Pathophysiology assingnment PDF

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Mr Smith a 63 year old retired truck driver have been receiving treatment for Hypertension and diabetes for the past 20 years. He has had episodes of shortness of breath in the past but has worsened over the past 5 weeks. This has decreased his mobility and sleep because he couldn’t catch his breath...

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Mr Smith a 63 year old retired truck driver have been receiving treatment for Hypertension and diabetes for the past 20 years. He has had episodes of shortness of breath in the past but has worsened over the past 5 weeks. This has decreased his mobility and sleep because he couldn’t catch his breath. This has developed into a dry cough but with no audible wheezing. Few days ago he developed unusual weakness and numbness in his left arm and leg accompanied with dizziness. Mr Smith complains that numbness, tingling and burning affect his feet, interfering with his mobility and sleep. Mr Smith retired as a truck driver 2 years ago and smokes around 15 cigarettes daily with a beer or two. My intention in Mr Smith’s case is to identify the nature of underlying problems based on symptoms or signs stated by Mr Smith using appropriate diagnostic methods.

Shortness of breath: From the vital signs of the patient, we can see that Mr Smith has a pulse rate of 100 bpm and a respiration rate of 20 bpm. Compared to normal adult, resting HR values lie between 60 and 100 bpm and respiration rate of 12–28. (2) This is slightly higher than average therefore this case study will look into respiratory system for diagnosis of shortness of breath. From the patient statement, Mr Smith has experienced episodic shortness of breath during the past year, but this has worsened during the past 5 weeks especially during physical movements. Shortness of breath also referred to as Dyspnoea is a subjective sensational awareness of difficulty in breathing. (1) The pathophysiology of the dyspnoea involves interactions between respiratory, cardiovascular system and neural response and any abnormalities can cause difficulty in breathing. The respiratory system consists of alveolar epithelium which exchanges gases, a diaphragm and chest wall which acts as vacuum pump pulling air into the lungs, a respiratory tract and a central nervous system that regulates breathing function. Shortness of breath is not a sign but a symptom, patience experience it subjectively. (1) Medical examination such as physical and chest x-ray are required for evaluation. Possible causes of shortness of breath can be from a range of different disease that affects the respiratory system. Mr Smith is complaining of shortness of breath especially when exerting himself, easily becoming fatigue and losing energy to do anything. A possible cause of this can be pulmonary fibrosis that affects the alveoli and lung's ability to stretch and expand causing inefficiency in permeability of gases exchange and the increased pressure and volume for each breath needed to expand the thick and stiff lung tissue. As pulmonary fibrosis worsens, patient progressively runs of breath. quicker which again is evident in Mr Smith’s case where he is forced to take rests even for short periods of walking.

Another plausible cause can be from chronic obstructive pulmonary disease and asthma that primarily affects the pressure and volume of the respiratory conduction system which brings in air to the lungs for gases exchange to occur. (3) These obstructions of air flow can alter lung function because of expiratory flow limitation and gas trapping which is the abnormal

retention of air in the lungs making it difficult to exhale completely thus increasing the work of breathing. (4). A condition that greatly contributes to Chronic obstructive pulmonary disease is emphysema which causes damage to the alveoli; the tiny sacs in the lungs that take oxygen in. Over time the inner walls of the alveoli weakens and ruptures merging into larger air spaces instead of the many smaller ones decreasing their ability to absorb oxygen resulting in less oxygen in the blood. Damaged Alveoli stretches out and loses the lungs springiness, allowing air to get trapped in the lungs which can’t be exhaled out resulting in the feeling of short of breath. Emphysema is direct result of exposure to smoking in which the symptoms develop slowly and show signs when patients are at least 40. Mr Smith’s episodic shortness of breath over the past year and the worsening of it over the last 5 weeks are symptoms of his 63 year of age and his habit of smoking 15 cigarettes a day. Mr Smith’s occupation as a truck driver involved him sitting for prolong hours. This mean his sitting posture may have affected his breathing function as rounded shoulders and forward head posture while driving tightens the chest. Mr Smith is complaining that on several occasions he has woken up from sleep suddenly because he couldn’t catch his breathe. Mr Smith’s Posture may have affected his breathing pattern because the tightening of the chest limits the ability of the rib cage to expand as chest relies on secondary muscles around the neck and collarbone instead of the diaphragm, causing rapid and shallow breaths. This explains why when sitting up, Mr Smith is able to breathe better. The forward-leaning position of the head and neck are in proper alignment; reducing air obstruction, decreased activity of the neck muscle while increased contribution of the accessory muscles to rib cage elevation. (5) The use of more than 2 pillows by Mr Smith helps his upper part of the body be in an inclined position. This limits congestions, relives chest and the respiratory system allowing for a clear path for oxygen to be inhaled and co2 exhaled. (6)

