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Multiple Sclerosis Case Study

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Multiple sclerosis is an illness whereby the immune system is eating away it’s a protective covering of the nerves. It is a disabling disease of the brain and the spinal cord or the central nervous system. In multiple sclerosis, the immune system is attacking the protective sheath or the myelin that is responsible for covering nerve fibers. This leads to communication issues between the brain and the entire parts of body. In due course, the disease also results in permanent damage or deterioration of the nerves (Dobson & Giovannoni, 2019).).
The symptoms of multiple sclerosis tend to vary and this is depending on the number of damages that occur on the nerve and the type of nerves that are affected. It is usually a common thing for individuals diagnosed with this condition to lose their ability to walk independently. In some situations, some people might experience extended periods of remission with no symptoms (Dobson & Giovannoni, 2019). The symptoms of multiple sclerosis can include numbness or weakness in or more limbs and it usually occurs on one side of the body at a time or even legs and trunk.
Individuals also experience electric-shock sensations that are felt during the movement of the neck more so in a forward bending of the neck. There is a tremor and a lack of coordination or unsteady gait. Patients also experience vision issues for example partial or complete loss of vision of a single eye at a time which is accompanied by pain. Patients can also experience long-term double vision and blurry vision. Other symptoms include fatigue, dizziness, slurred speech, tingling or pain in other regions of the body, problems with the functions of the bowel and bladder in addition to the sexual problems (Dobson & Giovannoni, 2019).
One of the causes of this condition is the infection associated with bacteria or viruses. The viruses lead to inflammation and the breakdown of myelin thus triggering multiple sclerosis. Bacteria and viruses that have identical components to that brain cell trigger the immune system to wrongly identify normal brain cells as the foreign body thus causing their destruction.
The environment is also a key factor in the occurrence of multiple sclerosis especially in the nations that are far from the equator. The role of the environment in the occurrence of multiple sclerosis is associated with the role played by vitamin D and its benefits on the immune system function. Individuals who are living in the equator are more exposed to sunlight, therefore, their bodies produce a larger amount of vitamin D (Zostawa et al., 2017). The longer the skin is exposed to sunlight, the more the body is naturally generating vitamin. This condition is an immune-mediated illness, therefore vitamin D and sunlight are linked to this condition.
Multiple sclerosis is also linked to genetics since people with this condition are born with genetic susceptibility that reacts to some unrecognized agents from the environment. The autoimmune response of the body is triggered by these agents upon their encounter. The immune system is also the cause of this condition due to its malfunctions that makes it attack the central nervous system.
The risk factors for this condition include stress, smoking, heat, medication, lack of sleep, and infections. Even though this condition does not have a single test to help in the diagnosis, three tests are and considered to be useful. These tests include magnetic resonance imaging (MRI), the Visual Evoked Potentials (VEP), and cerebrospinal fluid (CSF) (Zostawa et al., 2017). The physical examination of patients with this condition is remarkable for urinary incontinence, gait disturbances, increase in reflexes, spasticity, optic neuritis, internuclear ophthalmoplegia, and ihermitte symptoms.
This paper is therefore focused on providing an evidence-based research paper that provides details of a patient in the case study. The paper also provides subjective and objective data of the patient in the case study, formulation of the differential diagnosis, developing a care plan (non-pharmacological and pharmacological treatment, patient education, and the follow-up plan).
The patient’s case
The Patient’s Name: L.B Date of the visit: 28th May, 2021 Time: 100HRS

Age: 42-year-old Sex: Female

Subjective

Chief Complaint (C/C): “I have been having urinary incontinence. I had two accidental urination within the last 24 hours. I am feeling kind of embarrassed about the issue. I have also been feeling tired and having some fatigue. This has been the issue for the last 6 months.”

History of the Patient Illness (HPI): A 42-year-old female patient reports a complaint of urinary incontinence. She reported having had two accidental urination in the last 24 hours. She is also reported tiredness and fatigue which has been there for the last 6 months. The patient reports that she is experiencing some weaknesses and tiredness in her lower extremity and this has been the problem for the last three months.

Medication: The patient denies having been on any medication for her condition.

Past Medication History (HPI)

Allergies: No known Drug Allergy
Intolerance to any medication: the patient denies any medication intolerance.

Chronic Illness or the Major traumas: The patient denies having been hospitalized for a longer period or having any history linked to the child abuse. She also denies any hospitalization as a result of chronic illness.

Family History: The father is a 75-year-old and still alive; the mother is 65-year-old and is alive and on medication for hypertension. One sister is on medication for hypertension

Social History: She is married with two children of ages 14 and 10 respectively. She is not using any illegal drugs or smoking. She does not use alcohol. She is an accountant at the local healthcare facility. She is spending her time with her children at restaurants or sometimes visiting parks during weekends.

