CASE STDUY

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CASESTUDYFINAL-CHRISTINAOREGON10-25-2020.docx

MIDTERM CASE STUDY TUYEN VO 1

MIDTERM CASE STUDY TUYEN VO 14

Advanced Pathophysiology

Tuyen Vo

Gonzaga University

1. Differential Diagnosis Table

Possible Diagnosis (listed in order of likelihood)

Signs and Symptoms seen in This patient that make you consider this as a diagnosis

1. Guillian-Barre Syndrome

-A fault in feet and ankles, incapability to walk, numbness and tingly in toes, feet, tingly at fingertips and weakness of the legs. Unable to sleep well due to back pain and secondary to GI distress.

Recent viral illness with fever, bladder incontinence, fatigue, dysesthesias in bilateral legs below knees and sacral area.

2. Spinal Tumors

Fever, weakness in his feet and ankles, and inability to walk.

Low back pain, buttock and legs, numbness, tingling and burning sensation in feet, toes, and fingertips and bladder incontinence.

3. Ankylosing Spondylitis

Intermittent back pain, a long standing problem with occasional exacerbations after a weekend of working in the yard, fever, loss of appetite, fatigue, and weakness.

4. Spinal Cord Abscess

Low-grade fever, vomiting, low back pain, aching, spasm of the back muscles, weakness, bladder incontinence.

5. Cauda Equina Syndrome

Low back pain, reduced and absent lower extremity reflexes lower extremity weakness, and bladder incontinence.

6. Lumbar Spinal stenosis

Numbness, tingling and weakness in the legs, burning sensation in feet and toes, bladder incontinence, problems with walking, and low back pain.

7. Transverse Myelitis 

Recent viral illness, fever, burning to bilateral legs below the knees, sacral area and fingers with light touch, low back, buttocks, and bilateral leg pain, weakness and bladder incontinence. 

8. Lumbar disc hernia

Numbness or tingling of the feet and toes, low back pain, and weakness.

2. Most Likely Diagnosis: Guillian-Barre Syndrome

a. Expand upon your most likely diagnoses.

i. Define the pathological condition, disease or syndrome.

The pathological condition that patient is likely to be suffering from is the Guillain-Barre Syndrome (GBS). It is not a common disorder, as it makes (take this out) the immune system of the body to(take this out) attack(s) the nerves(,) therefore, producing the tingling effects. In extreme cases the weakness and tingling are the indication of this disorder, whereby with time the disorder will spread and thereafter paralyzing the whole body (National Institute of Neurological Disorder and Stroke, 2020).

ii. Explain why the pathology is a possibility for this patient.

1. Why do the clinical manifestations this patient has make you consider the pathophysiological problem?

The diagnosis of the patient basically has provided all the symptoms of this disorder therefore(,) making the pathology a possibility for this patient. The patient diagnosis showed that he has the (exhibited) symptoms of numbness and tingly in toes, having (take this out?)(followed by increased) difficulty in walking, feet and ankles had fault and finally fatigues and the weakness of the legs(making this diagnosis likely with the greatest number of symptoms). These are the same symptoms that a patient with GBS exhibits (this sentence could be taken out) (McCance & Huetehr, 2019). At the same time (,) apart from the physical diagnosis the patient was also able to exhibit other symptoms that are part of the pathophysiology of the disease, like not being able to obtain dysesthesias (dysesthesia is pain, I would take this out and instead put reflexes) in bilateral legs below the knee, bilateral ankles (Mayo Clinic, 2020).

2. Explain each clinical manifestation or abnormal finding in the case with a reason for why it matters in the diagnosis you are considering. Explain the relationship of these signs and symptoms to the pathophysiology.

The most common symptom for GB is fever, the fever is manifested because the neuropathy is inflamed from the cross reactivity which is between the antibodies and the antigens in the neural system, whereby it is mots (most) induced by the infection; Campylobacter jejuni (CDC, 2020). The Campylobacter jejuni bacteria is what causes the diarrhea and vomiting after it has inflamed the GI tract (Leonhard et al., 2019).

On the other hand(,) the weight that was recorded was significant(,) but it can be explained(, take this comma out) by the viral illness. At this point it is evident that the cranial nerve holds some deficits, the patent consequently has loss of appetite, reduced oral intake and fatigue that can explain the weight loss (National Institute of Neurological Disorders and Stroke, 2020).

