Case study

CASESTUDYSECTION1-6TODAY10-23-2020.docx

Midterm & Final Exam Instructions

Nursing 523

Please download and review the expanded clinical scenario. Read thru this patient’s story. Answer the following questions in order asked, and answer under the specific heading of each question. This is NOT a formal APA paper. Please keep your responses as brief as possible while remaining thorough. Feel free to use tables, algorithms, outlines, or whatever format you believe would best explain your responses, but these must be in the same document you submit, and they must be your responses. Do make sure that you provide responses to each question. As always, please provide all appropriate citations and references and make the work your own. At least 2 of your references must be obtained from Foley library. Please review APA 6th edition of appropriate citation of references. Plagiarism will not be tolerated. Poor grammar and spelling errors will result in point deduction. No more than 10-11 pages maximum (not counting reference page). The instructions are in an outline format, but you do not have to use this outline to submit your work. The outline will guide you through everything that I am looking for you to cover.

This assignment should not be in APA format (although your references should be). Instead, please use the numbers 1 to 5 to separate out each of the categories below, answering each of the areas within each heading. If you do cite a reference, then please do give credit as an in-text reference (Author, year). When completing this assignment please give your responses in the same sequence as the outline below. If you do not submit with your answers below the heading of each area, it will be returned to you to be resubmitted with a late penalty. References should be in APA format for your last page of the assignment.

To Submit: Click into “Turn it in.” It will guide you through the process step by step. Make sure your first & last name are on the top of the document. “Turn it in” is in the same area you found the mid-term case. It is an easy process (even I was able to do it). If you have difficulty you can always email: [email protected]

The midterm is due by Sunday October 25 @ 11:59 PM PST & the final is due by Sunday November 29 @ 11:59 PM.

1. Differential Diagnosis Table

a. Complete a differential diagnosis table for this patient (see below)

i. A differential diagnosis list is a list of all the possible diagnoses this patient could have based on the symptoms the patient presents with, the available history and the physical exam. Examine what you know about this patient, and consider the pathophysiology as you make your list of possible diagnoses.

ii. You should be able to generate a list of at least 4-5 possibilities, though there is space for more if you would like.

iii. Put them in a list of most likely being number 1, to less likely.

1. Your number one diagnosis is the one you think this patient has, given the history and physical exam. This is the most likely diagnosis given that there are more clinical manifestations and findings in the history and exam that support this diagnosis.

2. Include any differential that you think is appropriate for this patient, given the information you have, but make sure it is in the order of most likely.

3. Be specific in your possible diagnosis. Do not use generic diseases or diagnoses. If there are more than one type of a disease, list each separately, as likely the pathophysiology is different.

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
2.Spinal Tumors
3.Ankylosing Spondylitis
4.
5.
6.
7.
8.

2. Most Likely Diagnosis: Guillain-Barre syndrome

a. Expand upon your most likely diagnoses (Guillain-Barre syndrome).

i. Define the pathological condition, disease or syndrome.

Guillain-Barre syndrome (GBS) is a rare neurological disorder which the body’s immune system mistakenly attacks part of its peripheral nervous system (National Institute of Neurological Disorders and Stroke, 2020). It is also a rare demyelinating disorder caused by a humoral and cell-mediated immunologic reaction directly to the peripheral nerves (McCance & Huether, 2019). It rapidly damages peripheral nerves and might hinder movement, sensation or organ function and depending on which nerves are involved (McCance & Huether, 2019).

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?

Patient presented with the symptoms of fault in feet and ankles, incapability to walk, numbness and tingly in toes, feet, tingly at fingertips, weakness of the legs, and fatigue. Patients with GBS can be experienced with weakness in the legs, inability to walk, having pain with achy worse at night, difficulty with bladder control (Mayo Clinic, 2020). Patient could not sleep well due to back pain and secondary to GI distress. Patient also had one time incontinence of urine in the morning before the physical exam. GBS usually occurs after gastrointestinal infection (McCance & Huether, 2019). In this case, patient had recent vomiting and diarrhea after eating chicken. During physical exam, patient also had fever at 100.8 and positive with neuro exam. Patient was unable to obtain bilateral ankles and dysesthesias in bilateral legs below knees and sacral area. Those symptoms above are matched with the disease pathophysiology.

