My Clinical Experience
As an advanced practice nurse student, there are various clinical experiences that I have gained during this very last week. Some of the most crucial areas that have required much experience are the ones involving my performance and comprehensive assessments while managing this older generation that can present with various chronic health problems. Additionally, I will say that this experience also involves utilizing knowledge and coming with plans to reduce illness among them and how better with the help they need in a way that is actually best for them due to their age limitation. As an NP student, I have learned that it is important to ensure collaboration in care management, promoting a comprehensive primary care provider can determine how well and fast we can provide and really help this patient in a more productive and effective way.
There are various challenges and successes that I have faced while in this practice. Some of these challenges involve incorporating family beliefs in treating patients in general. Further, assessing some of the specific patient illnesses has coped with various challenges, especially from family members who are not supportive of this practice. On the other hand, some of the successes include integrating various backgrounds and considering the different individuals’ beliefs in care provision. I have also ensured that family members’ have involvement while deciding and designing the best therapy for their loved ones. Worth noting, developing strategies to be used in the provision of primary care. Most importantly, the success we can have while treating these patients can be attributed to the fact of having various approaches used while managing various diseases.
Chief complaint: Extreme tiredness
A 73-year-old woman is in 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 started to become unsteady on her feet for a while now. She has had no significant previous medical illnesses she can refer to. She is a retired teacher and lives alone. For the past 2 years, she is 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 medication. Her mother and one of her two sisters have 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 is 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, apallesthesia, and Romberg test positive.
- 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.
- 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 is 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.
- Complete CBC and differential.
- Mean corpuscular volume (MCV).
- Complete metabolic panel.
Cervical and Thoracic MRI
Somatosensory evoked potential (SSEP) (Gilman et al., 2018).
In my opinion, this patient has severe macrocytic anemia and neurological signs due to vitamin B12 deficiency. This can cause macrocytic anemia reducing tissue oxygenation and therefore affecting most organ systems. The symptoms and signs of anemia depend on its rapidity of onset. 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. The white cell count is usually moderately reduced. There is often a mild rise in serum bilirubin giving the patient a ‘lemon-yellow complexion. As in this patient, profound vitamin B12 deficiency also causes 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, it 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).
There are various lessons that I have learned in the clinical experience of this week that are beneficial to my practice and to my development as a Nurse Practitioner. First, as an advanced nurse practitioner, it is important to ensure that there is the incorporation of the family’s beliefs during the provision of treatment. Additionally, ensuring that patients’ education is handled correctly while managing their condition is important to ensure that they take proper care, hence always promoting their wellbeing. It is also important to consider patients’ beliefs and other spiritual aspects that go hand in hand with treatment during care provision. Care coordination is also essential for advanced nurses since they can deal with different professionals than can contribute with their knowledge to the improvement of the patient health and diagnosis. Competent advanced nurse practitioners can ensure that they coordinate their patients’ activities and ensure that they receive proper treatment depending on their specific health problems.
Additionally, nurses also have a responsibility to advocate for their patient’s needs and ensure that the provision of evidence-based practice needed is meet. Importantly, I have learned the importance of ensuring the use of proper plans during care provision for different patients. These plans should also promote the patients’ health and wellness, hence reducing the rate of risks and infections that can come along while treating a patient.
Antony, A. C. (2018). Megaloblastic Anemias. Hematology, 514-545.e7.
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).
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.
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.
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.v. 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.