners would additionally need to account for man-dated reporting laws for populations at risk (elderly or under age 13). Clinicians are to review the restrictions to confidentiality with the patient while engaged in risk assessments. Additionally, given this patient's presentation of self-injurious behavior, symptoms of depression, and the need to assess for potential suicidality, it is highly likely that a patient of a more vulnerable age will require external supports, such as a caregiver, to execute any safety plan fully. REFERENCES AND RESOURCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed. ). Arlington, VA: Author. Baruth, L. G., & Manning, M. L. (2012). Multicultural counseling and psychotherapy: A lifespan approach (5th ed. ). Boston: Pearson.
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524 Resolutions Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440. doi:10. 1007/ s10608-012-9476-1. Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression and diagnostic severity measure. Psychiatric Annals, 32, 509-521. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical Care, 41, 1284-1292. Mundt, J. C., Greist, J. H., Jefferson, J. W., Federico, M., Mann, J. J., & Posner, K. (2013). Prediction of suicidal behavior in clinical research by lifetime suicidal ideation and behavior ascertained by the electronic Columbia-Suicide Severity Rating Scale. The Journal of Clinical Psychiatry, 74(9), 887-893. Riddle, M. (2016). Pediatric psychopharmacology for primary care (2nd ed. ). Itasca, IL: American Academy of Pediatrics. Steer, R. A., & Beck, A. Use of the Beck Depression Inventory, Hopelessness Scale, Scale for Suicidal Ideation, and Suicidal Intent Scale with adolescents. (1988). Advances in Adolescent Mental Health, 3, 219-231. Whitlock, J. L., Exner-Cortens, D., & Purington, A. (under review). Validity and reliability of the non-suicidal self-injury assessment test (NSSI-AT).
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525 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 9. 3 Postpartum Depression RESOLUTION What is the diagnosis and its contributing factors? For Jake Small for gestational age (SGA), etiology unknown, requiring catch-up growth: SGA babies are at risk for later neurodevelopmental problems due to the interuterine growth retar-dation implied by SGA. For Laura Maternal postpartum depression (PDD): Aside from observation of the mother alternating between a flat affect and anxiety, Laura has some risk factors for developing PDD: She Has a previous history of depr ession. Lives in a northern climate with a winter-born baby, who requires extra care. Is socially isolated. Has a difficult baby. SGA babies typically tend to be fussy and difficult to comfort, often reject-ing attempts to cuddle them, which can discourage maternal bonding. Mothers of SGA babies require a lot of support and this mother doesn't seem to have that support. A pr evious history of infertility is associated in some studies with depression in the case of mar-ital conflict and social isolation. There are breastfeeding concerns related to closely spaced feedings, the undersize of the infant, lack of supplemental calories for catch-up growth, lack of maternal knowledge regarding what constitutes enough milk per feeding for a small baby, and other breastfeeding concerns. Why must concerns about Laura be addressed at this appointment? Laura's depression can alter her interactions with the baby, thereby negatively affecting Jake's development. Depressed mothers engage less with their babies, and have trouble reading their infant's cues. Animated face-to-face engagement stimulates the growth of the brain through the release of dopamine. Dopamine serves as a growth stimulus for the orbital frontal region of the brain and is implicated in neurodevelopment. Depressed mothers' lessened engagement with their infants reduces the amount of dopamine bathing the orbital region of the infant's brain, thereby increasing the infant's risk for developmental and behavioral problems.
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526 Resolutions What additional information is needed? Formal depression scr eening for Laura. While the Edinburgh Postnatal Depression Screen (EPDS) is the most commonly used instrument to screen for PPD, the Patient Health Questionnaire (PHQ-9) also has strong reliability and validity. Both instruments are brief at 10 questions each. Resource for availability of mother-infant support services in Laura's area. What are the treatment options? For Jake Vitamin D supplement 600 IU by mouth daily. Give second dose of the Hepatitis B vaccine. Encourage pacifier use over prolonged pacification at the br east to give Laura's milk supply a chance to replenish for the next feeding. Continue with br eastfeeding if Laura is amenable to this, as the research indicates that it is an effective feeding method for SGA infants. Proper nutrition for an infant with SGA with the goal of catch-up growth is one contributing factor to optimizing neurodevelopmental outcome. Encourage Laura to provide three bottle feedings a day with either pumped breast milk or for-mula fortified with extra calories to further encourage catch-up growth, and to allow for more options for who may feed the infant to allow Laura to attend to her own needs. Refer to Early Intervention Program developmental services for developmentally at-risk infants and toddlers if Jake lags in milestones or continues with hyperactive reflexes and ankle clonus. For Laura Consult the American Academy of Pediatrics (APA) recommended Lact Med website for medica-tion safety with the breastfed infant for consideration of starting Laura on an antidepressant. What are the plans for referral and follow-up care? Include resources that may be needed to determine treatment options. Refer Laura to an International Board of Lactation Consultant (IBCLC) certified lactation con-sultant in her area to help with her breastfeeding goals in the context of Jake's special needs. An IBCLC consultant is the only lactation support service specifically trained in working with at-risk breastfeeding mothers and infants with special needs. Refer to the Visiting Nurses Association to support Laura's adjustment to caring for a challeng-ing infant and to recommend community mother-infant support resources in the family's community. They can also monitor the baby's weight at home to reduce the number of office visits, thereby reducing Jake's exposure to illness during the flu season. Psychiatric referral r esource for therapy as needed after medication is initiated. Instructions on how to access mother-baby Internet cafes for in-home support. Follow up with primary care clinic for weight check, immunizations, and continued develop-mental assessment in 4 weeks. Return sooner if weight gains level or drop off per VNA report. Refer Jake to Early Intervention if needed per neurodevelopmental assessment over subsequent office visits. What demographic characteristics might affect this case? More affluent families may be able to pay out of pocket for cost-related services. The family's proximity to an urban ar ea might give more choices for services than may be avail-able in a more rural area. A person who is a fluent English speaker might also have access to a gr eater range of services. A woman who can stay at home is not faced with the concerns of r eturning to work that a woman who must work would have in terms of finding someone who is able and willing to continue with Jake's intensive care plan. Women returning to work have the additional concern of how to continue with breastfeeding, especially if working in an environment that does not provide time or facilities for pumping breast milk.
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Postpartum Depression 527 Are there any standardized guidelines that should be used to treat this case? If so, what are they? The AAP, in its practice guidelines, recommends medicating depressed mothers even if breastfeed-ing, since the evidence of the harm to breastfeeding infants of any maternal medication that might pass into breast milk is currently much less than the evidence of the harm to the infant when the depressed mother is left unmedicated. REFERENCES AND RESOURCES Carducci, B., & Bhutta, Z. A. (2018). Care of the growth-restricted newborn. Best Practice & Research in Clinical Obstetrics & Gynaecology, 49, 103-116. Castanys-Munoz, E., Kennedy, K., Castaneda-Gutierrez, E., Forsyth, S., Godfrey, K. M., Koletzko, B., .  .  .  Ong, K. K. (2017). Systematic review indicates postnatal growth in term infants born small-for-gestational-age being associated with later neurocognitive and metabolic outcomes. Acta Paediatrica, 106(8), 1230-1238. Edinburgh Depression Scale. (n. d. ). https://www. fresno. ucsf. edu/pediatrics/downloads/edinburghscale. pdf Falah-Hassani, K., Shiri, R., & Dennis, C. (2016). Prevalence and risk factors for comorbid postpartum depres-sive symptomatology and anxiety. Journal of Affective Disorders, 198, 142-147. International Board of Lactation Consultant Examiners. https://iblce. org. Kesavan, K., & Devaskar, S. U. (2019). Intrauterine growth restriction: Postnatal monitoring and outcomes. Pediatric Clinics of North America, 66(2), 403-423. Lact Med. https://toxnet. nlm. nih. gov/newtoxnet/lactmed. htm Patient Health Questionnaire (PHQ-9). (n. d. ). https://www. uspreventiveservicestaskforce. org/Home/ Get File By ID/218 Pope, C. J., & Mazmanian, D. (2016). Breastfeeding and postpartum depression: An overview and methodical recommendations for future research. Depression Research and Treatment, 2016(2). Sachs, H. C., & Committee On Drugs. (2013). The transfer of drugs and therapeutics into human breast milk: An update on selected topics. Pediatrics, 132(3), e796-e809. Sethna, V., Pote, I., Wang, S., Gudbrandsen, M., Blasi, A., Mc Cusker, C.,.  .  .. Mc Alonan, G. M. (2017). Mother-infant interactions and regional brain volumes in infancy: An MRI study. Brain Structure and Function, 222(5), 2379-2388. Smith-Nielsen, J., Tharner, A., Krogh, M. T., & Vaever, M. S. (2016). Effects of maternal postpartum depression in a well-resourced sample: Early concurrent and long-term effects on infant cognition, language, and motor development. Scandinavian Journal of Psychology, 57.
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529 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 9. 4 Anxiety RESOLUTION What are the top three differential diagnoses in this case and why? Generalized anxiety disorder: Jonathan presents with symptoms consistent with generalized anxiety disorder, including excessive anxiety, irritability, sleep disturbance, and concentration difficulties. Substance/medication-induced anxiety disorder: Jonathan reports drinking 2-3 twelve-ounce Red Bull energy drinks per day and 2-3 beers daily in the evening. Reducing or eliminating intake of alcohol and caffeine could help to determine to what degree they are contributing to his anxiety symptoms. Adjustment disorder with anxiety: To meet criteria for adjustment disorder with anxiety, symptoms must emerge in response to an identifiable stressor that occurred within the prior 3 months. It is unclear if Jonathan's anxiety is a reaction to a recent increase in stress at work. Which diagnostic tests are required in this case and why? Diagnostic tests, including TSH, CBC with differential, basic metabolic panel, B12, and folic acid should be obtained to rule out underlying medical conditions including hyperthyroidism, B-12 deficiency, electrolyte imbalances, and infectious and malignant processes. GAD-7 should be com-pleted to assess both the severity of Jonathan's anxiety symptoms and their impact on his daily functioning. What are the concerns at this point? It is important to distinguish between substance-induced anxiety disorder and generalized anxiety disorder. Reducing or eliminating caffeine and alcohol could assist in determining the extent to which they are contributing to his anxiety symptoms. Understanding the impact of anxiety symp-toms on Jonathan's functioning and level of distress can serve to inform the development of an appropriate and comprehensive treatment plan. Without appropriate treatment, the severity of Jonathan's anxiety symptoms put him at risk of developing comorbid depression. Ask 3-5 case-specific questions:How long have anxiety symptoms been present?
