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Case- based Assignment IntroductionThe aim of this report is to interpret and examine the information that is given to provide differential diagnoses. The differential diagnoses would be used to identify Mr Smith’s condition along with the examination of his signs and symptoms. This would help find ...

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Case- based Assignment Introduction

The aim of this report is to interpret and examine the information that is given to provide differential diagnoses. The differential diagnoses would be used to identify Mr Smith’s condition along with the examination of his signs and symptoms. This would help find the source of the patient’s condition. There would be discussions of the patient’s signs and symptoms which would display the severity of Mr Smith current condition and recognise any abnormalities. Mr Smith’s physical examination would also be acknowledged and any problems would be outlined. The laboratory tests would be examined to assist in finding the medical condition for Mr Smith. Moreover, the additional diagnostic tests would show what tests would assist in finding the possible diagnosis.

Patient’s signs and symptoms

The patient’s age is a major risk factor to cardiovascular and respiratory diseases as older age is more prone to such diseases. Mr Smith is presented with hypertension and diabetes which are high risk factors for atherosclerosis. Atherosclerosis is a cardiovascular disorder affecting patients where the walls of the arteries build up in plaque. In addition, Diabetes is a chronic disorder which enables the body to secrete insufficient amounts of insulin. Mr Smith has had diabetes for 20 years, along with hypertension which increases the chances other cardiovascular diseases. He most likely has Type 2 diabetes mellitus as patients are usually older in age, have hypertension, and are overweight. Furthermore, hypertension refers to high blood pressure and is considered a common

disorder however is known to be He is treated with Minidiab and tritace for diabetes and hypertension respectively. He also only regularly self-monitors his Blood pressure and Blood glucose levels which highly impacts on his current condition. Hypertension should be managed as it could reduce the risks of cardiovascular disorders and prevent organ damage.

Mr Smith is showing signs of ‘shortness of breath’ which is formally known as dyspnoea and this discomfort is a symptom for many cardiovascular or respiratory diseases. Dyspnoea is important in the aetiology of many cardiovascular, respiratory and neuromuscular systems. (Kuzniar, 2018). Mr Smith also has ‘marked weakness and shortness of breath during short walks’ which refers to dyspnoea that is induced by physical activity. This sensation of discomfort can be exacerbated through physical activity which leads to increased levels of breathing after the release of chemoreceptors to send signals to the brain to increase heart rate. Dsypnoea is also a symptom of Chronic Obstructive Pulmonary Disease (COPD), and congestive heart failure.

Mr Smith awakens from sleep with dry cough and could not catch his breath with no audible wheezing this means he may have issues with his respiratory system. Mr Smith does not have a chronic cough which lasts for more than 8 weeks (Kuzniar, 2018). In this case, Mr Smith may have acute cough which is less severe and his cough could be relieved when he is in upright position. He also does not show symptoms of chronic bronchitis however he does have a history of smoking which may cause his dry coughs. His dry cough is an automatic response when your body acts upon foreign particles or bacteria in the body. Furthermore, Mr Smith may also be susceptible to respiratory disorders such as Chronic Obstructive Pulmonary disorders or pneumonia.

Moreover, he developed a ‘weakness and numbness in his left arm and leg with dizziness’ is a symptom of diabetic cardiovascular disease. This is known as paraesthesia’s of the arm and leg which could be caused by neurological disorders, nerve damages or disruption to the nerve impulses. Mr Smith also feels ‘numbness, tingling and burning effect on his feet’ which interferes with his mobility and sleep. These signs and symptoms are most common for diabetic patients and these sensations are the result of diabetic neuropathy (Malik, Alam, Azmi, 2018). These sensations are referred to as dysesthesias meaning abnormal sensation which affects many people with diabetes due to damages to the nerves.

Mr Smith is also a smoker which creates higher chances to be at risks to cardiovascular and respiratory disorders. COPD is the leading causes of smoking which is the most probable diagnosis for Mr Smith. The prevention of smoking could avoid most deaths and other diseases. Smoking could lead to damages to the endothelium causing the two main lipoproteins to perform actions such as Low Density Lipoproteins to dissolve in the body and High Density Lipoproteins (HDL) to reduce (Pleikosa, 2018). Low density lipoproteins (LDL) are considered as ‘bad cholesterol’ hence an abundance of LDL would be detrimental to one’s health. Patients who are obese have higher risks of Chronic Obstructive Pulmonary Disease (COPD). Mr Smith has higher chances of developing this disease due to his older age and COPD is developed over chronic smoking.