Considering the fact that the nerves are interrupted in GBS, the patient’s immune system is likely to damage the myelin sheath and the axons, which results (to: take out to and replace it with in) the nerves not being able to transmit signals effectively(;) thereafter, the muscles lack the path to respond (the; take out the and add to ) commands of the brain (which may explain the patients weakness) (therefore the weakness that was experienced by the patient take out this part). The Peripheral nerves and the nerve roots (present; take this out) have been inflamed, (and may be (it was take this out)what led to the incontinence of urine and the symmetrical ascending paralysis (Amatya et al. 2013).

3. What other information would you need to know to help with this diagnosis?

The additional information that would be useful with the diagnosis is the completed workup results. According to Olshanksy 2007, a patient with GBS is likely to register an elevated cerebrospinal fluid protein that has the normal count for the white blood cells. Meaning that the diagnosis of the GBS can be emphasized by the cerebrospinal fluid analysis. At the same time according to CDC (2020), there can be an increased risk of GBS, especially after swine flu vaccination in 1976, the history of flu vaccination is valuable information that may be useful in this case – maybe reword)another useful additional information that can be useful in this case.

iii. Emphasize and discuss the pathophysiology of this diagnosis.

1. What causes it?

According to CDC (2020), there are several things that can trigger GBS. Almost half of the patients that have been diagnosed with GBS had (a)respiratory illness or diarrhea, several weeks before developing the symptoms of GBS. At the same time the (take out the and add an) (an) infection with the bacteria Campylobacter jejuni is the prominent symptom as it is what causes the diarrhea (maybe reword – is a prominent symptom and associated risk factor of GBS) making one of eth common risk of GBS. At the same time the GBS infection can be accompanied by other infections like the Epstein Barr Virus, Flue, Cytomegalovirus, Corona Virus Infection and the Zika virus. Around 40% of the campylobacter infection in the United States have been tied to GBS cases.

2. How does it develop?

In GBS the immune system that is naturally designed to attack only organisms that are foreign (invading), begins to attack the nerves. Whereby(,) the most common GBS (syndrome DO YOU MEAN SYMPTOM?)that is registered in the country is the protective covering of the nerves (myelin sheath) gets damaged. This damage is what inhibits the nerves from transmitting signal to the brain, resulting in paralysis, numbness and weakness.

3. What role does genetics have in the development of the disorder, if at all?

Genetics do not have a role in the development of GBS.

4. Discuss all the body organ (s) or system affected by the disease.

GBS is likely to affect different body systems such as the immune system, nervous system, renal system, cardiovascular system, gastrointestinal and the musculoskeletal system. In depth, the disease affects the feet, hands and (leads to )has a sensation of descending upward muscle weakness and paralysis that is flaccid. Associated symptoms are exhibited in the (be experience at the take this out) back, and shoulders, the heart, kidney, heart (cardiac arrhythmias), GI and the immune and nervous systems.

5. How are normal anatomy and physiology altered?

(It; take this out and replace it with GBS) is associated with acute polyradiculneouropathy that basically means, the progression and onset of GBS affects the peripheral nerves rapidly. (GENERALLY, THE ONSET OF OTHER DISEASES SUCH AS THE ZIKA VIRUS PRECEDES GBS)Thereafter(,) the disease will lead to the onset of other disease such as the Zika Virus and others that have been mentioned before. What will happen is that there will be molecular mimicry that will make the antigens form the bacteria or the viral infection appear to be similar to the lipids of the myelin sheath:therefore, destroying the myelin sheath (Liu, Dong & Ubogu, 2018). It will lead to the axonal impairment in the peripheral nervous system that will cause muscle weakness, paresthesia, and impairment of vision, speech and reflexes, in the extreme case it might cause death (REFERENCE)

6. How is normal body function compromised?

It will lead to the axonal impairment in the peripheral nervous system that will cause muscle weakness, paresthesia, and impairment of vision, speech and reflexes, in the extreme case it might cause death (Willison, Jacobs, & Doorn, 2016).

