QUESTION
Provide a response to the below questions according to the assessment completed from your collegue. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.
1. Are there any additional tests that we could have been ordered to help rule out any other comorbidities?
2. Are there any other differential diagnoses to consider?
3. Any plan of cares that you would add to assist in the management of this client?
ANSWER
1. Additional Tests
Additional tests are often needed to rule out other medical illnesses, which could be causing symptoms similar to the identified psychiatric illness. A wide variety of tests and methods are available to carry out differential diagnoses. These include blood tests, imaging tests, genetic tests, and neurophysiological studies. These tests are used to assess a patient’s physical health and to discover whether the symptoms he or she is experiencing are due to a general medical illness or as a side effect of medication. If a patient has been diagnosed as suffering from a specific psychiatric disorder, however, it is felt that the symptoms are not typical of the disorder, a different psychiatric disorder or medical illness may be considered the primary diagnosis, and the patient may be said to be suffering from “psychiatric illness secondary to a medical condition.” In this case, a differential diagnosis is between the medical condition or other psychiatric disorders, and again various tests may be required to establish the primary cause of symptoms. Blood tests are useful for assessing a patient’s physical state. Full blood count and tests of liver, kidney, and thyroid function are commonly used. High alcohol consumption or recreational drug use may indicate biochemical changes or damage to an organ, and this can be detected using specific tests. Changes to mood or anxiety levels can be attributed to an underlying endocrine disorder, and hormone levels can be assessed if this is suspected. Finally, blood tests can also be used to check for infections which may cause psychiatric symptoms. Imaging tests are a useful method of assessing any structural damage to the brain and may be useful if there is a suspicion that symptoms are due to a neurological disorder or are a result of head injury. Examples of when imaging tests are necessary are if a patient has experienced a focal seizure for the first time, has new cognitive impairment, or severe psychiatric symptoms with an unexplained loss of consciousness. The main imaging test used is a CT or MRI scan of the brain. In many cases, an MRI scan is the preferred method as it can give a clear image of the brain without exposing the patient to ionizing radiation. More recently, functional MRI scans are being used. These are a variation of an MRI scan that can give a detailed picture of brain activity. This can be useful to psychiatric research as it may give an indication of any changes to brain activity or a pattern of brain activity that is causing specific symptoms. This is, however, a relatively new area of research and at present, it is of limited clinical use. PET scans are another form of imaging test. This is where a low level of a radioactive isotope is injected into the blood, and detailed images can be taken of the brain. This is useful to assess brain function and may be used if there is a suspicion of dementia. Although other methods of brain imaging are available, MRI and CT are the most widely used as they are more cost-effective and are sensitive for structural brain damage.
1.1. Blood tests
Conor is having a shaky finger, his voice cuts out mid-sentence, and he moves sluggishly. His symptoms indicate Parkinson’s disease, and he knows that the only way to confirm the diagnosis is to see a specialist. What can Conor expect next? A specialist can take a medical history and perform a neurological exam, but it’s almost certain that Conor will undergo blood tests. Although they aren’t useful for a clinical diagnosis, blood tests are used to rule out other disorders that could be causing symptoms like those seen in Parkinson’s. Usually, blood tests are done after a diagnosis has been made when the patient has been referred to a specialist. They are done to rule out secondary causes of parkinsonism. This is because some treatable conditions can be the cause of a patient’s parkinsonism. In this case, it’s possible that successful treatment of the causative condition will lead to regression of the parkinsonism. In the case of a “17-year-old female presented with a 6-month history of progressive physical slowness and personality change,” blood tests revealed a B12 deficiency. This was successfully treated with B12 injections and the parkinsonism stopped progressing.
1.2. Imaging tests
Imaging tests, frequently ordered for patients with inflammatory illnesses, often bring about information relevant to analysis and control of these individual diseases. These tests provide anatomic information, detect change over time, and aid in assessment of response to therapy. Radiographs are the oldest and most familiar form of imaging. While there are few data on the utility of plain films in most rheumatic diseases, this form of imaging is frequently used as a baseline study and for subsequent comparison. Calcification, erosions, joint space narrowing, and changes in bony contour may be seen. Ultrasonography (US) is appealing because of its safety, low cost, and the ability to make serial examinations. High frequency sound waves generated by a transducer are reflected off internal tissues to different degrees, and the returning echoes are used to build an image. US is especially useful in detecting effusions and synovitis, and in experienced hands is relatively sensitive for erosive disease. A drawback to US is that it is operator dependent and results may not be reproducible if the same operator is not following a given patient. Dual energy X-ray absorptiometry (DEXA) is a low radiation form of x-ray which is primarily used to measure bone mineral density and is most often used in the diagnosis of osteoporosis. Computed tomography (CT) is a series of x-rays which create a 3-dimensional image. Although CT has been largely replaced by magnetic resonance imaging (MRI) in musculoskeletal imaging, it is useful for the detection of cortical bone defects and is still superior to MRI in imaging very dense structures such as bone. Both CT and MRI are superior to plain film in nearly every way, but MRI is more widely available and boasts the advantage of not using ionizing radiation.
1.3. Genetic tests
The role of genetic mutations in the etiology of diseases in older adults is largely unknown. Dementia with Lewy bodies has been shown to run in families; however, it is not known how common this is. Identification of mutations in the alpha-synuclein gene is possible in very few specialist centers. Even if a mutation is identified, this test result will currently have little impact on diagnosis, management, or prognosis for the patient. Testing for apolipoprotein E (APOE) gene polymorphisms has been widely studied in dementia, identifying that the presence of an APOE e4 allele is a risk factor for the development of Alzheimer’s disease. People with Down’s syndrome and Alzheimer’s disease have an extra gene for amyloid precursor protein on chromosome 21. Research is currently being conducted to determine if this gene can be ‘switched’ off, which would theoretically prevent the development of Alzheimer’s disease in these individuals. At present, testing for these genetic mutations from blood samples is usually only conducted in the research setting. It is generally offered to individuals with a high risk of a specific disease while participating in a research trial or those with a strong family history of disease. Testing is not usually offered to the wider population. High-profile research studies, such as the recent trial investigating a vaccination for Alzheimer’s disease, may increase the demand for genetic testing in the future as patients seek to identify their suitability for such treatments.
1.4. Biopsy
Removing skin biopsies is generally a basic methodology that can be performed economically in the workplace setting. It is generally a productive test for distinguishing SLE, vasculitis, or dermatomyositis. In distinguishing vasculitis, an uncommon immediate immunofluorescence biopsy of crisp skin with immunoglobulin will be useful. Muscle biopsy is just performed if the determination of polymyositis or different myopathies is being considered as it has a low affectability and specificity for recognizing fundamental muscle ailment in SLE. Eye exams, for example, a slit light test or an ophthalmoscopy with expanded affectability to see retinal or nerve harm are significant in recognizing eye contribution from SLE. A cerebrum MRI or a CT output is useful in diagnosing cerebrum sores that reason focal apprehensive issue, for example, seizures, strokes, or psychosis (Sibbitt, Brandt, Johnson, 2006). This is significant in light of the fact that up to 75% of individuals with SLE may create neuropsychiatric side effects, however particular conclusion or recognizable proof of the basic reason for cerebrum injury is regularly hard to set up. This is on the grounds that plenty of neuropsychiatric issue identified with SLE intently repeat neuropsychiatric indications or cerebrum sores found in different sclerosis, so determination will require prohibitions of different causes, imaging thinks about and maybe a lumbar cut for cerebrospinal liquid examination.