HUBS2505 Human Pathophysiology

Introduction

The case describes a scenario based on Mr Deependra Sidhu, also known as Deep, who is admitted to the hospital following certain cardio vascular emergencies. The patient is a 68 year old man of Indian origin, presently settled in Melbourne, Australia. He was admitted following dyspnea while lying down, along with extreme pain in the chest. He has been consuming his prescription medications, which include aspirin, atenolol, furosemide, pravastatin, and GTN spray. In addition to these, he also took Viagra from time to time. He admits that he avoids taking furosemide since it makes him go on bathroom breaks too often, but withholds his usage of Viagra few hours prior to hospitalization. His vitals were taken during the time of admission, which suggested tachycardia, hypertension, hyperventilation, with lower oxygen saturation levels. His temperature was slightly lower, and his slower limbs exhibited signs of pitting edema. The following questionnaire attempts to elaborate on the different approaches that might be adopted to rectify the situation, while also addressing the dilemmas that might be encountered while doing so.

Answer 1

An ECG is the abbreviated form of electrocardiogram, which is a voltage versus time graph obtained by the process of electrocardiography. Electrocardiograms are useful in measuring the electrical activity of the heart (Al Rahhal et al., 2016). It is done with the help of electrodes situated on the surface of the skin, which can detect depolarisation and repolarisation following each cardiac cycle, which is then depicted in the electrocardiogram. The test is prescribed to patients who are suffering from abnormalities of the heart, such as heart failure.

Blood tests are an efficient way of determining or confirming the presence or absence of many kinds of physiological ailments, for example, heart failure. Doctors may order a blood test subsequent to an incident involving cardiac abnormality to rule out a few things. Apart from a complete blood count test or a thyroid test, the doctor may prescribe a blood test to check for the levels of the hormones BNP and NT-proBNP. N-terminal prohormone of brain natriuretic peptide is an inert prohormone and brain natriuretic peptide, or B-type natriuretic peptide are both secreted by the ventricles of the cardiac muscles following an increase in the ventricular volume of blood. Therefore, a spike in the levels of BNP and NT-proBNP might suggest heart failure, which can be detected with the help of a blood test (Cao, Jia & Zhu, 2019).

Both should be done as an added measure to confirm heart failure, since disorders of the heart may not show up on the ECG every time. Similarly, a spike in the BNP and NT-proBNP levels might not always be due to a cardiac failure.

Other blood tests include troponin blood test, which is a protein found in blood following damage to the cardiac muscles (Eggers, Jernberg & Lindahl, 2019). Troponin is found in low levels in the blood at other times, making it an efficient factor which might be able to indicate heart ailments.

Answer 2

Heart failure is a critical emergency, which requires immediate medical assistance (Ziaeian & Fonarow, 2016). An event of a heart failure can be defined by a state where the heart is no longer able to function properly resulting in decreased cardiac output. This in turnhinders blood flow required for cellular metabolism and sustenance. The incidents of heart failure are characterized by:

Shortness of breath or dyspnea while strenuous activities or lying down (Sun et al., 2015)

Weakness

Tachycardia or arrhythmia

Wheezing or coughing consistently

Formation of ascites, leading to weight gain from fluid retention

Edema in the lower limbs.

Angina or chest pain due to reduced blood flow.

Patient suffering from diabetes, hypertension, et cetera often develop impaired blood vessels (Leon, & Maddox, 2015; Kjeldsen, 2018). Since the pressure of the blood is higher inside the arteries, the heart has to pump harder to facilitate proper circulation of the blood throughout the system. This may lead to disorders in the ventricles, resulting in cardio vascularailments.Another risk factor the patient has is high levels of cholesterol content in his blood (Huang et al., 2018). Hyperchloremia may result in hardening of the arteries, also known as coronary atherosclerosis. It is characterised by degeneration of the capillary walls made of epithelial layers, giving rise to lesions. These lesions trigger a cascade of immune responses, and over time, deposition in the inner lumen makes the blood vessels narrower, until completely or almost blocked. Such blockages lead to diminished blood flow in heart, leading to a heart failure.

Outcomes of a heart failure are marked by the occurrence of a number of factors:  

Decrease in stroke volume, cardiac output, arterial pressure and ejection fraction.

Increase in end-diastolic pressure, vascular resistance, venous pressure and blood volume.