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 symptoms onset of GBS are fever due to an inflammatory neuropathy with the cross reactivity between neural antigens and antibodies that is induced by specific infections such as Campylobacter jejuni (Walling & Dickson, 2013). Infection with the bacteria causes inflammation of the GI tract and result in vomiting and diarrhea. (Centers for Disease Control and Prevention, 2020). Patient can have significant weight loss in the first two weeks due to viral illness. Because of cranial nerve deficits, patient has impairing oral intake, leads to loss of appetize, and fatigue (Walling & Dickson, 2013). With acute inflammatory demyelinating polyradiculoneuropathy (AIDP), a patient has rapidly progressing symmetrical weakness, numbness, and tingling in the lower extremities (Olshansky, 2007). Patients have decreased or absent deep tendon reflexes because of sensory and motor abnormalities starting distally and travel toward the trunk, arms, and face (Olshansky, 2007). In most cases of GBS, the immune system damages the myelin sheath and the axons, as a result, the nerves cannot transmit signals efficiently and the muscles are unable to respond well to the brain’s commands and leads to weakness (National Institute of Neurological Disorders and Stroke, 2020). Because of the peripheral nerves inflammation and nerve roots presents, it can cause symmetrical ascending paralysis and lead to incontinence of urine (Amatya, Khan, Whishaw, & Pallant, 2013).

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

A completed lab workup results are helpful with the diagnosis. Patient with GBS usually confirmed by elevated cerebrospinal fluid protein with normal white blood cell count (Olshanksy, 2007). GBS can diagnosis by cerebrospinal fluid analysis and nerve conduction studies (Olshanksy, 2007). A history of flu vaccination would be helpful for the patient. According to CDC, there was a small increased risk of GBS after having swine flu vaccination in 1976 (CDC,2020).

iii. Emphasize and discuss the pathophysiology of this diagnosis.

1. What causes it?

Guillain-Barre syndrome is an autoimmune disorder which the body’s immune system attacks and destroy the myelin sheath (Harvard Health Publishing, 2020). The most common form of GBS is acute inflammatory demyelinating polyneuropathy (AIDP) (McCance & Huether, 2019). GBS often occurs after a respiratory track or gastrointestinal infection and can associate with surgery, immunization, and viral infections such as Zika virus (McCance & Huether, 2019).

2. How does it develop?

Excess weight has been found to increase the risk of developing autoimmune diseases (Global Autoimmune Institute, 2019). When adipose tissue accumulates and becomes dysfunction, it increases and dysregulates the secretion of adipokines and lead to inflammation and alteration of immune system function (Global Autoimmune Institute, 2019). With a history of smoking for twenty years, it can impact the immune system including inflammatory responses, immune suppression, dysregulation of cytokines, and the development of autoantibodies (Global Autoimmune Institute, 2019).

The function of myelin is to protect the nerve and helps to speed the transmission of electrical impulses down the nerve (McCance & Huether, 2019). However, when the body’s immune system attacks, it destroy the myelin sheath (McCance & Huether, 2019). If the myelin is destroyed, it has an impact on the transmission of electrical impulses. As a result, the nerve impulses travel to the muscle very slowly and can become disrupted (Harvard Health Publishing, 2020). When the muscles don’t have proper stimulation through the nerves, they will not function properly (Harvard Health Publishing, 2020). In addition, when the autoantibodies invade the nodes of Ranvier, they activate complement and disrupt sodium-channel clusters and axoglial junctions and leads to nerve conduction failure and muscle weakness (McCance & Huether, 2019).

The most common bacterial infection are Campylobacter jejuni, cytomegalovirus, Epstein-Barr virus, and Mycoplasma pneumoniae (Harvard Health Publishing, 2020). Campylobacter jejuni usually causes intestinal infections (McCance & Huether, 2019).

