HLT54115 Nursing

Case Study Two

Isabella Pearson is a 30 year old who has presented to her GP with a six week history of feeling jittery and unwell.

She reports her symptoms as follows –

• Weight loss
• Increased appetite
• Loose bowel actions
• Restlessness and an inability to sleep
• Hand tremors
• Heart palpitations

Her GP conducts a thorough head to toe assessment and orders a series of blood tests to aid in their diagnosis, the results are as follows –

TSH level is 1.00mlU/L (normal range 0.5 – 4.2mlU/L)

Free T4 40 pmol/L (normal range 10-20 pmol/L)

Free T3 16 pmol/L (normal range 3.5 – 6.0 pmol/L)

Her blood tests reveal a diagnosis of Hyperthyroidism (Graves Disease)

1. Provide an outline of the main structures of the endocrine system
2. Write a brief overview of the normal function of the endocrine system
3. Describe the pathophysiology of hyperthyroidism (Graves Disease)and risk factors
4. Discuss Isabella’s signs and symptoms and link to pathophysiology
5. Briefly outline the main structures of the digestive system
6. Briefly write a brief overview of the normal function of the digestive system (include metabolism and nutrition)
7. Briefly provide an over view of the man function of the immune system
8. Briefly define the pathophysiology of an autoimmune disease
9. Outline your assessment of Isabella and your immediate actions
10. Name some other health professionals involved in Isabella’s care and their role (medical and allied health)

Case Study Three

Daisy Mae is a 21 year old female who presents to her GP with a long standing history of blurred vision, bilateral numbness in both legs, urinary urgency, poor memory and problems with balance.

Daisy is married, has two young children aged 1 & 2 and she works part time in the family business. Daisy is very active taking care of her family and participates in regular sporting activities. She does not smoke, maintains a healthy diet and has no other relevant past medical history.

Daisy reports an increase in her symptoms since the birth of her youngest child, at times the symptoms improve but she notices at times they affect her activities of daily living. She reports also that she has been experiencing intermittent severe jaw pain, much like a tooth ache.

After a thorough head to toe physical assessment, her treating Doctor orders a series of tests, including an MRI (magnetic resonance imaging) and lumbar puncture. The results show multiple lesions and scarring on daisy spinal cord, a diagnosis of Multiple Sclerosis (MS) is made. Daisy is promptly referred to a neurologist with speciality in treating patients with MS.

1. Provide a brief overview of the function of the nervous system
2. Describe the pathophysiology of multiple sclerosis (MS)
3. Discuss daisy’s signs and symptoms and link to the pathophysiology
4. Outline the main structures of the urinary system
5. Provide a brief overview of the function of our special senses.
6. Explain how the special senses of (smell, taste, vision, equilibrium and hearing) may be affect in people with multiple sclerosis (MS)and link to pathophysiology
7. Define the terms edentulousand dentate
8. Daisy is complaining of a tooth ache, explain how oral health diseasemay be impacting upon her.
9. Outline you assessment of daisy and your immediate actions
10. Name some other health professionals involved in Daisy’s care and their role (medical and allied health)

Case study one:

Mr John Allen (62 years, male), with a history of hypertension and COPD in under medication and medical consultation. He reported the emergency department of fever lasting for 3 days along with coughing, shortness of breath, and cough producing sputum that is dark green and thick. He also has reported of episodes of chest pain when exerted and he recently felt a crushing pain in the central chest radiating to his jaw while climbing stars. The pain subsided after sometime of rest. John is a smoker, moderately obese and sits for long periods of time. He follows a poor diet, and has a family history of heart attack.

Cardiovascular system components:

The cardiovascular system is comprised of the heart, blood vessels that form the circulatory system and blood. The circulation of blood occurs via two loops: Systemic loop (circulating blood through the body) and Pulmonary loop (circulating blood through the lungs). The blood vessels are of three types, Arteries (carrying oxygenated blood from the heart, except Pulmonary artery), Veins (carrying deoxygenated blood to heart, except Pulmonary Vein), and Capillaries (that interconnects the arteries and veins, and innervates the tissues). In addition, portal systems also exist that connects one organ to the other (like Hepatic portal system that connects the digestive system to the liver) (Rizzo, 2015).

[Figure 1: Cardiovascular system. Source: https://sphweb.bumc.bu.edu/otlt/mph-modules/ph/ph709_heart/ph709_heart2.html]

Functions of Cardiovascular system:

The cardiovascular system is responsible for the transport of oxygen, hormones, nutrients, and metabolic wastes in the body. The blood is circulated via two circuits- the pulmonary circuit that flows through the lungs and the systemic circuit that flows through the rest of the body. The white blood cells and antibodies that are circulated in the blood helps in protecting the body from pathogens, while the platelets and RBC’s help in blood clot formation and wound healing. The cardiovascular system also helps in the maintenance of homeostatic balance, regulated by the hypothalamus (Waldstei, & Elias, 2015).

