Case Study-Patient Care

Patient Name: Jack Xiu

Date of Birth: 12/31/1959

Clinical Notes: Patient presents with left hip, left leg, and left wrist pain. Mr. Xiu reported slipping on an icy surface as he exited his vehicle. He fell backward and landed on his left hip. He also reports hitting his wrist and hand on the edge of his car door as he attempted to brace himself during the fall.

Visual examination of his wrist reveals significant redness and swelling.

The range of motion in the left wrist is limited to 10 degrees without pain and 20 degrees with moderate pain.

Mr. Xiu’s provider suspects that he has sprained his wrist.

Question #1: Briefly explain why his wrist appears red and swollen.

Swelling and redness are due to the collection of fluid in joints and spaces of tissues in the injured area, which depends on the severity of the sprain. The swelling and redness are due to inflammation and activation of inflammatory markers in the wrist region (Chen et al., 2017).

Question #2: List and briefly explain two diagnostic procedures that may be relevant for this patient.

Ultrasound- An ultrasound will analyze the tear and inflammation in the ligaments and injuries of associated joints and nerves (Dean et al., 2020).

X-ray- An X-ray will be used to visualize wrist fractures (Dean et al., 2020).

Question #3: How might NSAIDs help Mr. Xiu?

NSAIDs reduce pain and inflammation (Ho et al., 2020). NSAIDs will thus reduce the inflammation causing the swelling and help with the wrist pain.

Question #4: Explain why collagen will be necessary during Mr. Xiu’s wrist healing.

During the wrist injury, the collagen was damaged. Collagen attracts fibroblasts and encourages new collagen deposition on the wound bed (Lee & Lee, 2016). Collagen is thus required to promote wound healing. Collagen will stimulate angiogenesis, new tissue growth, and reepithelization (Lee & Lee, 2016).

Question #5: Explain how the pain Mr. Xiu is feeling is acting as a defense mechanism.

Pain is a self-defense mechanism to protect Mr. Xiu from harm. There is the release of nociceptive chemicals during the injury to inform the patient that there is harm, and hence, corrective measures should be implemented to prevent further damage.

Patient Name: January Jones

Date of Birth: 2/29/1980

Clinical Notes: The patient presents to the urgent care clinic with a deep cut on the palmar surface of her left hand and thumb. She reports that she was cutting vegetables with a large chef’s knife when her left hand slipped under the knife blade. She reports that the wound bled immensely for several minutes. She wrapped her hand and thumb tightly in gauze and immediately left home to seek care.

Visual examination reveals that the entire epidermis and dermis thickness has been lacerated. The area is red and swollen, but the bleeding has stopped.

Sutures are recommended to close the wound and reduce scarring.

Question #1: Explain why Ms. Jones’ wound has stopped bleeding, even though it has not yet healed.

The clotting mechanism prevents excessive blood loss. Clotting factors such as fibrin and fibrinogen and the platelets form a meshwork that prevents blood loss and complications that arise from blood loss. Vascular mechanisms, prostaglandins, enzymes, proteins, and platelets contribute to the clotting mechanism, which comes together to form blood clots, preventing blood loss (Grover & Mackman, 2019)

Question #2: If there were bacteria on the knife she was using, which types of leukocytes would respond to this injury, and how would they respond?

Neutrophils are the first line of defense. They will kill and digest bacteria (Marshall et al., 2018)

Question #3: Explain how her lymphatic system will assist the immune response to pathogens entering her open wound.

The lymphatic system has lymph nodes that trap and process pathogens. They also activate specific immune responses, which lead to pathogen destruction. They produce lymphocytes and other immune cells, which destroy foreign invaders (Kataru et al., 2019).

Question #4: There are four types of acquired immunity. Assuming a pathogen has entered the open wound, which type of immunity will Ms. Jones’ acquire? Explain your answer.

Natural acquired immunity. The body will develop antibodies against the invading pathogens (Marshall et al., 2018).

Question #5: Briefly explain why angiogenesis is crucial during the proliferative phase of wound healing.

Angiogenesis is required to deliver immune cells, remove debris, and provide nutrients for tissue regeneration. It leads to the formation of new blood vessels from existing vessels (DiPietro, 2016). It does this by invading the wound clot and organizing the microvascular network.

Patient Name: Ricky Squire

Date of Birth: 5/21/1991

Clinical Notes: The patient reports falling during a hike last weekend during a camping trip. He scraped his right knee on a sharp branch, creating an open wound. Initially, the skin around the wound was red. He reports having no first aid care until he returns home on Monday. He applied a topical antibiotic, but the area surrounding his knee was swollen and moderately painful by then. A decreased range of motion in the right knee is noted upon physical examination.

Question #1: Explain how Mr. Squire’s first line of defense failed to respond to his injury adequately.

The first level of defense is the innate system, which consists of skin as the physical barrier (Marshall et al., 2018). The skin allowed the entry of pathogens, activating the inflammatory responses and causing pain and swelling.