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530 Resolutions Do symptoms wax and wane or are they constant throughout the day? When are symptoms at their worst? Can the patient identify what makes anxiety worse or anything that helps to relieve symptoms? How are symptoms impairing functioning at work, at home, and in relationships? What is the plan of treatment? It is critical to first treat any underlying medical condition. In the absence of an underlying medical condition, determine the severity of anxiety symptoms based on GAD-7 score. Jonathan's GAD-7 score is 14, which indicates moderate anxiety. Appropriate treatment options include cognitive behavioral therapy, medication, or a combination of the two. Patient preference should be consid-ered. There are situations when medication can help to facilitate cognitive behavioral therapy. SSRIs are first-line pharmacological treatment for anxiety disorders. Escitalopram is a good choice. It is generally effective in treating anxiety symptoms with relatively low risk of GI distress, insomnia, and agitation in comparison to other SSRIs. It is important to review the risks, benefits, and common side effects of escitalopram with the patient. Any worsening of symptoms should be reported immediately. It is important for the patient to understand that escitalopram needs to be taken daily and that beneficial effects may not be fully realized for 6-8 weeks. It is generally recommended that medication be continued for 6-9 months to reduce the risk of anxiety recurrence and discontinuing medication should be done under the supervision of the prescribing clinician. Treatment may also include psychotherapy. Cognitive behavioral therapy (CBT) is an effective treatment for anxiety, alone or in combination with pharmacological interventions. Educate the patient on how exercise, adequate sleep, relaxation, and other behavioral strategies may also help to relieve anxiety symptoms. What are the plans for referral and follow-up care? Jonathan should return for follow-up in 2-4 weeks to assess his anxiety symptoms and how well he is tolerating the medication. Although beneficial effects may require more time, it is important to assess for any worsening of symptoms and medication tolerability. A referral for cognitive behavioral therapy (CBT) would be beneficial. Jonathan could benefit from engaging in this evidence-based intervention and, in doing so, be followed closely and sup-ported by a clinician with an expertise in treating anxiety disorders. What health education should be provided to this patient? It is important to educate Jonathan about what to expect of treatment, including how long it may take to feel better and that symptom improvement will be gradual. Lifestyle strategies that can help relieve anxiety symptoms including exercise, yoga, and stress management techniques should be emphasized. It is imperative to also advise Jonathan on behaviors that may worsen his symptoms, including poor sleep hygiene and regular use of caffeine, alcohol, and other substances. What demographic characteristics might affect this case? Men and non-white Americans are less likely to seek and engage in mental health treatment, so a culturally sensitive approach is critical to ensure participation. Does the patient's psychosocial history impact how you might treat him? Patients with few psychosocial supports may not respond as robustly to pharmacological interven-tions as patients with strong supports. They are also at a higher risk of developing a comorbid depression or substance use disorder. It will be necessary to educate and assist the patient in iden-tifying ways to make improvements in this area. Urban settings are more likely to have adequate treatment resources; however, access to these resources may be delayed due to a scarcity of mental health clinicians.
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Anxiety 531 What if the patient lived in a rural (or urban) setting? If the patient lives in an area with inadequate health services, it may be more difficult to engage in treatment without traveling a significant distance. The use of telemedicine would be one way to address this issue. Are there any standardized guidelines that should be used to treat this case? If so, what are they? The American Academy of Family Physicians has published guidelines for the treatment of anxiety in adult patients. Up To Date provides treatment guidelines for anxiety in adults and children. REFERENCES AND RESOURCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed. ). Arlington, VA: Author. Craske, M., & Bystritsky, A. (2019). Approach to treating generalized anxiety disorder in adults. Up To Date. Waltham, MA: Up To Date Inc. https://www. uptodate. com (accessed September 9, 2019. ) De Sanctis, V., Soliman, N., Soliman, A. T., Elsedfy, H., Di Maio, S., El Kholy, M., & Fiscina, B. (2017). Caffeinated energy drink consumption among adolescents and potential health consequences associated with their use: A significant public health hazard. Acta bio-medica: Atenei Parmensis, 88(2), 222-231. Hentz, P. (2008, March 18). Separating anxiety from physical illness. Clinical Advisor. Locke, A., Kirst, N., & Schultz, C. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American Family Physician, 91(9), 617-624. National Institute for Mental Health. (2018). Anxiety disorders. Retrieved September 9, 2019 from https:// www. nimh. nih. gov/health/topics/anxiety-disorders/index. shtml#part_145338 Saeed, S., Cunningham, K., & Bloch, R. (2019). Depression and anxiety disorders: Benefits of exercise, yoga, and meditation. American Family Physician, 99(10), 620-627.
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533 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 9. 5 Trauma RESOLUTION What are the most likely differential diagnoses in this case and why? Post-traumatic stress disorder (PTSD): This diagnosis is supported by the symptomology in addition to the recent ongoing traumatic events of witnessing emotional and physical domestic violence within the home. Brittany reports difficulty sleeping, recurrent distressing dreams, markedly diminished interest/participation in significant activ-ities, and difficulty concentrating. Furthermore, her school counselor's statements speak to feelings of detachment and estrangement from others, all of which is causing impairment in her social and academic areas of functioning. Further assessment needs to be completed to determine if the content of Brittany's nightmares relate to the traumatic events and if Brittany experiences avoidance of stimuli associated with the traumatic event(s). As both of these questions can be framed as “yes or no” questions (e. g., “Do your bad dreams relate to what used to happen at home with Mom being hurt by Stepdad?”), it is likely that Brittany will be more apt to answer than with an open-ended question that requires her to verbalize the trauma in detail. If these questions result in affirmative answers, Brittany meets the full criteria for a PTSD diagnosis. Unspecified trauma-and stressor-related disorder: Without further information about the trauma stimuli avoidance and a known link between the trau-matic events and distressing dreams, Brittany will not meet the full criteria for a diagnosis of PTSD. Frequently, an adolescent will not initially disclose details of their trauma symptoms due to the distress-ing nature of the thoughts (“I don't want to talk about it or think about it”). For Brittany, there was an exposure to trauma with significant symptoms that are impacting her functioning across environments. Diagnosing the depressive or anxiety symptoms without taking into account the trauma experienced will not capture the likely root cause of Brittany's struggles or help assure proper management and treatment. Thus, this diagnosis can be helpful in communicating that the symptomology is related to trauma, while acknowledging that the full criteria for another disorder in this diagnostic class is not met at this time based on the information provided by the patient. If this diagnosis is needed, as soon as enough information is gathered through interviews and screening tools to allow for a more specific diag-nosis (PTSD, other specified trauma-and stressor-related disorder), the diagnosis should be updated. Major depressive disorder (MDD): While Brittany describes several symptoms of MDD such as a diminished interest in activities and a diminished ability to think or concentrate, she does not report enough symptoms to meet the criteria
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534 Resolutions for this disorder, and the symptoms reported do not include enough information to indicate a depressed mood, despite the fact that a shift in Brittany's typical presentation is noted. Further assessment—with age-appropriate screening tools—is recommended to assure a full picture of Brittany's mood. Generalized anxiety disorder (GAD): Brittany describes several symptoms of anxiety, including worrying something bad will happen and difficulty concentrating, both of which are impacting her functioning at school. However, GAD requires at least 6 months of anxiety symptoms, and Brittany's report is that her symptoms began about 3 months ago with the move of homes. Similar to MDD, Brittany's anxiety symptoms are likely better explained as a response to her exposure to significant trauma. Child affected by parental relationship distress: This Z-code in the DSM-5 (Z codes describe other areas of clinical focus that may influence a child's mental or medical well-being) allows for a descriptor of conditions that may explain the need for treatment and provide information on a patient's circumstances. Given Brittany's exposure to partner violence between her mother and stepfather, this would be an important code to utilize to allow future providers to understand Brittany's presentation and symptomology. Which diagnostic tests required in this case and why? Further screening questionnaires and assessment are indicated at this time. The Patient Health Questionnaire-9 (PHQ-9) and the Columbia-Suicide Severity Rating Scale (S-SSRS) are recom-mended for use in primary care to further screen for concerns related to depression and anxiety (PHQ-9) and suicidality (C-SSRS). The Non-Suicidal Self-Injury Assessment Tool (NSSI-AT) can be used to guide assessment in terms of standardized self-injury questions. Because the patient is reporting extreme fatigue, as well as frequent headaches and changes in mood stability, baseline blood panels are useful to include a thyroid panel (including thyroid-stimulating hormone (TSH), T3 and T4 hormone levels) for specific indicators of a thyroid condition contributing to the patient's mood stability as well as a CBC with diff and a metabolic panel to further explore the headaches and fatigue to ensure that there is no organic contributing factor to the depressive symptoms. Hypothyroidism (from an underactive thyroid) is the most common medical condition associated with depressive symptoms; however, hyperthyroidism (from an overactive thyroid) and Cushing's disease are also associated with depression and should not be overlooked. Checking electrolytes and liver and kidney functions are also important, as medications (including SSRIs that can help with depression) are involved in the elimination of depression medications. Brittany also does not regularly follow one provider and does not rou-tinely receive primary care, making baseline lab tests important, given her presentation. Diagnostic Tests Thyroid Panel CBC and Differential Lytes and Metabolic Panel TSH: 1. 7 mi U/L Total T3:. 9 ng/d LFree T3: 1. 0 ng/m LTotal T4: 5. 0 mg/d LWBC: 5. 9 × 10 3/mm3 RBC: 5. 0 × 106/mm3 Hgb: 12. 0 g/d LHct: 37%MCV: 100 f LRDW: 14%Retics: 1%Neutrophils: 3. 6 × 10 9/L Monocytes:. 3 × 109/L Platelets: 389 × 109/LNa: 140 mmol/LK: 4. 1 mmol/LGlucose: 101 mg/d LCa: 2. 0 mol/LCl: 95 mmol/LMag: 2 m Eq/LBUN: 9 mg/d LCreatinine: 1. 0 mg/d LUrea: 1. 2 mmol/LUric acid: 0. 19 mmol/LTriglycerides: 100 mg/d LTotal cholesterol: 5. 0 mmol/LHDL: 40 mg/d LLDL: 85 mg/d L
