3B Group 1C

A CASE STUDY ON P.A., A 40 YEAR OLD

FEMALE WITH MULTIPLE SCLEROSIS
Case Scenario
P.A. is a 40-year-old female admitted to CVGH PPS Ground Room 108 with complaints of tingling,
numbness and clumsiness of both hands for 1 week PTA, with a band of numbness from the
umbilicus to the axillae. Six months earlier, following an upper respiratory tract infection, she had
experienced paresthesia in the feet, numbness from the waist downwards and 'burning' pains
behind the right ear. She was anxious because her maternal grandmother had suffered from
multiple sclerosis.

On neurological examination, she had absent abdominal reflexes with brisk tendon jerks and
bilateral extensor plantar responses. Blood investigations were normal, including hemoglobin,
white-cell count and differential, erythrocyte sedimentation rate, vitamin B12 and folate levels and
syphilis serology. A lumbar puncture was carried out. 
CSF Investignation
MULTIPLE SCLEROSIS
Multiple sclerosis (MS) is a condition that can affect the brain and spinal
cord, causing a wide range of potential symptoms, including problems with
vision, arm or leg movement, sensation or balance. It's a lifelong condition
that can sometimes cause serious disability, although it can occasionally
be mild. In many cases, it's possible to treat symptoms. Average life
expectancy is slightly reduced for people with MS. It's most commonly
diagnosed in people in their 20s and 30s, although it can develop at any
age. It's about 2 to 3 times more common in women than men. MS is 1 of
the most common causes of disability in younger adults. 
WHAT CAUSES MULTIPLE SCLEROSIS?

MS is an autoimmune condition. This is when something goes wrong with

the immune system and it mistakenly attacks a healthy part of the body –
in this case, the brain or spinal cord of the nervous system. In MS, the
immune system attacks the layer that surrounds and protects the nerves
called the myelin sheath. This damages and scars the sheath, and
potentially the underlying nerves, meaning that messages travelling along
the nerves become slowed or disrupted.Exactly what causes the immune
system to act in this way is unclear, but most experts think a combination
of genetic and environmental factors is involved. 
Stages of Multiple Sclerosis
1. Clinically Isolated Syndrome
• Clinically Isolated Syndrome (CIS) is the first episode of neurological
symptoms experienced by a person, lasting at least 24 hours. The
person may experience a single sign or symptom, or more than one at
the same time. As with MS, it is caused by inflammation and
demyelination in the central nervous system.
• The symptoms of a CIS flare don’t last long. Your doctor may prescribe
steroids or other medications for relief. They may want to do another
MRI 3 or 6 months after your diagnosis to check for new lesions.
2. Relapsing-Remitting Multiple Sclerosis

• Relapsing-remitting MS is defined by inflammatory attacks on myelin (the layers

of insulating membranes surrounding nerve fibers in the central nervous system
(CNS)), as well as the nerve fibers themselves. During these inflammatory
attacks, activated immune cells cause small, localized areas of damage which
produce the symptoms of multiple sclerosis.
• Most people with multiple sclerosis have a type called relapsing-remitting MS, it
usually starts in our 20s or 30s. it is a type of multiple sclerosis characterized by
flare-ups with periods of remission in between. No two people with MS are likely
to have the same symptoms in the same way. Some may come and go or appear
once and not again.
• The most common symptoms reported in RRMS include fatigue, numbness,
vision problems, spasticity or stiffness, bowel and bladder problems, and
problems with cognition.
• If you have relapsing-remitting MS, you can take steps to manage your condition.
• Medications
• Physical Therapy
• Healthy Habits
3. Primary Progressive Multiple Sclerosis
• In primary progressive multiple sclerosis, there’s little inflammation that occurs.
Nerve damage is the main problem. Lesions form along the damaged nerves in
the brain and spinal hence, they can’t send and receive signals the way it should.
It is less common than RRMS, which occurs most commonly after the age of 40
years. Only 10% to 15% of people with multiple sclerosis have this form. Initial
symptoms include weakening of legs and having trouble walking. 
• Some treatments for RRMS are less effective in treating the symptoms of PPMS,
but The medication ocrelizumab (Ocrevus) is approved to treat PPMS.
4. Secondary Progressive Multiple Sclerosis
• People with secondary progressive multiple sclerosis start out with another type
of multiple sclerosis which is relapsing-remitting multiple sclerosis. If you have
been diagnosed with SPMS, it means that you may have had relapsing-remitting
MS for a decade or more. That is when you may begin to feel a shift in your
disease. The changes are often not easy to recognize. But you may notice that
your relapses may not seem to fully go away. About 80% of people who have
relapsing-remitting MS eventually get secondary progressive MS. The relapses
and remissions that used to come and go change into symptoms that steadily get
worse. 
Categorizing Multiple Sclerosis
• Active: A time that includes attacks and new evidence that the disease is
progressing.
• Not active: A period during which the person is stable, and there is no apparent
evidence that the disease is progressing.
• Worsening: A confirmed and notable increase in the person’s disability following a
relapse.
• Not worsening: The person experienced a relapse but shows no new or more
severe signs of disability.
Risk Factors and Clinical Manifestations
• Genetics • Vision Problems
• Tingling and Numbness
• Smoking
• Pain and Spasms
• Obesity • Weakness or Fatigue
• Race, Sex, Age • Balance Problems or Dizziness
• Bladder Issues
• Sexual Dysfunction
• Cognitive Problems
BRIEF PATHOPHYSIOLOGY
Early in the disease course, MS involves recurrent bouts of CNS inflammation that results in damage to both
the myelin sheath surrounding axons as well as the axons themselves. Histologic examination reveals foci of
severe demyelination, decreased axonal and oligodendrocyte numbers, and glial scarring. The exact cause of
inflammation remains unclear, but an autoimmune response directed against CNS antigens is suspected. 