Question #2: Explain how the phagocytosis occurs and how it benefits Mr. Squire.

Phagocytosis is the process of engulfment of foreign substances that enter the body. Phagocytes bind to the foreign substances on the cell surface and draw them inward while engulfing them (Marshall et al., 2018). The patient has an open wound; hence, many foreign substances, such as pathogens, will try to enter the body. Phagocytosis will help in the engulfment and elimination of these substances.

Question #3: Which cardinal signs of inflammation are present in this case? List and explain each sign.

The four cardinal signs of inflammation include redness, pain, heat, and swelling. The signs that the patient has are pain, redness, and swelling. Pain occurs when the swelling and fluid build-up press against the nerves, sending signals to the brain (Chen et al., 2017). Redness occurs due to the release of inflammatory mediators, which cause tiny blood vessels to dilate and cause more blood to flow (Chen et al., 2017). Swelling occurs due to the entry of immune cells into the tissues and fluid entry (Chen et al., 2017).

Question #4: Mr. Squire’s healthcare provider recommends over-the-counter NSAIDs and prescription oral antibiotics. How will each of these drugs benefit the patient?

NSAIDs will help to reduce pain and inflammation (Ho et al., 2020). Antibiotics will help fight the bacteria, preventing infection and sepsis (Negut et al., 2018).

Question #5: What complications may occur if Mr. Squire does not follow the recommended treatment?

The patient may develop sepsis if antibiotics are not given. Sepsis is the spread of infections into the bloodstream. Symptoms of sepsis include mental shock and a high respiratory rate (Gyawali et al., 2019).

References

Chen, L., Deng, H., Cui, H., Fang, J., Zuo, Z., Deng, J., Li, Y., Wang, X., & Zhao, L. (2017). Inflammatory responses and inflammation-associated diseases in organs. Oncotarget, 9(6), 7204-7218. https://doi.org/10.18632/oncotarget.23208

Dean, B. J., Carr, A., Trickett, R. W., Kluzek, S., Riley, N., Bretherton, C. P., Wilson, M. K., Hayton, M. J., Rupani, N. R., Hsieh, C. C., Clifton, L. J., Dacombe, P., Milnes, L. K., Jayasuriya, R. L., George, H. A., Das, R., Mayne, A., Brown, M. T., & As-Sultany, M. (2020). The presentation, diagnosis, and management of non-traumatic wrist pain: An evaluation of current practice in secondary care in the UK NHS. Rheumatology Advances in Practice, 4(2). https://doi.org/10.1093/rap/rkaa030

DiPietro, L. A. (2016). Angiogenesis and wound repair: When enough is enough. Journal of Leukocyte Biology, 100(5), 979-984. https://doi.org/10.1189/jlb.4mr0316-102r

Grover, S. P., & Mackman, N. (2019). Intrinsic pathway of coagulation and thrombosis. Arteriosclerosis, Thrombosis, and Vascular Biology, 39(3), 331-338. https://doi.org/10.1161/atvbaha.118.312130

Gyawali, B., Ramakrishna, K., & Dhamoon, A. S. (2019). Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Medicine, 7, 205031211983504. https://doi.org/10.1177/2050312119835043

Ho, K. Y., Cardosa, M. S., Chaiamnuay, S., Hidayat, R., Ho, H. Q., Kamil, O., Mokhtar, S. A., Nakata, K., Navarra, S. V., Nguyen, V. H., Pinzon, R., Tsuruoka, S., Yim, H. B., & Choy, E. (2020). Practice advisory on the appropriate use of NSAIDs in primary care. Journal of Pain Research, 13, 1925-1939. https://doi.org/10.2147/jpr.s247781

Kataru, R. P., Baik, J. E., Park, H. J., Wiser, I., Rehal, S., Shin, J. Y., & Mehrara, B. J. (2019). Regulation of immune function by the lymphatic system in lymphedema. Frontiers in Immunology, 10. https://doi.org/10.3389/fimmu.2019.00470

Lee, C., & Lee, Y. (2016). Collagen-based formulations for wound healing applications. Wound Healing Biomaterials, 135-149. https://doi.org/10.1016/b978-1-78242-456-7.00007-6

Marshall, J. S., Warrington, R., Watson, W., & Kim, H. L. (2018, September 12). An introduction to immunology and immunopathology. Allergy, Asthma & Clinical Immunology. https://doi.org/10.1186/s13223-018-0278-1

Negut, I., Grumezescu, V., & Grumezescu, A. (2018). Treatment strategies for infected wounds. Molecules, 23(9), 2392. https://doi.org/10.3390/molecules23092392

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Question

These case studies are real-life scenarios that will help you explore the concepts of the immune system, diagnostic tests, and treatments.
Download and read each of the patient scenarios. Then, answer the questions by using the lesson content from this module, your textbook, and perhaps additional research.