Week 6

Week 6: Comprehensive Case Study on COPD, Heart Failure, Hypertension, and Diabetes Mellitus

Review the following case study and complete the questions that follow. For this assignment, write your responses to each question as one narrative rather than separating your responses by question number. Include an introduction and a conclusion. Submit your answers using APA format, well-written sentences, and detailed explanations. Your analysis must be scientifically sound, necessary, and sufficient.

You must also include a bibliography of at least 3 sources (with at least one non Internet source). Your textbook may not be included as a source for this assignment. Refer to the rubric for more information on how your assignment will be graded.

Case Study

M.K. is a 45-year-old female, measuring 5’5” and weighs 225 lbs. M.K. has a history of smoking about 22 years along with a poor diet. She has a history of Type II diabetes mellitus along with primary hypertension. M.K. has recently been diagnosed with chronic bronchitis. Her current symptoms include chronic cough, more severe in the mornings with sputum, light-headedness, distended neck veins, excessive peripheral edema, and increase urination at night. Her current medications include Lotensin and Lasix for the hypertension along with Glucophage for the Type II diabetes mellitus.

The following are lab findings that are pertinent to this case:

1. What clinical findings correlate with M.K.’s chronic bronchitis? What type of treatment and recommendations would be appropriate for M.K.’s chronic bronchitis?

1. Which type of heart failure would you suspect with M.K.? Explain the pathogenesis of how this type of heart failure develops.

1. According to the B.P. value, what stage of hypertension is M. K. experiencing? Explain the rationale for her current medications for her hypertension. Also, discuss the impact of this disease in the U.S. population.

1. According to the lipid panel, what other condition is M.K. at risk for? According to this case study, what other medications should be given and why? What additional findings correlate for both hypertension and Type II diabetes mellitus?

1. Interpret the lab value for HbA1c and explain the rationale for this value in relation to normal/abnormal body function?

Refer to the rubric for more information on how your assignment will be graded.

Due: Sunday, 11:59 p.m. (Pacific time)

Points: 300

Safe Assign results below:

1 COMPREHENSIVE CASE STUDY ON COPD, HEART FAILURE, HYPERTENSION AND DIABETES MELLITUS

Comprehensive Case Study on COPD, Heart Failure, Hypertension and Diabetes Mellitus

1 The following is a comprehensive case study on COPD, Heart Failure, Hypertension and Diabetes Mellitus.

The patient is a 45 year old, obese female with an extensive smoking history along with a poor diet. In addition, she has Type II DM along with hypertension and was recently diagnosed with chronic bronchitis which is manifested in some of her current symptoms. 3 Current home medications include, Lotensin, Lasix and Glucophage.

Patients with chronic bronchitis are often overweight and has a history of smoking as in this case. 2 Cigarette smoking is the most important risk factor for the development of chronic bronchitis.

Over 90 percent of patients with chronic bronchitis have a smoking history, although only 15 percent of all cigarette smokers are ultimately diagnosed with some form of obstructive airway disease. 4 Chronic bronchitis is a clinical diagnosis characterized by a cough productive of sputum for over three months’

http://www.aafp.org/afp/1998/0515/p2365.html

duration during two consecutive years and the presence of airflow obstruction.

http://www.aafp.org/afp/1998/0515/p2365.html

Pulmonary function testing aids in the diagnosis of chronic bronchitis by documenting the extent of reversibility of airflow obstruction.

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The following treatments and recommendations would be appropriate.

4 Documentation of airflow obstruction by pulmonary function testing is critical for the diagnosis of chronic bronchitis and provides valuable therapeutic information about the patient’s responsiveness to inhaled bronchodilator therapy.

http://www.aafp.org/afp/1998/0515/p2365.html

A measured forced expiratory volume in one second (FEV1) of less than 70 percent of the total forced vital capacity (FVC)—the FEV1/FVC ratio—defines obstructive airway disease.

