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Research in Clinical Reasoning

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A 59 years old male presented to the emergency department on 01/04/18 with overall weakness and found to have exacerbationmultiple sclerosis. He noticed a decline in strength over the last 3 weeks with the acceleration of symptoms in the last several days. Magnetic resonance imaging(MRI) and lab screening were obtained. MRI of the brain showed many scattered white matter plaques along with new lesions in the right cerebellum. Lab screening result showed hyperkalemia and dehydration. The patient complains of frequent nocturia had been on oxybutynin for several months. He has a history of acute cystitis without hematuria, neurogenic bladder, neurogenic bowel, ataxia, weakness, seizure, spasticity, hypopituitarism, central hypothyroidism, hypogonadotropic, hypogonadism, and sexual dysfunction. He has no known allergy. His lower extremities are weak, has difficulty walking, and uses two front wheel walker. While the patient is getting treatment in the hospital, the patient developed confusion. Urinalysis was done and was grossly positive and suggestive of urinary tract infection.

Patient vital signs BP 94/60, HR 87, RR 18, Temp 98.6, Spo2 98%. Admitted weight 168lband current weight also has no significant change 168lb. Alert and oriented X4.This patient has an alteration in the central nervous system (CNS) and that can affect different body part. Symptoms of include loss of mobility, sensory disorder, sexual dysfunction, pain, weakness, fatigue, and impaired coordination, spasticity, bladder and bowel dysfunction and confusion.

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The mechanism of demyelination in multiple sclerosis may be activation of myelin-reactive T-cells in the periphery, which then express adhesion molecules, allowing their entry through the blood-brain barrier (BBB).T-cells are activated following antigen presentation by antigen-presenting. Perivascular T-cells can secrete pro-inflammatory cytokines. Ongoing inflammation leads to epitope spread and recruitment of other inflammatory cells then they make antibodies for the myelin for further degradation and the cytokines can be toxic to the myelin as well. The white matter tract of the central nervous system is the most commonly affected by the demyelination process. However, grey matter tract can also be involved there is a predilection for the optic nerve. Both sensory and motor neuron are affected. At times the inflammatory phase can resolve the area of demyelination can heal. Allowing the disease to go into remission and the periods between relapses are characterized by a lack of new symptoms, although the underlying disease process may be continuing.

Most of the symptom which stated in our textbook or any reliable website is quite similar to this patient symptom. For example, seizure, trouble walking, fatigue, muscle weakness, seizure, impaired coordination, blurred or double vision, sexual problems, and bladder dysfunction symptoms which is also listed in our textbook. However, the patient also has a diagnosis of the pituitary tumor which is not stated in the pathophysiology textbook, but current studies do not completely associate multiple sclerosis and brain tumors, and it is difficult to define. However, diagnosis of brain tumor multiple sclerosis patients may seem more frequent than in the general population due to frequent neuroimaging scans performed in these patients. On the other hand, a patient symptom of sexual dysfunction could also be related to prolactinoma which is a tumor in pituitary that secret excessive amount of prolactin that decreases the testosterone level in the body and leads to low libido or sexual dysfunction. Moreover, the patient also has hypothyroidism. As stated in the above, the cause of this problem might arise from hypopituitarism or may associate with the main diagnosis. Studies stated there is a significant co-occurrence of thyroid disease in a patient with multiple sclerosis compared to the general population.

There is no single test or set of tests that can establish a diagnosis of multiple sclerosis however, his laboratory panel, clean catch urine analysis is one result shows >100,000 CFU/ml non-lactose terminating cram negative rods are found, in addition, WBC (urine) >50, BUN is high 33, BUN/creatinine ratio is high 27, cortisol is high 49.7, neutrophil is high 91.3, lymphocyte low 7.5, testosterone is low 224, pituitary prolactin is high 22.2ng/ml. In addition to lab results, the patient also has MRI that is done on 1/5/2018 thoracic spine with and without contrast. The result showed multiple T2 hyperintense lesion in the thoracic cord than compared to 2014 result. Findings are compatible with demyelination from multiple sclerosis, it also showed multilevel degenerative cervical spondylosis progressive when compared to 2010 result. Sometimes cerebral spinal fluid (CSF) studies can be done which is not found in this patient. Elevated levels of IgG and other immune system proteins found in the CSF but not in the blood indicate the kind of abnormal immune response seen in multiple sclerosis S but it might not be accurate in all patients. According to studies, CSF analysis is normal in 10% to 20% of people with MS and O-bands are also present with other diseases, thus results from CSF analysis cannot be used alone to diagnose MS. we can also use a patient symptom to diagnose this disease. https://library.med.utah.edu/kw/ms/lab.htmlAll the above values and finding are significant and there are no lab value findings that surprised me. They indicate the patient is having multiple sclerosis and other complication which arise from it.

