Nursing

CASE:

Adele  Spencer is a 45 y/o F complaining of weakness and fatigue. She also reports weakness in the right arm with clumsiness, numbness, tingling but denies pain.

The patient complained of worsening vision. The patient noticed difficulty with viewing distant objects. She also reports blurry vision and double vision when looking to the side but denies having eye pain.   Physical examination significant for  left optic disc pallor and edema dilated left eye pupil, decreases left eye acuity (20/200), slow left pupillary response, right upper extremity weakness, diminished sensation, hyperreflexia, and repetitive occupational motion/ stress bilateral arms. Father had a recent stroke.

PRIMARY DIAGNOSIS:

MS

DIFFERENTIAL DX :

1 VASCULITIS

2 MYELITIS

3 BRAIN NEOPLASM

ANSWER

MS Diagnostic

Primary Diagnosis and ICD-10 code: The primary diagnosis is MS ICD 10 G35; apparently, there is no specific test for MS, and the symptoms are addressed via taking precise scans, thereby ruling out others. For a verified diagnosis, the doctor must find at least two damaged parts in the brain or the spinal cord and see signs damaged by the illness. The most suitable way to diagnose MS is to evaluate muscle strength, nerve function, reflexes, and other physical and mental complications. One differential diagnostics is vasculitis, which includes the affection of arteries, veins, and capillaries. The symptoms include fever, tiredness, and joint pains. The potential causes include immunologic diseases and infections. The treatment depends on the type of vasculitis, age, and general health condition. One of the reasons for choosing it was the joint pains, thus relating it to MS (Solaro, Gamberini & Masuccio 2018). The second DX is transverse myelitis, typically caused by bacterial infections, fungal infections, parasites, and viral infections. The symptoms are back pain, numbness, and muscle spasms, loss of appetite, and weakness or paralysis. It is a relative DX because of its symptoms, which are related to those of MS. Finally, the third DX is brain neoplasm, which is typically a brain tumor. Its diagnosis involves a neurological exam, imaging tests, collection and testing of abdominal tissue samples and also cancer tests in various parts of the body. Its treatment is surgery, radiation therapy, radiotherapy, and chemotherapy.

It is a DX because of its symptoms and effects on the human body, thereby relating it to MS (Oh, Vidal-Jordana & Montalban 2018).

Additional laboratory and diagnostic tests: Additional laboratory tests involve those to check the muscles’ function ability, nerve function, and reflexes. MRI is vital to test to evaluate the extent of MS; it consists of scanning the spinal cord or brain to determine lesions that are possible symptoms of Ms. Other major tests include those of spinal tap, evoked potential study and various blood tests. Most of these tests require parent or sibling permission to perform them due to their complex nature.

Consults: Key referral includes a therapist’s help to manage fatigue, a nutritionist to handle the recommended food consumption. In most cases, the referrals will depend on the type and extent of the MS and the patient’s age. The patient can also visit OHSU to seek medical advice while at home. IN case of direct admission, I would recommend comprehensive care, bladder and muscle relaxants. I would also recommend stool softeners to avoid using too much energy and strain of the spinal cord, thus preventing further damages.

Therapeutic modalities: The primary approved pharmacological treatment is the monoclonal antibody medication, which is typically used to treat both the primary-progressive and relapse-remitting forms of MS. Research shows that it reduces the relapse rate and slows adverse conditions of disability in both MS types. The non-pharmacological modalities include physical therapy, consumption of a healthy diet that is low in fats and high in grains. Relaxation exercises, yoga, and oral cannabis extract precisely to reduce muscle stiffness and pain. Other forms of management include moist moderate heat and massage; technological devices such as WalkAide and Bioness are recommended to enhance walking for MS patients.

Health Promotion: The key risk factors include age, sex, and race, which are likely to increase contracting MS disease chances. Studies have shown that the contraction rate of MS increases with age; genetically, women stand twice as men to develop the MS condition. Other risk factors include family history, climate, autoimmune diseases, and Vitamin D levels.

Patient education: Patients should strictly follow the recommended food consumption and exercises. The patients should also consider hot weather, working on stagnant positions, wearing comfortable shoes, and using non-skid bath mats. Other recommended remedies are staying active and brain training as recommended. The family members should provide conducive environments for the recovery process and strictly follow the doctor’s recommendations to haste the recovery process.

Disposition/follow-up instructions: The treatment process involves several relapses, which mostly lasts 24 hours. Administration of corticosteroids is usually recommended to counter the relapses. In severe cases, the patient should call for emergency care and involve the doctor’s advice to avoid complications. Physical and occupational therapists are also recommended to help with the recovery process.

References

Braley, T. J., & Boudreau, E. A. (2016). Sleep disorders in multiple sclerosis. Current neurology and neuroscience reports, 16(5), 50.

Oh, J., Vidal-Jordana, A., & Montalban, X. (2018). Multiple sclerosis: clinical aspects. Current opinion in neurology, 31(6), 752-759.

Solaro, C., Gamberini, G., & Masuccio, F. G. (2018). Depression in multiple sclerosis: epidemiology, aetiology, diagnosis and treatment. CNS drugs, 32(2), 117-133.