Case study

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.