[Figure 2: Respiratory System. Source: https://www.microbiologynotes.com/respiration-and-respiratory-organs/]

Components of respiratory system:

The respiratory system comprises of organs responsible for the absorption of oxygen from the environment, and allowing them to be picked up by the circulatory system. In humans, the respiratory system consists of the following parts: upper tract (that includes nose and nasal cavities, pharynx, sinus and the portion of the larynx that lies above the vocal cord), lower tract (that includes the lower larynx, trachea, the branching bronchi and bronchioles), and the terminal alveolar sacs. The lungs are supplied with blood via the pulmonary circulation path through Pulmonary artery (supplying venous blood to heart) and pulmonary vein (carrying oxygenated blood to heart) (Gilbert-Barness, Spicer & Steffensen, 2014).

Interaction between cardiovascular and respiratory systems:

The deoxygenated blood from the systemic circulation enters the pulmonary artery from the heart (right atrium). The pulmonary artery, after successive branching, forms arterioles and finally capillaries that line the alveolar sacs. Transport of oxygen occurs through the single cellular walls of the capillaries and alveoli. CO2 from the venous blood enters the alveoli, while O2 from the alveoli enters the blood (combining with Hemoglobin) thereby oxygenating it. This exchange is facilitated by the difference in partial pressures of O2 and CO2 in the blood and lungs. The oxygenated blood in the lungs flows from the capillaries, that unites to form the pulmonary vein that circulates back the oxygenated to to the body (Morton et al, 2017).

Effect of age on cardiovascular system: 

Ageing can cause changes both in the heart and blood vessels, thereby affecting the cardiovascular system (Chiao at al., 2016):

Effect on Heart: Detoriation of the Sino arterial (SA) node, causing a slower heart rate. Thickening of the walls of the heart causes a decrease in its blood volume capacity. Cardiac arrhythmias caused due to the changes in heart. Deposition of specific pigments called lipofuscin in the heart. Degeneration of the cardiac muscles and stiffening of the valves also can be a common effect.

Effect on Blood Vessels: Degeneration of the baroreceptors often causing orthostatic hypotension. Thickening of capillary walls causes the slowed rate of diffusion of substances through them. Thickening of aorta causes hypertension and increasing stress to the heart.

Effect on Blood: Decrease in blood volume, slower production of RBC and decrease in the number of neutrophils.

Common problems that can occur due to these changes are: Angina, Arrhythmia, Anemia, Arteriosclerosis, Congestive cardiac failure, coronary artery disease, hypertension, aortic stenosis and transient ischemic attacks.

Effect of age on respiratory system: 

Ageing can cause changes in the bones and muscles of spine and chest, lung tissue, and the nervous system that have an overall affect on the respiratory system (Bonomini, Rodella & Rezzani, 2015).

Effect on muscle and bones of spine and chest: Bones become thin, and changes shape, thus limiting movement of rib cage and can also cause weakening of diaphragm.

Effect on lungs: Muscles and tissues at the airways can degenerate, thereby unable to keep the passage properly open. Alveoli can lose their shape.

Effect on nervous system: Brain centers that regulate respiration can be affected. Nerves that trigger coughing can have had a reduced sensitivity.

The common problems that occur due to these changes are: lung infections (like pneumonia or bronchitis), abnormal breathing or shortness of breath, low levels of O2.

Pathophysiology of Angina: 

This is a form of chest pain caused due to improper blood flow to the heart muscles. This can be due to obstruction of the coronary artery. The obstruction is caused due to the development of myocardial ischemia. During this process, adenosine that is degraded from ATP diffuses to the extracellular space, causing arteriolar dilation and pain. This creates an oxygen demand in the myocardial cells, and a switch to anaerobic metabolism.

Signs and symptoms include: pain in the chest accompanied by a feeling of tightness/ heaviness/ burning/ choking sensation/ pressure (Kaski, 2016).

Pathophysiology of Emphysema:

This condition is caused due to damage to the alveoli, thereby reducing oxygenation of blood. Inflammatory immune response in the epithelial layer of the lungs (due to noxious substances) causes the transport of antigens to the BALT (bronchial associated lymphatic tissue layer). Release of proteolytic enzymes and proteases, free radicals, cytokines, growth factors causes a destruction of the epithelial layers of the lungs followed by improper regrowth of the alveoli and epithelium. The newly formed alveolar layers are larger, and inefficient, thereby reducing the efficiency of lungs.