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

There is no genetics related in the development of the disease.

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

GBS has major affected on the body systems including nervous system, immune system, cardio and musculoskeletal system, gastrointestinal and renal system.

It first has an affected on hands and feet, and descending upward with muscle weakness and flaccid paralysis. Pain most commonly in shoulders, back, and thighs. Having affected on the kidney with urinary retention, heart with cardiac arrhythmias (cardio and musculoskeletal sytems), GI, and nervous systems, Immune system

5. How are normal anatomy and physiology altered?

6. How is normal body function compromised?

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

Patients can have breathing difficulties, residual numbness, irregular heart rhythms, fluctuated blood pressure, gluggish bowel function and urine retention, developing blood clots, and relapse (Mayo Clinic, 2020). The complications of muscle weakness, patients can be paralyzed. Patient can also have respiratory failure and autonomic complications (National Institute of Neurological Disorders and Stroke, 2020).

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

1. Why are persons at risk?

With high in fat and calories, mild abdominal obesity, and BMI at 31.65, the patient is considered obesity (CDC, 2020). Patient also smokes one pack of cigarette for the past twenty years. Therefore, obesity and smoking are two of the factors that are the risk factors to develop autoimmune disease for this patient. Patient might have gastrointestinal infection due to recent symptoms of vomiting and diarrhea after eating chicken. Patient also had elevated temperature during the physical exam. The patient tried to do better with chicken and fish instead of red meat. It is possible that patient ate undercooked chicken. GBS is more common in males than females and can affect with all ages groups (Mayo Clinic, 2020). The most common bacterial infection is campylobacter jejuni and usually found undercooked poultry (Mayo Clinic, 2020).

2. How can it be prevented?

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

3. Second Most Likely Diagnosis: Spinal Tumors

a. Expand upon your most likely diagnoses (Spinal tumors).

i. Define the pathological condition, disease or syndrome. (Make sure you include a reference for your definition).

Tumor means a new growth of body tissue and can be benign or malignant (Johns Hopkins Medicine, 2020). A spinal tumor is an abnormal growth or uncontrolled cell division from any of the tissues within the spinal cord canal or the bones that make up the spine (Johns Hopkins Medicine, 2020). Spinal tumors can be cancerous or noncancerous, and is originally in the spine or spinal column (Johns Hopkins Medicine, 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?

Patient presents with back pain, legs weakness, tingling and numbness of the legs, and having incontinence in the morning. Patients with spinal tumors may have common symptoms including back pain, weakness, numbness in the arms or legs, and having change in normal bowel or bladder habits (The Spine Hospital, 2020).

Tender to palpation to bilateral lower lumbar paraspinal region

Tumor markers can be found in a tumor cell, in the blood, in the spinal fluid, or in urine (McCance & Huether, 2019). According to American Association of Neurological Surgeons (2020), the signs and symptoms of spinal tumors can develop by compresses on the spinal cord, the nerve roots, blood vessels, or bones of the spine. Patient had incontinence, weight loss, history of smoking, and obesity due to high fat and calories diets with high BMI at 31.6% (Centers for Disease Control and Prevention, 2020). Smoking can be the risk factors for brain and spinal cord tumors (American Cancer Society, 2020). The most-studied known or suspected risk factors of cancer include alcohol consumption, obesity, tobacco, and diets (National Cancer Institute, 2015).

Based on the patient’s history and physical exam, patient presented with a history of weakness in his feet and ankles, and is unable to walk due to secondary to weakness. Patient has throbbing, achy low back pain, buttock and legs. He also has numbness, tingling and burning sensation in feet, toes, and fingertips. Patient had incontinence, weight loss, history of smoking, and obesity due to high fat and calories diets with high BMI at 31.6%. He had fever , complained of fatigue, and positive with neuro exam. NEED RESEARCH ().

American Association of Neurological Surgeons. (2020). Spinal tumors. Retrieved from: https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Spinal-Tumors#:~:text=A%20spinal%20tumor%20is%20an,)%20or%20malignant%20(cancerous).

