Tony is a 69-year old Caucasian male with a history of a right-hand tremor for several years. He is accompanied by his wife today to the clinic who is very concerned because Tony is having difficulty with balance

Tony is a 69-year old Caucasian male with a history of a right-hand tremor for several years.

HPI: Tony is a 69-year old Caucasian male with a history of a right-hand tremor for several years. He is accompanied by his wife today to the clinic who is very concerned because Tony is having difficulty with balance and walking, which is becoming slower.

You suspect Parkinson’s disease (PD). Briefly describe the etiology of PD.

PE: What will you examine in the neurological examination of Tony? Describe at least three neurological examinations you will perform.

Diagnostics: You know that PD is primarily a clinical diagnosis, but there are several diagnostic tests that can be useful in making the diagnosis. Describe at least two diagnostic tests that may be helpful in the diagnosis of PD.

Diagnosis: You diagnose Tony with early-stage PD. What are some of the key principles of treatment? List at least two principles of treatment.

Plan/Referrals:

As the NP you decide that Tony does not require medication treatment at this time, but you will make the following referrals. Describe at least three referrals and the rationale for each.

Follow-up: You will want to see Tony in 3 months. What are some of the things you will want to follow in addition to his neurological status? List at least three questions you will explore.

Expert Answer and Explanation

Parkinson’s disease Diagnosis and Treatment

Parkinson’s disease (PD) is a brain or neurological condition that causes uncontrolled and unintended movements such as difficulty with coordination and balance, stiffness, and shaking (Trist et al., 2019). The symptoms of the disease worsen over time. As the disease progresses, a patient might find it difficult to walk or move other body parts. The disease is also characterized by bradykinesia, rigidity, and tremor with postural instability appearing in some individuals (Trist et al., 2019). The purpose of this assignment is to analyze the provided case and discuss the diagnosis and treatment of PD.

Etiology of PD 

In PD, certain neurons in the brain gradually die or break. Many of the PD symptoms are due to the loss of dopamine-producing neurons. Dopamine is a chemical messenger that regulates movement. When it decreases, brain activity will reduce, leading to movement problems and other signs of PD. The exact cause of PD is not known. However, Kouli et al. (2018) noted that factors such as genes and environmental triggers play a huge role in the development of PD. The authors noted that genes linked to PD are known as PARK. To date, researchers, link 23 PARK genes to PD (Bryois et al., 2020).

Bryois et al. (2020) noted that 10%-15% of people with PD report a family history of the disease. Apart from genes, PD is also linked to environmental triggers. One of the triggers of PD is cigarette smoking. Kouli et al. (2018) noted that cigarette smokers are more likely to develop PD than people to do not smoke cigarettes. Another risk factor is 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Kouli et al. (2018) found that 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) is associated with nigrostriatal degeneration increasing people’s chances of developing PD.

Neurological Exam 

One of the neurological exams that should be performed for the patient is motor function and balance. PD affects motor and balance, and this is why it should be assessed. The motor function may be tested by asking the patient to pull and push against the nurse’s hands with his legs and arms. Balance may be checked by asking the patient to stand and walk. The nurse will then assess how he stands or walks.

The second examination is speech. PD affects speech and makes one speak slowly or quickly. The patient’s speech can be examined by having a conversation with him. The third examination is assessing the patient’s reflexes such as smiling, blinking, or swimming hands when walking. The nurse can make a joke to see whether the patient smiles. Blinking will be assessed by observing how the patient responds to light.

Diagnostics

Bloem et al. (2021) noted that there are no specific tests to diagnose PD. A neurologist can diagnose a patient based on presenting symptoms, a neurological exam, and a patient’s medical history. However, one of the tests that can be used to diagnose the patient is a dopamine transporter (DAT) scan. This test shows the level of dopamine in the brain (Bloem et al., 2021). Second, magnetic resonance imaging of the brain (MRI brain) can be used to rule out other medical problems.

