Multiple Sclerosis case study 44 PDF

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Case Study 44 Multiple Sclerosis

1. Identify four risk factors in this patient that consistent with multiple sclerosis The patient being of Northern European Descent (Belgian) and 2). the region she resides in of the Northen Atlantic (Wisconin) 3) Sex- Female (Ratio now 3:1, female to male occurrence) 4) Caucasian (Incidence 2x as high in Caucasian Americans, and Asians).

2. What probably precipitated this most recent attack of multiple sclerosis? Although Multiple Sclerosis relapses tend to be unpredictable, viral infections can trigger an MS attack. Although exacerbations do not have a specific trigger, it is caused by inflammation in the central nervous system. The inflammation damages myelin causing disruptions of transmission of nerve impulses and causes the symptoms if MSA probable precipitating factor of the recent Multiple Sclerosis attack is the “bad cold” that patient H.J. developed two weeks ago.

3. Should any of the patient’s vital signs be a cause for concern? No, the patients BP is sitting at 115/70 which is almost close to perfect. The patient pulse is 74 and regular showing no signs of tachy or bradycardia to be concerned for. Her temperature (97.2) is in the range for normal temperatures. The patient’s RR are 13 and unlabored showing she is having no anxiety or trouble breathing. The patient’s vital signs are within normal limits showing no reason for concern.

4. Does the rectal examination provide any information that the patients constipation is a result of multiple sclerosis? Constipation, obstructed defecation, and fecal incontinence are frequent complaints in multiple sclerosis. The patient’s rectal examination shows that she has diminished anal reflexes. Diminished anal reflexes results from multiple sclerosis contributing to the patient’s complaints of constipation. In multiple sclerosis there are lesions known as plaques which represent myelin degradation. Common sites of these lesions include the spinal cord, brainstem and optic nerve. Spinal cord lesions contribute to weakness and diminished anal and/or abdominal reflexes contributing to constipation. Constiption is a common manifestation in multiple sclerosis. This can be caused by an interruption of impulses to the brain that signal the need for a bowel movement.

5. Briefly explain how a Romberg maneuver is done and what it may reveal The Romberg Test is a neurological test which detects poor balance because of deficits in proprioception. The test involves standing with feet together and eyes closed. The patient will be observed to see how well they can maintain their balance and an upright posture. The neurologist often pushes slightly to see whether the patient is able to compensate and regain their posture. A positive Romberg sign is the excessive swaying or falling over. A positive sign signals that there is damage to the CNS. This patient had a positive Romberg test showing damage to her CNS which correlates with multiple sclerosis.

6. Is a positive Romberg sign good or bad? A positive Romberg sign is bad, it mean there is damage to the patients central nervous system. A positive Romberg's sign indicates one or more of these problems: •Vertigoor Vestibular Ataxia- problems with the balance organs inthe inner ear or sensory feedback. These can be caused by1problems in the inner ear itself2problems in the cranial nervesupplying the ear (CN VIII)3lesions in the Ponsregion of the brainstemwhere CN VIII arises4damage to other central nervous systempathways which connect to the Pons•Cerebellar Ataxia- this is dysfunction caused by damage to a brainregion called the cerebellumor to nervous pathways connecting to it. The cerebellum is responsible for assimilating sensory data, for example limb position and visual data, and co-ordinating movements resulting from that. A positive test is usually indicative of loss of the ascending proprioceptive function of the lower limbs.

7. Identify all of the abnormal blood chemistry test results in table 44.2 and provide a reasonable explanation for each abnormal test result. Her Cl- Chloride 109 mEq/L normal is 96-106 mEq/L -elevated Chloride is an important electrolyte and works to ensure that your body's metabolism is working correctly. Your kidneys control the levels of chloride in your blood. Therefore, when there is a disturbance in your blood chloride levels, it is often related to your kidneys. Chloride helps keep the acid and base balance in the body.