To minimize the damage accompanying the event of heart failure, the system goes through a number of changes, such as:

Inducing ventricular dilation and increasing heart rate

Release of vasopressin and atrial natriuretic peptide, in order to induce vasoconstriction and increase blood volume.

Reduction of vagal activity.

Increased levels of catecholamines in the system.

The patient is at an increased risk of developing cardio vascular ailments due to a number of risk factors such as older age, hypertensive state and excess levels of cholesterol in his blood (Farmakis et al., 2015). In addition to that he has a history of myocardial infarction and angina, which further increases his risk of developing serious cardio vascular diseases.

Answer 3

The electrocardiogram is that of a normal 12 lead sinus rhythm ECG.

Rhythm: regular

Rate: higher than the normal range

Presence and regularity of p waves: upright and similar   

ST segment:Inverted or shortened T waves can be indicative of many ailments, such as, ischaemia, hyperventilation, et cetera.

This electrocardiogram is indicative of tachycardia, which is normal during shortness of breath or dyspnea, as was the state of the patient when the electrocardiogram was taken. Shortness of breath is a normal occurrence in patients suffering from heart failure.

Answer 4

Shortness of breath or breathlessness can be one of the earliest signs of an impending heart attack (Berliner et al., 2016). Also called dyspnea, it occurs when one indulges in physical activities, which causes exertion. This can be attributed to the heart not being able to exert pressure on itself to pump harder following the strenuous activity. Often, the condition worsens as one lies down. Orthopnea occurs due to increased pressure in the blood vessels present in the lungs. Patients suffering from cardio vascular ailments might have trouble pumping blood efficiently while in a supine position, leading to increased pressure in the blood vessels present inside the lungs. At times, this may further lead to spilling of fluid out of the capillaries into the lungs. This subsequently leads to shortness of breath while lying down.

Deep has been eating a lot of soup recently in an attempt to lose weight. This might be a cause of further worsening his cardio vascular health. Food items like canned soup may contain a significant amount of sodium in them, which may lead to an increased blood pressure levels (Jinap et al., 2016; Grillo et al., 2019). This in turn may result events such as heart ailments, or stroke.

He had been missing his diuretic medication, the furosemide tablets, which might result in elevating his hypertensive state, increasing his risk of developing heart failure or cerebro vascular accident.

Answer 5

Viagra is the brand name for sildenafil, a medication prescribed to patients suffering from erectile dysfunction (Goldstein et al., 2019; Krishnappa et al., 2019). While healthy men suffering from the disorder can take the drug, patients of hypertension should not take sildenafil since it may lower blood pressure significantly, resulting in life threatening events. Sildenafil acts by dilating blood vessels, not only of the penis, but also of any blood vessel, which release nitric oxide. Prescribing nitrates to patients suffering from cardio vascular ailments, who have recently taken Viagra may pose life threatening physiological effects. Glyceryl Trinitrate medicationshould not be administered to such patient in any mode, be it oral, spray, or slow release drugs. It also includes intra venous preparations and topical application such as transdermal patches.Viagra acts by restricting phosphodiesterase type 5, intensifying the effect of nitric oxideresulting in vasodilation during arousal.Further addition of nitrates result in the leads to excessive vasodilation, which may lead to a fatal drop in blood pressure, which is evident in case of Mr. Sidhu by his severe fall in blood pressure, increased heart rate, decreased blood oxygen level and excessive sweating. On ingesting Viagra, it approximately takes up to 24 hours of time for the plasma concentration of the drug to significantly lower to not pose life threatening effects following administration of Glyceryl Trinitrate in healthy individuals. However, it may take a longer amount of time in individuals above the age of 65. The patient is 68, and suffers from diabetes, which may further cause complications with the clearing of sildenafil from the system. Other analgesic medication should be administered to treat angina in such patients, such as aspirin or morphine.

Mr. Sidhu may have thought it best to withhold such information to avoid being embarrassed or judged by the health care providers. Patients also tend to withhold information to avoid being informed of the ill effects of their risky behaviour.