In progressive MS, inflammation is a less defining pathological hallmark. Instead, progressive MS is

characterized by neurodegeneration of the white and grey matter resulting in brain and spinal cord atrophy
on a background of mild-moderate inflammation. Predominant factors driving neurodegeneration include
mitochondrial dysfunction due to defective oxidative phosphorylation and nitric oxide production, resulting in
a chronic state of virtual hypoxia due to unmet energy demands,and age-dependent iron accumulation in
myelin and oligodendrocytes leading to oxidative tissue damage.Further research is needed to understand how
these different pathologic subtypes affect prognosis and response to treatments. Currently, brain biopsy is the
only method to definitively determine pathologic subtypes, but studies are underway to find blood,
cerebrospinal fluid, and MRI biomarkers.
BRIEF
PATHOPHYSIOLOGY
Client in Context
Patient P. A., 40 years old, born on January 12, 1981, female, married, with college
graduate as her highest educational attainment and is currently employed as a high
school public teacher at Consolacion National High School, a Filipino, Roman
catholic, was admitted last January 20, 2021 at 8:00 am in Cebu Velez General
Hospital for the first time via jeepney and admitted via wheelchair and accompanied
by her daughter, T.A.  Information was obtained from the patient herself and her 19-
year-old daughter. Under the services of Derek Shepherd, MD and Meredith Grey,
MD from the Department of Internal Medicine, with case number 58172 and
hospital ID 19-138324, currently situated in PPS Ground Room 108.
History of Present Illness
6 months PTA, patient P. A., had experienced paresthesia in the feet, numbness from the waist downwards and
'burning' pains behind the right ear following an upper right respiratory infection. She also reported difficulty
walking because of the tingling and numbness she experiences. She stated, “I have difficulty walking for long
distances. I try to ask someone to accompany me because I’m afraid I’ll fall.”
2 months PTA, P.A. had started experiencing slight blurriness in her vision and migraines and reported that she
had become more fatigued that she had to stop doing her work by 7pm.
1 month PTA, P.A. had reported thinking “slow”. She stated that, “Information seems to take longer. I’m not as
sharp as I used to be. The constant migraines don’t help either.”
1 week PTA, P.A. started experiencing numbness and tingling of both hands. She also reported that she has
trouble holding heavier objects such as kitchen pots and bigger books. The patient also reported, “I feel some
kind of numbness that connects from my umbilicus to my armpits.”
1 hour PTA, P.A. reported that she could not hold smaller objects such as her pens and utensils. She stated that
she felt alarmed because she would not be able to do her work anymore if she does not get herself checked.
She asked her daughter, T.A., to accompany her to the hospital.
Past Health History
Client is a non diabetic, non tuberculous, and non drug user. She states that
she has no known allergies and has had no difficulty with anesthesia in the
past. She states that she had a history of chickenpox when she was ten
years old. Client has no previous blood transfusions. Patient has no history
of any medical-surgical procedures and hospitalization. Heredofamilial
disease includes hx of hypertension and diabetes on the paternal side and
her maternal grandmother had a hx of multiple sclerosis.
Previous Hospitalizations
Px was last hospitalized around July 10, 2020 in Chong Hua Hospital for
upper respiratory tract infection. She reports that she was given antibiotics
and was put on IV fluids.
Health Perception-Health Management
The patient defined health as “kanang bawal magkasakit kay kalas kwarta”. She rated her
current state of health as 6/10. The patient’s perception of her general state of heath is a
hindrance to her because she cannot work and cannot properly take care of her children.
She further added that she was anxious because her maternal grandmother had suffered
from multiple sclerosis. She looks forward to being healthy again.
Patient does not have any maintenance medication. Patient claimed that she practices self-
medication, medications include: Biogesic (Paracetamol) 1-2 tabs every 6 hr or as
needed. Max: 8 tab/24 hr for fever. She also uses herbal medicine as an alternative
medication. She takes kalabo to relieve throat irritation and non-productive cough
prepared by decoction and drinks it before going to bed every night amounting to 150-180
ml.
Family Genogram
Nutritional-Metabolic Pattern