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Trauma 535 What are the concerns at this point? Brittany's diagnostic lab panel and physical assessment were normal. Her fatigue and lack of sleep, as well as frequent headaches, are still a concern. However, the immediate concerns at this visit include: Suicide risk assessment Self-harm risk assessment Safety of going home What is the plan of treatment? Suicide risk assessment: Given the changes in Brittany's presentation and functioning, a clinical suicide risk assessment should be completed. This assessment would clarify if Brittany has ever had suicidal ideation or plans, and has the means to harm herself. Brittany should be asked if she has or has ever had (present or historical) thoughts of ending her life/killing herself (suicidal ide-ation). If Brittany responds affirmatively, screening would need to continue to find out if Brittany had ever thought about how she might end her life (plans), and, if so, how she would kill herself (means) (see Case 9. 2, “More than Depression,” for more in-depth suicidal assessment). Given that adolescents may be more likely to share information in writing than verbally, a PHQ-9 and/or a Columbia-Suicide Severity Rating Scale Screener will also offer helpful information in addition to the interview and guide the clinician in standardized questioning of statements. Self-harm risk assessment: While Brittany has not stated self-harm, given the trauma exposure and the internalizing nature of her symptoms, a self-harm risk assessment should also be completed. Brittany should be asked if she's ever thought of or carried out harming herself (without the inten-tions of killing herself). If Brittany responds yes, further assessment of any physical injuries should be completed. Safety of going home: Safety at home and Brittany's current feelings of safety in general should be discussed. Brittany should be asked about any alcohol or other substances being utilized in the home given mother's history of alcohol use, and about her plans if she at any point feels unsafe at home or with her caregivers. Fatigue: Brittany's fatigue is most likely related to a lack of sleep and her PTSD. Thyroid con-cerns for fatigue have been ruled out from the labwork as well as organic causes of fatigue from a normal CBC and electrolyte panel. Brittany also describes poor sleep hygiene, which is common in adolescents regardless of mental health concerns. Sleep hygiene: Sleep problems are symptomatic of a variety of mental health disorders and it is important to obtain more information about sleep patterns and hygiene, as lack of sleep can also exacerbate mental health concerns. Sleep hygiene can be saved for a future visit, as this is not the most pressing concern at this time. However, since Brittany is registered for SBHC use, the nurse practitioner can follow up for a sleep-related visit in the near future. Consideration of SSRI to manage anxiety symptoms related to post-traumatic stress: Not every patient who presents with depressive symptoms, anxiety symptoms, and a history of trauma should be automatically be started on SSRIs. In some cases, specifically when a patient begins therapy (such as cognitive behavioral therapy [CBT]), a medication to manage anxiety symptoms can aid in reaching therapeutic goals. If after further assessment of Brittany medication is deemed appro-priate, escitalopram (Lexapro) 10 mg QD would be a good choice related to trauma presenting with anxiolytic properties. For further determination on if psychotherapeutic medication should be used, please see Case 9. 2. Regardless of medication utilization, psychotherapy should be considered first and foremost. Cognitive behavioral therapy with a trauma-informed therapist may help for longer-term symptom reduction. A referral should be made as soon as possible and discussed with mother. What is trauma-informed care? The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma-informed care as “a program, organization, or system that .  .  .   realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma
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536 Resolutions in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization. ” Trauma-informed frameworks also include six key principals, per SAMHSA: (1) Safety; (2) Trustworthiness and Transparency; (3) Peer Support; (4) Collaboration and Mutuality; (5) Empowerment, Voice and Choice; (6) Cultural, Historical, and Gender Issues. Two research-supported therapy models for trauma-informed care for adolescents are trauma-focused cognitive behavioral therapy and eye movement desensitization and reprocessing (EMDR). What are the plans for referral and follow-up care? For the referral to behavioral health services, Brittany should be asked if she's ever attended counseling before and her willingness to try it out or return to treatment. Attending therapy should be normalized as taking care of herself and helping Brittany return to the level of functioning that she enjoyed before her symptoms began. As this visit is taking place in a school-based health center, it's likely that the provider has access to a behavioral health provider colleague to whom Brittany can be referred. A trauma-informed therapist who is familiar with trauma-informed treatment modalities would be best suited for Brittany based on her clinical presentation and history known at this point. If an SSRI is prescribed, a follow-up visit is needed within the first 2 weeks of treatment to eval-uate for effect of the medication as well as any potential side effects. SSRI black box warnings regarding worsening of suicidal ideation or intent should be considered and a follow-up suicide assessment conducted. Basic sleep hygiene (aka good sleep habits) includes consistency at bedtime. Going to bed the same time each night and getting up at the same time each morning, including on weekends, is especially difficult for preadolescents and adolescents, but is instrumental in forming a healthy sleep pattern. Integrative sleep medicine experts also recommend that the bedroom is quiet, dark, relaxing, and at a comfortable temperature and that all electronic devices (TVs, computers, smart-phones) be turned off or even removed from the bedroom. Exercising and being physically active during the day can help with fall asleep but exercising too close to bedtime can also cause difficulty falling asleep. Avoiding large meals, caffeine, and alcohol before bedtime is also important. Excessive consumption of caffeine, especially late in the day, is common in adolescents and assessment and psychoeducation should be done with Brittany related to caffeine intake. Brittany can also complete a sleep log to better track quantity and quality of sleep. There are many examples online but the American Academy of Pediatrics recommends the Bright Futures sleep log at: www. brightfutures. org/mentalhealth/pdf/families/ec/diary. pdf. What demographic characteristics might affect this case? Depending on Brittany's cultural background, she and her family might have questions or con-cerns about seeing a therapist or mental health provider of any kind, given some cultures' beliefs that the appropriate way to handle family problems is within the family system. Psychoeducation about the counseling process and benefits of therapy at this time rather than waiting until Brittany's symptoms potentially worsen may be needed. Additionally, some cultures and families from dif-ferent backgrounds may be very opposed to psychotherapeutic medications, including SSRIs. Exploring the family's knowledge and possible concerns with SSRI use will be helpful and should be done as soon as possible in case SSRI is indicated once therapy begins. Does the patient's psychosocial history impact how you might treat her? Given Brittany's exposure to significant domestic violence and the concern that her stepfather has a no contact order with the children suggests that careful follow-up should be completed to assure Brittany's safety and care.
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Trauma 537 If this patient was male (instead of female), how might that change management and treatment? As with other mental health disorders, trauma symptoms may include more externalizing behav-iors with adolescent boys. Symptomology may include irritability and/or disruptive and defiant behaviors, which are often diagnosed as a behavioral disorder rather than a response to trauma or another mental health concern. While treatment may be the same, it is easy for providers to forget to assess for trauma or more serious underlying mental health issues when “behavioral” or “out of control” concerns seem to be the primary presenting problem. REFERENCES AND RESOURCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed. ). Arlington, VA: Author. Earls, M. (2018). Trauma-informed primary care: Prevention, recognition, and promoting resilience. North Carolina Medical Journal, 79(2), 108-112. doi:10. 18043/ncm. 79. 2. 108 Hagan, J. F. Jr., Shaw, J. S., & Duncan, P. M. (Eds. ). (2017). Bright futures: Guidelines for health supervision of infants, children, and adolescents (4th ed. ). Elk Grove Village, IL: American Academy of Pediatrics. Kovachy, B., O'Hara, R., Hawkins, N., Gershon, A., Primeau, M. M., Madej, J., & Carrion, V. (2013). Sleep dis-turbance in pediatric PTSD: Current findings and future directions. Journal of Clinical Sleep Medicine, 9(5), 501-510. doi:10. 5664/jcsm. 2678 Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression and diagnostic severity measure. Psychiatric Annals, 32, 509-521. Mundt, J. C., Greist, J. H., Jefferson, J. W., Federico, M., Mann, J. J., & Posner, K. (2013). Prediction of suicidal behavior in clinical research by lifetime suicidal ideation and behavior ascertained by the electronic Columbia-Suicide Severity Rating Scale. The Journal of Clinical Psychiatry, 74(9), 887-893. Riddle, M. (2016). Pediatric psychopharmacology for primary care (2nd ed. ). Elk Grove Village, IL: American Academy of Pediatrics. Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). SAMHSA's concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA). Rockville, MD: Author. Available at: http://www. traumainformedcareproject. org/resources/SAMHSA%20TIC. pdf
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539 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 10. 1 Forgetfulness RESOLUTION What are the top three differential diagnoses in this case and why? Major depression: PHQ‐9 indicates moderately severe depression and combined with her history and physical exam findings, Sophie's depression is not well controlled and she is experiencing an exacerbation. Cognitive impairment: The Mo CA score reveals mild cognitive impairment (MCI). Her symptoms of forgetfulness are concerning and she has diabetes, which is associated with cognitive impairment. Anxiety disorder: Sophie is exhibiting increased anxiety symptoms by displaying excessive worry, accompanying sleep disturbance, and ongoing family stressors, which are contributing. Which diagnostic tests are required in this case and why? Brain imaging, preferably MRI to rule out an intracranial abnormality such as a stroke. The patient has demonstrated cognitive impairment on exam and several vascular risk factors, which increase the risk of a stroke. Referral for neuropsychological testing: The patient's in‐office testing indicate MCI and also major depression. In addition, she has anxiety and insomnia, which also can contribute to cognitive impairment. Neuropsychological testing can ascertain whether this patient is experiencing an emerging dementia or if her underlying psychiatric diagnoses are confounding her clinical picture. Laboratory workup to rule out an underlying metabolic disorder, which can cause memory decline. These tests include: a. CBC b. TSH c. Vitamin B12 d. CMP e. RPR or FTA testing (if applicable) f. Hg A1C to assess the patient's overall glycemic control
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540 Resolutions What are the concerns at this point? 1. Cognitive impairment 2. Depression exacerbation 3. Anxiety exacerbation 4. Sleep disturbance 5. Breakthr ough DPN pain What are 3-5 case‐specific questions to ask the patient? Are you experiencing any thoughts of harming yourself? Do you feel your anxiety and depression ar e currently well controlled on your prescribed medications? Have you forgotten names of your family, important dates, or left the oven/stovetop on? Is the Trazodone or Alprazolam helping you sleep? Do you find the gabapentin to be helpful for your DPN? What is the plan of treatment? Rule out an underlying intracranial abnormality and possible metabolic cause for the cognitive impairment, including brain imaging, referral to neuropsychological testing, and lab testing. Consider referral to a psychiatrist for management of anxiety and depression. This may not be fea-sible and wait times can be quite lengthy, so the provider should consider reducing Buproprion, as this may be contributing to anxiety. Start to address polypharmacy at this visit. The patient is on multiple central nervous system-acting medications, which all may possibly be contributing to her cognitive impairment and could increase the risk of falls. The patient is on the maximum dose of Citalopram. Consider switching to Duloxetine to treat both depression and DPN. Consider reducing gabapentin as the patient is on the maximum dose and is still experiencing breakthrough pain that is contributing to her sleep disturbance. The patient is on benzodiazepines, which has shown to be associated with cognitive impairment. It is preferable that she be weaned off this med-ication very slowly in the future once her depression and anxiety are under better control. What are the plans for referral and follow‐up care? Referral to neuropsychologist Referral to psychiatrist Referral to counseling services; can also consider cognitive behavioral therapy, which is indi-cated for depression, anxiety, and sleep disturbance. Follow‐up in 2 weeks to assess response to medication changes Possible referral for caregiving respite services if family indicates a need Possible referral for driving evaluation to assess for any safety concerns given her cognitive impairment What health education should be provided to this patient? Provide written information on mild cognitive impairment. MCI increases the risk of developing dementia and the patient is already at risk, especially for vascular dementia, given her PMH of Type 2 DM, HTN, HLD. Provide medication information including the reason for prescribing, adverse effects, and how to take the medication. What demographic characteristics might affect this case? Age, which increases the risk of adverse drug events due to polypharmacy. Does the patient's psychosocial history impact how you might treat her? Yes, the provider needs to take Sophie's history of PTSD and the fact that she is a survivor of domestic abuse into consideration and be sure to establish trust and shared decision making with the patient and her family.