7. What are the potential complication or sequelae of the disease process?

Interrupted bowel function, urine retention, HYPOTENSION OR HYPERTENSIONblood pressure that is fluctuated, residual numbness, breathing difficulties and irregular heart rhythms. The patient can be paralyzed (AS THE DISEASE PROGRESSES, (TAKE THIS PART OUTwith the continuous development of the disease because of the muscle weakness. Death can OCCUR IN (TAKE THIS OUTbe) the most extreme caseS that arises from worsening of any of the conditions.

iv. Who is at risk for developing this pathological condition?

1. Why are persons at risk?

The patient who smokes and is obese, is likely to develop this pathological condition. At the same time, a patient who is male and over THE AGE OF 50 years is likely to have a high risk OF developING GBS (CDC, 2020).

2. How can it be prevented?

Acute care, which can be done through two common treatments. The first one is high dose immunoglobin therapy (IVIg) the other treatment is Plasma exchange (plasmapheresis). The safety and immunogenicity of GBS serotype V is a tetanus toxoid conjugate vaccine that can be administered to prevent the potential of the GBS infection. Mainly because all the predisposing factors(THESE CANNOT BE GIVEN SIMULTANEOUSLY( cannot dealt with TAKE THIS OUT) simultaneously (CDC, 2020).

3. Explain how this risk is present for this patient.

(This is a risk- TAKE THIS OUT) Risk factors for this patient include his age of (because he is ) 50 years old (,)which is a predisposing factor; additionally, he has a significant smoking history He has been smoking for 20 years and drinks moderately on weekends.

3. Second Most Likely Diagnosis: Spinal Tumors

a. Expand upon your most likely diagnoses.

i. Define the pathological condition, disease or syndrome.

Tumors basically means that there is a new growth of body tissue that mainly begins with a malignant. A spinal tumor that can be the most likely other diagnosis is the abnormal growth of any tissue in the spinal cord (Mayo Clinic, 2020). THIS WORDING IS HARD TO FOLLOW

ii. Explain why the pathology is a possibility for this patient.

1. Why do the clinical manifestations this patient has make you consider the pathophysiological problem?

The numbness in the legs, back pains, leg weakness, tingling sensation and incontinence in the morning. These are the same pathological symptoms of patients with spinal cord tumors that are mostly accompanied by abnormal bowel habits. At the same time, spinal tumor sometimes are accompanied by tumor makers which are found in tumor cells in the spinal fluid or urine. According to Mayo Clinic (2020), the symptoms of spinal tumor can lead to the development of compression on the nerve roots, spinal cord, blood vessels and the spine. At the same time Additionally, smoking can be a predisposing factor for spinal and brain tumors whereby the patient has smoked for almost 20 years.

2. Explain each clinical manifestation or abnormal finding in the case with a reason for why it matters in the diagnosis you are considering. Explain the relationship of these signs and symptoms to the pathophysiology

Given this patients rapidly worsening symptoms, including an The diagnosis showed that the patient showed inability to walk, increasing weakness in his ankles and feet, diffuse pain in his low back, legs and buttocks, achy back pain, legs and buttocks, as well as numbness and tingling sensation in the feet and toes, makes this a likely diagnosis caused by spinal cord compression. Early diagnosis and treatment is needed to Caused by spinal cord compression, the patient that will have prevent worsening nerve impingement, that will lead to focal weakness, limb paresthesia, back pain and urine incontinence (Brenner & Borke, 2019). The patient also exhibited loss of appetite, fatigue, fever and weight loss. According Mayo Clinic (2020), “the spinal tumors process can mimic the hypothalamic with the effect of excess feedback signaling from leptin (a protein hormone that regulates adipose tissue mass).”

3. What other information would you need to know to help with this diagnosis?

A biopsy and a complete laboratory studies (study) of the spine lesion should be obtained, that is likely to the ready after all the radiographic studies have been conducted and would be very helpful in making this diagnosis a success. At the same time it would be helpful to have in place additionally, information that has complete a a thorough history and physical, family history and and additional imaging ,(i.e., plain radiography, MRT, CT and technetium scanning of the bone) may lead to a definitive diagnosis for this patient.

iii. Emphasize and discuss the pathophysiology of this diagnosis.