Because MS suspected to be an autoimmune disease directed against the CNS available treatment involve preventing inflammatory cells from crossing the blood-brain barrier. Immunomodulating agents reduce the clinical attack of new MS lesion they may have an impact on disability progression. Immunosuppressive agents can also be used to suppress TCell immune reaction. Although none of the treatment can cure this disorder, they may reduce the number of days that person suffers from those symptoms. They may also help in reducing the lesion in CNS. Corticosteroid also another treatment option used to reduce acute inflammation fast recovery from exacerbation MS. In this patient, since he is diagnosed with Exacerbation of MS, he took a high dose of prednisone and also taking other medication for related problems. I believe that the patient is getting standard treatment based on his diagnosis.At present, there is no cure for multiple sclerosis and full recovery is not expected but effective management can improve the patient’s quality of life. The goal of medical management is vary based on the disease progresses and symptoms of the patient. In this patient, stopping the disease process, reduce the number of relapse and steroid use, maintain hormone level through supplement; symptom management such as such as paint, fatigue, spasticity, and use of physical and occupational therapists to prevent complications and secondary disabilities, prevent seizures and other complication are the next best outcomes. Besides all the medical treatment the patient showed improvement he is gaining back his strength and helped us by transferring him a bed to chair; he denied any pain; his appetite was good.

Loss of bone density is a common complication of persons with MS. It correlates with a loss in the ability to ambulate and bear weight but occurs to a greater extent even in individuals still able to walk. With the decreased ability to walk comes a greatly increased risk of falling, and as bone mineral density decreases, so does the risk of fractures. In addition to the risks of decreased ability to bear weight, many MS patients require either multiple short-term or long-term courses of corticosteroids. These drugs can also decrease bone mineral density. Multiple treatments can be initiated, depending on the severity of the bone density loss and the potential for recovery. Measures to reduce or prevent osteoporosis in those with MS include education regarding adequate calcium and vitamin D intake, avoidance of smoking and excessive alcohol intake, and regular exercise, particularly weight-bearing exercise.http://www.ijmsc.org/doi/pdf/10.7224/1537-2073-2.2.27 Treatment of DecreasedBone Mineral Density is Encourage patients weight bearing prolonged walking and running and standing as much as possible. If independent standing is not possible, use a standing frame to allow weight bearing at least once per day, as long as tolerated and use calcium citrate and vitamin D supplement.

Another common complication of multiple sclerosis is impairment of bladder function. These significantly increases the risk of urinary tract infections (UTIs), Bladder sensation is often impaired, leading to infrequent voiding and inability to feel the discomforts of a UTI. Patients may choose to dehydrate themselves to avoid urinary frequency and loss of control. the use of steroids, which may decrease the individual’s ability to fight the infection. To prevent this problem drinking plenty of water around 6-8 glasses a day is recommended to dilute your urine and help flush out bacteria. If the classic symptoms of a UTI are present—increased urinary frequency and urgency, altered urine color and odor, dysuria, and lower abdominal pain—the diagnosis can easily be made. All too often, however, because of decreased bladder sensations, these symptoms are lacking, and other manifestations are present. Most commonly these include worsening of lower extremity spasticity and weakness, increased fatigue, increased numbness and tingling or tremors, or increased imbalance. In other words, either existing neurologic symptoms are worsened, or previous neurologic symptoms reappear. A person being evaluated for an MS relapse should first have a screening, by history, examination, and if appropriate laboratory studies, for infection, especially a UTI and need to be treated with an antibiotic. Birnbaum, G. (2009).

Potentiates the action of dopamine in the CNS. Prevents penetration of influenza A virus into the host cell.