American Cancer Society. (2020). Risk factors for brain and spinal cord tumors. Retrieved from: https://www.cancer.org/cancer/brain-spinal-cord-tumors-adults/causes-risks-prevention/risk-factors.html

Centers for Disease Control and Prevention. (2020). Healthy Weight, Nutrition, and Physical Activity. Retrieved from: https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html

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

National Cancer Institute. (2015). Risk factors for cancer. Retrieved from: https://www.cancer.gov/about-cancer/causes-prevention/risk

The Spine Hospital. (2020). Spinal tumors. Retrieved from: https://www.columbiaspine.org/condition/spinal-tumors-and-vascular-malformations/

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

Patient presented weakness in the feet and ankles, inability to walk, back pain and wake up at night with throbbing, achy low back pain, buttock and legs, and numbness, tingling and burning sensation in feet and toes. Due to spinal cord or cauda compression and nerve root impingement, patients with spinal tumors can experience with back pain, limb paresthesia or focal weakness, paraplegia, and bladder dysfunction (Brenner & Borke, 2019). Patient also had sudden weight loss, fatigue, and loss of appetize. According to Suzuki et al. (2013), when tumors process, they can induce or mimic the hypothalamic with the effect of excess negative feedback signaling from leptin (a protein hormone that regulates adipose tissue mass). As the result, the expected outcome would be sustained for lack of appetite, muscle wasting, and waste loss (Suzuki et al., 2013).

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

Suzuki, H., Asakawa, A., Amitani, H., Nakamura, N., & Inui, A. (2013). Cancer cachexia--pathophysiology and management. Journal of gastroenterology, 48(5), 574–594. Retrieved from: https://doi.org/10.1007/s00535-013-0787-0

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

A complete laboratory studies and a biopsy of the spine lesion after all radiographic studies are helpful with the diagnosis. The laboratory studies include a complete blood count and differential, a basic serum chemistry, erythrocyte sedimentation rate, C-reactive protein (Goldstein & Sama, 2018). Elevated of serum, or alkaline phosphatase also show the evidence for neoplastic bone processes (Goldstein & Sama, 2018). It also would be helpful to have additional information with a complete family history, imaging studies including a plain radiography, CT, MRI, and technetium bone scanning (Goldstein & Sama, 2018).

iii. Emphasize and discuss the pathophysiology of this diagnosis-DETAIL OF PATHOPHYSIOLOGY

1. What causes it?

It is not clear why spinal tumor develops and is possible related to defective genes (Mayo Clinic, 2020). People who are smoking, somehow damage DNA and is more develop to spinal cord tumors (American Cancer Society, 2020).

2. How does it develop?

NEED GOOD INFORMATION

Originally, tumor can refer to a new growth resulting from an abnormal following uncontrolled proliferation (). It can be benign or malignant tumor (). Benign tumors are not cancers and are usually encapsulated with connective tissue with well-differentiated cells and well-organized stroma (). Benign tumors do not invade and spread. When benign tumors become extremely large, they can cause morbidity, life-threatening by compressing normal tissue, and prevent blood flow to the region (). On the other hand, malignant tumors are different with rapid growth, loss of differentiation, and absence of normal tissue organization ().

Tumor stem cells lack of normal mechanisms that regulate proliferation and differentiation, resulting in uncontrolled production (Safari & Khoshnevisan, 2014). Spinal tumors are uncommon lesions and affect a minority of the population but can have signficiant impact on limb dysfunction and mortality as well (Safari & Khoshnevisan, 2014).

Safari, M., & Khoshnevisan, A. (2014). An overview of the role of cancer stem cells in spine tumors with a special focus on chordoma. World journal of stem cells, 6(1), 53–64. https://doi.org/10.4252/wjsc.v6.i1.53

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

Spinal cord tumors can link to inherited syndromes include neurofibromatosis 2 and von Hippel-Lindau disease (Mayo Clinic, 2020). Neurofibromatosis 2 can develop in the spinal canal tumors and Von Hippel-Lindau is rare and is associated with blood vessel tumor in the spinal cord (Mayo Clinic, 2020).

