Patho Assignment 1 PDF

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Assignment 1 - Ankle swelling and fatigue in a 60yo.

A 60yo male teacher from the local high school presents to you with complaints of swelling in the feet/ankles by the end of the day, frequent urination at night and increasing fatigue/shortness of breath upon light exercise like taking the steps to a different floor. He does not sleep well at night and feels that breathing while in bed seems to be a bit harder than when sitting or standing. Use of added pillows seems to help. He has a history of heart disease in the family and he has previously been diagnosed with mild atrial fibrillation, which is only being monitored. Upon examination, you find BP 170/110, pulse rate 70-75, normal temperature and mild pitting edema at the ankles bilaterally. Chest exam reveals light crackles (rales) upon respiration and no abnormal heart sounds. There is no dullness upon listening to the heart. Rectal exam reveals normal sized prostate and no bleeding/blood in the stool. Abdominal exam reveals only mildly enlarged liver, normal spleen and no areas of tenderness. The jugular vein appears distended when in a reclined position to 30 degrees, but not when upright. Central venous pressure measured by JVD is 9cm H2O. 1) Considering the Starling forces (not cardiac Frank-Starling law) affecting fluid movement in a capillary, describe two ways to promote an increase in net fluid movement into the interstitium (i.e. increase/decrease in a given force that is part of calculating net fluid movement). (2pts) (MO 2,3; i.e. Relates to Module Objectives 2 & 3 as found under Module 1 Overview) One way to promote an increase in fluid movement into the interstitium is through an increase in capillary hydrostatic pressure or more specifically blood pressure, which is occurring in this patient. This can be a result of venous obstruction or salt and water retention. Another way is through a decrease in plasma oncotic pressure. This decrease occurs because plasma albumin attracts water and when the plasma albumin is decreased the amount of water attracted is as well. This can be a result of things like liver protein malnutrition, glomerular kidney diseases and liver disease such as cirrhosis of the liver. (Huether & McCance, 2017, p. 115) 2) Given the Starling forces that can promote movement describe above, list three organs that need to be evaluated because of their ability to promote such edema and why (i.e. how is the Starling forces altered by dysregulation of that organ). (6pts) (MO 1,2,3) The heart, liver and kidneys. Heart failure, renal failure and cirrhosis of the liver are all associated with salt and water retention, which can lead to plasma overload and eventually edema. The kidneys and liver also affect plasma oncotic pressure because plasma proteins are lost in kidney diseases and cirrhosis of the liver, causing a decrease in plasma oncotic pressure, leading to build up of water in the interstitium and edema. (Huether & McCance, 2017, p. 116) 3) Describe why he is having shortness of breath using Starling forces terminology. (2pts) (MO 2,3) The shortness of breath can be a result of this increase in capillary hydrostatic pressure and decrease in plasma oncotic pressure. The heart may be becoming less efficient at pumping blood leading to back up

fluid in and around the heart and lungs. These conditions are called pulmonary edema, pleural effusion and pericardial effusion. (Huether & McCance, 2017, p.116) 4) Describe how interstitial fluid compares to plasma. Is interstitial fluid intracellular or extracellular? (2pts) (MO 1,2) Interstitial fluid is fluid in the tissues or in between cells and makes up for about 15% of the extracellular fluid. Extracellular fluids accounts for about 20% of total body weight. Plasma accounts for about 5% of total body weight, therefore has a lower volume than that of the interstitial fluid. (Huether & McCance, 2017, p.114)

Bloodwork reveals a normal ESR (a non-specific measure of inflammation), normal hemoglobin, hematocrit, white blood cell count/distribution, albumin and blood glucose levels. Chest X ray show some shadowing of lung tissues more prominently in the base, confirming the presence of edema. The ventricles of the heart are enlarged. No other abnormality noted. A 24 hour urine collection revealed no abnormalities. 5) Given the above information, you diagnose him with congestive heart failure. You consider various medications for his treatment, which aim to improve his cardiac function by slowing the rate and increasing contractility. Digoxin is one such drug (though it does appear to have a 20% higher all-cause mortality rate in atrial fibrillation patients, so it is not given without careful consideration). How does digoxin work in terms of altering movement of Na+, K+ and Ca++ and how does that relate to the improvement in cardiac function (increased contractility and slower heart rate)? (5pts) (MO 1,2) Digoxin blocks the sodium/K+ ATPase pump and intracellular calcium is increased. This pump ordinarily causes Na+ to leave the cells and K+ to enter. The blockage of this can result in higher K+ serum levels, therefore digoxin toxicity can cause hyperkalemia. Hypokalemia however enhances the therapeutic effect of digoxin and the risk of toxicity. This occurs through the ability of digoxin to more easily bind to the ATPase pump and strengthen its effects. By blocking the ATPase pump vagal activity is increased and AV conduction is decreased, improving cardiac function. (Edner et al, 2009, p.187)

A 15yo girl presents with a sore throat and headache x 5 days. She has been treating it with Advil. Examination reveals slightly elevated heart rate, oral temperature of 99.7 degrees, and sore neck on palpation with enlarged lymph nodes. Rapid Strep test is positive. 6) In general, what is the most common cause of sore throat in children 15yo and younger? (2pts) (MO 9) Group A streptococcus, the bacteria that causes strep throat. (Mayo Clinic, 2019)

7) Why is it important to treat strep throat within the first nine days or so? What is the mechanism for damage beyond the throat area (rare, serious complications) if left untreated? (6pts) (MO 9)

If left untreated strep throat can become much more serious. When the body recognizes strep if sends antibodies and if left untreated these antibodies can attack the joints and heart, leading to swelling and scarring. This can leave the heart and heart valves damaged permanently and result in heart failure. (Mayo Clinic, 2019) 8) During alkalosis, as can occur from vomiting and or diarrhea, causes what kind of shift in K+ concentrations occur (regarding fluid compartments, i.e. extracellular (plasma and interstitial) vs intracellular) and thus may show up in blood chemistry readings? (1pt) (MO 1,3,4) ECF hypokalemia can develop when potassium shifts from the ECF to the ICF during alkalosis in exchange for hydrogen, to maintain the plasma acid-base balance. (Huether & McCance, 2017, p. 122)

References Huether, S. E., & McCance, K. L. (2016). Understanding pathophysiology. 6th ed. St. Louis, Mo.: Mosby/Elsevier. Edner, M., Ponikowski, P., Jogestrand, T., (2009). The effect of digoxin on serum potassium concentration. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/8385796 Mayo Clinic. (2019). Strep Throat. Retrieved from https://www.mayoclinic.org/diseases conditions/strep-throat/symptoms-causes/syc-20350338...