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Forgetfulness 541 REFERENCES Edlund, B. J., Lauerer, J., & Drayton, S. J. (2015). Recognizing depression in late life. The Nurse Practitioner, 40(2), 37-42. Falk, N., Cole, A., & Jason Meredith, T. (2018). Evaluation of suspected dementia. American Academy of Family Physicians, 97(6), 398-405. Harvey, P. D. (2012). Clinical applications of neuropsychological assessment. Dialogues Clinical Neuroscience, 14(1), 91-99. Kang, H., Zhao, F., You, L., Giorgetta, C., Venkatesh, D., Sarkhel, S., & Prakash, R. (2014). Pseudo‐dementia: A neuropsychological review. Annals Indian Academy of Neurology, 17(2), 147-154. doi:10. 4103/0972‐2327. 132613 Tobe, E. (2012). Pseudodementia caused by severe depression. BMJ Case Reports, 2012, 1-4. doi:10. 1136/ bcr‐2012‐007156 Tsoi, K. K., Chan, J., Hirai, H. W., Wong, S., & Kwok, T. (2015). Cognitive tests to detect dementia: A systematic review and meta‐analysis. JAMA Internal Medicine, 175(9), 1450-1458.
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543 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 10. 2 Behavior Change RESOLUTION Which diagnostic or imaging studies should be considered to assist with or con-firm the diagnosis? The choice of diagnostic tests should be guided by the list of likely differential diagnoses. Many factors guide the choice of diagnostics, including urgency of the clinical condition, sensitivity and specificity of the diagnostic test, availability of the test, burden to the patient (cost, invasiveness, and transportation), and, most importantly, the goals of care. The clinician should consider whether the results of the specific diagnostic test will change the treatment plan in any way. If the answer is no, the diagnostic test should be reconsidered. In this case, laboratory and diagnostic studies should be used as part of a targeted evaluation based on clues in the history and physical (Inouye, Westendorp & Saczynski, 2014) to detect common conditions such as infection, dehydration, metabolic imbalance, or other acute illness. These typically include complete blood count with differential, serum electrolytes, glucose, calcium, measurement of renal, liver and thyroid function, drug levels (e. g., digoxin, lithium), toxicology screen, ammonia level, vitamin B12 and folate levels, cortisol level, arterial blood gas, and culture of urine, blood and sputum. EKG and CXR may be ordered in persons with cardiac or respiratory diseases or symptoms and an EEG may be useful in some patients to rule out occult seizures (Inouye et al., Oh, Fong, Hshieh, & Inouye, 2017; Westendorp & Saczynski, 2014). Brain imaging (such as CT or MRI) is indicated in patients with focal neurological findings or those suspected of having a brain lesion (e. g., stroke, bleed, or tumor) and/or patients without other identifiable causes of delirium. Patients with delirium and recent unexplained falls or symp-toms of NPH (triad of gait changes, memory disturbance, and urinary incontinence) should also be referred for brain imaging. Lumbar puncture is used for patients with meningeal signs or suspicion of encephalitis (e. g. fever with headache). Additional diagnostic tests should be based on the patient's clinical presentation (Inouye et al., 2014). For Antonio, the studies would include an EKG because of his history of coronary artery disease with assessment findings of bradycardia and irregular rhythm. His new complaint of heartburn may also be cardiac in origin. Pulse oximetry should be done to provide a quick, noninvasive assessment of oxygen saturation. Antonio's recent fall and his gait and balance difficulties are sus-picious, and a head CT should be ordered. If head trauma had been sustained, he has any localizing
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544 Resolutions neurological findings, or if he was taking warfarin (an anticoagulant), intracranial bleeding would be high on the list of differential diagnoses. A standardized depression screen using the GDS or PHQ‐9 may be useful because depression can mimic dementia, coexist with delirium and dementia, and/or mimic hypoactive delirium. Standardized screening tools identify individuals needing further assessment and provide indica-tors of responses to treatment over time. Depression screening may not be feasible in the acutely delirious person, due to impaired attention and/or more urgent clinical symptoms. Antonio has difficulty staying focused, so this assessment should be deferred. Taking orthostatic vital signs (blood pressure and pulse in both lying and standing positions) is useful to obtain a baseline in all geriatric patients. Orthostatic blood pressure and pulse measurement are essential in patients with a history of falls, symptoms of lightheadedness, or weakness with position changes. Older adults are more likely to experience orthostatic drops in blood pressure due to changes in baroreceptor sensitivity in the carotid sinus. Orthostasis is more likely in patients on antihypertensives and/or diuretics and in patients who are dehydrated. Orthostatic hypoten-sion is unlikely to be a sole cause of persistent delirium, but it may be one indicator of hypovolemia (e. g., due to dehydration and/or anemia) that may impair brain perfusion and precipitate delirium (Oh et al., 2017). If the initial workup does not reveal a cause, physician and/or neurology consultation is recom-mended. Patients with fever or other features suggesting possible meningitis or encephalitis require a lumbar puncture (after brain imaging). An EEG may be ordered to rule out seizure activity in patients with altered level of consciousness (Inouye et al., 2014; Oh et al., 2017). Which differential diagnoses should be considered at this point? Delirium: Antonio had an acute onset of symptoms, including inattention, disorganized thinking, and an altered level of consciousness. (Symptom fluctuation pattern is unclear and may be complicated by antipsychotic administration. ) Antonio's clinical presentation is consistent with delirium. Delirium is an acute change from baseline mental status that develops over a short period of time (usually hours to days) and tends to fluctuate over the course of the day (increasing and decreasing in severity). Key features include altered arousal (lethargic or hyperalert or alternating from one to the other), impaired attention (reduced ability to focus and/or distractibility), and dis-turbed cognition (a confusing flow of ideas, incomprehensible conversation, and/or unpredictable switches in topic; Diagnostic and Statistical Manual, 5th ed. [DSM‐5], American Psychiatric Association [APA], 2013). The Confusion Assessment Method (CAM) is a standardized, efficient assessment tool to assist clinicians in recognizing delirium and differentiating it from dementia or depression. It is usually completed after elements of cognitive assessment are conducted, including attentional testing (trail‐making, digit span or reciting months of the year, days of the week or spelling words (such as “world” backward) (Inouye, Fearing, & Marcantonio, 2009). These tasks specifically challenge attention span and focus, and help to distinguish delirium from dementia and depression (Inouye et al., 1990; Waszynski, 2007). Dementia is more subtle in onset (months to years) and slowly progressive, with problems in memory and executive function (planning, sequencing, and performing goal‐directed activities). Attention processes are normal until later stages, and arousal is not impaired. Lewy body dementia may be difficult to distinguish from delirium since patients with this disease may experience hal-lucinations and/or fluctuating cognition as part of the dementia. The coexistence of Parkinson's‐like features of Lewy body dementia and the less acute onset may help distinguish between the diagnoses. Persons with preexisting dementia or other types of brain disease are vulnerable to developing superimposed delirium; and therefore any sudden, significant deviations from usual cognition, behavior, or function should be assumed to be delirium until it is ruled out (Fick, Hodo, Lawrence, & Inouye, 2007).