Signs and symptoms include pain in chest, shortness of breath, persistent wheezing cough (Goldklang & Stockley, 2016).

Risk factors shared between Angina and Emphysema

The common risk factors shared between Angina and Emphysema are:

• Age- above 45 for males and above 55 for females.
• Smoking
• Hypertension
• Obesity
• Physical inactivity
• Family history of cardiovascular disease
• Stress

(Brusselle, Bracke, & De Pauw, 2017)

Outline of assessment, and immediate suggested actions:

The patient has a medical history of Emphysema, with a recent history of fever, coughing, shortness of breath, and dark sputum. The occurrence of sharp chest pain radiating to the jaw can be attributed to Angina and the development of myocardial ischemia. Since the patient shares a lot of risk factors (like smoking, obesity, physical inactivity and a family history of cardiac dysfunction), the following tests needs to be done for the patient: ECG/EKG, Stress Test, Echocardiogram, Nuclear Stress Test, Chest X ray, Blood test, Coronary Angiogram, CT scan. These tests can detect any structural or functional change in the heart (Doenges, Moorhouse & Murr 2016).

Healthcare professionals involved in John’s care and their roles

General Physician- involved in providing primary medical help. Emergency Department- providing emergency medical help. Emergency Registrar- providing emergency medical help. In addition, the patient needs to consult a dietician, and counseling to improve his diet and reduce or stop smoking.

Artificially Acquired Immunity

Artificially Acquired Immunity refers to the induction of an immune response artificially, on a controlled scale, in order for the body to create an immune memory. The procedure is also called vaccination (like FluVax), and it involves injection of an antigen in a form that will not cause the disease, but will invoke the immune response. Invoking this response allows the body to memorize the antigen, and self-initiate a second response upon re-exposure (Aickelin, Dasgupta, & Gu 2014).

It can be concluded that the episodes of pain is related to the patient’s medical history of COPD and shows signs of Emphysema and Angina and has the risk of developing myocardial ischemia. The patient is in the risk group due to his lifestyle and food habits.

Case study two:

Isabella Pearsons (30 year, female) with history of feeling jittery and unwell and experienced symptoms like: weight loss, increased appetite, loose bowel actions, restlessness and inability to sleep, hand tremors, heart palpitations. She has a high level of T4 and T3 hormones in blood and low levels of TSH. The blood test also shows Hyperthyroidism (Grave’s Disease).

Endocrine System:

This is a collection of hormone secreting glands like pineal, pituitary, hypothalamus, pancreas, testes, ovaries, thyroid and parathyroid and adrenal glands. These ductless glands secretes the hormones directly into the circulatory system by which it can regulate distant tissues. These glands can have regulatory effect on each other, and is controlled by the nervous system (Hypothalamus). In addition, few organs also have secondary endocrine activities, like bone, liver, kidney and heart (Tang et al., 2017).

[Figure 3: Endocrine System. Source: https://www.pinterest.com/ghkageyama/endocrine-system/]

Function of the Endocrine System:

Endocrine System acts like information signaling system, as in case of nervous system, however acting much slower than them, with the effects being more prolonged, and following different mechanism. The system regulates the metabolic activities of distant tissues, mediated by the action of hormones that are secreted into the circulatory system. The system is controlled by the Hypothalamus. Often the signals are transmitted sequentially from one gland to the other, following an axis (hypothalamic-pituitary-thyroid axis) (Tang et al., 2017).

Pathophysiology and risk factors of hyperthyroidism (Grave’s disease):

Grave’s disease is one of the most common causes of Hyperthyroidism (Menconi, Marcocci & Marinò, 2014). This is an autoimmune disease; excess amount of thyroid hormone is produced due to Thyroid Stimulating Immunoglobins (TSI) type IG1. These immunoglobulins bind to and activates the TSH receptors (on the extracellular domain), causing the secretion of thyroid hormone. The release of TSI can be stimulated by viral or bacterial infection of thyroid.

The risk factors for developing Grave’s disease are:

• Gender- Females are more prone.
• Family History
• Stress
• Other autoimmune disease- increases the risk of developing Grave’s disease.

Clinical review of Isabella Pearson:

Blood test conducted on the patient shows elevated levels of T4 (thyroxine) and T3 (tri iodo thyronine), while suppressed levels of TSH hormones. This suggests hyper secretion of thyroid gland. The patient has also reported being jittery and unwell the last six weeks, and have lost weight, bowel action, and getting hand tremors and heart palpitations. Since thyroid hormone is crucial for the normal cellular function, an excess of the hormone over stimulates metabolism while exacerbating the effect on sympathetic nervous system.