Mr Smith’s high blood pressure is due to his ongoing hypertension for 20 years. He shows symptoms of Tachycardia as his pulse rate is irregular and has shortness of breath. Although Mr Smith is between normal heart rate of 100 beats per minute however, any heart rate that

exceeds 100 beats can be confirmed to have Tachycardia. The normal heart rate can also vary between different age groups. The main causes of tachycardia are due to hypertension or other ongoing cardiovascular diseases.

Physical examination

The patient is moderately overweight hence the breathing difficulties with pale skin and bluish lips and tongue. He may have the condition where his body lacks oxygen which is referred to as cyanosis. Cyanosis is where there is the lack of oxygen circulation in blood causing discolouration to the skin. He also has weak pulse at the peripheral leg arteries, which could due to the lack of oxygen circulation in the blood stream. Hence, he has weak pulse, which is associated with Peripheral Artery Disease (PAD), which also causes numbness of the leg (Armstrong, 2017). The causes of PAD are atherosclerosis which causes blockage of arteries of the lower extremity.

He has moderate swelling of the leg and pitting is present on pressure around the ankles. Mr Smith has oedema which is obvious swelling that is palpable due to an abundance of interstitial fluid in the tissue (Rosenthal, Cumbler, 2018). The abnormal growth of interstitial fluid caused other spaces or local systems to be affected such as increase in plasma volume. (Trayes, Studdiford, Pickle and Tully 2013). Oedema affects many people and can cause ulceration of the foot for patients with diabetes. Oedema is most commonly caused by congestive heart failure as well as obstruction in the leg vein.

Coarse inspiratory crackles are heard, this is a clinical feature of lung disorders which means there is fluid in the alveoli or there is a narrowing of blood vessel lining. It is also a feature of COPD emphysema, Bronchiectasis, and pulmonary oedema. The crackles, that are heard during auscultation are an indication of the condition COPD.

He also has irregular and fast heart activity with a S3 sound which may indicate he may have heart failure. The third heart sound is defined as the sound after the first and second heart ‘Lub’ and ‘dub’ respectively. The third heart sound is identified in patients with congestive heart failure and this evidence has been by many studies. (Minami et.al. 2014). Minami (2014) suggests that patients who showed an S3 sound had higher levels of creatinine and heart rate in comparison to patients showing no signs of S3 sound.

Laboratory tests The laboratory tests include blood tests and urinalysis which are important in showing Mr Smith’s condition. The significance of blood test allows to show the high levels of glucose in the blood proving he has diabetes and enables to display he has high urea and low creatinine in the blood.

High glucose levels Mr Smith may have Type 2 diabetes mellitus which is a common disorder which affects most patients that are overweight and are of older age. The blood test resulted in high levels of glucose in the blood which confirms that he has insufficient insulin production. This would

result in imbalance of glucose in the blood as insulin is a hormone that controls the level of glucose.

Elevated creatinine The blood test show that Mr Smith has high levels of creatinine in blood, this may cause kidney failure and kidney disease. Hypertension may also cause in high creatinine and urea in the blood. Creatinine is known to be the waste product of metabolism which should be released via the kidneys. The levels of Creatinine will rise in the blood due to an impairment of the kidneys (Amerman, 2016). As a result, Creatinine is used to measure for renal disease and kidney failure.

High urea levels Elevated urea can mean that the kidneys are dysfunctional which would increase the levels of urea. High levels and urea and creatinine may indicate kidney failure hence, the waste products cannot be filtered out of the body. Urea is removed by the kidneys and exits our body in urine, if our kidneys failure to remove urea there is a high concentration in our body.

Possible diagnoses

The possible diagnoses for Mr Smith are Chronic Obstructive Pulmonary disease (COPD), Atherosclerosis, congestive heart failure and chronic kidney disease. The summary of the patient signs and symptoms show the high risks of COPD and Atherosclerosis. However, the blood tests show that there is elevated creatinine and urea which could mean he may have renal failure. Hypertension and diabetes are also strong factors which could cause kidney

disease and Atherosclerosis. Hypertension can cause future implications such as heart attack and stroke. In addition, Diabetes could cause long term problems such as the management of glucose levels, chronic renal disease, and at risk of amputation.