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Behavior Change 545 A new onset of primary psychiatric disease is possible, but less likely in this case. Medical causes of delirium should also be ruled out prior to attributing symptoms to psychiatric disease. Antonio has no apparent symptoms of psychosis (paranoia, hallucinations, delusions, or thought disorder) and no past psychiatric history. Depression may slow mental processing and impair cognitive performance on mental status tests. The depressed patient may make a poor effort on cognitive testing or answer questions with “I don't know” or “I can't. ” Antonio has recently experienced grief and associated anxiety and sleep disturbance, but he was beginning to improve in activity and social engagement. His irrita-bility may be a sign of depression; but his distractibility, impaired attention, and acute behavior changes are classic symptoms of delirium, rather than depression or dementia. His mood and mental status should both be reassessed after infection or other acute contributors to delirium are treated. Delirium is a syndrome or cluster of symptoms, rather than a diagnosis. It reflects a condition in which precipitants or “insults” overwhelm individual capacities due to underlying predisposing factors or “vulnerabilities” (Inouye et  al., 2007). If delirium is suspected, a prompt, systematic search for reversible contributors should be conducted. The mnemonic “MIND ESCAPE” is useful in remembering potential reversible contributors to changes in mental status in the elderly (Molony, Waszynski, & Lyder, 1999, p. 78). The mnemonic and findings from Antonio's assessment that cor-respond to each potential contributor are listed in Table 10. 2. 1. After reviewing Antonio's history and exam findings, infection, metabolic disturbance, nutri-tional deficiency, drug effects, and cardiac problems are identified as the most likely precipitants of delirium, with sensory deprivation (poor vision and hearing) and possibly sleep deprivation as contributing factors. Older adults often have atypical presentations of disease (Wilbur, Gerson, & Mcquown, 2017). This is particularly true in advanced age and in persons with multiple chronic conditions or frailty. For example, older adults may have serious infections (including sepsis) with only a low‐grade fever and minimal elevation in the white blood cell count. Myocardial infarctions may present Table 10. 2. 1. Potential Contributors to Antonio's Delirium. Potential Contributor to Delirium Antonio's Risk Factors Metabolic changes (e. g., dehydration, electrolyte imbalance, hypercalcemia, liver, kidney, or thyroid disease, hypo‐ or hyperglycemia, hypoxia, and hypercarbia)Lab work pending; dry oral mucosa—possible dehydration; irregular rhythm/K+, ARB, diuretic—possible K+ imbalance Infection (acute or chronic)/impaction/inability to void Fever, adventitious lung sounds—possible respiratory infection; BPH—risk for urinary retention; need further assessment of bowel function Nutrition (B12/folate, other nutritional deficiencies/ neoplasm/NPHPoor appetite, recent loss/grieving, recent 3‐lb. weight loss Drugs/drug withdrawal (including prescription and OTC or street medications)Haldol dose; OTC medication for heartburn may be deliriogenic; beta blocker—risk for bradyarrhythmia; need further assessment re: street drugs, opioids, etc. Environmental toxins/environmental changes Recent move to CCRC Sleep deprivation/sensory overload or sensory deprivation Slight decline in visual acuity; decreased hearing related to cerumen impaction Cardiovascular/cerebrovascular (stroke, hypoxia, shock, heart failure, myocardial infarction, arrhythmia)History of cardiovascular disease, heart failure, bradycardia, irregular rhythm Alcohol or alcohol withdrawal/anemia Need additional history Pain Not applicable Emotional or mental illness Depression may be present; further assessment needed
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546 Resolutions without chest pain (“silent” or atypical symptoms such as sudden shortness of breath, hypotension, dyspnea, mental status change, or gastrointestinal symptoms). Hyperthyroidism may present with apathetic lethargy and constipation. Depression may present with irritability and feelings of worth-lessness or helplessness instead of sadness. Older adults with acute intraabdominal conditions (e. g., appendicitis, ruptured diverticulum, mesenteric thrombosis) may present without severe pain, guarding, or rebound tenderness. Poor appetite, declining physical function, new urinary incontinence, falls, and mental status changes are often the heralds of geriatric clinical distress. These symptoms signal a need for skilled assessment and management. Older adults have a lower resting body temperature at baseline as well as a lowered ability to produce a febrile response (High, 2017). Therefore, Antonio's temperature is >2. 4°F above his base-line, a sensitive threshold for possible infectious disease (High et al., 2009), and his lung findings suggest a possible pneumonia. The urinalysis and chest X‐ray will help to identify a source of infec-tion and guide treatment. Adverse drug effects are common contributors to delirium. A comprehensive medication list that includes prescription, over‐the‐counter (OTC), and nutritional/herbal supplements is an important part of clinical assessment in all health visits with older adults. Older adults have changes in body composition, liver enzyme systems, and renal function that affect drug distribution, activity, and clearance (Rochon, Gill, & Gurwitz, 2017). They are also more likely to experience drug‐drug, drug‐food, and drug‐disease interactions, due to the number of medicines prescribed, the presence of multiple concurrent diagnoses, and the use of inappropriate doses (based on half‐life, renal function, etc. ). Older adults may also be more sensitive to drugs that cross the blood‐brain barrier. While some medicines have been identified as potentially inappropriate for older adults due to risks that out-weigh benefits, it is essential for the clinician to review all medicines as possible contributors to delirium (American Geriatrics Society [AGS], 2019; Molony, 2003, 2009). Pharmacist consultation is recommended, if available. Antonio received Haldol, an antipsychotic medication with extrapyramidal side effects including dystonias (prolonged unintentional muscular contractions), Parkinson's‐like symptoms (i. e., tremor, rigidity, and bradykinesia) and akathisia (restlessness, often exhibited as pacing or rocking). Akathisia is often mistaken for worsening agitation and treated with additional doses of the offend-ing antipsychotic agent. Haldol also has anticholinergic properties (including confusion, dry mouth, urinary retention, and constipation). The higher the degree of anticholinergic burden related to medication dosing, the higher the risk for cognitive impairment. These medications are considered potentially inappropriate for older adults, based on the updated 2019 Beers criteria. Anticholinergic effects of different drugs accumulate and may contribute not only to delirium, but also to urinary retention in patients with BPH. Antonio reported using some type of OTC product for heartburn. Many proton pump inhibitors and histamine‐2 receptor antagonists such as omepra-zole (Prilosec ®) and cimetidine (Tagamet®) are available OTC for short‐term treatment of heart-burn. Cimetidine worsens delirium or combines with other medications to precipitate delirium. Cimetidine, particularly in higher doses, may interact with other medicines, through effects on cytochrome P450 enzyme systems in the liver (AGS, 2019; Medical Letter, 2018). Constipation is common in older adults if they take insufficient fluid or fiber; are inactive; are immobile; and/or take constipating medicines such as iron, calcium, and/or opioids. Prevention, assessment, and management of constipation are important aspects of geriatric care. Adequate fluid and fiber intake are important prevention strategies (Mounsey, Raleigh & Wilson, 2015). Fecal impac-tion or bowel obstruction may contribute to delirium, but these have been ruled out for Antonio. Primary neurologic diseases such as Parkinson's disease (PD), normal pressure hydrocephalus (NPH), and cerebrovascular accident (CVA) are less likely diagnoses for Antonio. PD is sometimes mis-diagnosed in patients with drug‐induced parkinsonism. Antonio's small, shuffling steps could be con-sistent with parkinsonism, particularly if they appeared only after he received antipsychotic medication; but his gait may also reflect generalized imbalance, fear of falling, and chronic changes. His gait should be monitored during follow‐up visits. He does not display cogwheel rigidity, resting tremor, or bra-dykinesia, which are the cardinal signs of PD (Kotagal & Bohnen, 2017). His slight decrease in upward
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Behavior Change 547 gaze is consistent with normal aging. Persons with normal pressure hydrocephalus (NPH) typically have a wide‐based gait with difficulty taking steps (sometimes described as a magnetic gait). In NPH, urinary incontinence and memory loss cluster together with gait changes to form a diagnostic triad typ-ical of the disease. A cerebrovascular accident (ischemic, thrombotic, or hemorrhagic) is possible in view of Antonio's cardiovascular risk factors, but his examination revealed no focal neurological deficits. Small infarcts may still be present, and brain imaging has been ordered to rule this out. If his EKG dem-onstrated new‐onset atrial fibrillation (a‐fib), a common condition in older adults, the clinical suspicion for CVA would be much higher, since a‐fib increases the risk of thrombotic stroke. What is the treatment plan? Antonio's chest X‐ray shows left lower lobe infiltrates consistent with pneumonia and his WBC is elevated. These findings are consistent with pneumonia. His BUN is elevated and his BUN:creatinine ratio is 26:1 (usually 14:1). This suggests impaired renal perfusion, most likely due to hypovolemia/dehydration (other possible causes include acute hypotension, heart failure, or renal ischemia due to artery stenosis). The first priority is to decide whether to treat Antonio's pneumonia in the hospital. By prevent-ing unnecessary hospitalization, iatrogenic risks that may worsen cognitive function (e. g., changes in medication, sleep patterns, diet, sensory stimulation, and/or environment; antibiotic‐resistant infections; and/or immobility) may be avoided. On the other hand, older adults are at higher risk for serious complications of pneumonia, including sepsis or respiratory failure; and hospitalization is indicated for high‐risk groups and/or worrisome clinical presentations. Otherwise‐healthy older adults with community‐acquired pneumonia may be treated as outpa-tients with appropriate followup. The decision to treat in the community relies in part on the clini-cian's assessment of the overall severity of illness and patient function, the patient's (or caregiver's) ability to follow through with the treatment plan, the ability to monitor clinical status, and the ability to contact the clinician if symptoms persist or worsen. The severity of the delirium, the ability to take needed fluids and medication, and the availability of around‐the‐clock support until mental status improves will also be factored into the decision. Algorithms such as the Pneumonia Severity Index (PSI) and the CURB‐65 are available to assist with decision‐making regarding the site of care for older adults with community‐acquired pneumonia (del Castillo & Sánchez, 2017). Antonio's age, BUN, and confusion place him in an intermediate to high risk category, and his pulse oximetry reading is declining. The decision to hospitalize him should be made. Antonio's delirium should improve with appropriate diagnosis and treatment of reversible con-tributors and with the provision of supportive care, but some cases of delirium linger for weeks or months (Kiely et al., 2009). Skillful nursing care is needed to minimize polypharmacy and optimize nutrition and hydration, oxygenation, electrolyte balance, comfort, bowel and bladder function, sleep, and activity. Regular reassessment of function and care needs is important to prevent negative sequelae (Yevchak et al., 2017). Are any referrals needed? Pneumonia, dehydration, and delirium are the top three concerns, and physician involvement is advisable. Cardiology consultation is recommended due to the recent changes in Antonio's beta‐blocker therapy and episode of pulmonary edema. A geriatric team consult is indicated to advise re: supportive care for delirium and to make recommendations for fall prevention. What aspects of the health history require special emphasis in older adults? One of the most important components of geriatric assessment is the functional assessment. It is essential to assess and document the degree to which an older adult can independently complete activities of daily living (feeding, toileting, bathing, turning in bed, moving from bed to standing or bed to chair, and walking) and the amount of supervision or assistance needed. Older adults in independent living should also be assessed for the ability to perform instrumental activities of daily living (cooking, housecleaning, laundry, managing medications, using a telephone, managing finances, shopping, and use of transportation).
