Case Study: Neurological and Musculoskeletal Pathophysiologic Processes

Scenario: 74-year-old male with a history of hypertension and smoking is having dinner with his wife when he develops sudden onset of difficulty speaking, with drooling from the left side of his mouth and weakness in his left hand. His wife asks him if he is all right, and the patient denies any difficulty. His symptoms progress over the next 10 minutes until he cannot lift his arm and has trouble standing. The patient continues to deny any problems. The wife sits the man in a chair and calls 911. The EMS squad arrives within 5 minutes. Upon arrival in the ED, the patient‘s blood pressure was 178/94, pulse 78 and regular, and PaO2 97% on room air. Neuro exam – Cranial nerves- Mild left facial droop. Motor- Right arm and leg extremity with 5/5 strength. The left arm cannot resist gravity, left leg with mild drift. The sensation was intact. Neglect- Mild neglect to the left side of the body. Language- Expressive and receptive language intact.

Mild to moderate dysarthria. Able to protect the airway.

This seems to be a Right Sided CVA (stroke)

To prepare:

The Assignment (1- to 2-page case study analysis)

In your Case Study Analysis related to the scenario provided, explain the following:

  • Both the neurological and musculoskeletal pathophysiologic processes would account for the patient presenting these symptoms.
  • Any racial/ethnic variables that may impact physiological functioning.
  • How these processes interact affects the patient.
  • Refer to the rubric for more instructions

Rewriting the prompt is not an introduction. The introduction should introduce the disease problem and present a purpose statement on what the reader should expect from the paper (you, the author).

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If you write a paper with correct and accurate information describing some other issues but missing what is on the rubric grading criteria, your paper will not earn a good grade.

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Answer

Neurological and Musculoskeletal Pathophysiologic Processes

The nervous and musculoskeletal systems are two organ systems that work closely to ensure, movement, locomotion, coordination, and balance. These systems are connected through nerves and synapses at the neuromuscular junction. The brain as the central command center plays an important role in various neurological and musculoskeletal diseases. Various health risks of the cardiovascular, neurological, and muscular system influence the neuro-musculoskeletal pathophysiologic processes. The diagnosis of the patient’s case scenario has a right-sided stroke. Stroke is one of the cardiovascular accidents and has significant mortality and morbidity outcomes among the affected patients. The purpose of this paper is to describe the pathophysiology of stroke, describe how these pathophysiologic processes interact to affect the patient, and explain any racial or ethnic variables that may impact this patient’s functioning.

Pathophysiologic Processes for this Patient’s Presentations

Stroke can broadly be classified into two classes: hemorrhagic and embolic or ischemic stroke (Murphy & Werring, 2020). These two types of stroke have related but slightly different pathophysiologic processes. However, the symptomatology remains the same. From this patient’s information in history and physical examination, it is difficult to decipher the type of stroke he could be having. Therefore, imaging evaluation studies such as computed tomography scans or magnetic resonance imaging would help make this difference that will impact the type of treatment that this patient would receive. Nevertheless, he has identifiable risk factors that predisposed him to stroke.

Stroke results when the brain tissue is deprived of oxygen as a result of a blocked supply or bleeding from the supplying vessels. Risks such as chronic hypertension such as the one this patient had leads to constant high pressure on blood vessel walls and the formation of microaneurysms on these walls (Kuriakose & Xiao, 2020). With time these walls get weaker and weaker and may rupture to lead to an aneurysm bust and hypertensive hemorrhage into the brain parenchyma or in the intracranial space. Alternatively, one-time trauma or repeated micro-trauma can lead to damage to blood vessels and thus, bleeding into the cranial cavity or the brain. It is the result of this bleeding that forms a hematoma that causes a mass impact on brain tissue as well as a reduction of blood supply to the brain region, ultimately resulting in the death of the brain cells (McCance & Huether, 2022). This condition is characterized by a particular brain region and can result in a variety of symptoms. Hematomas are formed when a collection of blood forms within a tissue space within the central nervous system, usually in the brain. It is important to note that the causes of these clots can be congenital or acquired.

Atherosclerosis, thromboembolism, injury, or both may cause brain perfusion to be limited in the area supplied by the artery due to atherosclerosis, thromboembolism, injury, or both (Kuriakose & Xiao, 2020). Atherosclerosis can involve the internal carotid artery in the brain on arteries outside the brain. When this atherosclerotic plaque dislodges, it is pumped together with blood into narrower and smaller brain arteries leading to occlusion or near total occlusion that deprives the brain cells supplied by the involved artery of blood. Similarly, blood clots that form in the distant arteries including the heart endothelium can travel into brain arteries to cause this occlusion. This reduces ATP production, shifts neuronal metabolism into anaerobic respiration, and decreases ATP production. As a result of hypoperfusion and hypoxia in the region, glutamate reuptake by astrocytes is decreased while glutamate levels in the extracellular fluid are increased. As a result of ATP reduction, the Na/K ATPase pump is also reduced, which leads to calcium influx and ultimately to cell death.

