CASE STDUY

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).

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, and immune system.

5. How are normal anatomy and physiology altered?

The normal function of myelin is to protect the nerve and helps to speed the transmission of electrical impulses down the nerve (McCance & Huether, 2019). When the myelin damages, the nerve impulses travel to the muscles become disrupted (Harvard Health Publishing, 2020). As a result, the normal anatomy and physiology of the body was altered and created many problems (Harvard Health Publishing, 2020).

6. How is normal body function compromised?

When immune system cause abnormally low activity or over activity of the immune system, the immune deficiency decrease the body’s ability to fight invaders and causing vulnerability to infections (Robinson, 2020). When the myelin sheaths are damaged, the ability of nerve cells in the brain and spinal cord to communicate with each other and with muscles is compromised (Kirkwood, 2015). Therefore, when there is less electrical impulse signal from the nerve, the muscle tissue can’t contract well and leading to weakness (Kirkwood, 2015).

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, sluggish 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?

There are several risk factors that develop the disease include obesity and smoking. When patients are obese, they can increase the level of adipokines which is the substance tend to be pro-inflammatory and alter the immune system function (Global Autoimmune Institute, 2019). Smoking cigarette also produce toxic to the body and having an impact to the immune system through various complex interactions include the inflammatory responses, dysregulation of cytokines, and the development of autoantibodies (Global Autoimmune Institute, 2019).

2. How can it be prevented?

Since GBS is not a disease itself and not known exactly how it occurs, it is very difficult to prevent GBS (CDC, 2020). The simple way is to prevent by not having infected by a viral or bacterial infection such as Campylobacter jejuni (CDC, 2020).

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

With high in fat and calories, mild abdominal obesity, the patient is considered obesity. 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 previously vomiting and had fever during the exam.

3. Second Most Likely Diagnosis: Spinal Tumors

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

i. Define the pathological condition, disease or syndrome.

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).

Tumor markers can be found in a tumor cell, in the blood, in the spinal fluid, or in urine (McCance & Huether, 2019). 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 (McCance & Huether, 2019). Patient had incontinence, weight loss, history of smoking, and obesity due to high fat and calories diets with high BMI at 31.6% (CDC, 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).

2. Explain each clinical manifestation or abnormal finding in the case with a reason for why it matters in the diagnosis you are considering.

Patient presented weakness in the feet and ankles, inability to walk, back pain and tingly 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). 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).

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?

Spinal tumors are uncommon lesions and affect a minority of the population but can have significant impact on limb dysfunction and mortality as well (Safari & Khoshnevisan, 2014). Originally, tumor can refer to a new growth resulting from an abnormal following uncontrolled proliferation (Safari & Khoshnevisan, 2014). It can be benign or malignant tumor (Safari & Khoshnevisan, 2014). Benign tumors are not cancers and are usually encapsulated with connective tissue with well-differentiated cells and well-organized stroma (Safari & Khoshnevisan, 2014). Benign tumors do not invade and spread. Tumor stem cells lack of normal mechanisms that regulate proliferation and differentiation, resulting in uncontrolled production (Safari & Khoshnevisan, 2014). On the other hand, malignant tumors are different with rapid growth, loss of differentiation, and absence of normal tissue organization (Safari & Khoshnevisan, 2014).

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.

There are different areas that have an affected from spinal tumors include cervical, thoracic, lumbar, and sacrum. 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 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. When benign tumors become extremely large, they can cause morbidity, life-threatening by compressing normal tissue, and prevent blood flow to the region (Safari & Khoshnevisan, 2014). When the immune system is overwhelmed by a tumor, it fails to identify and respond to the threat (Cancer Treatment Centers of American, 2017).

6. How is normal body function compromised?

Tumors can cause widespread and variable disruption of the immune system and also suppressing local immune responses (Norris, 2020). The normal immune system is designed to recognize and fight back against the threat of tumors. Therefore, it responses by having elevated temperature, aches, pains, inflammation and swelling (Cancer Treatment Centers of American, 2017).

