Arlena Davis

Based on the clinical scenario is Mrs. X’s altered mental status due to a focal neurologic deficit or is it related to a more global etiology? Why?

Mrs. X altered mental status is not due to focal neurologic deficit as she does not show focal neurologic signs. Some of the signs of focal neurologic deficit are impairment of the spinal cord, nerves and brain activities impairment of the nerves, spinal cord and brain affects certain areas of the body and causes weakness in the right leg and left arm. Mrs. X does not have impaired of the spinal cord, nerves and the brain according to the medical examination. Mrs. X does not have weakness in the left arm and right leg. The neurologic examination shows Mrs. X has no problem. Mrs. X has grip strength of 5/5 bilaterally. The Dorsi and plantar flexion is 5/5 bilaterally. Mrs. X has no focal spinal and costovertebral angle tenderness. Thus, the altered mental status is linked to a more comprehensive etiology. The altered mental status can be due to overdose of Percocet and use of narcotics. Mrs. X took 80 tablets of 10mg Percocet within 72 hours before she started experiencing the symptoms. In addition, Mrs. X has misused narcotics as evidenced by the family’s reaction. Overuse of narcotics and withdrawal can change the mental status of a patient.

McCance, K. L., & Huether, S. E. (2014). Pathophysiology: The Biologic Basis of Disease in Adults and Children (7th ed.). Maryland, MO: Mosby Elsevier.

2. Based on the available information what differentials can the NP absolutely rule out? Give a rationale as to why you are ruling out each differential.

Differential diagnosis is conducted to rule out certain diseases and hence ensure the diagnosis is accurate. The NP should rule out some differential diagnoses. The NP should rule out a focal neurologic deficit diagnosis as Mrs. X does not show signs and symptoms of focal neurologic deficit according to the historical and examination data. Additionally, the NP should rule out influenza DFA diagnosis as the patient does not show signs of DFA influenza. They can rule out diarrhea as a result of influenza according to the examination done by the doctor the diarrhea is not be due to influenza, but narcotic withdrawal. Mrs. X has been misusing narcotics and she has not used the drugs since she became sick and this might have contributed to the diarrhea. Further, the NP should rule out narcotic overdose diagnosis as the patient does not show signs of narcotic overdose.

McCance, K. L., & Huether, S. E. (2014). Pathophysiology: The Biologic Basis of Disease in Adults and Children (7th ed.). Maryland, MO: Mosby Elsevier.

3. What differential diagnoses still need to be ruled out?

Other differential diagnosis that still need to be eliminated is serotonin syndrome and encephalitis. She could be dehydrated, her urine is dirty she could have a UTI, she has not eaten since onset of symptoms so the Hydroxycut could be causing her to metabolic alkalosis. Loss of fluid through diarrhea and not eating and drink are related to metabolic alkalosis.

Boyer EW. Serotonin syndrome. http://www.uptodate.com/home. Accessed June. 12, 2014.

Gasper,M.L.,&Dillon,P.M.(2011).Clinical Simulations for Nursing Education – Learner Volume. Philadephia, PA: F.A Davis

4. What are the signs of narcotic overdose? Is Mrs. X’s condition consistent with a narcotic overdose?

There are different signs of narcotic overdose. The first sign of narcotic overdose is respiratory depression. The respiratory rate is low and apnea is evidenced in serious cases. The patient can have a respiratory arrest if the overdose is significant. Hypoxia can cause pulmonary edema as it impairs the permeability of the pulmonary capillary. Pupil constriction is common expect in severe hypoxia when dilation can be seen. The formation of urine is decreased because of the reduction in the flow of renal blood. Other signs of narcotic overdose are hypotension, cold clammy skin and bradycardia. Moreover, patients presenting narcotic overdose show other symptoms. The symptoms include nausea, vomiting, constipation and slurred speech, confusion, poor judgment and decreased level of consciousness. Mrs. X’s condition is not consistent with narcotic overdose. Mrs. X. does not have a reparatory depression which is the main sign of narcotic overdose. Mrs. X has an elevated respiratory rate and a heart rate of 22 and 97 respectively. Mrs. X does not have constricted pupils as they are reactive to light. However, Mrs. X has decreased level of consciousness and she is confused.

Goldberg, R.(2013).Drugs Across the Spectrum. Stamford, CT: Cengage Learning

5. What are the signs of narcotic withdrawal? Is Mrs X’s condition consistent with a narcotic withdrawal?

Patients using narcotics show different signs after withdrawal depending on the dosage and how long they have used the drug. The patients can be restless and have insomnia. Also, patients can be anxious, long for the drug and have a flu. Patients can have abdominal cramps, body aches, loss of appetite, Rhinorrhea, fever, confusion, irritability and loss of appetite. Also, patients can have increased respiratory rate, pulse rate and blood pressure in late withdrawal. Patients have gastrointestinal problems including nausea, vomiting, diarrhea and loss of weight. Mrs. X’s condition is in line with the signs of narcotic withdrawal. Mrs. X has an increased heart rate, blood pressure and respiratory rate. Mrs. X heart rate, respiration rate and blood pressure are 97, 22 and 135/55 respectively. Also, Mrs. X has fever and flu- like disease. She has decreased appetite as she has not eaten anything since she became sick. Also, she has lost 25lb in the past 2 months after taking hydroxycut. In addition, Mrs. X has diarrhea and she has been restless and confused.

