Anatomy, Physiology, And Pathophysiology Of A Patient With Rheumatoid Arthritis, Falls, And Pneumonia
Patient history
This case study presents John Smith (pseudonym), who was admitted to the hospital 14 days ago. The main reason for his admission was that he had experience a fall and got injured as a result. He was admitted to the ward for management of the injuries he sustained. A diagnosis of rheumatoid arthritis was made after an x-ray was done He however developed hospital-acquired pneumonia which made him to be transferred to an isolation room for further management. This case study aims to provide all the necessary details pertaining the patient, therefore illustrating the particular anatomy, physiology, pathology of the rheumatoid, falls, pneumonia and other conditions of concern in his past medical history.
Mr. Smith is a 72 years old male who has been admitted to the hospital and treated several times in the past due to conditions that comes as a result of his advancing age (see Appendix A). He is married to Jane and have four children who are working. He was admitted for the first time when he was 53 years old, where he was diagnosed with type 2 diabetes. This has however been managed with insulin or the past years.
Four weeks post admission he had fallen while heading to the house from parking however his wife held him since they were together. Two weeks later, he felt again while alone the house and injured his right arm severely. He got a cut which peeled most of the skin. He almost lost the function of it, however the doctor has reported that he will recover. He also reports to have been experiencing pain on his wrist joints which has greatly affected his activities of daily living. The main reason for seeking medical attention is that the pain on his wrist had been increasing and the wrist joint is swellon and stiff. He also feels pain on other joints. He was admitted accompanied by her wife, Jane. On admission, John’s temperature was 38.6?C, respiratory rate was 26 breaths per minute, pulse rate of 81 beats per min and a blood pressure of 126/81 mmHg. He was started on analgesics to ease his pain. A diagnosis of rheumatoid arthritis was made on admision after an X-ray was taken and the patient was started on treatment. Three days after hospitalization the patient started experiencing difficulty in breathing and chest pain. He was diagnosed to have acquired hospital acquired pneumonia which has been managed effectively.
Rheumatoid arthritis Immunology of rheumatoid arthritis
Rheumatoid arthritis is a long term autoimmune disease the commonly affect old people. It primarily affects wrist joints and manifest through pain and stiffness which worsen following rest. The joints may be warm, swollen and joints of both sides of the body are affected. Other body parts may also be affected by the disease resulting in a low count of red blood cell, inflammation around the hearth and lungs. Low energy and fever may also be present but they take up to even months to manifest. There is no known cause of rheumatoid arthritis but it is believed to be a combination of environmental and genetic factors. The presenting mechanism involves immune system of the body attacking the joints leading to the joint capsule being inflamed and thickened (Fassbender, 2013). Arthritis is the leading cause of falls especially in elderly (Huang et.al, 2012). The disease cause falls because it decreases muscular strength because of pain, joint swelling and muscle atrophy. Diminished proprioception is another factor which causes falls. This is because of mechanical damage and bony deformities leading to reduced sensory information about arthritic joints. The patient therefore has impaired perception of limb position information necessary for safe movement. Impaired balance due to reduced ability to detect and control postural sway can also lead to falls. Pain further compromises muscle function increasing risk of falls further.
The disease starts as a persistent cellular activation leading to autoimmunity in joints and other organs. Synovial membrane is the first site of the disease and that is where infiltration of immnune cells occurs as a result of swelling and congestion. The disease progresses in three phases; the initiation phase, the amplification phase and chronic inflammatory phase (Brunner, 2010).
Genetic factors which cause adaptive immune response to change can lead to initiation of an immune response that is abnormal. Once this response is initiated it becomes permanent and chronic. Other factors that contribute are environmental and hormonal factors. This is explained by increased risk in women especially after child birth or after hormonal medication use. A positive feedback for antigens like IgG Fc attached to rheumatoid factor and citrullinated fibrinogen bound by antibodies to citrullinated peptides, overcomes the negative feedback that normally maintains tolerance. People with rheumatoid arthritis have antibodies which are abnormally glycosylated and have been known to cause joint inflammation.
Symptoms may take many years before appearing but when the abnormal immune response become established the plasma cells derived from B lymphocytes produce rheumatoid factors and ACPA of the IgM and IgG classes in large amount. This leads to macrophages activation through Fc receptor and complement binding causing intense inflammation. The N-glycan antibody mediates binding of autoreactive antibody to the Fc receptor in people with rheumatoid arthritis. This antibody is altered in people with rheumatoid arthritis to promote inflammation. A local inflammation in a joint especially the synovium results with vasodilation, edema and entry of T-cells that are activated (CD4 and CD8 cells). The macrophages and dendritic cells at the synovial join expressing MHC class II since they act as Antigen Presenting Cells which establish an immune reaction in the tissues.
Pathophysiology of Rheumatoid Arthritis and clinical manifestation
As the disease develops, granulation of tissue at the edges of the synovial lining, pannus with extensive angiogenesis and enzymes result damaging the tissue. These result in thickening of the synovium, cartilage and underlying bone disintegration. Cytokines, chemokines and immune cells (T- cells, B-cells, macrophages and monocytes) attract and accumulate in the joint space. They cause bone degradation by triggering osteoclast production through signaling by the RANK pathway. Tumor necrosis factor also plays an important role in causing inflammation. Tumor necrosis factor alpha is a pro inflammatory cytokine that plays an important role in rheumatoid arthritis by regulating inflammatory response. If it is activated by B- or T-cells, it results in hypersensitivity reaction thus inflammation.
Diabetes may also have contributed to the fall that John experienced. Old people using insulin to control blood sugar are at risk of hypoglycemia. Hypoglycemia can cause blurred vision, dizziness and weakness therefore causing falls. Type 2 diabetes mellitus has been found to have strong genetic link. There is impaired insulin secretion and insulin resistance.