1. What causes it?

It is not clear on the exact cause of spinal tumors. But researcher have directed some fault to defective genes; moreover, But at the same time it is unclear if the defective genes are inherited or develop over a period of time. On the other hand Rather, spinal tumors might be due to environmental exposure to something on the environment like , such as harmful chemicals. Spinal cord tumors also are linked to known syndromes that are inherited like von Hippel-Linadu and Neurofibromatosis (Mayo Clinic, 2020).

2. How does it develop?

It most of the time Generally, spinal tumors can be start as a malignant or benign; tumor, whereby, benign tumors are usually encapsulated (with corrective tissues) and not cancerous. This means that this type of tumor does not spread and invade. When this tumor is extremely large they it can be life threatening due to compression of tissue and prevent blood flow (Harvard Medical School, 2019). On the other hand Malignant tumors are cancerous and have rapid growth, the stem cell does not have normal mechanism that regulate proliferation; therefore, resulting to uncontrolled production (REFERENCE)

3. What role does genetics have in the development of the disorder, if at all?

Genetics do play a role in the development of this disorder, according to Mayo Clinic (2020), “however, spinal cord tumors are linked to known inherited syndromes, such as neurofibromatosis 2 and von Hippel-Lindau disease.” (THIS IS A DIRECT QUOTE AND NEEDS A PAGE AND PARAGRAPH FOR REFERENCE)That are carried by the genes.

4. Discuss all the body organ (s) or system affected by the disease.

There are various body organs that can be affected bun by the disorder. The spine, lower extremities, nerves and kidneys. The sacrum, lumbar, cervical and thoracic parts of the spine can be affected by the disorder. On the other hand there are other body organs such as the back bone, spinal column, brain, spinal nerve cells, vertebra and spinal canal. The body systems include the musculoskeletal, renal areas, cardio, hematologic, neurologic among others (American Association of Neurological Surgeons, 2020).

5. How are normal anatomy and physiology altered?

Spinal tumors are likely to compress spinal nerves, this will lead to loss of mobility and sensation, likely below the tumor. At times this type cause can lead to changes in bladder and bowel functions, such as incontinence. In serious cases nerve damage may be permanent. When it is accompanied by Neurofibromatosis 2, there can be tumors near the vestibulocochlear nerve, which may lead to progressive hearing loss, on either ears or one ear either the left or right ear, or both (Mayo Clinic, 2020).

6. How is normal body function compromised?

Movement will be compromised. Hearing will be compromised and unusual bowel functions that might affect the excretory system.

7. What are the potential complication or sequelae of the disease process?

Spinal tumors are likely to cause the compression of spinal nerves, which will lead to loss of movement and sensation; consequently, if the vestibulocochlear nerve is compressed, this may cause hearing loss. On the other hand if the hearing nerves are compressed it will lead to hearing loss. At the same time It is important to understand that at extreme cases the nerves will be damaged completely.

iv. Who is at risk for developing this pathological condition?

1. Why are persons at risk?

A person who is likely obese and has been smoking for some years is at a high risk of developing this pathological condition. Patients with weak immune system and have been exposed to environmental factors like harmful chemical exposure are likely to be at high risk (Harvard Medical School, 2020).

2. How can it be prevented?

Prevent or reduce radiation exposure and smoking cessation, early diagnosis. Considering that spinal tumors have not been tied with a cause they are very difficult to prevent; therefore, maintaining a healthy weight and quitting smoking is the only prevention.

3. Explain how this risk is present for this patient.

The patient has been smoking for the past twenty years and has been moderately drinking. These factors are predisposing factors to cancer which might lead to other cancers like the spinal tumors.

4. Third Most Likely Diagnosis: Ankylosing Spondylitis

a. Expand upon your most likely diagnoses.

i. Define the pathological condition, disease or syndrome.

Ankylosing Spondylitis (AS) it is a disorder that is inflammatory that leads to small bones present in the spine to fuse (Biswas et al., 2016). The fusion of the small bones leads to a less flexible spine and a limited spine (Mayo Clinic, 2019). In other words this disorder will lead to the stiffening of the spine.

ii. Explain why the pathology is a possibility for this patient.