Main structures of the digestive system:

The human digestive system comprises of the GI (Gastrointestinal) tract, accessory organs involved in digestion like pancreas, liver and gall bladder, and additional components like mouth, salivary glands, tongue, teeth, epiglottis (Rizzo, 2015). The GI tract starts with the mouth and ends with the anus, and consists of the esophagus, stomach, small intestine and large intestine.

[Figure 4: Digestive system. Source: https://www.tes.com/lessons/ei0o19ZpUQwA9A/summer-school-biology-project-digestive-system-resources]

Normal function of Digestive system:

The primary function of the digestive system is the digestion and absorption of nutrients from food (Rizzo, 2015). The food is treated by the following processes:

• Ingestion
• Propulsion of food due to peristalsis
• Secretion of enzymes that breaks down the food, liquefies it, and adjusts the pH
• Mechanical digestion by breaking the food in small pieces
• Chemical digestion by enzymes
• Absorption of the nutrients from the digestive tract into the adjacent blood/ lymph channels.
• Defecation of the undigested matter.

Main Function of the Immune System:

The main function of the immune system is to provide protection from environmental agents like microbes or chemicals. The immune system can differentiate between self and the response to non self. The immune system can be categorized as acquired immunity and innate immunity. The system contains cellular components like the WBC and molecular components like antibodies. These components work to bind the invading antigen, and remove it from the body (Abba, Lichtman & Pillai, 2014)

 Pathophysiology of an Autoimmune disease (Multiple Sclerosis):

Autoimmune disease occurs when the body’s immune system is unable to differentiate between self and non-self cells, and produces an immune response against the healthy body cells.

Multiple Sclerosis is an autoimmune disease that is caused due to action of activated immune cells on the nervous system, causing inflammatory demyelination. This results in the formation of lesions. Examination of the lesions reveals deterioration of oligodendrocytes, myelin loss, reactive astrogliosis, and damage to axon cylinder (Lublin et al., 2014).

Assessment of Isabella, and recommended actions:

The patient is showing symptoms of Hyperthyroidism, evidenced by the blood report and her usual physical state. It is therefore necessary to determine the cause of overstimulation of the thyroid gland. Study of radioiodine uptake and TSI antibodies can be suggested to determine the cause. For treatment, the patient can opt for radioiodine therapy (ingesting iodine 131), medication (beta blockers and anti-thyroid drugs) or surgical removal of thyroid gland. Additionally a diet should also be maintained to limit the consumption of iodine (Jonklaas at al., 2014).

Additional health professional involved:

General Physician and hematologists was consulted by the patient. The patient also needs to consult endocrinologist and dietician. If surgery is needed, the patient needs to consult a surgeon. The general physicians are involved in providing general medical assistance and healthcare. The hematologists and laboratory technicians are involved in diagnosis and testing. Endocrinologists are involved in analyzing the endocrine function/ dysfunction of the patient.

Her usual symptoms and physical condition is evidence for Hypothyroidism. Therefore it is important to identify the cause of the overstimulation of the thyroid gland, for which radioiodine uptake analysis and TSI antibody analysis can be done. The patient should be recommended medications, radio iodine therapy and diet control.

Case study three:

Daisy Mae (21 year, female) having episodes of blurry vision, bilaterally numbness in legs, urinary urgency, poor memory and problems with balance. She is married with 2 children (age 1 and 2), and works part time in a family business. She is very active active taking care of her family and participates in regular sporting activities. She does not smoke, maintains a healthy diet and has no other relevant past medical history. Daisy reports an increase in her symptoms since the birth of her youngest child, at times the symptoms improve but she notices at times they affect her activities of daily living. She reports also that she has been experiencing intermittent severe jaw pain, much like a tooth ache.

Results from MRI and and Lumbar Puncture shows Multiple Sclerosis.

Overview of the function of Nervous System:

The primary function of the nervous system is to transmit/ relay signals. The signals can flow from one cell to next or from one part of the body to another. It works faster and with higher specificity than hormones, and the signals are conducted via nerve cells. The nervous system therefore helps in the control and coordination of the body. It can acquire/ pick up stimuli from the environment from receptors, and send them to the nervous system for processing, and transmit the response to effectors (Nieuwenhuys, Hans & Nicholson, 2014). In humans, the nervous system is responsible for language, abstract representation, transmission of memes, and basically underlies every form of human interaction.