Atherosclerosis would lead to narrowing of the lumen due to a build-up of plaque which interrupts with blood flow. A common form of atherosclerosis is that it affects the carotid artery and leads to carotid artery stenosis. This is the build-up of atherosclerotic plaques which come from fatty streaks (Lal, 2017). Carotid artery stenosis causes stroke which is the main causes of death among patients. Stroke is when there is a blockage to a blood vessel causes low supply of oxygen and other important nutrients towards the brain. Strokes can be fatal which and are divided into two types of strokes such as ischemic stroke and haemorrhagic stroke (CDC, 2018). Ischemic stroke refers to the build-up of fatty particles or plaque which blocks the blood vessel. Whereas, haemorrhagic stroke is when the blood vessel ruptures in the brain causing other structures of the brain to be interrupted. Major risk factors also include, older age, existing hypertension and smoking are all evident in the patients records.

Mr Smith may have COPD due to his ongoing smoking problem which blocks the airways as he also has shortness of breath and cough. COPD includes the chronic bronchitis and emphysema as two conditions that is related with the responsiveness of the lungs. The aetiology of COPD is that smoking causes the dysfunction of inflammatory responses, cilia breakdown and cause injury. (Best Practice, 2017). Patients should stop smoking to reduce symptoms of COPD and other lung diseases. COPD affects the airways of the lungs which are central and peripheral.

Some key diagnostic risk factors include: -

Smoking

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Advancing age

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Coughs

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Shortness of Breath

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Coarse crackles (Best Practice, 2017)

The diagnostic risk factors that are listed above are all evident in Mr Smith’s clinical profile and are common in COPD patients. The complications of COPD include ‘cor pulmonale’ which is right sided heart failure and affects the patient in the long term. Other complications include smoking which damages cilia and causes oxidation and injury which contributes to COPD cases. Furthermore, the possible diagnoses include chronic kidney disease.

Chronic Kidney disease is mostly caused by diabetes and hypertension which is usually not recognised in the earlier stages. The patient may have evidence of kidney damage or a dysfunctional kidney which lasts for 3 months (Australian government, department of health, 2016). The ageing population also raises chances of Kidney disease, and most patients have cardiovascular disease. Many people have shown no symptoms and can only be diagnosed through laboratory tests. Hence, Mr Smith may have asymptomatic response however, through the blood tests he is at risk of Kidney disease. Therefore, the use of dialysis is important for the treatment of Chronic Kidney disease. In addition, Mr Smith may be susceptible to cardiovascular diseases along with kidney disease.

He may be susceptible to congestive heart failure due to a many symptoms which are shown in the Mr Smith’s records. The rise in number of patients with this cardiovascular disease is due to the ageing population as well as many risk factors. This condition occurs when the heart is unable to produce enough cardiac output for the body hence increases the diastolic pressure. Congestive heart failure is a term for patients with shortness of breath and oedema due to inadequate amounts of sodium and water production (Yusuf, 2017). Mr Smith should also be monitored as he has high risks of cardiovascular and kidney disease. Yusuf (2017), suggests some instructions for monitoring patients with congestive heart disease are: “weight checks, sodium restrictions, tobacco and alcohol cessation, and a strict control of hypertension and diabetes”.

Common heart diseases include congestive heart failure and ischemic heart disease are differential diagnoses. Other diseases pulmonary embolism and lung diseases may also be differential diagnoses. (Best Practice, 2017). These differential diagnoses may indicate that Mr Smith may be prone to respiratory tract infections as well as deteriorating lungs because of his smoking. However, he may be susceptible to pulmonary embolism which is the clotting of blood in the deep vein which can occur to the arteries in the lungs. Patients however diagnosed with pulmonary embolism are often shortness of breath and have chest pain. Mr Smith does not have chest pain but additional diagnostic tests such as an ECG would help examine if they have cardiovascular diseases.

In summary, Mr Smith may be diagnosed with COPD and Chronic Kidney disease. This is because of the factors which impact on the patient’s condition, such as chronic smoking,

hypertension and diabetes which are risk factors for COPD. The patient’s signs and symptoms also indicate that there are high chances of COPD and kidney disease.

Additional diagnostic tests Additional diagnostic tests would help determine the cause of Mr Smith’s condition and allow to confirm the diagnosis. There would be different tests that would be ordered for further diagnostic tests which would support the possible diagnosis of the patient. These diagnostic tests listed below would help find the cause of the patient’s condition.

