Response to Jewelia Duncan’s Post

Respond to the two posts
Responsd to Jewelia Duncan’s post
Dr. Jenn's 40-year-old sister complains of joint pain in her hands and ankles which is worse in the morning. List your differential diagnosis. What additional assessments would you perform?
Due to the patient’s age, sex, and the suggestion symmetrical joint pain, which is worse in the morning, rheumatoid arthritis tops the list of differential diagnosis (Heither & McCance, 2019). Rheumatoid arthritis is a chronic inflammatory autoimmune disease primarily affecting the synovial joints but may potentially have other systemic effects (Conforti, et. al. 2021). Other possible diagnosis includes viral arthritis, Lupus, gout, and other rheumatic diseases (Huether & McCance, 2019).
A detailed health history and physical assessment is essential to establish the diagnosis of rheumatoid arthritis. (Huether & McCance, 2019). The onset and duration of symptoms need to be established. Symptoms of systemic inflammation including fever, fatigue, weakness, generalized aching and stiffness would support this diagnosis (Huether & McCance, 2019). Generally, morning joint stiffness persists for an hour or longer in the rheumatoid arthritis patient (Conforti, et. al., 2021). A physical assessment of the joints specifically inspecting for joint swelling and the presence of any rheumatoid nodules which appear in approximately 30% of rheumatoid arthritis patients (Huether & McCance, 2019). The joints should be palpated assessing for heat and a bogginess of the synovial membrane (Huether & McCance, 2019). Range of motion should also be assessed (Huether & McCance, 2019). Joint pain and swelling are usually symmetrical in rheumatoid arthritis (Huether & McCance, 2019). If indicated by the physical assessment, x-rays, and lab work would need to be assessed for signs and symptoms of rheumatoid arthritis. Initial lab work should include CBC, CRP, CMP, ESR, rheumatoid factor, anti-cyclic citrullinated peptide antibody, and urinalysis (Conforti, et. al., 2021). A referral to a rheumatologist would be the next step to treatment and medication management for a diagnosis of rheumatoid arthritis.

References
Conforti, A., Di Cola, I., Pavlych, V., Ruscitti, P., Berardicurti, O., Ursini, F., ... & Cipriani, P. (2021). Beyond the joints, the extra-articular manifestations in rheumatoid arthritis. Autoimmunity Reviews, 20(2), 102735. https://doi(dot)org/10.1016/j.autrev.2020.102735 (Links to an external site.)
Huether, S. E., & McCance, K. L. (2019). Understanding Pathophysiology-E-Book. Elsevier Health Sciences.



Dr. Jenn's eight-year-old niece comes in with a sore throat and fever. What is your differential diagnosis? What assessments and tests would you perform and why?

Most sore throats are caused by viral infections and viral pharyngitis is the most likely diagnosis (Tanz, 2018). When presenting with fever a group A streptococcal infection should be ruled out due to the risk of the development of rheumatic fever in untreated group A streptococcal infections (Ismail, et. al., 2019). Covid-19 should also be ruled out as a diagnosis (Gathorpe, et. al., 2020).
A detailed history of presenting illness should be obtained. This should include onset, severity, and duration of the symptoms. The patient should be questioned about pain in ears, dysphagia, changes in breath odor, headache, presence of scarlatiniform rash, and abdominal pain. The throat should be assessed for, “red and swollen tonsils, crypts filled with purulent exudate, enlarged anterior cervical lymph nodes, and palatal petechiae” (Ball, et. al., 2019, p. 280). A throat culture should be performed to assess for group A streptococcal infection (Tanz, 2018). The patient should also be tested for Covid-19 infection (Gaythorpe, 2020).