The patient claimed that she usually has a good appetite, but she noticed that her appetite
slowly decreased 6 months ago. She claimed that she tried to start eating more when she
noticed her weight loss but because of her decreased appetite this only made her feel
nauseous. The patient prefers to eat meat and carbohydrate rich food such as rice and
bread but ever since her condition worsened, she prefers to eat her meals in smaller
proportions, and she avoids overeating because this made it difficult to breathe.  The
patient does not follow a particular diet and she does not have any religious or cultural
beliefs affecting her diet.
The patient claimed that she is concerned about her current weight due to her continuous
weight loss in the past 2 months. During her hospitalization, the patient has felt hunger
and increased appetite giving her less concerns and feeling a lot healthier with her
weight.
Activity-Exercise Pattern
The patient states that she had become easily fatigued. The numbness of her legs and
hands makes it difficult for her to work both in her professional life and home life. She
stated that she has to stop doing her schoolwork by 7pm because after that, she starts to
feel disoriented, and her vision would blur more frequently. Her migraines also worsen
when she is tired, so she tries to take naps in between her work schedule. She has
delegated much of the housework to her daughters because of the clumsiness of her
hands.
Sleep-Rest Pattern
The patient states that she has had to nap more because of increased fatigue, and also
stated that her migraines would worsen if she was tired. She tries to nap as much as
possible to avoid her migraines. The client starts sleeping by around 7:30pm on
weekdays, and on weekends, she would try to rest as much as she could to prepare
herself for her workload on the weekdays.
Cognitive-Perceptual Pattern
The patient states that it takes longer for information to process in her mind. She also feels
like she is constantly distracted by the pain behind her ears and her constant migraines.
The patient reports that her vision would blur randomly throughout the day, and she reports,
“My vision would take time to focus whenever I look at something else. I also noticed that
when I look at objects for a long time, whether it is my book or even faces, my vision
would start to unfocus.”
Self-Perception – Self-Concept Pattern
On the onset of her multiple sclerosis, she has had no complaints of how she looks and
sees herself the same and is content with her life. The only thing she was so worried
about while she was in the hospital was her work as she was anxious if she would stay in
the hospital for a long time possibly causing her to be removed from her job. Using the
Depression Screening Test, patient has no signs indicating that she has or is at risk for
depression and stated that she has not thought of committing suicide.
Role-Relationship Pattern
She claimed that her current illness had made her family extremely concerned for her. She
used to be the one always looking out for her family, now her family is looking out for her.
Client Ecomap
Sexuality-Reproductive Pattern
Patient’s OB score is G2T2P0A0L2 (8017). On her first pregnancy in 2000, she delivered a
normal baby girl in the hospital through NSVD attended by a physician. On her second
pregnancy in 2009, she delivered a normal baby girl in the hospital through NSVD and
was attended by a physician. Patient has a total number of 2 pregnancies with 2 living
children. Patient has had a history of prenatal check-ups with her OB-Gyne, Dr. Addison
Shepherd.
Coping-Stress Tolerance Pattern
Patient described stress as having a lot of work files to submit, whenever her students do
not pay attention to what she is teaching, reprimanding her students and whenever her
children get stubborn and lazy. However, when asked to describe stress after her
hospitalization she mentioned the presence of multiple sclerosis causing anxiety because
she cannot do both her school work and chores at home. Her focus in her life was her
work and her family, but because of her condition she was not able to work and care for
her family making her stressed. Patient stated that whenever she gets stressed, she
looks for someone to talk to and doesn’t really have a coping mechanism since she gets
busy at home.
Value-Belief Pattern
She previously attended masses every Sunday, however, upon hospitalization of her
current condition she was no longer able to attend physically. She stated that she was
able to attend masses through television and attended them every day while she was in
the hospital.