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548 Resolutions When assessing the health of older adults, the clinician should recognize that many conditions and symptoms are underreported in older adults. The geriatric review of systems and physical examination should therefore specifically include assessment for the following: cognitive impair-ment, dental/oral health, falls, foot problems, gait or balance problems, hearing loss, vision loss, incontinence, nutrition, pressure ulcers, mental health issues (including depression, anxiety, and grief), sexual history, and sleep problems. A careful and thorough review all medications, including oral, injectables, topical, inhalants, eye drops, over the counter, and herbal substances is necessary in the health history. It is recommended that older adults gather all medications when possible and review them with the practitioner. Assuring the safe and effective use of medications by older adults is a critical component of geri-atric assessment (Steinman & Fick, 2019). What if this patient were under age 65? Would that change the management plan? An otherwise‐healthy younger adult with community‐acquired pneumonia is likely to be treated as an outpatient. Treatment of pneumonia in younger adults would include consideration of appro-priate prescribing practices for possibly pregnant or breastfeeding women. What patient, family, and/or caregiver education is important in this case? Patient and family education should focus on prevention and early detection. If the patient is treated in the community, the importance of taking all medicine as prescribed must be emphasized. Education on prevention includes counseling to promote pneumonia and influenza vaccine, smoking cessation, and information about hand and cough hygiene. After hospital discharge, Antonio should be encouraged to continue cough and deep‐breathing exercises to clear mucus and to maintain adequate fluid intake. Oxygen safety principles should be reviewed if he is discharged on oxygen. Antonio (and/or his caregivers) should be educated regarding symptoms that require a call to the clinician, such as difficulty breathing, fever, or becoming more confused or very sleepy. It is essential that nursing assistants and personal care assistants benefit from the clinical educa-tion given to patients and family members. They are often the first ones to notice clinically important changes and are the most influential determinants in whether follow‐up care or self‐care strategies are maintained. Are there any standardized guidelines that should be used to assess or treat this case? Clinicians should be familiar with guidelines on the prevention, identification, assessment, and management of delirium (Australian Commission on Safety and Quality in Health Care, 2016); Young, Murthy, Westby, Akunne, & O'Mahony, 2010). The 2007 Infectious Diseases Society of America/American Thoracic Society consensus guide-lines on the management of community‐acquired pneumonia in adults and the 2009 update are key references (Lim et al., 2009; Mandell et al., 2007). Lower respiratory infections (LRIs) often result in avoidable hospitalizations in nursing home residents. INTERACT is a quality improvement model to reduce avoidable hospitalization due to LRI and/or other causes (Ouslander, Bonner, Herndon, & Shutes, 2014). Follow‐up: Antonio is admitted to the hospital, started on intravenous (IV) fluids and ceftriaxone. His atenolol is switched to labetalol in response to elevated blood pressure readings. On day 3 of treatment, he develops acute pulmonary edema treated with IV diuretics followed by an increase in his oral diuretic dose. On day 5, he develops watery diarrhea, which continues for days. Donnatal is ordered to treat the diarrhea. A C‐difficile titer is sent, and he is started on metronidazole (which is discontinued after negative titers ×2). On day 6 of his admission, he develops acute urinary retention and a Foley catheter is inserted. He is started on tamsulosin and finasteride. The diarrhea slows and the Foley catheter is removed. Antonio's lungs are clear, but he is weak and has no appetite. He is alert and oriented, and his mental status is back to baseline. He is discharged to the rehabilitation facility for physical therapy to improve strength, balance, and endurance.
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Behavior Change 549 His primary care provider is asked to see him because he had a “fainting spell” the day after admission, after walking 50 feet in physical therapy. His blood pressure at the time was 80 systolic (palpable). His temperature, pulse, and respiratory rate are normal. His weight is 157 lb. His color is good, and his Mo CA score is 24/30. His affect is mildly depressed. Oral mucous membranes and tongue are dry. His heart rate is 88 and regular with occasional pauses. His lungs are clear, and he has 1-2+ ankle edema (L > R). His blood pressure in both arms, while sitting, is 98/60 and drops to 84/50 upon standing. He is “woozy” after walking a few feet from the chair to the bed. His neuro-logic exam is unchanged from the previous exam and the remainder of the exam is unremarkable. What are some of the possible contributors to this patient's hypotension? Are any referrals needed? What management strategies should be considered? Age‐related changes in baroreceptor function increase the risk of orthostatic hypotension in the elderly. Medications, hypovolemia, and electrolyte imbalances may contribute to orthostasis. Autonomic nervous system disease or neuropathies are other common causes. Unexplained hypo-tension (with or without position change) may be an early sign of shock or cardiac pathology. Antonio is dehydrated and is taking several medicines that may contribute to hypotension, including tamsulosin, labetalol, and isosorbide mononitrate. In addition to ordering elastic support stockings, teaching Antonio to perform ankle exercises before standing, and increasing his oral fluid intake, it should be recommended that he discontinue the tamsulosin with instructions to monitor for urinary retention. While liberalizing sodium is an option in some cases or orthostatic hypotension, Antonio's history of heart failure warrants caution. His recent weight loss may repre-sent fluid and nutritional losses, and further assessment of his intake is needed. Donnatal, a highly anticholinergic agent, is not recommended for use in older adults. Anticholinergic medications can contribute to short‐term (delirium) and long‐term (dementia) cognitive deficits, as well as dry mouth, blurry vision and lack of coordination, often resulting in dizziness and falls. (AGS, 2019; Gray et al., 2015). REFERENCES AND RESOURCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed. ). Arlington, VA: Author. American Geriatrics Society (AGS) Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 67(4), 674-694. doi:10. 1111/jgs. 15767 Australian Commission on Safety and Quality in Health Care. (2016). Delirium clinical care standard. Sydney ACSQHC. Accessed at https://www. safetyandquality. gov. au/our‐work/clinical‐care‐standards/ delirium‐clinical‐care‐standard del Castillo, J. G., & Sanchez, F. J. M. (2017). General principles of pharmacology and appropriate prescribing. In J. B. Halter, J. G. Ouslander, S. Studenski, K. P. High, S. Asthana, M. A. Supiano, & C. Ritchie (Eds. ), Hazzard's geriatric medicine and gerontology (7th ed., Chapter 67). Mc Graw‐Hill. Fick, D. M., Hodo, D. M., Lawrence, F., & Inouye, S. K. (2007). Recognizing delirium superimposed on dementia: Assessing nurses' knowledge using care vignettes. Journal of Gerontological Nursing, 33(2), 40-47. Gray, S. L., Anderson, M. L., Dublin, S., Hanlon, J. T., Hubbard, R., Walker, R., .  .  .   Larson, E. B. (2015). Cumulative use of strong anticholinergic medications and incident dementia. Journal of the American Medical Association, 175(3), 401-407. High, K. P., Bradley, S. F., Gravenstein, S., Mehr, D. R., Quagliarello, V. J., Richards, C., & Yoshikawa, T. T. (2009). Clinical practice guideline for the evaluation of fever and infection in older adult residents of long‐term care facilities: 2008 update by the Infectious Diseases Society of America. Journal of the American Geriatrics Society, 57(3), 375-394. High, K. P. (2017). Infection: General principles. In J. B. Halter, J. G. Ouslander, S. Studenski, K. P. High, S. Asthana, M. A. Supiano, & C. Ritchie (Eds. ), Hazzard's geriatric medicine and gerontology (7th ed., Chapter 126). Mc Graw‐Hill.
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550 Resolutions Inouye, S. K., Fearing, M. A., & Marcantonio, E. R. (2009). Delirium. In J. B. Halter, J. G. Ouslander, M. E. Tinetti, S. Studenski, K. P. High, & S. Asthana (Eds. ), Hazzard's geriatric medicine and gerontology (6th ed., Chapter 53). Mc Graw‐Hill. Inouye, S. K., Van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confu-sion: The confusion assessment method: A new method for detection of delirium. Annals of Internal Medicine, 113(12), 941-948. Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. Lancet, 383(9920), 911-922. doi:10. 1016/S0140‐6736(13)60688‐1 Inouye, S. K., Zhang, Y., Jones, R. N., Kiely, D. K., Yang, F., & Marcantonio, E. R. (2007). Risk factors for delirium at discharge: Development and validation of a predictive model. Archives of Internal Medicine, 167(13), 1406-1413. Kiely, D. K., Marcantonio, E. R., Inouye, S. K., Shaffer, M. L., Bergmann, M. A., Yang, F. M., .  .  .  Jones, R. N. (2009). Persistent delirium predicts greater mortality. Journal of the American Geriatrics Society, 57(1), 55-61. Kotagal, V., & Bohnen, N. I. (2017). General principles of pharmacology and appropriate prescribing. In J. B. Halter, J. G. Ouslander, S. Studenski, K. P. High, S. Asthana, M. A. Supiano, & C. Ritchie (Eds. ), Hazzard's geriatric medicine and gerontology (7th ed., Chapter 67). Mc Graw‐Hill. Lim, W. S., Baudouin, S. V., George, R. C., Hill, A. T., Jamieson, C., Le Jeune, I., .  .  .  Woodhead, M. A. (2009). BTS guidelines for the management of community acquired pneumonia in adults: Update 2009. Thorax, 64(Suppl. 3), iii1-iii55. Mandell, L. A., Wunderink, R. G., Anzueto, A., Bartlett, J. G., Campbell, G. D., Dean, N. C., .  .  .  Whitney, C. G. (2007). Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community‐acquired pneumonia in adults. Clinical Infectious Diseases, 44 (Suppl 2):S27-S72. doi:10. 1086/511159 Medical Letter. (2018, January 15). Drugs for GERD and peptic ulcer disease. The Medical Letter on Drugs and Therapeutics, 60(1538), 9-16. Molony, S. L. (2003). Beers' criteria for potentially inappropriate medication use in the elderly. Journal of Gerontological Nursing, 29(11), 6. Molony, S. L. (2009). How to try this: Monitoring medication use in older adults. American Journal of Nursing, 109(1), 68-78. Molony, S. L., Waszynski, C. M., & Lyder, C. H. (Eds. ). (1999),. Gerontological nursing: An advanced practice approach (p. 78). Stamford, CT: Prentice Hall. Mounsey, A., Raleigh, M., & Wilson, A. (2015). Management of constipation in older adults. American Family Physician, 92(6), 500-504. doi:d12117 Oh, E. S., Fong, T. G., Hshieh, T. T., & Inouye, S. K. (2017). Delirium in older persons: Advances in diagnosis and treatment. Jama, 318(12), 1161-1174. doi:10. 1001/jama. 2017. 12067 Ouslander, J. G., Bonner, A., Herndon, L., & Shutes, J. (2014). The interventions to reduce acute care transfers (INTERACT) quality improvement program: An overview for medical directors and primary care clini-cians in long term care. Journal of the American Medical Directors Association, 15(3), 162-170. doi:S1525‐8610(13)00690‐7 Rochon, P. A., Gill, S. S., & Gurwitz, J. H. (2017). General principles of pharmacology and appropriate pre-scribing. In J. B. Halter, J. G. Ouslander, S. Studenski, K. P. High, S. Asthana, M. A. Supiano, & C. Ritchie (Eds. ), Hazzard's geriatric medicine and gerontology (7th ed., Chapter 24). Mc Graw‐Hill. Steinman, M., & Fick, D. (2019). Using wisely. A reminder on how to properly use the American Geriatrics Society Beer's Criteria ®. Journal of Gerontological Nursing, 45(3), 3-6. Yevchak, A., Fick, D. M., Kolanowski, A. M., Mc Dowell, J., Monroe, T., Le Viere, A., & Mion, L. (2017). Journal of Gerontological Nursing, 43(12), 21-28. Young, J., Murthy, L., Westby, M., Akunne, A., & O'Mahony, R. (2010). Diagnosis, prevention, and management of delirium: summary of NICE guidance. British Medical Journal, 341. http://dx. doi. org/10. 1136/bmj. c3704 Waszynski, C. M. (2007). How to try this: Detecting delirium. The American Journal of Nursing, 107(12), 50-59, quiz 60. Wilber, S. T., Gerson, L. W., & Mc Quown, C. (2017). Emergency department care. In J. B. Halter, J. G. Ouslander, S. Studenski, K. P. High, S. Asthana, M. A. Supiano, & C. Ritchie (Eds. ), Hazzard's geriatric medicine and gerontology (7th ed., Chapter 17). Mc Graw‐Hill. http://accessmedicine. mhmedical. com/content. aspx?boo kid=1923&sectionid=144518612.
