multiple sclerosis - Nursing Case Study
Pathophysiology
• Primary mechanism: MS is primarily an autoimmune disease where the body's immune system mistakenly attacks myelin, the protective sheath covering nerve fibers in the CNS. This leads to communication problems between the brain and the rest of the body.
• Secondary mechanism: The chronic inflammation from the autoimmune response leads to axonal damage and neuronal loss, which further exacerbates the neurologic symptoms and disability in MS patients.
• Key complication: Over time, the disease can cause permanent damage and deterioration of the nerves themselves, leading to severe complications such as impaired mobility, cognitive changes, and decreased life expectancy.
Patient Profile
Demographics:
58 years old, Female, Former school teacher
History:
• Diagnosed with Multiple Sclerosis 15 years ago, history of hypertension, diabetes, and recurrent urinary tract infections
• Current medications include Interferon beta-1a, Baclofen, Gabapentin, Losartan, Metformin, and Trimethoprim-sulfamethoxazole
• Allergic to Penicillin resulting in rash
Current Presentation:
• Chief complaint of increasing weakness, difficulty walking, frequent falls, increased confusion, and a new onset of slurred speech
• Key symptoms include muscle spasms, fatigue, dizziness, numbness or weakness in limbs, and chronic pain
• Critically abnormal vital signs: Blood pressure is 180/110 mmHg, Heart rate is 110 beats per minute, Respiratory rate is 24 breaths per minute, Temperature is 38.5 Celsius, and Oxygen saturation is 88% on room air.
Section 1
New Diagnostic Results:
Upon further testing, the patient's blood glucose levels were found to be critically elevated at 450 mg/dL, suggestive of uncontrolled diabetes. An immediate test for HbA1c confirmed poor blood sugar control over the past few months, with a value of 9.5%. In addition, urinalysis revealed a high white blood cell count, indicating another urinary tract infection, a frequent complication in MS patients due to bladder dysfunction.
Given her hypertensive crisis, an EKG was ordered and showed signs of left ventricular hypertrophy, a common complication of chronic hypertension. Furthermore, an MRI of the brain revealed new demyelinating lesions, corroborating her worsening neurological symptoms.
These findings are significant as they reflect the complexity of managing multiple comorbid conditions in a patient with advanced MS. The uncontrolled diabetes and recurrent urinary tract infection could be exacerbating her MS symptoms and could potentially lead to sepsis. The hypertensive crisis and left ventricular hypertrophy pose a significant risk for cardiovascular complications, including heart failure and stroke. The new demyelinating lesions confirm disease progression and may be contributing to her increased weakness, difficulty walking, and cognitive changes.
Section 2
Change in Patient Status:
Shortly after the tests, the patient's status rapidly deteriorated. She became increasingly dyspneic, with a respiratory rate climbing to 28 breaths per minute, oxygen saturation dropping to 88% on room air, and she began to show signs of altered mental status. She was struggling to answer questions, had slurred speech, and seemed confused. Her blood pressure remained elevated at 180/95 mmHg. The change in her mental status, in combination with her respiratory distress and persistently high blood pressure, raised the concern for possible hypertensive encephalopathy.
On neurologic exam, her muscle strength was significantly reduced compared to the initial assessment, particularly on the right side, with a power of 3/5 in both the upper and lower limbs. She was also noted to have an increased tone and brisk deep tendon reflexes on the right side, suggestive of a new upper motor neuron lesion. These findings, along with her worsening cognitive status, are concerning for a possible acute MS exacerbation or even a stroke.
This sudden deterioration makes it imperative to rapidly control her blood pressure and blood glucose levels while also addressing her respiratory distress and possible underlying infection. The team must promptly decide on the best course of action to manage these multiple life-threatening complications concurrently while not overlooking the primary neurological pathology.
Section 3
New Diagnostic Results:
The patient's rapid deterioration prompted immediate further evaluation. A stat CT scan of the head was ordered to rule out a potential stroke. The results showed no acute intracranial hemorrhage or ischemic changes, but there was evidence of new demyelinating lesions in the periventricular white matter, suggestive of an acute MS exacerbation. Blood cultures were also drawn due to her fever and tachycardia, to investigate the possibility of an underlying infection.
In addition, a chest X-ray was performed given her worsening respiratory status, which revealed bilateral infiltrates consistent with a possible pneumonia. This could explain her decreased oxygen saturation and increased respiratory rate. Laboratory findings showed a blood glucose level of 250 mg/dL, leukocytosis with a white blood cell count of 15,000 per microliter, and elevated C-reactive protein levels indicating systemic inflammation. The combination of these diagnostic findings suggests the patient is experiencing an acute MS exacerbation, complicated by a likely pneumonia and poorly controlled hypertension and hyperglycemia. The clinical team now faces the challenge of managing these concurrent crises, while also determining the optimal treatment plan for her newly detected MS exacerbation.
Section 4
Change in Patient Status:
Overnight, the patient's condition deteriorated further. Her fever spiked to 39.6°C (103.3°F) and her respiratory rate increased to 28 breaths per minute. Saturation levels on room air plummeted to 88%, necessitating supplemental oxygen via nasal cannula at 4 litres per minute. Additionally, she developed increased lethargy and became increasingly disoriented and agitated, making it difficult for her to cooperate with the medical team's instructions. This significant change in her neurological status, in addition to her worsening respiratory status, is concerning for a possible septic shock secondary to pneumonia, a common complication in patients with compromised immune systems, such as those with severe MS exacerbations.
Her blood pressure readings also remained persistently high at around 180/100 mmHg, despite the initiation of an antihypertensive regime. Moreover, her blood glucose levels continued to elevate, reaching 300mg/dL, indicating uncontrolled diabetes. This clinical picture points towards a potential diagnosis of a hyperosmolar hyperglycemic state, a severe and life-threatening complication of diabetes. This is a critical point in her care, requiring immediate aggressive medical management of her infectious process, hypertension, hyperglycemia, and MS exacerbation, while also maintaining a high level of suspicion for any emergent complications.
Section 5
New Diagnostic Results:
Following her change in status, a range of diagnostic tests were ordered. A repeat chest X-ray showed progressive bilateral infiltrates suggestive of pneumonia, supporting the suspected diagnosis of septic shock secondary to pneumonia. Additionally, blood cultures were drawn and sent to the lab for further study.
Her complete blood count revealed a leukocytosis of 18,000 cells/mm3, with a left shift, indicating an active infection. Her elevated procalcitonin level of 2.5 ng/mL also pointed towards a bacterial infection, further reinforcing the suspicion of septicemia. In addition, her high glucose levels were confirmed by an elevated HbA1c of 11%, indicating poor long-term glycemic control. Her serum osmolality was also high at 320 mOsm/kg, supporting the diagnosis of a hyperosmolar hyperglycemic state.
Her MS was evaluated using a gadolinium-enhanced MRI, which showed multiple new enhancing lesions in the brain and spinal cord, suggesting an active exacerbation of her MS. The combination of septic shock, uncontrolled hypertension, hyperglycemia, and an MS exacerbation, along with the new diagnostic findings, point towards a critical juncture in her care, necessitating a multifaceted and aggressive treatment approach.