Assessment

Laboratory Tests
The complete blood count tests are utilized in determining values like creatinine, chloride, glucose, and ALT. the results of the test include Creatinine lower at 0.72, chloride high at 108 mmol/L, Glucose high at 147 mg/dL, ALT high at 34. Urinalysis is a test that relies on urine samples due to the easier and non-invasive collection process. The urinary myelin basic protein-like material is representing a material that is reactive with a cryptic epitope found in peptides 84-89 of human myelin basic protein. Urinary myelin basic-like material is at a moderate level in adults (Thompson et al., 2018). Patient with multiple sclerosis has higher levels of this component especially when the condition of the patient is at a secondary progressive level.
MRI for the scanning of the brain and spine to help in the production of the images that assist the doctor in making a successful diagnosis. The presence of the lesions in the patients’ central nervous system appears as dark spots and this is depending on the type of damage and the type of scanning for individuals suspected to be having multiple sclerosis.
Basic Metabolic Panel (BMP) is a test that is used to measure eight different substances in the blood. BMP tests are done to help in testing the deficiency of Vitamin B12. This test is helping in providing information about the chemical balance and metabolism. Another laboratory test to be used for this patient is the electromyogram (EMG) that is used for the assessment of muscle health through measurement of the responses of the muscles through stimulation (Siva, 2018). EMG is helping the physician to help in the diagnosis of the patient’s condition that leads to the weakness of the muscles.
Cerebrospinal fluid studies through cerebrospinal fluid analysis are helping in the confirmation of the demyelination illness of the nervous system. The results show an increase in immunoglobulin concentrations in patients suffering from the disease that is associated with the symptom presented by the patient in the case study (Deisenhammer et al., 2019). A comparison between IgG levels in cerebrospinal fluid and serum becomes elevated in patients suffering from multiple sclerosis. Another laboratory test is the Antinuclear Antibody Test (ANA) and the increase in ANA is greatly increased in patients with multiple sclerosis.

Diagnosis

Primary Diagnosis
Multiple sclerosis (G35): this is an inflammatory demyelinating illness of the central nervous system. The activated immune cells are invading the central nervous system and this results in inflammation, neurodegeneration, and damages to the tissue. Even though the cause of this condition is known, the key symptoms include vision problems, sexual dysfunction, cognitive problems, sexual dysfunction, bladder problems, pains and spasms, tingling and numbness, and dizziness (Siva, 2018). The patient in the case study reported having experienced sporadic blurred vision and fatigue.

Differential Diagnosis

Urinary tract infection (N39): this condition is an infection of any part of the urinary system for example kidneys, bladders, or urethra. This condition is common amongst women and it is usually experienced in the bladder or urethra but severe infections occur in the kidney. The infection of the bladder leads to the pain of the pelvic, an increase in the urge to urinate, pain during urination, the presence of blood in the urine. The infection of the kidney leads to the symptoms associated with back pain, nausea, fever, and vomiting. There is also a burning sensation upon urination; occasional passage of urine that usually occurs in smaller amounts; cloudy urine; the stronger smell of the urine; and reddish, bright pink, or cola-colored urine which indicates the sign of the blood in the urine. This condition is considered since the patient had accidental urination for the last 24 hours (Thompson et al., 2018). However, it is ruled out because the patient never reported pain, burning sensation, and odor during urination.
Anemia (D64.9): this is a condition whereby the blood is lacking adequate healthy red blood cells. It is caused by the absence of red blood cells or the dysfunction that occurs in the body’s red blood cells. This condition results in a reduction in the supply of oxygen in the body organs. The key symptoms of this condition include fatigue, skin pallor, shortness of breath, rapid heartbeat, and light-headedness. It is evident from the case study that the patient presented the symptoms of fatigue and tiredness. However, this condition is ruled out as a result of the absence of shortness of breath, fever, and changes in skin color or jaundice (Momeni et al., 2019).
Vitamin B deficiency (E53.9): this condition is caused by an absence of a key essential substance known as an intrinsic factor that occurs as a result of the mistaken attack of the stomach cells by the immune system. The stomach cells are responsible for the production of the intrinsic factor. The symptoms of this condition vary and they depend on the type of vitamin deficient that a person has. The symptoms range from confusion to anemia or compromising the immune system (Momeni et al., 2019). A patient can also report rashes of the skin. This condition is selected since the patient in the case study reported tiredness and fatigue and weakness. However, it is ruled out since the patient denies changes in appetite, confusion, and even weight loss.
Amyotrophic Lateral Sclerosis, ALS (G12.21): this is a condition that leads to a progressive nervous system illness that is affecting the nerve cells in the brain and the spinal cord. This leads to the loss of muscle control and affecting the physical function of the patient. This condition leads to the breakage of the nerve cells thus leading to the reduction of the function in the muscle hence muscle weakness due to weakness in the arms. The condition is selected since the patient in the case study experiences muscle weaknesses (Thompson et al., 2018). However, the condition is ruled out since the patient never admit difficulty in movement or normal daily activities, cognitive or behavioral changes, inappropriate yawning, laughing, or even slurred speech