[Figure 5: Nervous system, schematics. Source: https://www.news-medical.net/health/What-is-the-Nervous-System.aspx]

[Figure 6: Nervous system. Source: https://www.pinterest.com/pin/96545985739385039/]

Pathophysiology of Multiple Sclerosis:

This disease is caused due to action of activated immune cells on the nervous system, causing inflammatory demyelination. This results in the formation of lesions. Examination of the lesions reveals Detoriation of oligodendrocytes, myelin loss, reactive astrogliosis, and damage to axon cylinder. The symptoms include visual changes, weakness, paralysis, vertigo, urinary retention or incontinence, muscle spasticity, bad muscle coordination, fatigue, tremor (Solaro, Trabucco & Uccelli, 2013).

Discussion of the patients sign and symptoms in relation to Pathophysiology:

The patient shows symptoms of nervous damage, and results from MRI and lumbar puncture shows scarring and lesions of the spinal cord that supports the conclusion (Solaro, Trabucco & Uccelli, 2013). The blurred vision, numbness of legs, urinary urgency, and memory and balance problems suggests symptoms of MS.

Main structure of Urinary system:

Urinary system, also called the renal system comprises of kidneys, ureters to each kidney, urinary bladder, and urethra. The kidney consists of millions of nephron, which are the functional units, responsible for the filtration of blood. The nephron converges to form the collecting ducts that further converge to form minor and major calyces that finally join the pelvis of kidney (Rizzo, 2015).

Overview of special senses:

Special senses are those that specialized organs dedicated to collect their stimuli, and the organs include: The eye (that collects visual stimulus, within the visible spectrum of light), Ear (that collects stimulus transmitted by audible mechanical waves and helps in maintaining balance and coordination), Nose (that collects olfactory stimulus) and Tongue (that collects information about taste via chemoreceptors) (Wullimann, 2017).

[Figure 7: Sensory receptors and organs. Source: https://slideplayer.com/slide/5698037]

Effect of MS of sense organs:

One of the most common symptoms of MS is sensory problems, due to the loss or change of sensitivity of neurons caused by the lesions. A tingling sensation, numbness weakness and blurred vision are also common in MS, further evidencing neurological damage. These lesions prevent proper signaling at the nerve synapse, causing a dysfunction in the associated nerve cluster or sensory organ (Solaro, Trabucco & Uccelli, 2013).

Edentulous and Dentate:

Edentulous also called toothlessness, or a condition of having missing teeth. It can be partial or complete.

Dentate is the condition of having/ developing teeth or teeth like projections.

Effect of Oral Health issues:

The patient is experiencing intermittent jaw pain, like that of tooth ache. This can suggest a lack of oral care, or an oral health issue that can underlie the tooth ache. It is vital to maintain a good oral health and hygiene since the mouth forms the entry point of the alimentary canal, and can serve as the weak spot for pathogen invasion if not well protected (Halvari et al., 2013). Few of the symptoms experienced by the patient can have an underlining of oral health problem.

Assessment of the patient, and suggested diagnosis:

The patient has a healthy lifestyle, but is experiencing symptoms of neuronal degeneration and MS. This is evidenced by the routine checks done on the patient. Since the condition have no treatment, the patient can be suggested for therapy to manage the symptoms. Administering intravenous corticosteroids can be considered to manage acute attacks of MS. Relapsing MS can be subjected to disease modifying treatments (like interferon beta 1a/ 1b, glatiramer acetate or mitoxantrone) (Wingerchuk & Carter, 2014). Alternative medicine can also be suggested for the patient like using dietary supplements, Vitamin D, relaxation and yoga techniques, herbal medicine like cannabis, acupuncture, hyperbaric oxygen chamber therapy and reflexology.

Other healthcare professionals involved:

Apart from the general physician, the other professionals involved are neurologists, laboratory technicians, nurse, dieticians and alternative medicine practitioners. The general physicians are involved in providing general medical guidance and healthcare. Neurologists are involved in the study of the neuronal lesions cause by MS, and its effects. Dieticians are required to suggest the patient the proper diet she needs to follow. Laboratory technicians and nurses are involved in the diagnostic and therapeutic process. Alternative medical practitioners can provide additional methods to manage the symptoms of MS.

Patient is facing symptoms of neurological degeneration and lessoning. The condition has not treatment; however different therapeutic and management strategies can be utilized to manage the symptoms. The patient can also opt for alternative medications and lifestyle support.

References:

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Wullimann, M. F. (2017). Nervous System Architecture in Vertebrates. The Wiley Handbook of Evolutionary Neuroscience, 236-278.