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551 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 10. 3 Tremors RESOLUTION What are the top three differential diagnoses in this case and why? Parkinson's disease (PD): PD is in the differentials given his tremor history and also his PMH of anxiety, which is a common nonmotor symptom of PD. Essential tremor (ET) (This is the diagnosis): The patient has bilateral hand tremors that are present with action and has no other signs or symptoms on exam to suggest Parkinson's disease. His spiral drawing also reveals a tremor consistent with ET. Anxiety: The patient could also be experiencing enhanced physiological tremor worsened by his PMH of anxiety. However, an enhanced physiological tremor is intermittent and the patient is experiencing tremors consistently. Which diagnostic tests are required in this case and why? The diagnosis of essential tremor and Parkinson's disease really rests in the provider's ability to complete a thorough history and physical exam. Mr. Suarez's neurological exam does not reveal any focal neurological abnormalities with the exception of action and postural tremors, which are consistent with a diagnosis of essential tremor. Given the possibility of enhanced physiological tremor, the provider would want to rule out a metabolic cause such as a thyroid abnormality or liver toxicity. In addition it would be important for the provider to assess any heavy metal exposure (e. g., does the patient have well water?), as these can cause tremors. Check TSH Check LFTs Check serum lead, arsenic, mer cury (if the history indicates) Imaging is not necessary due to the absence of focal neurological findings on exam. What are the concerns at this point? How much are the tr emor symptoms interfering with daily life? (ADLs, hobbies, etc. ) How does the patient feel his anxiety is controlled at this point?
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552 Resolutions Do any other family members have symptoms of tremors? What is the patient worried about most in regar d to his hand tremors? Does alcohol improve the tr emor? (Alcohol can decrease essential tremor, but it is not a recom-mended treatment!) Does the patient he drink alcohol to help with anxiety? This is important to assess for any emerging alcohol use disor der. What is the plan of treatment? Utilizing shared decision making, the NP needs to assess how problematic these symptoms are and, given the fact that they are interfering with some of the patient's ADLs and hobbies, treatment can be discussed. It is important for the NP to understand that the mainstay of treatment in ET is symptom management. Utilizing the American Academy of Neurology (AAN) ET treatment guidelines, level A evi-dence advises starting with Propranolol or Primidone. The NP should know that Propranolol is contraindicated given the patient's pulmonary disease. Primidone should therefore be initi-ated as long as the patient desires treatment. Also, consider the dose of Fluoxetine. This medication can cause tremors as an adverse ef fect or exacerbate tremors. Occupational therapy (OT) is also highly recommended to assist the patient in utilizing tech-niques at home that may make it easier to complete ADLs. Also, OT can provide specific devices such as weighted utensils that make it easier for individuals with ET to consume meals. What are the plans for referral and follow‐up care? Start Primidone at a low dose: 50 mg at bedtime for 1 week and then increase to 50 mg bid for 1 week; then can incr ease to 50 mg tid until f/u. Referral to occupational therapy. Follow up in 6 weeks. Assess response to therapy at this time. Assess anxiety and consider switching to another agent. What health education should be provided to this patient? Provide written information about essential tremor, including the etiology, causes, and tr eatment options. Provide written information on Primidone, including adverse effects and how to take medication. Provide r eassurance to the patient and his daughter that at this time, his physical exam and history is consistent with a diagnosis of essential tremor and that he does not have Parkinson's disease. It is important to stress to the patient and his daughter that medication for essential tr emor can only work to reduce the tremor and that this disorder is, unfortunately, chronic and typically does worsen over time despite medication treatment. What demographic characteristics might affect this case? The patient's age, widowhood, and that he lives alone. Does the patient's psychosocial history impact how you might treat him? Yes, the NP would want to make sure his anxiety is well‐managed with not only his current reg-imen but also advise on nonpharmacological options such as meditation or cognitive behavioral therapy. The NP would also want to make sure that his alcohol consumption is carefully monitored for the emergence of an alcohol use disorder and also for safety reasons since he does live alone.
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Tremors 553 What if the patient lived in a rural (or urban) setting? Treatment and recommendations would be the same. However, it would be imperative that the pr ovider assess for access to transportation to get medications and to go to occupational therapy. Are there any standardized guidelines that you should use to treat this case? If so, what are they? The American Academy of Neurology treatment guidelines for essential tremor. Are there other history questions that are pertinent when assessing a patient with tremors? Other history questions that are pertinent when assessing a patient with tremors may include: ⚬ Any history of environmental or toxic exposur e to chemicals or heavy metals? Ask about past military and occupational experience. ⚬ Does the patient's anxiety increase the tr emors? ⚬ Is he anxious about attending social events due to his tremors? If this patient did not have insurance, would that change the management strategy? Primidone is a generic medication and the cost averages about $9. 00 for a 1‐month supply. Occupational therapy would be very expensive, so this may be prohibitive without insurance. The provider could inquire if any local schools that have OT programs offer free care to people in the community. REFERENCES AND RESOURCES Crawford, P., & Zimmerman, E. E. (2011). Differentiation and diagnosis of tremor. American Family Physician, 83(6), 697-702. Deuschl, G., Bain, P., Brin, M., & Ad Hoc Scientific Committee. (1998). Consensus statement of the Movement Disorder Society on Tremor. Movement Disorders, 13(3), 2-23. Jankovic, J., & Fahn, S. (1980). Physiologic and pathologic tremors: Diagnosis, mechanism, and management. Annals of Internal Medicine, 93(3), 460-465. Louis, E. D., Rohl, B., & Rice, C. (2015). Defining the treatment gap: What essential tremor patients want they are not getting. Tremor and Other Hyperkinetic Movements, 5, 1-12. doi:10. 7916/D87080M9 Pal, P. K. (2011). Guidelines for management of essential tremor. Annals of Indian Academy of Neurology, 14, S25-S28. doi:10. 4103/0972‐2327. 83097 Puschmann, A., & Wszolek, Z. K. (2011). Diagnosis and treatment of common forms of tremor. Seminal Neurology, 31(1), 65-77. doi: 10. 1055/s‐0031‐1271312 Shanker, V. L. (2016). Case studies in tremor. Neurologic Clinics, 34, 651-655. http://dx. doi. org/10. 10. 1016/j. ncl. 2016. 04. 012 Sharma, S., & Pandey, S. (2016). Approach to a tremor patient. Annals of Indian Academy of Neurology, 19(4), 433-443. doi:10. 4103/0972‐2327. 194409 Zesiewicz, T. A., Elble, R. J., Louis, E. D., Gronseth, G. S., Ondo, W. G., Dewey, R. B. Jr., .  .  .  Weiner, W. J. (2011). Evidence‐based guideline update: Treatment of essential tremor. Neurology, 77(19), 1752-1755.
