NUR 612 Weekly Clinical Experience and Patient Assessment Discussion Reply

Discussion Response:

Weekly Clinical Experience

My clinical experience for this week has been fulfilling, dynamic, and successful. The clinical environment throughout the week has been amicable characterized by a lot of learning. I enjoyed working with assistive clinical practitioners alongside the very helpful mentors who walked with me during the week. With the help of mentors, I had a successful clinical practice. Besides, I got to interact with patients who opened up to me regarding their illnesses and conditions. Therefore, I learned a lot during the week and gained more confidence in clinical practice.

Patients Assessment

Chief complaint: Extreme tiredness and numbness.

HPI:

A 73-year-old woman came to the office today complaining of extreme tiredness. She has been increasingly fatigued over the past year, but in recent weeks she has become breathless on exertion, light-headed, and complained of headaches. Her feet have become numb, and she has started to become unsteady on them. She has had no significant previous medical illnesses. She is a retired teacher and lives alone. During the last 2 years, she has been active, walking 3 or 4 miles a day. She is a non-smoker and drinks about 15 units of alcohol per week. She is taking no regular medications. Her mother and one of her two sisters have a prior history of thyroid problems.

Focus Health Assessment:

Her conjunctivae are pale and her sclerae are yellow. Her temperature is 37.8°C. Her pulse rate is 96/min regular, and her blood pressure 142/72 mmHg. Examination of her cardiovascular, respiratory, and abdominal systems is normal. Neurological exams show a symmetrical distal weakness affecting her arms and legs. Knee and ankle jerks are absent, and she has extensor plantar responses. She has sensory loss in a glove and stocking distribution with a particularly severe loss of joint position sense. Global deeps reflex decreased 1+, distal hypoesthesia, paresthesia, and Romberg test with a positive result.

Diagnosis

  • Posterior cord syndrome G83. 83: is a rare type of incomplete spinal cord injury that affects the dorsal columns of the spinal cord. Posterior cord syndrome typically presents with sensory ataxia or impaired voluntary movement coordination caused by a lack of proprioception. Sensory ataxia can result in decreased balance, poor coordination, unsteady walking, and frequent falls. These symptoms typically worsen in dark environments or when a person closes their eyes, as the body can no longer rely on sight to maintain balance (Gilman et al., 2018). In addition, some individuals may experience sensory losses including an impaired sensation of vibration and fine touch, while their sensation of pain and temperature is preserved.

Differential Diagnosis:

  • Vitamin B12 deficiency anemia, unspecified- D51. 9: Vitamin B12 deficiency is associated with hematologic, neurologic, and psychiatric manifestations. It is a common cause of macrocytic (megaloblastic) anemia and, in advanced cases, pancytopenia. Neurologic sequelae from vitamin B12 deficiency include paresthesia, peripheral neuropathy, and demyelination of the corticospinal tract and dorsal columns (subacute combined systems disease). Vitamin B12 deficiency also has been linked to psychiatric disorders, including impaired memory, irritability, depression, dementia, and, rarely, psychosis (Antony, 2018). In addition to hematologic and neuropsychiatric manifestations, vitamin B12 deficiency may exert indirect cardiovascular effects.
  • Multiple sclerosis is G35: This another cause of posterior cord syndrome, where the immune system attacks the protective sheath of myelin that covers nerve fibers and causes demyelinating disorders of the brain and spinal cord. Signs and symptoms of MS vary widely and depend on the amount of nerve damage and which nerves are affected. Numbness or weakness in one or more extremities typically occurs on one side of the body at a time (Matute-Blanch et al., 2018). Multiple sclerosis symptoms may also include slurred speech, fatigue, dizziness, tingling or pain in parts of the body, problems with sexual, bowel, and bladder function.
  • Acute transverse myelitis Management G37. 3: Transverse myelitis is an inflammation of both sides of one section of the spinal cord causing damages to the myelin. Transverse myelitis interrupts the messages that the spinal cord nerves send throughout the body. This can cause pain, muscle weakness, paralysis, sensory problems, or bladder and bowel dysfunction (Greenberg et al., 2019). There are four classic symptoms of transverse myelitis, weakness in the extremities, sensory symptoms such as numbness or tingling, pain, discomfort, bladder dysfunction, and/or bowel motility problems.

Plan:

Laboratory studies:

  • Complete CBC and differential.
  • Mean corpuscular volume (MCV).
  • Platelets
  • Complete metabolic panel.
  • Glucose

Brain MRI

Cervical and Thoracic MRI

EMC/NVC

Somatosensory evoked potential (SSEP) (Gilman et al., 2018).