Care Plan

Intervention

A nurse ensures that the blood pressure is monitored to help in the prevention of potential complications. A physician plan for the counseling program to help in the improvement of the patient’s emotional ability. The physician to order CBC tests to help in further determination of the blood levels to detect the potential infection. There is a plan for nutritional education to assist in reducing the salt intake, to allow the patient to report reduced saturated fat level, and to supplement it with Omega-3 and Omega-6. It also helps patients with the elimination of sugar and to increases the consumption of raw foods like fruits and vegetables (Paolino et al., 2021). The physician to order thyroid profile, lipid profile, and liver enzymes to assists in the diagnosis of the major components of blood and the likelihood of liver infection.

Patient Education

· Educating the patient on how to report and monitor the blood pressure
· Nutritional education to the patient to improve the diet.
· Educating the patient to understand the disease and the treatment options
· Initiating and instructing the patient on the management of the disease with long term adherence to therapy or medication
· Providing instructions and initiating the patient education and counseling for the client and the family
· Patient informed to get a lot of time for resting, ensure there is a reduction in the level of stress, ensure that there is a reduction in the chances of getting urinary tract infections

Treatment

Pharmacological

· The patient is treated using corticosteroid therapy, muscle relaxants (baclofen), and medication that helps in the reduction of fatigue (amantadine). Patient informed to get a lot of time for resting, ensure there is a reduction in the level of stress, ensure that there is a reduction in the chances of getting urinary tract infections.
· Prescribing amlodipine to help in the maintenance of the blood pressure and reduction in the risk of cardiovascular. A nurse must monitor the output and assess the blood pressure of the patient.
· Prescribing prednisolone 40 mg 1 tablet orally once daily for 1 week. This is important in reducing the inflammation response triggered by the injury. A nurse must educate the patient concerning the immunosuppression effects of the medication when used for the long term.

Non-Pharmacological

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Referral

· The referral, in this case, is for the vaccination and physical therapy and getting the support system
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Follow-up

· A 4-week follow-up for the review of the condition of the client and to determine the medication tolerance. It also helps in determining whether the prescribed medication is working or whether there is a need to make the necessary adjustment on medication to improve the condition of the patient. A follow-up program is necessary for the review of the ordered laboratory tests.

References
Deisenhammer, F., Zetterberg, H., Fitzner, B., & Zettl, U. K. (2019). The cerebrospinal fluid in multiple sclerosis. Frontiers in immunology, 10, 726. https://doi.org/10.3389/fimmu.2019.00726

Dobson, R., & Giovannoni, G. (2019). Multiple sclerosis–a review. European journal of neurology, 26(1), 27-40. https://doi.org/10.1111/ene.13819

Paolino, S., Gotelli, E., Goegan, F., Casabella, A., Ferrari, G., Patane, M., … & Cutolo, M. (2021). Body composition and bone status in relation to microvascular damage in systemic sclerosis patients. Journal of Endocrinological Investigation, 44, 255-264. https://doi.org/10.1007/s40618-020-01234-4
Momeni, A., Abrishamkar, R., Penahi, F., Eslami, S., Tavoosi, N., & Zadeh, A. R. (2019). Fingolimod and changes in hematocrit, hemoglobin, and red blood cells of patients with multiple sclerosis. Clinical and Experimental Immunology, 8 (4), 27-31.
Siva, A. (2018). Common clinical and imaging conditions misdiagnosed as multiple sclerosis: a current approach to the differential diagnosis of multiple sclerosis. Neurologic clinics, 36(1), 69-117. https://doi.org/10.1016/j.ncl.2017.08.014
Thompson, A. J., Banwell, B. L., Barkhof, F., Carroll, W. M., Coetzee, T., Comi, G., … & Cohen, J. A. (2018). Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. The Lancet Neurology, 17(2), 162-173. https://doi.org/10.1016/S1474-4422(17)30470-2

Zostawa, J., Adamczyk, J., Sowa, P., Adamczyk-Sowa, M. (2017). The influence of sodium on pathophysiology of multiple sclerosis. Neurological Sciences, 38 (3), 389-398.