Thyroid supplementation hypothyroidism. Treatment or suppression of euthyroid goiter.Adjunctive treatment for thyrotropin-dependent thyroid cancer.

The biggest safety risk for my patient is a fall risk. My patient has a weakness, history of seizure, difficulty walking and unsteady gait. He is Bed alarms also notify and alert nursing staff to respond to the alarm whenever he tries to stand up. Furthermore, seizures can happen without warning, therefore as a nurse, we must ensure safety. Useand pad side rails with a bed in lowest position and administers medication as directed may minimize injury Seizure. The patient is treated with respect by accommodating all his needs (bath, giving time to visit with his wife and low stimuli environment). The patient is stable in overall condition and discharged to a short-term rehabilitation center to improve his strength and mobility.

The first goal is to maintain safety throughout the day. Since he is in fall and seizure preauction, we put the bed in lowest position; side rails up and a pad on it while he is in bed. The other goal is to help his stand, walk at least 1 feet and transfer to a chair before discharge with the observance of proper gait and assistance. At 11; 00 AM after we gave him a bath, we assisted him to stand and walk about 3 feet with his front wheel walker and help him to sit on a chair that has firm seat and arms on both sides. This will help the patient to support in case of weakness and ambulation helps to increase his mobility. The last goal is encouraging the families to join in the care of the patient through the day. His wife was with the patient the whole time and participated in his care me and the nurse was helping them until the patient is discharged. This Provides a way to communicate with the significant others and being participative may make the patient feel that he or she is being supported by his or her loved ones.

One of the interdisciplinary team that is important to the client is physical therapy. The role of physical therapy depends on the patient needs, disability and disease progress due to relapse. However, the goals of physical therapy will remain the same, to help to achieve the quality of life, safety, independence. and maintain physical functioning by doing a range of motion, gait training, functional transfer training and bladder retraining there along with another rehab goal. In this particular case, the report shows the patient improving the strength of bilateral extremities, leading to display balance impairment. The role of occupational therapy is helping the patient in the plan of care by teaching skills such as endurance training, activities of daily living, Fatigue management, Activity modification, use of adaptive equipment and technologies and Strategies to Compensate impaired body function. As a nursing student, we can also help our patients by doing a range of motion, give massages and relaxing baths, ambulate the patients needed, teach Fatigue management and energy conservation techniques learned from nurses and the occupational therapist.

Patient teaching

•Exercise may improve your strength. A physical therapist can help you determine which exercises are safe for you.

•Get plenty of rest. Extreme tiredness is a common symptom of MS.

•Plan your activities in advance.

•Avoid excessive heat and cold or infectious agents.

•Use a walker or other aid to help you get around and conserve energy if needed.

•Stretching can be used with medicines to help symptoms of stiff muscles.

•Eat a diet that is high in fiber to promote health and good bowel elimination.

•Do not skip doses and stop medications suddenly

•some medications may accentuate weakness such as some antibiotics, muscle relaxants, antiarrhythmics, antipsychotics, check with a healthcare provider or pharmacist before taking any new medications.See your provider if you have one of the following symptoms

•Blurry, foggy, or hazy vision, eyeball pain, loss of vision, or double vision.

•A feeling of heaviness or worsening of weakness,

•Tingling or a pins-and-needles sensation; numbness; tightness in a band around the trunk, arms, or legs; or electric shock sensations moving down the back, arms, or legs.

•Problems with memory, attention span, finding the right words for what you mean, and daily problem-solving.

•If you have any mood change or feel sad.

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Research in Clinical Reasoning. (2018, April 30). GradesFixer. Retrieved May 11, 2021, from https://gradesfixer.com/free-essay-examples/research-in-clinical-reasoning/
“Research in Clinical Reasoning.” GradesFixer, 30 Apr. 2018, gradesfixer.com/free-essay-examples/research-in-clinical-reasoning/
Research in Clinical Reasoning. [online]. Available at: <https://gradesfixer.com/free-essay-examples/research-in-clinical-reasoning/> [Accessed 11 May 2021].
Research in Clinical Reasoning [Internet]. GradesFixer. 2018 Apr 30 [cited 2021 May 11]. Available from: https://gradesfixer.com/free-essay-examples/research-in-clinical-reasoning/
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