1. Why do the clinical manifestations this patient has make you consider the pathophysiological problem?

The patients clinical manifestations diagnosis pointed out that the patient suffered from long standing problems, intermittent back pain and exacerbations that were occasional after a weekend working in the yard. Stiffness and low back pain are the early symptoms of the disorder (Mayo Clinic, 2019). Since the AS can lead to early pain and loss of motion which come from the inflammation and reflex of muscle spasm, this would explain the inability of the patient obtaining a bilateral ankles, knees and triceps reflex. The patient experienced lack of sleep due to back pain, loos of appetite and mild fever, early stage of AS can be loss of appetite general discomfort and mild fever that might result from the inflammation.

2. Explain each clinical manifestation or abnormal finding in the case with a reason for why it matters in the diagnosis you are considering. Explain the relationship of these signs and symptoms to the pathophysiology

It has been established that AS makes small bones on the spine to fuse, the fusing leads to a spine that is not flexible. This is the first is what leads to the following clinical manifestation. Low back pain because there is no flexibility, the ankle cannot reflexes which is retrieved from the fused spine. The mild fever which likely results form the inflammation. Lack of sleep due to back pain, leads to fatigues. Whereby fatigue causes weight loss and loss of appetite as there is discomfort or the body feels under the weather.

3. What other information would you need to know to help with this diagnosis?

Additional information that would be useful in this diagnosis would be genetic information and health history of the family. Considering the fact that patients with AS will have swelling and inflammation there are likely to have erythrocyte sedimentation rate (ESR). Whereby an X-ray and blood test would be an instrumental information that would show the elevated level if the ESR (Cedars Sinai, 2020).

iii. Emphasize and discuss the pathophysiology of this diagnosis.

1. What causes it?

According to Mayo Clinic, 2019, the disorder does not have a specific cause but genetic factors seem to be a suspected cause. Particularly individuals who have the gene identified as the HLA-B27 have the highest risk of developing AS.

2. How does it develop?

The early sign of AS are pain and stiffness in the lower back and the hips, most specifically in the periods of inactivity n din the morning. Considering that it is a type of arthritis the disease leads to inflammation of the large joints and the spine and that is what leads to the stiffness. That is where the complications begin to develop.

3. What role does genetics have in the development of the disorder, if at all?

Genetics do lay a role in the development of this disorder, in fact genetics is a predisposing factor. Most individuals who have AS have the HLA-B27 gene.

4. Discuss all the body organ (s) or system affected by the disease.

The spine is a the majorly affected body organ because of the stiffening. At the same time the fusion can also lead to stiffening of the rib cage that will restrict the proper functioning of the lung and the overall lung capacity (Mayo Clinic, 2019). Compression fractures can weaken the vertebrae and make it to crumble; therefore, affecting the overall body posture. Additionally, AS can lead to eye inflammation (uveitis) which is basically sensitivity to blurred light. At the same time AS can because problems with the aorta, as the inflamed aorta can enlarge to the level that its shape is distorted in the heart therefore impairing its function (Mayo Clinic, 2019).

5. How are normal anatomy and physiology altered?

According to Cedars Sinai, (2020), (CHECK WITH PERDUE OWL, BUT I AM ALMOST POSITIVE THAT YOU NEED TO REFERENCE THE YEAR IN PARENTHASIS) the following are the normal anatomy and physiology that are altered by the disorder. Back Pain, early morning stiffness, stooped posture in response to back pain, reduced lung capacity, appetite loss, weight loss, fatigue, fever, mild eye inflammation and organ damage (eyes, lungs and heart). (THE FIRST LETTER IN THE WORD DOES NOT NEED TO BE CAPITILIZED)

6. How is normal body function compromised?

The aorta will be inflamed meaning that blood circulation in the body will be compromised. The lung capacity is reduced meaning that respiration will be a problem.

The eye is mildly inflamed creating a problem for vision. Back pain and fatigue will affect the normal functioning of the body. Stooped posture is not great as it will lead to organ damage.

7. What are the potential complication or sequelae of the disease process?

In severe AS, new bones will form as a stimulus form the body trying to heal. The new bones will gradually close the gaps between the damaged vertebrae, these parts of the spine will become stiff and inflexible. This fusion will stiffen the ribcage therefore reducing lung capacity. Another potential complication of AS is that there will be eye inflammation (CHANGE THE E in eye it doesn’t need to be capitalized) (uveitis). Heart problems caused by the inflamed aorta is another complication that is expected. (Reference)

iv. Who is at risk for developing this pathological condition?