4. Discuss all the body organ (s) or system affected by the disease. Spine, Nerve, lower extremity, kidneys,

There are different areas that have an affected from spinal tumors include cervical, thoracic, lumbar, and sacrum. It can also depend on the location within the spine include intradural-extramedullary, intramedullary, and extradural (American Association of Neurological Surgeons, 2020). Others body organ and systems are also involved such as the vertebra, spinal canal, brain, spinal nerves cells, spinal column, and back bone (American Association of Neurological Surgeons, 2020). The body systems can include neurological, hematologic, renal areas, cardio, musculoskeletal, lymphatics, and others (American Association of Neurological Surgeons, 2020).

5. How are normal anatomy and physiology altered?

The brain and spinal cord are the body’s central nervous system. The main function of spinal cord is the pathway for sending messages by the brain to the brain to the body and from the body to the brain (McCance & Huether, 2019). The network of nerves from the spinal cord spread throughout the body and deliver commands from the brain to parts of the body (McCance & Huether, 2019). When there is a tumor present, it can block and compress on the nerves and have an effected to many organs or system.

6. How is normal body function compromised?

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

Spinal tumors can lead to complication of recurrences or metastases. With neurologic complication, it causes to radicular pain, weakness from impingement on a nerve root, paraplegia from direct pressure on the spinal cord (Goldstein & Sama, 2018). Other complications are related to surgical, radiation, or chemotherapeutic treatment of the tumors (Goldstein & Sama, 2018).

Goldstein, J. A., & Sama, A. (2018). What are the possible complications of spinal tumor? Medscape. Retrieved from: https://www.medscape.com/answers/1267223-165893/what-are-the-possible-complications-of-spinal-tumors

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

1. Why are persons at risk?

Obesity and smoking

Increase chances when someone already having a history of brain or spinal cord tumor. Family history of cancer and smoking. In this case, patient has a history of smoking one pack of cigarette per day. Patients also have a weakened immune system, and other environmental factors such as chemical exposure (American Cancer Society, 2020).

2. How can it be prevented?

Smoking cessation, early detection, and reduced radiation exposure.

Spinal tumors is difficult to prevent and there is no known way to prevent all spinal tumors (Brain and Spine Care, 2020). Decrease the risk of having cancers by quitting smoking and maintaining a healthy weight (Brain and Spine Care, 2020).

Brain and Spine Care. (2020). Spinal tumors. Retrieved from: https://www.seton.net/brain-and-spine-care/spinal-tumors/

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

Patient has been smoking for twenty years, alcoholism. Alcohol probably also increases the risk of cancer of the stomach, and might affect the risk of some other cancers as well (American Cancer Society, 2020). Maintain a healthy weight.

https://www.cancer.org/cancer/cancer-causes/diet-physical-activity/alcohol-use-and-cancer.html

4. Third Most Likely Diagnosis: Ankylosing Spondylitis

a. Expand upon your most likely diagnoses (Ankylosing Spondylitis).

i. Define the pathological condition, disease or syndrome. (Make sure you include a reference for your definition).

Ankylosing spondylitis (AS) is an inflammatory disease that can cause some small bones in the spine (vertebrate) to fuse. The fuse leads to limit and less flexible of the spine (Mayo Clinic, 2020). Ankylosing spondylitis is a chronic inflammatory joint disease characterized by stiffening and fusion of the spine and sacroiliac joints (McCance & Huether, pp. 1454-1455, 2019).

Mayo Clinic. (2020). Ankylosing spondylitis. Retrieved from: https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/symptoms-causes/syc-20354808

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?

Patient presented with intermittent back pain, a long standing problem with occasional exacerbations after a weekend of working in the yard. The common early signs of AS are low back pain and stiffness (McCance & Huether, pp. 1454-1455, 2019). During the neuro exam on reflexes, patient was also unable to obtain bilateral ankles, 1+ bilateral knees, biceps, branchioradialis 2+ triceps. AS can present with early pain and loss of motion are caused by the inflammation and reflex muscle spasm (McCance & Huether, p. 1454, 2019). Patient also had mild fever, loss of appetite, malaise, and could not sleep well due to back pain. According to Spondylitis Association of America (2020), the early stages of AS can have mild fever, loss of appetite, and general discomfort.