Answer 6

Generic name	Atenolol	Furosemide oral
Drug group	Beta blocker	Diuretic
Mechanism of action	The drug functions by selectively binding to beta-1 adrenergic receptorspresent in the smooth muscles of the heart. This leads to hindered function of catecholamines, resulting in restricted sympathetic stimulation. It exerts its action by lowering of heart rate and blood pressure levels (Rehman, Sanchez & Shah, 2020).	Loop diuretics restrict the luminal Na-K-Cl symporter present in the ascending limb of the loop of Henle portion of the nephron. By competitively binding to the chloride binding site, resulting in a reduction in sodium, potassium and chloride levels in the urine. This results in significant urine output (Khan, Patel & Siddiqui, 2020).
Complications/ side effects	Bradycardia, heart blocks, cardio genic shock, diabetes, et cetera.	Dehydration, electrolyte imbalance, and hypotension.
Nursing consideration	Assessing orientation, blood pressure and pulse rate. Monitoring hepatic and renal activity also recommended.	Monitoring for dehydration and electrolyte imbalance is required.Vital signs and kidney functions should also be assessed.

Answer 7

Non adherence can be defined as the unintentional failure to follow the medication plan, due to occurrence of side effects, lack of understanding, confusion, or being unable to bear the expenses of medical treatment (Lam & Fresco, 2015). According to research and surveys, medical non adherence among patients suffering from chronic conditions is prevalent in high numbers, with almost 40 to 50 per cent of the patients being affected by the same. It is estimated that the wide spread prevalence of non adherence or not following the treatment regimenmight have caused at least 100,000 preventable deaths. In spite of the grim figures and statistics, the issue of medical non adherence is largely ignored by the health care providers.In this scenario, a lot of factors might have led Mr. Deep Sidhu to avoid taking his medications. Some of these are:

Fear or embarrassment: The patient stopped taking his diuretic medication because it made him take frequent bathroom breaks. The patient, being elderly, found it inconvenient. Moreover, making frequent trips to the bathroom is embarrassing in social situations.

Too many medications: the patient was prescribed a lot of medications, which must have led him to get overwhelmed.

Misunderstanding the need of medication and lack of adverse effects on non adherence: many a times, patients are not made aware of the need of their medication and the effect of non adherence. Mr. Sidhu found that not taking the diuretics reduced his bathroom breaks, which was convenient for him. However, he was oblivious to the adverse effects that would follow.

Adherence can be improved by:

Educating patients on the need and effects of adherence, and the ill effects of non adherence.

Promoting a healthy, transparent nurse-patient relationship.

Scheduling appointments at regular intervals to check up on patient and assess the need for revising medication regimen.

Conclusion 

The case presents facts and scenarios which are very common in the health care industries. Incidents of non adherence, withholding of sensitive information and the effects these have on the health and well being of the patients are discussed at length. In addition to that, the case study also provides useful insights on the kind of complications that might manifest while treating someone with cardio vascular ailments.  

Reference List 

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Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The differential diagnosis of dyspnea. Deutsches Ärzteblatt International, 113(49), 834. https://dx.doi.org/10.3238%2Farztebl.2016.0834 

Cao, Z., Jia, Y., & Zhu, B. (2019). BNP and NT-proBNP as diagnostic biomarkers for cardiac dysfunction in both clinical and forensic medicine. International journal of molecular sciences, 20(8), 1820. https://doi.org/10.3390/ijms20081820 

Eggers, K. M., Jernberg, T., & Lindahl, B. (2019). Cardiac troponin elevation in patients without a specific diagnosis. Journal of the American College of Cardiology, 73(1), 1-9. https://www.jacc.org/doi/full/10.1016/j.jacc.2018.09.082 

Farmakis, D., Parissis, J., Lekakis, J., & Filippatos, G. (2015). Acute heart failure: epidemiology, risk factors, and prevention. Revista Española de Cardiología (English Edition), 68(3), 245-248. https://doi.org/10.1016/j.rec.2014.11.004 

Goldstein, I., Burnett, A. L., Rosen, R. C., Park, P. W., & Stecher, V. J. (2019). The serendipitous story of sildenafil: an unexpected oral therapy for erectile dysfunction. Sexual medicine reviews, 7(1), 115-128. https://doi.org/10.1016/j.sxmr.2018.06.005

Grillo, A., Salvi, L., Coruzzi, P., Salvi, P., & Parati, G. (2019). Sodium intake and hypertension. Nutrients, 11(9), 1970. https://doi.org/10.3390/nu11091970 

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