- Pathophysiology of pneumonia
Smith also acquired pneumonia after admission. Elderly people have lowered body immunity. This therefore put them in risks of getting infection like Pneumonia easily. John also had diabetes which has been found to lower the body immunity. The use of some medication contribute to low immunity. Smith acquired pneumonia as a nosocomial infection due to his low immunity. Hospital-acquired pneumonia is usually caused by bacterial infection. When an organism, that is, bacteria reaches the lungs, they trigger an immune response (Singh, 2012). This causes the invading pathogen to be engulf by neutrophils and cytokines are released leading to inflammatory reactions. The lungs become hyperaemic. Fluid from the intravascular spaces enter into the alveoli and lung tissue since the capillaries become highly permeable. This causes the impairment of ventilation as the gaseous exchange space become small. Congestion of the lungs therefore occurs as a result of fluid shifting making the lungs appear hard and red. This is shown by the large amount of confluent exudates by red blood cells, fibrin and neutrophils which fills the alveolar space. The hyperemia then reduces however the lungs are still hard. It becomes gray in appearance since the red blood cells become disintegrated continuously and the fibrin exudates persist. This is attained by the reduction of blood to the lungs and the fibrin and leukocyte consolidate in the part that is affected (Driver, 2012). This is followed by the resolution of the infection whereby the pulmonary structure is restored. The exudates that are consolidated in the lungs are digested enzymatically and the macrophage ingests most debris which are coughed out thereafter. The lungs can then return normal and gaseous exchange resume if complete resolution occur.
Benzyl penicillin 2 million IU was given to Mr. smith after every 5 hours for 5 days to treat pneumonia (see Appendix B). This was effective since streptococcus pneumonia was suspected to be the causative agent.
Mr. Smith Rheumatoid arthritis was managed by use of the following drug. He was given ibuprofen which is Non-steroidal anti-inflammatory drug (NSAIDS) to help ease the swelling and pain (Bennell, Hunter, & Hinman, 2012). Initially he had also been given 1g of paracetamol which is an analgesic. This also helped to lower his temperature hence reducing fever. NSAIDS act by inhibiting the release of prostaglandins since it blocks the cyclooxygenase enzyme (cox-1 and cox-2). Prostaglandin is an important mediator in inflammation. The NSAID and analgesics also aided in the treatment of chest pain due to pneumonia.
Prednisone, a corticosteroid, was also administered to act as a temporary drug while waiting for Disease Modifying Anti-Rheumatic Drugs (DMARDS) to carry out their effects of anti-inflammation. A high dose of 20mg was administered stat but reduced to 10mg daily slowly. Methotrexate which is considered the first line DMARD was started since studies have proven that it reduces the sign and symptoms and also slows or stop the radiographic damage (Haraoui, & Pope, 2011). A dose of 12.5 mg was given orally in the first week and escalation is to be done to achieve 20 mg within three months.
People with rheumatic arthritis are at increased risk of infection and therefore, vaccination is recommended. The patient should receive influenza vaccine annually. Pneumococcal vaccine should be given once as the patient is above 65 years. The patient should also receive live attenuated zoster vaccine once as the patient is above 65 years of age. This will prevent against pneumonia and other viral infections which are more common in old people especially those with decreased immunity as in rheumatoid arthritis (Bingham.et.al, 2015).
Dietary supplements
Fatty acids
Foods containing omega-6 fatty acid have been found to be important in reducing pain, tender joint count and stiffness. Omega-3 fatty acid is important in lowering eicosanoid concentrations such as leukotriene in people with rheumatoid arthritis therefore reducing inflammation. Omega-6 and omega-3 are found in fish oil and marine oil (Lourdudoss, Wolk, Nise, Alfredsson, & van Vollenhoven, 2017)). Consumption of fish has also been found to alleviate pain in people with rheumatoid arthritis. Increasing fiber from fruits, vegetables and whole grains also helps in reducing inflammation.
People with rheumatoid arthritis have low levels of selenium, a mineral found in whole grain wheat (Deyab.et.al, 2018). It contains antioxidants which are believed to decrease inflammation. Giving supplements of selenium to patients will decrease inflammation. Vitamin D and calcium should also be given to prevent osteoporosis. Eggs, cereals and low fat milk contain calcium and vitamin D.
Exercise
Physical exercise is important in management of arthritis and diabetes. Exercising helps reduce pain and stiffness in joints, makes the joint more flexible, boost endurance and improve sleep. It also prevents muscle wasting and weakness especially in old people (Smolen.et.al, 2016). The type of exercise for people with arthritis should put minimal impact on the affected joints. Activities such as low-impact aerobic dance, water exercises, walking and stationary bicycles are encouraged. Exercise can also improve functional ability and psychological wellbeing. Rest is advised when one is experiencing arthritis flare-up. Taking a break from exercising for about two or three days will help reduce pain and inflammation.
Reducing pressure and discomfort in the patient’s hands while holding or working on objects can be achieved by recommending personalized adaptive equipment that will put less stress on the joint. This should be recommended by an occupational therapist depending on the work done by the patient. Instructing the patient on the use of compression garments and thermal agents (provide heat and cold) are important in alleviating pain. Helping the patient to analyze his activities and to avoid what is not necessary is important in reducing pain and weakness.
Conclusion
It is important to understand the conditions that predispose an elderly person to falls and harms associated with it. Understanding the anatomy, physiology and pathophysiology of underlying diseases at old age is very vital as it will help in improving a patient quality of life. Management of Mr. Smith conditions were aim at reducing the sign and symptoms which may lead to further complications in his health. In his old age, his immunity is also low and therefore diseases that arise, for example, pneumonia in his case should be treated promptly.
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