|Due By (Pacific Time)
||08/10/2017 12:00 pm
Endocrine and Musculoskeletal Conditions
Case Study 1
A 33-year-old Caucasian female presents with concerns about a four-month history of diffuse musculoskeletal pain and stiffness associated with fatigue and dry eyes. The pain varies with the weather and is worse in the morning. Her menstrual periods are irregular and she has frequent dyspareunia. Physical exam is remarkable for pain at different points all over the body, including neck, back, chest, elbows, hips, buttocks, and knees.
Based on the information above, Tharpe, Farely & Jordan (2017) begin their focus on the complaints of the symptoms that the patient presents with including the location of the pain including unilateral or bilateral, the onset, duration, relief, and severity. Many of those answers can provide the advanced practitioner with simple answers such as an acute injury or trauma versus a chronic injury. This patient complains of pain in all of her joints for about 4 months long. That tells me that along with her other symptoms, this is probably not the result of general aches associated with some sort of injury. Also, fatigue, dry eyes, irregular menses, and dyspareunia are providing other clues that need to be considered.
Diagnosis: Sjogren’s Syndrome
Sjogren’s syndrome is a disease in which the immune system targets the glands that make moisture, such as tears and saliva. The Mayo Clinic (2014) states that two main symptoms of Sjogren’s Syndrome are dry eyes and dry mouth. Other associated symptoms can include the following:
- Joint pain, swelling and stiffness
- Swollen salivary glands — particularly the set located behind your jaw and in front of your ears
- Skin rashes or dry skin
- Vaginal dryness
- Persistent dry cough
· Prolonged fatigue
(Mayo Clinic, 2014).
This patient has presented with several of these symptoms as well and her complaint of dyspareunia can be attributed to the vaginal dryness.
Rheumatoid Arthritis (RA):
RA is a disease in which the immune system attacks the lining of the joints throughout the body. painful, stiff, swollen, and deformed joints, reduced movement and function may have: fatigue, fever, weight loss, eye inflammation, lung disease, lumps of tissue under the skin, often the elbows, anemia (Office on Women’s Health, 2016).
The immune system is designed to attack foreign substances in the body. If you have lupus, something goes wrong with your immune system and it attacks healthy cells and tissues. Symptoms include: Pain or swelling in joints, muscle pain, hair loss, fatigue, swelling around eyes, red rash-most often to face (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2014).
Surgery can be done to close the tear duct drains, which would allow moisture to stay in the eyes and not drain away (Mayo Clinic, 2014).
This patient may use lubricating eye drops to help with her eye dryness. NSAID’s such as Motrin 600mg-800mg PO, tid can be taken for joint discomfort. Plaquenil, which is a antirheumatic/immunosuppressive drug) 200mg-400mg PO (maximum dose 6.5mg/kg/day), divided either qd or bid for pain relief as well.
Patients can increase their daily water intake to help with dryness. Water based lubricants can be used to during relations which may resolve the complaint of dyspareunia. Increasing indoor humidity (if possible) may help eye dryness along with avoiding sitting in front of a fan.
Treatment for Sjogren’s Syndrome is based mostly on relief of symptoms for the patient. Because primary Sjogren has been linked to other illnesses, the advanced practitioner should be on the lookout for signs and symptoms of other diseases. There is no definitive evidence to support screening guidelines for lymphoproliferative diseases in patients with Sjogren’s syndrome, the following features should raise the physicians index of suspicion: enlarged parotid glands, regional or general level adenopathy hepatosplenomegaly, pulmonary infiltrate, vasculitis, hypergammaglobulinnemia (Kruszka, & O’Brian, 2017).
Kruszka, P., & O'Brian, R. (2017). Diagnosis and Management of Sjogren Syndrome. In American Family Physician. Retrieved August 7, 2017, from http://www.aafp.org/afp/2009/0315/p465.html
Mayo Clinic. (2014, July 8). Sjogren's syndrome. In Mayo Clinic. Retrieved August 7, 2017, from http://www.mayoclinic.org/diseases-conditions/sjogrens-syndrome/basics/definition/con-20020275
National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2014, November). What Is Lupus? Fast Facts: An Easy-to-Read Series of Publications for the Public. In National Institute of Arthritis and Musculoskeletal and Skin Diseases. Retrieved August 7, 2017, from https://www.niams.nih.gov/health_info/lupus/lupus_ff.asp
Office on Women’s Health. (2016, April 28). Autoimmune diseases. In Office on Women’s Health. Retrieved August 7, 2017, from https://www.womenshealth.gov/a-z-topics/autoimmune-diseases
Tharpe, N. L., Farley, C., & Jordan, R. G. (2017). Clinical practice guidelines for midwifery & Women’s health (5th ed.). Burlington, MA: Jones & Bartlett Publishers.
Case Study 3
A 28-year-old Caucasian female comes to clinic concerned about three episodes of urinary incontinence associated with difficulty walking. The first two episodes resolved spontaneously after a couple of days without residuals, but this current episode has lasted a week. Today she began to have some blurred vision. Physical exam is remarkable for mild edema of the optic disc and difficulty with heel-to-toe walking. Deep tendon reflexes are 2+ and there is no extremity weakness.
1. Multiple Sclerosis (MS)- See Primary Diagnosis.
2. Stress incontinence- Involuntary leakage with effort or physical exertion, sneezing, or coughing (Schuiling & Likis, 2017). This is not associated with vision loss or difficulty walking so this can be ruled out.
3. Optic Neuritis- Occurs more often in younger adults, 20-50 years old and can be idiopathic or associated with MS (Dains, Baumann, & Scheibel, 2016). This can be caused by a viral infection. Not associated with urinary incontinence and difficulty walking unless related to MS.
Multiple sclerosis is an immune-mediated inflammatory disease that attacks myelinated axons in the central nervous system (Medscape.com, 2017). Prevalence of MS is higher in women and is usually diagnosed in persons aged 15-45 years, but can occur at any age. Symptoms include loss of vision, urinary incontinence, muscle spasticity, and loss of motor function (Medscape.com, 2017). Relapsing-remitting MS is the most common type and is characterized by recurrent attacks in which neurologic deficits appear in different parts of the nervous system and resolve over a short period of time (Medscape.com, 2017).
Treatment Plan and Education
A diagnostic test that would be ordered for this patient is magnetic resonance imaging (MRI) of the brain/spine because this is the procedure of choice for confirming MS. The treatment of MS is geared towards relieving symptoms of acute exacerbations, shortening the duration of relapse, reducing frequency of episodes, and preventing disease progression (Medscape.com, 2017). Immunomodulators are drugs indicated for the treatment of relapsing forms of MS. They help slow physical disability and decrease the frequency of exacerbations. Interferon beta 1b 0.0625mg SC every other day to be gradually increased every 2 weeks by 0.0625mg to reach 0.25mg is the recommended dosage regimen for MS (Medscape.com, 2017). Corticosteroids such as Solu-medrol and Prednisone can be used to treat acute exacerbation symptoms. Detrol 2mg PO BID can be used to treat and control urinary incontinence. The patient may benefit from taking over the counter Vitamin D 500 IU daily to reduce relapse rate. The patient will need to be educated regarding giving self SQ shots and keeping with the medication regimen. She will be given written material pertaining to her diagnosis and symptom management. This patient will need a neurology, ophthalmology, and possibly a urology consult.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Medscape.com. (2017). Multiple Sclerosis. Retrieved from http://emedicine.medscape.com/article/1146199-differential
Schuiling, K. D., & Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett Publishers.