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).

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

1. Why are persons at risk?

Obesity and smoking increase the risk of developing tumors. People with previous history of cancer can increase risk of having spinal cord tumor. Patients who have family history of cancer can also have a higher risk of developing spinal tumors. Other factors include having a weakened immune system and other environmental factors such as chemical exposure (American Cancer Society, 2020).

2. How can it be prevented?

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).

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

With a long history of smoking for the past twenty years and moderated drinking, patient might have a higher risk for developing spinal tumors. According to American Cancer Society (2020), alcohol consumption might have higher risk of developing different types of cancer. People with excess body fat might also increase cancer risk by affecting the body’s inflammatory, cell and blood vessel growth, insulin resistant, and others (American Cancer Society, 2020)

4. Third Most Likely Diagnosis: Ankylosing Spondylitis

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

i. Define the pathological condition, disease or syndrome.

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). AS is also a common type of spondyloarthropathy and a chronic inflammatory autoimmune disease that affects the spine joints, causing severe pain, and spine fusion (Zhu et al, 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 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). 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.

2. Explain each clinical manifestation or abnormal finding in the case with a reason for why it matters in the diagnosis you are considering.

Patients with AS can have inflammation of the GI before the onset of joint symptoms with a result of diarrhea and vomiting (Carteron, 2020). Due to the location, patient can have low back pain and sacroiliac pain around the buttock area and worse with resting at night (Diamond & Brent, 2020). AS can also have an effected to other body part with systemic symptoms include weight loss, fatigue, inflammation of entheses, and inflammation of the toe and fingers. The inflammatory of enthesopathy proessing to ossification and ankyloses (Maghraoui, 2011). The common extra-articular are represented by bowel disease with diarrhea, kidney involvement, and unexplained weight loss (Maghraoui, 2011).

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).

iii. Emphasize and discuss the pathophysiology of this diagnosis.

1. What causes it?

AS has no specific cause, however, it is more common with people who carry HLA-B27 gene (Mayo Clinic, 2020).

2. How does it develop?

The pathogenetic role of this gene is not clearly explained (Akassou & Bakri, 2018). AS can develop with a hypothesis of a molecular mimicry between the pathogens and self-peptides (Akassou & Bakri, 2018).As a result, the endoplasmic reticulum is stress and unfolded protein respond and leading to AS (Akassou & Bakri, 2018). The inflammation in the tendon insertion of many costostenal and costovertevral muscles might cause pleuritic chest pain and restricted chest movement (McCance & Huether, pp. 1454-1455, 2019). As the disease process, tenderness can occur to pelvic area, ischial tuberosities, and heels which lead to disturbance sleep at night, effects on limps and low back area (McCance & Huether, pp. 1454-1455, 2019).

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

As mentions above, there is a role of genetic involve in the development of this disorder. People who carry gene HLA-B12 are having higher risk of developing AS (Akassou & Bakri, 2018).

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

The main body organ involve in AS include spine, costovertebral, axial skeleton, ankles, hips, and knees (Diamond & Brent, 2020). The body system has an affected from AS include the neurologic, musculoskeletal, cardiac, and pulmonary (Diamond & Brent, 2020).

5. How are normal anatomy and physiology altered?

AS is a multisystem inflammatory disorder primarily involving the sacroiliac joints, the axial skeleton, and the vertebral column (Diamond & Brent, 2020). The inflammation causes pain and stiffness of these joints and can progress fusion of the joint (Diamond & Brent, 2020).

6. How is normal body function compromised?

The long-term inflammation of the spinal joints (spondylitis) that leads to the calcium deposit forming in the ligaments around the invertebral discs (University of Maryland Medical Center, 2020).. As a result, the ligaments become calcify and restricted the movements (University of Maryland Medical Center, 2020).. With the effects of inflammation, the body would compromise and response by having fever, pain, stiffness, and loss of mobility (University of Maryland Medical Center, 2020).

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).

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?

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