Diagnosis 

One of the treatments for PD is levodopa. It reduces symptoms of PD by being converted to active dopamine by nigrostriatal nerve terminals in the brain (Gray et al., 2022). Gray et al. (2022) noted that once converted to dopamine, it increases the level of domine in the brain, thus reducing PD symptoms. Another medication is monoamine oxidase type B inhibitor (MAO-B inhibitor). This medication works by preventing the breakdown of dopamine in the brain, thus reducing symptoms of PD (Binde et al., 2021). According to Binde et al. (2021), the medication can be taken in conjunction with levodopa to improve its therapeutic effects.

Referrals 

The referrals will be to a neurologist, a neurologist will examine the patient and determine the stage of PD. The neurologist can also determine if the patient needs medications or not. Second, I would refer the patient to a physical therapist. A physical therapist will help with his movement and motor activity. The physical therapist will provide a plan to help the patient walk and improve balance. The last referral is to a nutritionist. A nutritionist will help develop a diet plan that can help improve the patient’s muscle strength.

Follow-Up

1. How are you coping? I would want to know how the patient is coping with PD symptoms. I would want to know the measures he has taken to cope with the disease.
2. How is your support system? A support system is vital to a better quality of life for people with PD.
3. Do you have any mental health problems? One can be depressed by a PD diagnosis. Therefore, is vital to know the patient’s mental health status after diagnosis.

Conclusion

PD is a serious disease that can be caused by genetic and environmental problems. It can be diagnosed by examining the patient’s speech, motor function and balance, and reflexes. DAT and MRI brain can be ordered to rule out other conditions. It can be treated using levodopa and MAO-B inhibitor.

References

Binde, C. D., Tvete, I. F., & Klemp, M. (2021). Time until need for levodopa among new users of dopamine agonists or MAO-B inhibitors. Parkinson’s Disease, 2021. https://doi.org/10.1155/2021/9952743

Bloem, B. R., Okun, M. S., & Klein, C. (2021). Parkinson’s disease. Lancet (London, England), 397(10291), 2284–2303. https://doi.org/10.1016/S0140-6736(21)00218-X

Bryois, J., Skene, N. G., Hansen, T. F., Kogelman, L. J., Watson, H. J., Liu, Z., & Sullivan, P. F. (2020). Genetic identification of cell types underlying brain complex traits yields insights into the etiology of Parkinson’s disease. Nature genetics, 52(5), 482-493. https://www.nature.com/articles/s41588-020-0610-9;

Gray, R., Patel, S., Ives, N., Rick, C., Woolley, R., Muzerengi, S., & Wray, L. G. (2022). Long-term effectiveness of adjuvant treatment with catechol-o-methyltransferase or monoamine oxidase b inhibitors compared with dopamine agonists among patients with parkinson disease uncontrolled by levodopa therapy: The PD MED randomized clinical trial. JAMA neurology, 79(2), 131-140. doi:10.1001/jamaneurol.2021.4736

Kouli, A., Torsney, K. M., & Kuan, W. L. (2018). Parkinson’s disease: etiology, neuropathology, and pathogenesis. Exon Publications, 3-26. https://doi.org/10.15586/codonpublications.parkinsonsdisease.2018.ch1

Trist, B. G., Hare, D. J., & Double, K. L. (2019). Oxidative stress in the aging substantia nigra and the etiology of Parkinson’s disease. Aging cell, 18(6), e13031. https://onlinelibrary.wiley.com/doi/full/10.1111/acel.13031

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Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S (subjective)

CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).

HPI (history of present illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

· Location: Head

· Onset: 3 days ago

· Character: Pounding, pressure around the eyes and temples

· Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia

· Timing: After being on the computer all day at work

· Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better

· Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed. Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current and historical).

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any sexual concerns).

ROS (review of symptoms): Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:

· General:

· Head:

· EENT (eyes, ears, nose, and throat):

· Etc.:

Note: You should list these in bullet format, and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT:

· Eyes: No visual loss, blurred vision, double vision or yellow sclerae.

· Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Last menstrual period (LMP), MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

O (objective)

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A (assessment)

Differential diagnoses: List a minimum of three differential diagnoses. Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

P (plan)

Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.

Also included in this section is the reflection. Reflect on this case, and discuss what you learned, including any “aha” moments or connections you made.

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as, age, ethnic group, etc.), PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).

References

You are required to include at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.