1. Why are persons at risk?

Mostly occurs in young adults, most commonly in males, especially the Caucasian males (Morrison, 2018).

2. How can it be prevented?

Considering the fact that the disorder is genetic, then people with AS history should focus on the prevention of disabilities that might be caused by AS such as the Spinal Fractures. (THESE DO NOT NEED TO BE CAPITALIZED) Individuals can maintain a normal body weight, quit smoking and alcohol. This is because either no known ways to deal with AS (I AM NOT SURE WHAT THIS SENTENCE IS SAYING) (Morrison, 2018).

3. Explain how this risk is present for this patient.

The patient has been smoking for 20 years and moderated drinking on the weekends. The patient is Caucasian and has a sedentary lifestyle; therefore, is at high risk of developing AS.

5. How might you counsel/educate this patient, based on these top 3 diagnoses? What might this patient expect to encounter as a result of these pathophysiological issues? What might this patient expect to encounter as a result of these pathophysiological issues?

With the current symptoms, the patient would expect that there were major health issues that happen to him. From a healthy person without any history of disease-related, no history of surgery, and not taking any medications, the patient was anxious and wanted to find out what's wrong with his body. Even expected something very serious occurring, the patient was still surprised by any new diagnosis. Due to the severity of the symptoms and not having enough information, the patient might not take care well at the outpatient settings and need to go to the ED and admit to the hospital for further evaluation and treatment. The patient would have further testing information, including labs result, imaging, and others. After reviewing and completing additional information from family history, labs result, imaging, and understanding the diseases' pathophysiology, providers need to explain new findings from lab results, imaging, and other additional findings to conclude the final diagnosis.

The results would show that patient might have possible with one of three diagnoses above. The patient might deny and refuse to accept the truth. Refusing to acknowledge that relates to an illness is a way of coping with emotional conflict, stress, painful thoughts, and anxiety (Mayo Clinic, 2020). Therefore, the nurse needs to use communication styles and methods that demonstrate caring, respect, deep listening, authenticity, and trust to the patient (American Nurses’ Association, 2015).

As a future advanced nurse, providers need to analyze assessment data to determine actual or potential diagnoses and prioritize diagnoses, problems, and issues (American Nurses’ Association, 2015). The nurse also utilizes complex data and information obtained during the interview, examination, and diagnostic processes in identifying diagnosis (American Nurses’ Association, 2015). The nurse would explain in a simple term to help the patient understand the disease process, symptoms related to the disease, treatment plan with current symptoms, and short-term and long-term goals. The nurse needs to communicate effectively in all areas of practice (American Nurses’ Association, 2015).

The next step is to inform and educate the patient about the current treatment of the diseases. When the patient was diagnosed with GBS, the nurse needs to inform the patient that there is no cure for GBS. However, some treatments can speed recovery and reduce the illness's severity, including plasma exchange and immunoglobulin therapy (Mayo Clinic, 2020). The patient could also take pain medications to relieve pain and prevent blood clots. As a care team role, the nurse needs to develop a plan that prescribes strategies and alternatives to attain expected outcomes (American Nurses’ Association, 2015). The nurse develops an individualized plan in partnership with the patient, family members, and others and also includes strategies for health and wholeness across the lifespan and continuity in the plan (American Nurses’ Association, 2015). The nurse can inform the patient about the recovery process of GBS. For long-term impact, it can take several months to years for a patient to fully recover from the disease (Mayo Clinic, 2020).

In addition to the treatment plan, the patient should advise for a lifestyle change, including quitting smoking, drinking alcohol, healthy diets, and exercising. The nurse also provides health teaching that addresses lifestyles, risk-reduction behavior, and preventive self-care (American Nurses’ Association, 2015). All of the details treatment plan, follow up appointment, further labs work up, referral to a specialist such as a neurologist and physical therapy, and others can also discuss with providers at outpatient settings. Thus, the nurse must follow the standard of practice and standard of professionalism to provide optimal care to the patient.