When brain cells die of hypoperfusion, their function is lost. The symptoms of this patient depend on the region of the brain that this cell death or injury affects (Murphy & Werring, 2020). In this patient, the cell injury and possible death involved regions of the brain responsible for speech and movement for both the upper and lower left limbs. This is because the injury affected the right side of the brain to cause symptoms majorly on the left side of the body. Left-sided weakness was evident because neuronal fibers from the affected brain part crossover at the hindbrain to the other side of the body leading to this paradoxical weakness (McCance & Huether, 2022). The facial droop signifies that the stroke involved a brain region that also contains the nucleus of the pathways for the seventh nerve, the facial nerve.

Interactions Between these Pathophysiologic Processes to Affect the Patient

These patients’ symptoms arise from an interplay between neurological and neuromuscular, and muscular processes. The muscular function requires stimulation from the neurological system through the neuromuscular junction. In the presence of stroke, the involved specific brain region that sends impulses through the spinal cord or cranial nerves to a specific muscle is rendered hypo-functional or nonfunctional due to cell death or injury. Therefore, this muscle cannot be stimulated to contract and cause movement. In presence of partial cell death or injury, this muscle can still receive weak stimulation which is seen as limb weakness in this patient. With timely interventions, these functions can be restored if total cell death did not occur or the residual neurons were left intact to take up the function of the dead cells in cases of younger and plastic brains.

Racial and Ethnic Variables

Race and ethnicity play essential roles in disease development and outcomes. In this patient, his race could have played a role in his disease directly or indirectly. Race and ethnic variables such as socioeconomic status, access to care services, and health beliefs determined by their culture could have played various roles in his disease process (CDC, 2022). According to a study by Howard et al. (2019), race determines the epidemiological patterns and clinical outcomes of disease among Americans. Gardener et al. (2020) found that the risk of stroke is higher among white women. However, the risk of mortality and poor outcomes is twice among African Americans as among whites (American Heart Association, 2020). The aggression for preventive and curative services is higher among some ethnic groups owing to their cultural beliefs on health and related outcomes thus the differences in stroke outcomes. Therefore, racial and ethnic variables such as income, health-seeking behavior, genetic predisposition, and access to healthcare services determine patient functioning at the clinical level leading to various outcomes

Conclusion

A stroke is a cardiovascular accident that affects the blood supply to the brain and can have significant mortality and morbidity outcomes among patients. The pathophysiology of stroke can be broadly classified into two types: hemorrhagic and embolic or ischemic stroke. Ischemic stroke results when brain tissue is deprived of oxygen due to a blocked supply, while hemorrhagic stroke results from bleeding in the brain caused by ruptured blood vessels. Risk factors such as hypertension and atherosclerosis can lead to the formation of microaneurysms in blood vessels, which can rupture and cause bleeding in the brain. The type of stroke and symptoms will depend on the region of the brain affected by the injury or cell death. racial and ethnic variables such as income, health-seeking behavior, genetic predisposition, and access to healthcare services determine patient functioning at the clinical level leading to various outcomes.

References

American Heart Association. (2020, February 18). Race and gender may tip the scales on traditional stroke risk factors. Www.heart.org. https://www.heart.org/en/news/2020/02/18/race-and-gender-may-tip-the-scales-on-traditional-stroke-risk-factors

CDC. (2022, December 7). Stroke Facts. Centers for Disease Control and Prevention. https://www.cdc.gov/stroke/facts.htm

Gardener, H., Sacco, R. L., Rundek, T., Battistella, V., Cheung, Y. K., & Elkind, M. S. V. (2020). Race and ethnic disparities in stroke incidence in the Northern Manhattan Study. Stroke; a Journal of Cerebral Circulation51(4), 1064–1069. https://doi.org/10.1161/STROKEAHA.119.028806

Howard, V. J., Madsen, T. E., Kleindorfer, D. O., Judd, S. E., Rhodes, J. D., Soliman, E. Z., Kissela, B. M., Safford, M. M., Moy, C. S., McClure, L. A., Howard, G., & Cushman, M. (2019). Sex and race differences in the association of incident ischemic stroke with risk factors. JAMA Neurology76(2), 179–186. https://doi.org/10.1001/jamaneurol.2018.3862

McCance, K. L., & Huether, S. E. (2022). Pathophysiology: The biologic basis for disease in adults and children (9th ed.). Mosby.

Murphy, S. J., & Werring, D. J. (2020). Stroke: causes and clinical features. Medicine (Abingdon, England: UK Ed.)48(9), 561–566. https://doi.org/10.1016/j.mpmed.2020.06.002

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