Cardiovascular disease is another cause of shortness of breath which its mechanics overlap with those of the respiratory system. For example a systolic heart failure due to low output is not sufficient in meeting the oxygen demands of the body causing ischemia resulting in lactate generation and academia where patients with cardiac insufficiency often have pulmonary edema that impairs gas exchange increasing the work of breathing. This explains the moderate swelling around Mr Smith’s ankle which pits on pressure. However, Ischemia can also be caused by atherosclerosis where plaque has built up in the arteries slowing blood flow which further explaining why the pulse on the peripheral leg arteries is weak. The build-up of Plague stops the flow of blood to the limbs which can cause peripheral artery disease. The factors that increase the risk of developing Peripheral artery disease are smoking, diabetes, high blood pressure and an increase in age. High blood pressure can damage arteries. From Mr Smith’s case, we can identify that he is a 63 year old smoker, he has been diagnosed with diabetes and is currently receiving treatment. The symptoms Mr Smith are presenting of numbness, tingling and burning affecting his feet are similar to the symptoms of peripheral artery disease. The poor circulation of blood to the feet due to narrowed arteries means that the muscles aren’t able receive oxygen and therefore that burning sensation is the result of lactic acid build up in the blood stream.

From Mr Smith’s physical examination, the S3 or Ventricular gallop can be heard. The sound of S3 is produced during passive left ventricle filling when the blood strikes a complaint with the left ventricle. Although the hearing of this sound is normal with athletes, children and pregnant women, it is abnormal in other patients and usually indicated a sign of systolic heart failure. The complains of shortness of breath when sleeping or exerting, fatigue and weakness along with the swelling of the ankle and irregular heartbeat by Mr Smith strongly suggests a sign of congestive heart failure in particular systolic heart failure. A systolic heart failure is when the left ventricle can’t contract vigorously therefore not able to pump enough blood to the tissues of the heart as needed. The symptoms are impaired gases exchange and fluid collecting in the lungs and thus making it hard for the lungs to expand when a person inhale. Other symptoms of systolic heart failure which are similar to Mr Smiths are shortness of breath when sleeping, dry cough, and coarse inspiratory crackles which are explosive sounds that come from the lungs. Reduced cardiac output can reduce the amount oxygen within the blood stream thus showing the symptoms of cyanosis (pale and bluish coloured skin) on Mr Smith’s lips/tongue and skin. High levels of deoxygenated blood within the surficial surface of the skin cause this bluish appearance. Systolic heart failure is often caused by hypertension with other risk factors such as excessive use of alcohol, diabetes and smoking increase the risk of heart failure. Mr Smith has been diagnosed with hypertension, which is a long-term medical condition that causes persistent blood pressure to elevate in the arteries making the heart work harder. Mr Smith has been receiving treatment over the last 20 years but have not been fully compliant. Mr Smith’s lifestyle of smoking and drinking along with previous diagnosed condition correlates with that of systolic heart failure. The blood pressure is not within normal range

Physical examination finding: - How it occurs and what can cause it and stuff The physical examination have found that Mr Smith is/are:

Moderately overweight with slight breathing distress which contributes to his shortness of breath. Being overweight affects the respiratory system in several way. Fat deposition in the chest wall upper airways increase the work of breathing. In overweight individuals the mechanism of breathing gets impaired because excess fat limits the actions of the respiratory muscle through

structural changes in the thoracic-abdominal area. This impairment can lead to mechanical impairments of the respiratory as it restricts the mobility of the diaphragm and rib movement. This reduces the lung volume and the function of the respiratory muscle because of increased resistance imporsed by the presence of extra fatty tissue on the chest and abdomonen. This explains why Mr Smith is complaining of shortness of breath, not enough oxygen is being able be circulated through the gases exchange.