References

Amatya, B., Khan, F., Whishaw, M., & Pallant, J. F. (2013). Guillain-Barré syndrome: prevalence and long-term factors impacting bladder function in an Australian community cohort. Journal of clinical neurology (Seoul, Korea), 9(3), 144–150. Retrieved from: https: //doi.org/10.3988/jcn.2013.9.3.144

American Association of Neurological Surgeons. (2020). Spinal Tumors. Retrieved from: https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Spinal-Tumors

American Nurses’ Association. (2015). Nursing Scope and Standards of Practice. (3rd edition). Maryland: Nursesbooks.org. Retrieved from: https://www.nursingworld.org/nurses-books/nursing-scope-and-standards-of-practice-3rd-ed/

Ankylosing spondylitis by Mayo Clinic, November 18, 2019. Retrieved from https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/symptoms-causes/syc-20354808

Ankylosing Spondylitis by William Morrison. June 15, 2018. Healthline. Retrieved from https://www.healthline.com/health/ankylosing-spondylitis

Biswas, S., HAM, N. A., Biswas, P. K., Md Harun, U. R., Sarkar, P. K., Mostofa, K. C., . . . Chandra, S. B. (2016). Ankylosing spondylitis with peripheral neuropathy - A rare case report. Journal of Medicine, 17(1), 36-n/a. Retrieved from https://gonzaga.idm.oclc.org/login?url=https://www-proquest-com.gonzaga.idm.oclc.org/docview/1834479794?accountid=1557

Brenner, B., & Borke, J. (2019). Spinal cord neoplasms clinical presentation. Medscape. Retrieved from: https://emedicine.medscape.com/article/779872-clinical#b1

Cedars Sinai 2020. Ankylosing Spondylitis. Retrieved from https://www.cedars-sinai.org/health-library/diseases-and-conditions/a/ankylosing-spondylitis.html

Craig, A. (2019). Rehabilitation of Peripheral Neuropathy, Kansas City, Kansas: McGraw-Hill Education.

Guillain-Barre syndrome by CDC, 2020. Retrieved from https://www.cdc.gov/campylobacter/guillain-barre.html

Guillain-Barre syndrome by Mayo Clinic, Sept. 17, 2020. Retrieved from https://www.mayoclinic.org/diseases-conditions/guillain-barre-syndrome/symptoms-causes/syc

Harvard Health Publishing. (2020). Guillain-Barre Syndrome. Retrieved from: https://www.health.harvard.edu/a_to_z/guillain-barre-syndrome-a-to-z

Leonhard, S. E., Mandarakas, M. R., Gondim, F., Bateman, K., Ferreira, M., Cornblath, D. R., van Doorn, P. A., Dourado, M. E., Hughes, R., Islam, B., Kusunoki, S., Pardo, C. A., Reisin, R., Sejvar, J. J., Shahrizaila, N., Soares, C., Umapathi, T., Wang, Y., Yiu, E. M., Willison, H. J., … Jacobs, B. C. (2019). Diagnosis and management of Guillain-Barré syndrome in ten steps. Nature reviews. Neurology15(11), 671–683. https://doi.org/10.1038/s41582-019-0250-9

Liu, S., Dong, C., & Ubogu, E. E. (2018). Immunotherapy of Guillain-Barre Syndrome. Human Vaccines & Immunotherapeutics, 14(11), 2568-2579. https://doi.org/10.1080/21645515.2018.1493415

Mayo Clinic. (2020). Adult health. Retrieved from: https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/denial/art-20047926

McCance, K.L., & Huether, S.E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MI: Elsevier.

National Institute of Neurological Disorders and Stroke. (2020). Guillain-Barre Syndrome fact sheet. Retrieved from: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Guillain-Barr%C3%A9-Syndrome-Fact-Sheet#3139_5

Olshansky, A. (2007). Diagnosis and treatment of Guillain-Barre Syndrome. AMA Journal of Ethics. Retrieved from: https://journalofethics.ama-assn.org/article/diagnosis-and-treatment- guillain-barre-syndrome/2007-08

Spinal Cord Tumors, what Is It? By Harvard Health Publishing. February, 2019. Retrieved from https://www.health.harvard.edu/a_to_z/spinal-cord-tumors-a-to-z

Spinal Cord Tumor by Mayo Clinic, 2020. Retrieved from https://www.mayoclinic.org/diseases-conditions/spinal-cord-tumor/symptoms-causes/syc-20350103