NSG 3370 WEEK 7 PART 1 DISCUSSION

NSG 3370 WEEK 7 PART 1 DISCUSSION You are at the local mall and you see a patient who appears to be homeless by his physical appearance and you witness the person “walk 50 feet to a table sit down, and after 5 seconds he gets up and walks to a tree and urinates on it” He repeats this action 5 times apparently oblivious to his surroundings. When the police come he ignores them as if they aren’t there. Later, you go to work and sitting in exam room 3 is the same person! Now, he is your patient, when you talk to him he has no recollection of his behavior by the mall. • What is your differential diagnosis? • What tests do you order? • An MRI comes back and there seems to be a lesion in the temporal lobe does this change your differential? The EEG also comes back with unusual excitatory activity. What is your definitive diagnosis? In retrospect did anything bias your first differential? This case study is complex due to little information on the patient. The only information to assist in making a differential diagnosis is assuming he is homeless due to his physical appearance, his repetitive state of mind and oblivious to his surroundings, and now the patient is unaware of his actions. Several differential diagnosis comes to mind. Such information to assist in making a definitive diagnosis would be the patient’s age and history of his past medical, family, and social. Assuming this patient is homeless, many factors aid in his behaviour. Differential diagnosis are as follows: Traumatic Brain Injury Mental Illness Korsakoff syndrome Traumatic brain injury (TBI) can be caused by many factors such as falls, motor vehicle accidents, and assaults. Short term and long term deficits can alter neurological function that are caused by direct blow to the head. TBI is defined as a “blow or jolt to the head or a penetrating head injury that disrupts the [normal] function of the brain” (Anderson et al., 2014, p. 2210). The pathological aspect of TBI depends on the structural changes from head injury whether open or closed; damage to the cortical tissue; and hematoma formation that can damage subcortical structures leading to ischemia (Mott, McConnon, & Rieger (2012). Considering the patient exhibits no open head injury, the assumption is he possibly is suffering from closed head injury due to trauma/blow to the head. With a closed head injury, the frontal and temporal lobes are predominantly susceptible for severe damage (Anderson et al., 2014). TBI symptoms depending on severity of damage can affect concentration, fatigue, memory lapse, confusion, and difficulty sleeping. Along with TBI there may also be impaired decision making and the ability to solve problems (Anderson et al., 2014). The prevalence of TBI among homeless men is high with poor physical and mental outcomes observed (Anderson et al., 2014). Mental illness is common among homeless persons with many experiencing depression, anxiety, bipolar disorder, and/or schizophrenias; all lead to acute incidences of confusion, impaired though process, and inhibit ability to solve problems (Stergiopoulos et al., 2015). With chemical imbalances and genetic disorders which affect psychological and cognitive functions may be the result of this patient’s behaviour. Further tests and additional information on his H & P could clarify the significance of mental illness. The cause of mental illness is unknown, though a combination of factors such as biological, environmental, and psychological can contribute and alter one’s mental stability. Nerve cells within the brain communicate through chemicals via neurotransmitters. Medications maybe given to assist in balancing out the chemical and genetic proportions of the brain. Injury to the brain may also be a factor to mental illness disrupting the neurotransmitters (Stergiopoulos et al., 2015). This patient may have some degree of mental illness whether biological, environmental, and/or simply genetic. According to Anderson et al. (2014) majority of those persons who are homeless are due to mental health. Anderson et al. (2014) stated in their research “neuropsychological assessment of homeless persons tends to be scarce or absent, often due to limited personnel trained in assessment and inadequate financial resources within shelters” (p. 2211). Many studies have found that homelessness is related with higher incidence of mental illness, depression, substance abuse of drugs and alcohol, and behaviour issues (Anderson et al., 2014). “The Health Care for the Homeless Clinicians Network indicates that severe cognitive impairments resulting from TBI are sometimes misdiagnosed as schizophrenia” thus resulting in inappropriate treatment and medication regimen (Anderson et al., 2014, p. 2211). Korsakoff syndrome is a disorder with an acute onset of confusion, nystagmus, ophthalmoplegia, and ataxia due to thiamine deficiency. Alcoholism may contribute to the inadequate intake of thiamin, but Wernicke encephalopathy can lead to other conditions such as head injury, starvation, cancer, and AIDS (O’Malley & O’Malley, 2016). Increase intake of alcohol can disrupt the function of cells within the brain. Thiamine is an important co-factor for enzymes that break down lipids and carbohydrates in the brain and support in the making of amino acids; without thiamine to breakdown glucose, the brain function becomes impaired (McCance, Huether, Brashers, & Rote, 2013). Clinical symptoms of Korsakoff syndrome maybe mood changes, disorientation, memory lapse, the inability to recall new information, disruption of thought process, and confusion (O’Malley & O’Malley, 2016). Tests to order: To determine appropriate diagnosis, a CT and MRI of the head to determine the extent of brain injury or any neurological dysfunction. Labs such as CBC, BMP, liver and renal function, VitB12, thiamin, and niacin serum levels, and alcohol and drug screen should be tested. Further questioning the patient of his past medical history and/or family history. Along with physical and neurological assessment. An MRI comes back and there seems to be a lesion in the temporal lobe does this change your differential? The EEG also comes back with unusual excitatory activity. What is your definitive diagnosis? In retrospect did anything bias your first differential? This does not change my differential due to the information given in this case study. A lesion and excitatory activity can be related to trauma within the brain. The patient being homeless puts him at risk for TBI due to harsh elements of the environment. No, nothing biased me from my differential. With research, it’s noted that homeless people are at risk for TBI and many exhibit some form of mental health issue (Anderson et al., 2014). Just because the patient is homeless does not change the fact he should be treated just as any other patient who comes through the ED with TBI, mental illness, or who may have ETOCH issues. Anderson, J., Kot, N., Ennis, N., Colantonio, A., Ouchterlony, D., Cusimano, M. D., & Topolovec-Vranic, J. (2014). Traumatic brain injury and cognitive impairment in men who are homeless. An International Multidisciplinary Journal, 36(26), . doi: 10.3109/.2014. McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2013). Pathophysiology: The biologic basis for disease in adults and children. (7th ed.). St. Louis, MO: Mosby Mott, T. F., McConnon, M. L., & Rieger, B. P. (2012). Subacute to chronic mild traumatic brain injury. American Family Physician, 86(11), . O’Malley, G. F. & O’Malley, R. (2016). Wernicke encephalopathy. Retrieved from: Stergiopoulos, V., Cusi, A., Bekele, T., Skosireva, A., Latimer, E., Schultz, C…Rourke, S. B. (2015). Neurocognitive impairment in large sample of homeless adults with mental illness. Acta Psychiatrica Scandinavica, 131, 256-268. doi: 10.1111/acps.1239