8. Are the patients cerebrospinal fluid glucose and protein levels normal, abnormally high, or abnormally low?

The patient's CSF glucose level is 60 mg/dL and protein level is 60 mg/dL. Normal values for glucose is 50 - 80 mg/100 mL and normal values for protein range from 15-60 mg/dL. High glucose levels are used to aid in the diagnosis of tumors, inflammation and infection .High protein levels indicate nerve inflammation and injury. Both levels are normal. The patients CSF is clear and colorless fluid found in the brain and spine. Most patients with MS have normal cell counts and total protein levels. Even duringan acute exacerbation, total CSF protein and cell counts remain normal .Acccording to Rammohan, establishing CSF markers that permit evaluation of the various biological processes in multiple sclerosis remains a challenge. Detection of oligoclonal immunoglobulin bands in the CSF is now established as the single most useful laboratory marker in the CSF to aid in the diagnosis of multiple sclerosis.

9. Why is lymphocytosis in the CSF consistent with an attack of multiple sclerosis? Multiple sclerosis is an inflammatory disease which is characterized by the damage it causes to one’s brain and spinal cord by attacking myelinated axons in the central nervous system and destroying the myelin sheath. This disease leads to a progressive loss of physical mobility and central nervous system deficits. Lymphocytosis, which is an increase is number of lymphocytes is seen in someone when there is an attack on their immune system. Being that multiple sclerosis is an inflammatory disease there will be an increase in lymphocytes in the cerebrospinal fluid during a flare up of pre-existing multiple sclerosis. 10. Before a definitive diagnosis of multiple sclerosis is made, healthcare providers will often conduct various test on patients. Briefly explain the rationale for each of the following test. A. Serum vitamin B12 concentration – patients with low serum B12 deficiencies are associated with MS disorder. Patients with multiple sclerosis without anemia but very mild degrees of macrocytosis or borderline low serum vitamin-B12 concentrations are more common. Age of these patients is typical of multiple sclerosis (ie, young adults), which is unusual for vitamin-B12 deficiency. The cause of the deficiency is usually unclear.

B. Serum folate concentration - Some patients with multiple sclerosis (MS) test low for iron and benefit from iron supplementation. Myelin is continuously replaced in a process that requires iron and a normal folate-vitamin B12-

methylation pathway. This pathway is necessary to provide methyl groups for myelin regeneration. Iron acts as a catalyst in this pathway to increase the speed of the reactions. Myelin regeneration is necessary for remission of MS attacks.

C. Erythrocyte sedimentation rate - Sed rate, or erythrocyte sedimentation rate (ESR), is a blood test that can reveal inflammatory activity the body. A sed rate test isn't a stand-alone diagnostic tool, but it can help the doctor diagnose or monitor the progress of an inflammatory disease. High ESR in this patient can indicate presence of MS.

D. Antinuclear antibody (ANA) test- Antinuclear antibodies (ANAs) are unusual antibodies, detectable in the blood, that have the capability of binding to certain structures within the nucleus of the cells. The nucleus is the innermost core within the body's cells and contains the DNA, the primary genetic material. ANAs are found in patients whose immune system may be predisposed to cause inflammation against their body tissues. Positive ANAs suggest the possible presence of autoimmunity. Therefore, when they are detected in a patient'sblood doctors will consider the possibility that an autoimmune illness exists in that patient.

E. Serology for Lyme disease - Lyme disease exhibits a variety of symptoms that may be confused with immune and inflammatory disorders. According to CDC “Untreated Lyme disease can produce a wide range of symptoms, depending on the stage of infection. These include fever, rash, facial paralysis, and arthritis” Therefore, it is important to perform this test to rule out MS.

E. VDRL test- The VDRL test is a screening test for syphilis. It measures substances (proteins), called antibodies, which your body may produce if you have come in contact with the bacteria that cause syphilis. The patient is screened for this to detect an infectious cause for neurological symptoms and white matter changes.

Patient teachings

You have been diagnosed with multiple sclerosis a disease of the brain the spinal cord or both. MS involves the destruction of the covering of the nerves myelin sheath. When the nerves are damaged messages from the brain and not transmitted very well. You may not be able to move your body as well as you did before and may lose some of your ability to feel things such as heat or cold. Some people may have vision problems or trouble emptying their bladder....