In my opinion, this patient has severe macrocytic anemia, and the neurological signs are due to vitamin B12 deficiency. This can cause macrocytic anemia, reducing tissue oxygenation and therefore affecting most of the organ systems. The symptoms and signs of anemia depend on its rapidity of onset in the organism. Chronic anemia causes fatigue and pallor of the mucous membranes. Cardiorespiratory symptoms and signs include breathlessness, chest pain, claudication, tachycardia, edema, and other signs of cardiac failure (Ekabe et al., 2017). Gastrointestinal symptoms include anorexia, weight loss, nausea, and constipation. In pernicious anemia, the MCV can rise to 100–140 fL, and oval macrocytes are seen on the blood film. The reticulocyte count is inappropriately low for the degree of anemia that is present in the patient. The white cell count is usually moderately reduced. There is often a mild rise in serum bilirubin giving the patient a ‘lemon-yellow complexion. In this patient, profound vitamin B12 deficiency is also the cause of peripheral neuropathy and subacute degeneration of the posterior columns and pyramidal tracts in the spinal cord, causing sensory loss and increased difficulty walking. The peripheral neuropathy and pyramidal tract involvement produces the combination of absent ankle jerks and upgoing plantar. In its most extreme form, this can lead to paraplegia, optic atrophy, and dementia (Rita Carvalho, 2017). Vitamin B12 is synthesized by micro-organisms and is obtained by ingesting animal or vegetable products contaminated by bacteria. After ingestion, it is bound by an intrinsic factor, synthesized by gastric parietal cells, and this complex is then absorbed in the terminal ileum. Vitamin B12 deficiency is most commonly a gastric cause (pernicious anemia due to autoimmune atrophic gastritis; total gastrectomy), bacterial overgrowth in the small intestine destroying intrinsic factors, or malabsorption from the terminal ileum (surgical resection; Crohn’s disease) (Antony, 2018). The diagnosis of vitamin B12 deficiency has traditionally been based on low serum vitamin B12 levels, usually less than 200 pg. per mL (150 pmol per L), along with clinical evidence of disease. However, studies indicate that older patients tend to present with a neuropsychiatric disease in the absence of hematologic findings (Stabler, 2016).

Lessons Learned

I learned a lot during this week’s clinical experience. Firstly, I developed a positive attitude towards all patients. During my interactions with them, I realized they are suffering from a range of illnesses, and as a practitioner, I should do my best to ease their pain and improve their outcomes. I also got to reflect on Florence Nightingale’s message and dedication to nursing, requiring caregivers to promote all patients’ wellness with compassion. I gained a lot of knowledge on dealing with patients, bolstering my confidence in clinical practice. The art of teamwork was at the center of my clinical experience during the week. Therefore, I look forward to continuing with the practice in the coming weeks and expand my knowledge into clinical settings.

References

Antony, A. C. (2018). Megaloblastic Anemias. Hematology, 514-545.e7.

https://doi.org/10.1016/b978-0-323-35762-3.00039-1

Ekabe, C. J., Kehbila, J., Abanda, M. H., Kadia, B. M., Sama, C., & Monekosso, G. L. (2017). Vitamin B12 deficiency neuropathy; a rare diagnosis in young adults: A case report. BMC Research Notes, 10(1).

https://doi.org/10.1186/s13104-017-2393-3

Gilman, J. B., Ona, S. N., & McKinley, W. (2018). Poster 271: Ewing’s sarcoma causing epidural spinal cord compression and posterior cord syndrome: A case report. PM&R, 10, S90-S90.

https://doi.org/10.1016/j.pmrj.2018.08.283

Greenberg, B. M., Krishnan, C., & Harder, L. (2019). New-onset transverse myelitis diagnostic accuracy and patient experiences. Multiple Sclerosis and Related Disorders, 30, 42-44.

https://doi.org/10.1016/j.msard.2019.01.046

Matute-Blanch, C., Montalban, X., & Comabella, M. (2018). Multiple sclerosis, and other demyelinating and autoimmune inflammatory diseases of the central nervous system. Cerebrospinal Fluid in Neurologic Disorders, 67-84.

https://doi.org/10.1016/b978-0-12-804279-3.00005-8

Rita Carvalho, A. (2017). Vitamin B12 deficiency-induced psychosis – a case report. https://doi.org/10.26226/morressier.589b235bd462b8…

Stabler, S. P. (2016). Megaloblastic and nutritional Anemias. Nonmalignant Hematology, 113-123.

https://doi.org/10.1007/978-3-319-30352-9_12

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