Gasper,M.L.,&Dillon,P.M.(2011).Clinical Simulations for Nursing Education – Learner Volume. Philadephia, PA: F.A Davis

Munjal,Y.P.,Sharma,S.K.,Agarwal,A.K.,&Gupta,P.(2012).Api Textbook of Medicine. New Delhi, India: JP Medical Ltd

6. There are 2 clues which are related to one another in the H&P and both suggest the same potential differential diagnosis. The admitting physician did not pick up on the clues and consequently did not consider this in their differentials. What are the two clues? What additional historical information is missing from the H&P which should be obtained from the husband based on the 2 clues?

The two clues are the patient takes Ultram and Percocet, this combination of drugs cause serotonin syndrome. The physician noted that Mrs. X had excessively used narcotics, but did not put this two together with this outcome. In addition, the physician found she had not utilized narcotics for the last three to four days. The overuse of narcotics and withdrawal of narcotics could have led to altered mental status or decreased level of consciousness. As a result, the doctor encouraged Mrs. X to continue using her medications. The physician should have done a narcotic overdose or withdrawal differential diagnosis.

Additional historical information includes mental health history, smoking history and OTC and narcotic drug history. The physician should ensure the husband gives a detailed description of OTC and narcotic drugs used. The husband should identify the type of drug used, dosage, dosing schedule and reasons for using the drug. A detailed drug history enables the physician identify drug interaction cases and overdose. The family members have expressed concern over the misuse of narcotics as they believe Mrs. X is misusing narcotics. Nevertheless, they do not state the narcotics used and dosage. Dietary supplements can interact with other drugs and have an adverse impact on the patient. Further, the doctor should ensure the husband gives a comprehensive description of tobacco smoking history. The husband should state the number of packets she smokes in a day. Additionally, the doctor should obtained information regarding the mental status of the patient. Elderly people are prone to mental disorders and they negatively affect their functioning. Some of the mental illnesses are depression, focal neurologic deficit, delirium, dementia among others. Mental health problems affect cognitive functioning. Understanding the mental health history helps in determining the causes of symptoms elderly patients present with. In this case, Mrs. X is unable to speak and has altered mental status. The physician needs information about Mrs. X’s mental health history to determine the cause of the decreased level of consciousness. Mental disorders such as delirium, dementia and focal neurological deficit change the mental status of the patient.

7. Based on the available information what do you think the most likely diagnosis is for Mrs. X’s altered mental status?

Narcotic withdrawal has led to altered mental status. Mrs. X shows different symptoms of narcotic withdrawal including increased heart rate, blood pressure, respiration rate, diarrhea, and confusion. Other symptoms are fever and flu-like disease. Thus, Mrs. X has experienced the symptoms as she has not used narcotics for the last 4 days.

References

Gasper, M.L., & Dillon, P.M. (2011). Clinical Simulations for Nursing Education – Learner Volume. Philadephia, PA: F.A Davis

Goldberg, R. (2013). Drugs Across the Spectrum. Stamford, CT: Cengage Learning

Woods, A., & Spratto, G. (2011). Delmar Nurse’s Drug Handbook 2012 Edition. Stamford,CT: Cengage Learning

McCance, K. L., & Huether, S. E. (2014). Pathophysiology: The Biologic Basis of Disease in Adults and Children (7th ed.). Maryland, MO: Mosby Elsevier.

Boyer EW. Serotonin syndrome. http://www.uptodate.com/home. Accessed June. 12, 2014.

Gasper, M.L., &Dillon, P.M.(2011). Clinical Simulations for Nursing Education – Learner Volume. Philadephia, PA: F.A Davis

Goldberg, R. (2013). Drugs Across the Spectrum. Stamford, CT: Cengage Learning

McCance, K. L., & Huether, S. E. (2014). Pathophysiology: The Biologic Basis of Disease in Adults and Children (7th ed.). Maryland, MO: Mosby Elsevier.

Munjal, Y.P., Sharma, S.K., Agarwal, A.K., & Gupta, P. (2012). Api Textbook of Medicine. New Delhi, India: JP Medical Ltd

Woods, A., & Spratto, G. (2011). Delmar Nurse’s Drug Handbook 2012 Edition. Stamford,CT: Cengage Learning

Zerwekh, J. (2012). Illustrated Study Guide for the NCLEX-RN® Exam8: Illustrated Study Guide for the NCLEX-RN® Exam. Saunders: Elsiever Health Sciences