https://mrmjournal.biomedcentral.com/articles/10.1186/s40248-016-0066-z https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1440-1843.2011.02096.x Pale skin and his lips/tongue are faintly bluish. Mr Smith has pale skin and the colour of his lips/tongue are faintly bluish. This is due to lack of oxygen in the blood or poor circulation causing the bluish colour appearance. Blood that is rich in Oxygen in blood provide oxygen to the body tissue and usually appear pinkish or red. However a purple or bluish colour may indicate a condition called cyanosis. This is where oxygen is not able to bind to the haemoglobin during the gases exchange or poor circulatory of blood in the body causing a faint bluish appearance on the skin. This is often worsened by long term conditions such as asthma or chronic obstructive pulmonary disease that c ausesobs t r uct edai r fl owf r om t hel ungs.Oxy genat edbl oodi snotabl et oci r c ul at eorr eac hwher ei ti sneeded.

Pulse on peripheral leg arteries are weak, with moderate swelling around the ankle that pit on pressure: The weak pulse around the peripheral arteries are caused by circulatory problems where the arteries have narrowed in diameter due to plaque build-up, reducing the flow of blood to the limbs. The moderate swelling around the ankle that pits when pressured is applied is because of accumulation of fluid. Blood is not able to flow or circulate resulting in the build-up of fluid which gives the appearance of swelling that pits under pressure. The risk factors that have contributed to circulatory problems are consistent with Mr Smith’s sedentary lifestyle and other previously diagnosed health issues and explains why he has a swollen ankle and weak pulse on the peripheral arteries.

Coarse respiratory crackle ca be heard during auscultation over the lung base. Heart beat is irregular and fast, S3 can be heard at the apex. Crackles in the lungs are sounds that can be heard when the small airways in the lungs are filled with fluid. The sound is heard at the base of the lungs during inspiration when air passes through fluid. The Coarseness in the crackle are low pitch and longer lasting, often indicating a sign of early congestive heart failure or respiratory edema. https://www.sciencedirect.com/science/article/pii/B9781455733835000166?via%3Dihub#s0110

During Mr Smith’s physical examination, the sound of S3 is heard at the apex. The sound of the S3 is causedbyt hesuddendecel er at i onofbl oodflowi nt ot hel ef tv ent r i cl ef r om t he l ef tat r i um. It is abnormal to hear the S3 sound after S1 and S2 and usually indicate a sign of systolic heart failure. https://www.ahajournals.org/doi/pdf/10.1161/01.CIR.67.2.399 Laboratory Test

Looking at the routine blood test for Mr Smith, we can help interperate the results from the labs to uncover underlying health issues with Mr Smith and to help him keep overall track of his physical wellbeing. Hb – Haemoglobin From the lab report, we can look at his haemoglobin levels (Hb) which can help us detect abnormal concentrations of haemoglobin in the blood. Haemoglobin is a protein that is present in the blood which helps deliver oxygen from the lungs to all parts of the body, without this oxygen is not able to bind to the blood cells. From Mr Smith’s report, we can see that his Hb are within normal range at 135 g/l in reference to 130-170 g/l for men. RCC – Red blood cell count

The Red blood cell count estimates how much red blood cells are in per litre of blood. An abnormal amount of red blood cells from 4.5-6.5 x 1012/L can indicate various conditions, however in Mr smith’s report, his red blood cell count are within acceptable range of 4.5x1012/L. Hct – Haematocrits percentage: Haematocrit is the percentage measure of red blood cells to the total of blood volume. Abnormal levels outside 40-50% indicate various other conditions such as bone marrow failure or dehydration. However in Mr Smith’s report, his Hct levels are within normal range. WCC – Mean cell volume. The mean cell volume is an estimate of the red blood cells and is used to determine what type of an anaemia a patient have. Abornmally low or high may indicate other condition or disease outside of 4-11 x 109/L. However in Mr Smith’s case, his mean cell volume is a little high but still within the normal range.