ECG An electrocardiogram test would be ordered to show how the heart is operating. The ECG is a non-evasive test where it would show the electrical activity of the heart. It is recorded by placing the ECG electrodes on the patient’s skin which would produce an image showing waves the activity of the heart. ECG would show waves of P wave, QRS wave and T wave. The ECG also only reads that there is a net change in electrical activity and does not read if the change is negative or positive (Amerman, 2016). An ECG can detect any irregular heart beat as it measures the electrical impulses produced by the heart. Therefore, it is important for Mr Smith to have an ECG test which would determine if there are any more heart abnormalities.

Echocardiogram

This is also an non-invasive examination which uses advanced technology to check the activity of the heart. It produces sound waves of the hearts activity and images of the heart which shows the size and shape of the heart. This examination also shows how the chambers of the heart and valves are functioning. This is an important test for patients with high blood pressure, as an echocardiogram will show an increase in heart size. Patients with hypertension, and are at risk of heart diseases, or may have blood clots should be needing an echocardiogram completed (National Heart, Lung and blood Institute, 2018).

Chest x ray Additional diagnostic tests include the x ray of the chest which shows images of the thoracic cavity. An image produced by the x-ray would show any signs of pneumonia, heart failure or other lung disorders. An x-ray uses ionising radiation to capture the image of the body internal structures. (Amerman, 2016). Chest x-rays are performed on patients due to many benefits such as low costs, low radiation and easy access. (Choo et.l. 2016).

Pulse Oximetry A pulse oximeter can measure a patient’s oxygen saturation. This is important as it shows how much oxygen is in the blood, hence it helps monitor Mr Smith’s oxygen saturation. This would help Mr Smith’s weak pulse at the peripheral leg arteries through monitoring and due to low oxygen in arterial blood.

Renal Ultrasound

The use of renal ultrasound would be able to test any abnormalities in the kidneys. This procedure is harmless, where an ultrasound would show images of the kidneys where the kidney lengths and volumes could be found (Kent et.al.2009). A three-dimensional ultrasound can display images such as renal cysts that may be found in patients.

MRI of Kidneys A MRI refers to Magnetic Resonance Imaging which can be used to scan structures in the body for instance kidneys and heart. An MRI of the kidneys would be able to show any irregularities in the body such as tumours or kidney stones. Although it would also show an accurate image of the kidneys it is more at risk of radiation in comparison to renal ultrasound.

References

Adrian, H., Julia, L., Lukas, E., Yanik, B., Lars, L., Barbara, B., Michelle, M., Johannes, H., Andreas, C. (2015). Performanace of ultralow-dose CT with iterative reconstruction in lung cancer screening: limiting radiation exposure to the equivalent of conventional chest X-ray imaging. European Society of Radiology, 2016(26), 3643-3652. Doi: 10.1007/s00330-015-4192-3 Armstrong, E. (2017). Peripheral Arterial Disease. BMJ Best Practice. Retrieved from http://bestpractice.bmj.com/topics/en-gb/431 Atkin, L., Tansley, J., & Stephenson, J. (2018). Diabetic foot ulceration: the impact of oedema. Wounds UK, 14(1), 33-39. Australian Government Department of Health. (2016). Chronic Kidney Disease. Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/chronickidney BMJ Publishing Group. (2018). Assessment of elevated creatinine. Retrieved froma http://bestpractice.bmj.com/topics/en-gb/935 BMJ Publishing Group. (2017). Overview of Diabetes. BMJ Best Practice. Retrieved from http://bestpractice.bmj.com.ezproxy.uws.edu.au/topics/en-gb/534 Breathmach, C,S. (2012). Insulin. Ireland Journal of Medicine Science 2012(181), 15-18. Doi: 10.1007/s11845-011-0777-2 Centers for Disease Control and Prevention. (2018). Stroke. Retrieved from https://www.cdc.gov/stroke/about.htm Choo, Y,J., Lee,Y,K., Yu,A., Kim, H,J., Lee,H,S., Choi, W,J., Kang,Y,E., Oh,W,Y. (2015). A Comparison of digital tomosynthesis and chest radiography in evaluating airway lesions using computed tomography as a reference. European Society of Radiology, 2016(26), 3147-3154. Doi: 10.1007/s00330-015-4127-z

Coccia, CB., Palowski, GH., Schweitzer, B., Motoshi, T., Ntusi, NA. (2016). Dyspnoea: Pathophysiology and clinic...