Spondylitis Association of America. (2020). Most common symptoms. Retrieved from: https://spondylitis.org/about-spondylitis/types-of-spondylitis/ankylosing-spondylitis/symptoms/

-Low back pain:

-Unable to reflex: on ankle

- Mild fever,

-Weight loss and loss of appetite,

-Malaise and fatigue

-Not sleep well due to back pain

- Patients with AS can have inflammation of the GI before the onset of joint symptoms with a result of diarrhea and vomiting (Carteron, 2020).

Carterson, N. (2020). Other Conditions and complications of ankylosing spondylitis. Retrieved from: https://www.healthline.com/health/ankylosing-spondylitis/other-side-effects

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

Additional information on health history such as family history and genetic information that would be helpful with the diagnosis. Genetic testing is to find out if the person carries a copy of the gen HLA-B27 which altered gene for a disease (Cedars Sinai, 2020). There are also additional information such as X-ray and blood test with elevated level of erythrocyte sedimentation rate (ESR). When swelling and inflammation are present, patient with AS would have higher rate of ESR (Cedars Sinai, 2020).

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

iii. Emphasize and discuss the pathophysiology of this diagnosis.

1. What causes it?

2. How does it develop?

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

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

5. How are normal anatomy and physiology altered?

6. How is normal body function compromised?

Pain compromised

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

Patients with AS can have great risk of thinning of the bones and can result in spinal fractures. AS can also cause inflammation of the eyes, aortic valve, and intestinal tract (Cedars Sinai, 2020). Other complication when there is a fusion of the spine that can lead to a forward curvature of the spine, causing a forward-stooped posture (Spondylitis Association of America, 2020).

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

1. Why are persons at risk?

AS often occurs in young adults, more common in males, and more common in people with Caucasian descent (Morrison, 2018).

Morrison, W. (2018). Ankylosing spondylitis. Healthline. Retrieved from: https://www.healthline.com/health/ankylosing-spondylitis

Zhang, S., Li, Y., Xu, X., Feng, X., Yang, D., & Lin, G. (2015). Effect of cigarette smoking and alcohol consumption on disease activity and physical functioning in ankylosing spondylitis: a cross-sectional study. International journal of clinical and experimental medicine, 8(8), 13919–13927. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4613033/

2. How can it be prevented?

AS tends to run in the families with genetic disorder, people with families history of AS is likely 10 to 20 times to have it than someone without family history (Morrison, 2018). Due to genetics, there are no known ways of AS prevention (Morrison, 2018). When patients have the disease, they can focus on the preventing disability thinning such as spinal fractures. Patients can quit smoking and alcohol, maintaining a normal body weight, staying active, and eating a healthy diet (Morrison, 2018).

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

With a long history of smoking, moderated drinking on the weekend, sedentary lifestyle, therefore, the patient is high risk to develop AS. Smoking and alcohol consumption are major stimulators of the disease occurrence (Zhang, Li, Xu, Feng, Yang, & Lin, 2015). Cigarette smoking is associated with spinal radiographic progression in patients with axial spondyloarthritis (Zhang et al., 2015). The study of Zhang et al. (2015) also showed that heavy drinking AS patients were more likely to show functional disability.

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? Keep in mind that you will be giving the patient instructions at the level of an Advanced Practice nurse. Education & counseling is one area we excel in as NP’s. You should given patient & families education regarding their diagnosis, what the diagnosis means for them long-term, what is their overall prognosis or chances of full recovery, what the patient can expect as far as further testing, how the disease process is treated, pro’s & con’s of treatment etc…Consider yourself in the provider role.

What might this patient expect to encounter as a result of these pathophysiological issues?

6. Reference page (in APA format).