Platelets: Platelet are the first to activate when an injury occurs to a tissue or blood vessel. The platelets help clot the injured site to reduce bleeding. The platelet count estimates the number of platelets per litre of blood and can be used to monitor toxicity of medication to bone marrow but also diagnose problems associated with clotting, bleeding or bruising. The normal range count is within 150-400 x 109/L. In Mr smith’s report, this levels are considerably low but still within the normal range. ESR - Erythrocyte sedimentation rate ESR tests for inflammation in the body by measuring how quickly the erythrocyte settles at the bottom of a test that contains a blood sample. A faster than normal rate which is between 0-30 may indicate inflammation in the body. Mr Smith seems to have 12 mm/h which Is within normal range however there might be some inflammation. Urea, Creatine

Urea is tested for how well the kidneys are working, A working kidney normally filters about 90% of the urea it produce. The normal values are within 2.5 to 7.1 mmol/L. Creatinine measures amount of Creatinine in the blood to see the filtering capability of kidneys. Normal value is upto

0.11mmol/. From the lab results of Mr Smith, his urea levels are 11 mol\L which is significantly higher than normal range. This often indicated impaired kidney functions such as decreased blood flow to the kidneys however his creatinine levels are within normal range. BGL fasting – Blood Glucose Levels (fasting) Blood glucose levels measures the amount of sugar in the blood often used to diagnose or monitor diabetes. We know that Mr Smith is currently receiving treatment for diabetes. A normal range for BGL are within 4.0–7.8mmol/L, however any measurements within 48mmol/L during fasting indicates diabetes type 1. https://www.racgp.org.au/afpbackissues/2008/200811/200811phillips.pdf

Urinalysis: A urinalysis is used to detect and manage a range of disorders by testing the urine. Thi si nv ol v es

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Gl ucos ei snor mal l yfi l t er edandr eabsor bedi nt heki dney ,pat i ent swi t haposi t i v egl ucose coul dbehyper gl y caemi c .Themeanst hatt hepat i ent s ’ bl oodgl ucos ei sov er whel mi ngl yhi gh andt heki dneyi snotabl et or eabs or bt hegl ucoseandt her ef or eex c r et esi ti nt heur i ne.The nor mal r ef er encer angei snegat i v e,howev erwecans eet hati nMrSmi t h’ st est ,gl ucoseis high at 150 mg/d.

Differential diagnosis list (in order of likelihood as judged by you) COPD Chronic obstructive pulmonary disease (COPD) is one of the diagnosis I have found. COPD is an umbrella term for Emphysema which is a lung condition that causes shortness of breath. Emphysema

causes damage to the alveoli; the tiny sacs in the lungs that take oxygen in. Over time the inner walls of the alveoli weaken and ruptures. It then merges into larger air spaces instead of the many smaller ones decreasing their efficiency on picking up oxygen. Damaged Alveoli stretches out and loses the lungs springiness, allowing air to get trapped in the lungs which can’t be exhaled out resulting in the feeling of short of breath and coughing. As Emphysema reduces oxygen within the blood due to impairment in the gases exchange, the lack of oxygen in the blood shows a bluish apperance on lips/tongue. This faint bluish appearance

was observed in Mr Smith providing evidence of COPD. Emphysema is direct result of exposure to smoking in which the symptoms develop slowly and show signs when patients are at least 40. Mr Smith’s episodic shortness of breath over the past year and the worsening of it over the last 5 weeks are symptoms of Emphysema and his lifestyle choices off smoking 15 cigarettes a day along with his old age are the biggest causes of chronic obstructive pulmonary disease therefore supporting my diagnosis of COPD.

Congestive heart failure (Systolic heart failure) Mr Smith maybe diagnosed with systolic heart failure. This is when the left ventricle loses its ability to contract normally meaning that not much blood leaves the left ventricle every time it pumps and there isn’t enough force to push the blood into circulation. This prevents the body receiving enough blood that is rich in oxygen causing it to back up in the lungs resulting in symptoms of shortness of breath fluid build-up. The symptoms Mr Smith are complaining provide evidence for the diagnosed condition of Systolic heart failure where there is a reduced exercise intolerance. Mr Smith is unable to exert himself, easily fatigues and loses his energy to do anything to the point where even walking short distances leads to marked weakness. Breathing becomes more difficult and as systolic heart failure worsens, fluids backs up into the lungs and interfere with oxygen getting into the blood. We can see this in Mr Smith’s report where he wakes up at night short of breath and must sit on edge of his bed to catch his breath, the use of extra pillows helps him sleep better. Further evidence that supports this diagnosed condition is fluid retention and swelling in Mr Smith’s ankle is from the physical assessment where there is moderate swelling around the ankles that pits on pressure.

Peripheral arterial disease Another diagnosed condition based on the symptoms that the Mr Smith are presenting is peripheral artery disease which is a circulatory problem caused by Atherosclerosis. Plaque builds up within the arteries nar...