References
Ball, J., Dains, J., Flynn, J., Solomom, B., & Stewart, R. (2019). Seidel’s Guide to Physical Examination: An Interprofessional Approach-E-Book. Wlsevier Health Sciences.
Gaythorpe, K., Imai, N., Cuomo-Dannenburg, G., Baguelin, M., Bhatia, S., Boonyasiri, A., ... & Ferguson, N. (2020). Report 8: Symptom progression of COVID-19. Imperial College London, 10, 77344. https://www(dot)alnap(dot)org/system/files/content/resource/files/main/Imperial-College-COVID19-symptom-progression-11-03-2020.pdf
Ismail, P., Sobur, C. S., & Olivia, C. (2019). Recurrent Rheumatic Fever. Indonesian Journal of Rheumatology, 11(2). https://www(dot)doi(dot)org/10.37275/ijr.v11i2.103 (Links to an external site.)
Tanz, R. R. (2018). Sore throat. Nelson Pediatric Symptom-Based Diagnosis, 1. https://www(dot)doi(dot)org/10.1016%2FB978-0-323-39956-2.00001-7
Respond to Molly Clifton post
Dr. Jenn's 80-year-old neighbor complains that she can’t sleep unless she has some alcoholic beverages before bed. Her husband died last month. Her children came in town for the funeral but have since returned to their homes out of state. What risks might you be concerned about? What would you include in your treatment plan?
This patient is likely having disrupted sleep due to grief and a major change in her daily life. Sleep disturbances are a common symptom of grief (Shear et al., 2021). The patient could have shared a bed with her spouse or been a full-time caregiver. Either of these scenarios or many others may make it hard to adjust to the loss of a significant other and may be having a negative impact on her sleep pattern. Bereavement is an individualized process. People respond in their own unique way. This patient could be at risk for isolation, depression, increased falls, or alcohol dependency. Social support systems are especially important when dealing with the loss of a loved one. An evaluation of the patient’s current support system would need to be performed. Does the patient have friends, family, a religious institution, or other groups she belongs that she could utilize for additional support and prevention of isolation? Does she have any other interests that she would like to start exploring? A thorough health history should also be evaluated. Alcohol consumption can actually have a negative impact on sleep quality. Alcohol can increase the risk of obstructive sleep apnea, reduce the quality of REM sleep leading to daytime drowsiness, and increase fall risk (Petecho, 2022). Petecho (2022) describes this as an endless loop. Daytime sleepiness can also exacerbate depressive symptoms, and in this patient may prolong her inability to cope with the loss of her husband. Patients often increase caffeine intake and find it necessary to use alcohol to get to sleep due to insomnia.
It would be important to assess if this drinking pattern is different from before the husband’s death. How much she is drinking? What is she drinking? What other medications she is taking? What are her sleep habits? What is her caffeine consumption? Depressive, anxious, or hopeless thoughts? Any suicidal ideation?
This patient’s treatment plan would initially consist of empathizing with the patient regarding her loss and validating her feelings and concerns while educating the patient on the stages of grief and the effects of alcohol on sleep including risk factors and falls. Grief therapy and/or behavioral therapy would be recommended to provide a safe place for her to process her grief and change or modify behaviors and thoughts that may be contributing to her insomnia. Shear et al (2019) points out that while sleep disturbances can be a normal response to grief, therapy should be the first line treatment vs medications. Unresolved grief can progress into long-term clinical depression. It may be beneficial for the patient to trial a low dose melatonin to help initiate sleep. The patient should also be encouraged to practice sleep hygiene and reduce any or all caffeine intake. The importance of seeking out friends, family, and active participation in things she once enjoyed will be emphasized as well. Cessation of alcohol will be encouraged. This plan will be reevaluated in 4 weeks or sooner with worsening symptoms. Referral to grief therapy will be initiated.
Differential Diagnosis to be considered: anxiety disorder, depression, medication causes, obstructive sleep apnea, circadian rhythm disorder, restless leg syndrome, and/or alcoholism (Shear et al, 2021).
These differentials can be further evaluated at follow up if the patient does not see improvement with the initial suggested plan of care.
References
Pacheco, D. (2022, March 11). Alcohol and sleep. Sleep Foundation. https://www(dot)sleepfoundation(dot)org/nutrition/alcohol-and-sleep
Shear, M., Reynolds, C., Simon, N., & Zisook, S. (2021, November 10). Bereavement and grief in adults: management. UpToDate.
https://www(dot)uptodate(dot)com/contents/bereavement-and-grief-in-adults-management?search=grief%20in%20adult&source=search_result&
selectedTitle=2~141&usage_type=default&display_rank=2
Dr. Jenn's eight-year-old niece comes in with a sore throat and fever. What is your differential diagnosis? What assessments and tests would you perform and why?
A sore throat with fever can be caused by many different disease processes. In children the most common cause is viral and is often accompanied by other upper respiratory type symptoms, cough, runny nose, and nasal congestion (Johns Hopkins, 2022). Other common differential diagnoses include the covid-19 virus, influenza, and strep throat. More serious differential diagnoses would include epiglottitis, retropharyngeal, lateral pharyngeal, or peritonsillar abscess, and mononucleosis (Fleisher & Fine, 2022). They go on to highlight the importance of onset, as epiglottitis comes on rather quickly, where as mononucleosis occurs over a period of days to weeks.
A pediatric patient presenting with sore throat and fever would require collection of subjective data and a physical assessment paying close attention to potential respiratory distress, difficulty swallowing, or stridor, fever, fatigue, chills, headache, stomach pain, and duration of illness. The posterior pharynx should be visualized as well as the tonsillar pillars and any redness, inflammation, or areas of exudate noted. Many health care locations still require covid testing to be performed. The clinic I currently work in will test for covid, influenza, and strep if a patient complains of sore throat with fever. The patient should have a rapid strep test collected in office (Fleisher & Fine, 2022). This allows the provider to begin effective treatment quickly if the results are positive. A negative result should still be sent for culture to verify the result is indeed negative. On occasion a throat culture may grow streptococcal bacteria when the rapid is negative. Strep throat, when identified in children, should be treated quickly with antibiotic therapy due to the risk of rheumatic fever, poststreptococcal glomerulonephritis, poststreptococcal reactive arthritis, scarlet fever, or PANDAS (Mayo, 2022). Fleisher & Fine (2022) point out that it is also important to include an otoscopic exam of the ears to rule out otitis media that can often cause referred pain and the sensation of a sore throat.
Viral pharyngitis is generally treated by managing symptoms. Use of Tylenol and ibuprofen to help relieve pain and fever, offering cool drinks and popsicles, increasing fluid intake, and using throat lozenges if age appropriate (Johns Hopkins, 2022). If the child has upper respiratory symptoms such as a cough this can make a sore throat feel worse, so offering a cough medication may help improve sore throat severity.
Fleisher, G. & Fine, A. (2022, May 20). Evaluation of sore throat in children. UpToDate. https://www(dot)uptodate(dot)com/contents/evaluation-of-sore-throat-in- (Links to an external site.)
children?search=pediatric%20sore%20throat&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Johns Hopkins (2022). Pharyngitis and tonsillitis in children. Johns Hopkins. https://www(dot)hopkinsmedicine(dot)org/health/conditions-and-diseases/pharyngitis-
and-tonsillitis-in-children
Mayo (2022). Strep throat. Mayo Clinic. https://www(dot)mayoclinic(dot)org/diseases-conditions/strep-throat/symptoms-causes/syc-20350338