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555 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 10. 4 Weight Gain and Fatigue RESOLUTION Which diagnostic studies should be considered to assist with or confirm the diagnosis? The basic metabolic panel reveals the following: creatinine level: 0. 89; blood urea nitrogen: 14; sodium: 137; potassium: 4. 5; chloride: 104. Liver function tests are within normal limits. GFR is 85. Rapid HIV test is negative. Complete blood count—white blood count: 5. 7; hemoglobin: 14. 3; hematocrit: 43. 2; macrocytic corpuscle volume: 84; fasting blood glucose: 168; A1C: 8. 5. Testosterone is within normal limits. Erythrocyte sedimentation rate is within normal limits. Urinalysis is positive for 2+ glucose; trace protein. TSH is 4. 50. Because fatigue can be a marker for cancer, a chest X‐ray and investigation for other cancer markers would be appropriate. What is the most likely differential diagnosis and why? Diabetes mellitus Type 2: Maxwell has had a gradual onset of fatigue over the past few months, which presents as a classic symptom of diabetes. Noted also is nocturia, which awakens him at least 2 times during the night. Polyuria and/or nocturia are also classic presenting symptoms, due to the glucose‐concentrated urine creating a diuretic effect. He also has had a 15‐lb weight gain over the past 2 years. His body mass index has progressed from 29 (which is the overweight category) to 31 (the obese category). Obesity is a leading cause of insulin resistance. He reports a sedentary lifestyle, which contributes to the obesity and the insulin resistance. Low libido may be related to a lack of energy in conjunction with some erectile dysfunction relevant to the hyperglycemia causing an autonomic neuropathy. Fatigue is a major symptom reported with inadequately treated hypothyroidism, HIV, anemia, and inadequate testosterone levels. The patient does have a history of hypothyroidism and there-fore may require additional levothyroxine due to a thyroid hormone deficiency. Also, the patient reported occasional constipation, some cold intolerance, and significant weight gain. Patients with hypothyroidism have a diminished red blood cell mass, which may present as a macrocytic anemia. A small percentage of patients with hypothyroidism have the occurrence of pernicious anemia. Therefore, anemia is a relevant differential diagnosis. The patient reports that he is in a monoga-mous homosexual relationship and denies fevers and night sweats and has had a positive weight gain; however, it would be wise to rule out the diagnosis since he is in a high‐risk category. African Americans have the highest rates of HIV and AIDS in the United States. Maxwell exhibits high‐risk
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556 Resolutions behavior since he is a male who is sexually active with a male. Symptoms of HIV are often nonspe-cific but may include fatigue. The patient has numerous risk factors for diabetes due to family his-tory, hypertension, increased body mass index, sedentary lifestyle, and being African American. Detection of hypogonadism in males with sexual dysfunction is warranted. Male hormone defi-ciency can be a cause of fatigue as well as sexual dysfunction. What is the plan of treatment? The patient has a moderate degree of hyperglycemia ranging from 151 to 250. Therefore, diet, exercise, and 1 oral agent is appropriate therapy with which to begin. The patient's creatinine and liver function studies are within normal limits. Start with metformin 500 mg daily in the evening. Instruct the patient to take 1 tablet daily with the first bite of food in the evening. Explain the mech-anism of action, contraindications, adverse effects of the metformin, and the need to remain hydrated while taking the medication to prevent lactic acidosis. If he is unable to drink oral solutions and/or hold liquids down, then he should stop the metfor-min and call the office. If the metformin is well tolerated without significant gastrointestinal affects, then tell the patient to increase the dose of metformin to twice a day following the week of initia-tion. Provide him with basic education about diabetes signs and symptoms and potential treatment. Stress the importance of lifestyle modifications and consumption of a heart‐healthy diet and rou-tine modest aerobic exercise of 30 minutes, 5 days a week. Provide instruction in self-blood glucose monitoring and use of the glucose meter. Write prescriptions for the metformin, a glucose meter, and supplies of strips and lancets. Order routine diabetes management labwork such as fasting lipids and a urine microalbumin/creatinine ratio. Instruct the patient to call the office in 1 week for follow‐up regarding the use of the glucose meter and blood glucose readings. At that time, determine if the patient should receive another phone call or return to the clinic sooner than 1 month. Otherwise, schedule the patient to return to the clinic in a month for follow‐up of self-blood glucose monitoring results and possible adjust-ment of medications. Repeat the Hb A1C in 3 months along with fasting lipids and a urine microal-bumin/creatinine ratio if any of the previous levels are abnormal. Carefully monitor this patient for changes in his cardiac and renal health. What is the plan for referrals and follow‐up? A referral to a dietitian is appropriate for a discussion related to meal planning, cooking methods, and portion control. An ophthalmology referral for a dilated eye exam in 3 months will allow time for improved glycemia and improved vision. A referral should be made to a certified diabetes edu-cator for further diabetes education and co‐management. Offer the patient the opportunity to attend a series of diabetes education classes. Consider a cardiology referral given his risk factors and family history. Consider a podiatry referral for diabetic foot care and management. If the low libido persists following normoglycemia, then referral to a urologist would be appropriate. Follow up based on the results of the chest X‐ray. Does the patient's psychosocial history impact how you might treat him? This patient's psychosocial history does not impact how this patient will be treated. What if this patient were a premenopausal female? If this were a female patient, more questioning would be necessary to assess her menstrual cycle, including the duration and the amount of flow of her menses. A ferritin level would have been included in the initial workup. Also, a pregnancy test might be indicated. What if the patient were over the age of 80? Metformin may not be the first drug of choice since impaired renal function and the greater poten-tial for dehydration exists in this age group. The possibility of lactic acidosis is higher in this age group, though it rarely occurs. Patients over the age of 80 should have a normal creatinine clearance documented prior to beginning therapy. All patients on metformin should have their liver function test and creatinine checked annually.
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Weight Gain and Fatigue 557 Are there standardized guidelines that should be used to assess and treat this patient? American Diabetes Association. (2019). Introduction: Standards of Medical Care in Diabetes—2019, Diabetes Care, 42(Suppl. 1), S1-S2. https://doi. org/10. 2337/dc19‐Sint01 REFERENCES AND RESOURCES American Diabetes Association. (2019). Introduction: Standards of Medical Care in Diabetes—2019, Diabetes Care, 42(Suppl. 1), S1-S2. https://doi. org/10. 2337/dc19‐Sint01 Ferri, F. F. (2019). Diabetes mellitus. Ferri's clinicial advisor 2019 (pp. 424-433). Philadelphia: Elsevier. NOTE: The author would like to acknowledge the contribution of Vanessa Jefferson, MSN, BC‐ANP, CDE to this case in the first edition of this book.
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559 The Family Nurse Practitioner: Clinical Case Studies, Second Edition. Edited by Leslie Neal-Boylan. © 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd. Case 10. 5 Visual Changes RESOLUTION Which diagnostic studies should be considered to assist with or confirm the diagnosis? The history should include the date of the last eye exam, whether a retinal exam and glaucoma assessment was done, and a family history of eye disease. Assessment of the eye begins with measuring visual acuity. Acute vision loss or unexplained low vision warrants urgent referral (to an ophthalmologist or emergency room depending upon the clinical scenario (e. g., for risk factors for ocular or neurological disease, recent ocular injury, or foreign body). If a foreign body or pos-sible corneal scratch is suspected, fluorescein staining and Wood's lamp examination may be done. If overall visual acuity is within the usual range, a screening test for macular degeneration should be done using an Amsler grid (Su et al., 2016). Alternatively, visual acuity can be tested using an Internet‐based macular mapping test called Macu Flow TM can potentially be completed at home (Garcia‐Layana, Cabrerea‐Lopez, Garcia‐Arumi, Arias‐Barquet, L. & Ruiz‐Moreno, J., 2017). Other helpful assessment tools include the National Eye Institute Visual Functioning Questionnaire 25 (NEV‐VFQ‐25) (Abe et al., 2016). Although vision screening in asymptomatic older adults will not result in improved clinical outcomes, these tests may help to detect hidden diseases among at‐risk individuals and facilitate a tailored plan of care for older adults with visual impairment (Abe et al., 2016). Visual acuity assessment is an important consideration when devising integrated interventions designed to prevent and treat delirium, such as medication management (Carlson, Merel, &Yukawa, 2015). Which of the symptoms or signs related to Marion's eyes or vision represent pathological changes versus normal aging? Marion reports gradual, insidious changes in her vision. Her fear of blindness relates to her con-cern about having macular degeneration (like her mother). Normal aging changes in the eyes may result in an increased sensitivity to glare, difficulty with light/dark adaptation, decreased color discrimination, and loss of acuity in low‐contrast and low‐light conditions. Pupil size decreases. Visual processing time may also be decreased, potentially affecting reading and driving; but this may improve with training. While ectropion (outward turning of the lids) is not a normal aging change, it is a common, correctable condition (Golan, Rabina, Kurtz, & Leibovitch, 2016).
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560 Resolutions Which differential diagnoses should be considered at this point? What are the three most common diagnoses/conditions affecting vision in older adults? Are Marion's signs and symptoms similar to the clinical presentations of these conditions? The three most common pathological conditions in older adults include cataracts (the most common cause of low vision in the elderly), glaucoma, and macular degeneration. Diabetic retinopathy is also common in diabetics and this results in visual loss that will ultimately have a negative impact on safety due to cognitive deficits, such as falls, incorrect identification of appropriate medication and dose, as well as impairment on the patient's daily routines and function (Hanna, Hepworth, & Rowe, 2016). Symptoms of cataracts include increased sensitivity to glare and/or to light, decreased contrast sensitivity, and decreased blue‐yellow color vision. Although glaucoma decreases peripheral vision, the loss is gradual, painless, and rarely noticed until severe (Vujosevic et. al., 2019). Macular degeneration results in blurred or distorted central vision or central vision loss. Unless hemorrhage occurs, changes are gradual and may not be noticed until moderate or severe. A new onset of pain in the eye suggests a serious condition that must be evaluated promptly. Sudden vision loss in part or all of the visual field in one or both eyes is an emergency and may represent ocular, neural, or vascular pathology (including stroke, and retinal hemorrhage) (Abe et al., 2016). Older adults are also at higher risk for a condition known as temporal arteritis (also called “giant cell arteritis”), which may present with headache and sudden vision loss (Vujosevic et al., 2019). Immediate evaluation and treatment are necessary to prevent permanent blindness and to differentiate this condition from acute stroke (Powers et al., 2018). Based on this exam, what is the plan of care? Would you seek any referrals from the interprofessional team? A dilated retinal examination is needed to more thoroughly assess the health of the retina and macula. Marion should be referred to an ophthalmologist for this examination, as well as a measurement of eye pressure and peripheral vision testing (Vujosevic et al., 2019). If Marion were under 65 years of age, would the management plan change? These symptoms would be suspicious for ocular pathology in a younger person and comprehen-sive assessment and ophthalmology follow‐up would be essential. Macular degeneration is almost exclusively found in persons over age 55 and cataracts in a younger person are usually secondary to other diseases/conditions, such as uncontrolled diabetes (Vujosevic et al., 2019). Giant cell arteritis (GCA) is an inflammatory disorder that occurs primarily in adults 50 years of age and older and is associated with visual disturbances, due to ischemia in the cranial vessels, which causes headache and jaw claudication (Pioro, 2018). If GCA is suspected, emergent corti-costeroid treatment can prevent irreversible vision loss (Pioro, 2018). The provider should also rule out other possible conditions such as stroke, dementia, and Parkinson's disease (Miller, 2019; Powers et al., 2018). What patient, family, and caregiver education is most important in this case? Marion will require reinforcement regarding the importance of regular eye exams to ensure that her visual changes are consistent with her diagnosis. Marion will also benefit from learning about other potential age‐related changes in vision such as presbyopia (loss of accommodation), diminished acuity, delayed dark and light adaptation, increased glare sensitivity, reduced visual field, diminished depth perception and altered color vision, and slower visual information processing (Miller, 2019). A review of medications that may impact vision (such as nonsteroidal anti‐inflammatory agents, anticholinergics, phenothiazines, amiodarone, alpha blockers, diuretics, antihistamines, anticholinergics, phenothiazines, beta blockers, and anticoagulants) will be helpful (Miller, 2019). Moreover, although visual rehabilitation will not restore vision, it is helpful to ensure safety for persons with visual loss that is affecting function or quality of life (Miller, 2019).
Leslie Neal-Boylan - The Family Nurse Practitioner.pdf