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An FEV1/FVC ratio of less than 50 percent indicates end-stage obstructive airway disease.

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Hypoxemia is a common finding on arterial blood gas sampling in patients with advanced chronic bronchitis and ventilatory failure secondary to bronchospasm and inflammation.

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Radiographic findings correlate poorly with symptoms in most patients with chronic bronchitis.

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Common, but nonspecific, findings include hyperinflation, bullae, blebs, diaphragmatic flattening and peribronchial markings.

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A better understanding of the role of inflammatory mediators in chronic bronchitis has led to greater emphasis on management of airway inflammation and relief of bronchospasm.

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Inhaled ipratropium bromide and sympathomimetic agents are the current mainstays of management.

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While theophylline has long been an important therapy, its use is limited by a narrow therapeutic range and interaction with other agents.

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Oral steroid therapy should be reserved for use in patients with demonstrated improvement in airflow not achievable with inhaled agents.

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Antibiotics play a role in acute exacerbations but have been shown to lead to only modest airflow improvement.

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Strengthening of the respiratory muscles, smoking cessation, supplemental oxygen, hydration and nutritional support also play key roles in long-term management of chronic bronchitis.

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Proper treatment and management of chronic bronchitis is needed in order to prevent right-sided heart failure which is suspected in this case. 2 This can be in response to abnormally low oxygen levels in the vessels inside the lungs as a result of COPD.

The excess strain from pulmonary hypertension on the right ventricle can result in heart failure.

5 Right-sided heart failure causes fluid to accumulate in the legs, ankles and abdomen as well as the lungs.

6 Right-sided heart failure means that the right side of the heart is not pumping blood to the lungs as well as normal.

http://www.genesishcs.org/patients-visitors/health-library/healthwise-document-viewer/?id=tx4093abc

7 Most people develop heart failure because of a problem with the left ventricle.

But reduced function of the right ventricle can also occur in heart failure.

8 As blood begins to back up behind the failing left ventricle and into the lungs, it will become harder for the right ventricle to pump returning blood through the lungs.

7 Like the left ventricle, the right ventricle will weaken with time and start to fail.

In right-sided heart failure, the right ventricle loses its pumping function, and blood may back up into other areas of the body, producing congestion.

In addition to her chronic bronchitis and suspected heart failure, patient has stage I hypertension with a blood pressure of 158/98. 9 Readings between 140/90 and 159/99 usually indicate Stage I Hypertension, which means the force of the blood pressure in your arteries is higher than normal, putting you at increased risk of life-threatening problems such as heart attacks and stroke.

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Blood pressure in this range can also damage organs such as the heart and the kidneys, especially in people who already have chronic medical problems affecting these parts of the body.

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As she is already on Lasix and Lotensin, the diuretics will help to reduce blood pressure by increasing the removal of sodium and fluid from the blood into the urine by the kidneys. Diuretics also lower blood pressure by promoting dilation of small blood vessels. The ACE inhibitors will decrease blood pressure by reducing the production of angiotensin II, a potent constrictor of blood vessels. They are often prescribed for people with hypertension who also have kidney damage, heart failure or diabetes.

Having high blood pressure puts you at risk for heart disease and stroke, which are leading causes of death in the United States. 10 About 75 million American adults (32%) have high blood pressure—that’s 1 in every 3 adults.

5 High blood pressure costs the nation $46 billion each year.

This total includes the cost of health care services, medications to treat high blood pressure, and missed days of work.

11 With her abnormal lipid panel, patient is also at risk for coronary heart disease.

1 Cholesterol is required for the synthesis of steroid hormones and bile.

12 It is a necessary component of cell membranes.

If we don’t get cholesterol from our diet, the liver will make it.

However, most people do receive plenty of cholesterol from their diet resulting in high cholesterol levels (greater than 200 mg/dL).

The total cholesterol measurement is a sum of High Density Lipoprotein (HDL), Low Density Lipoprotein (LDL), and Very Low Density Lipoprotein (VLDL).

13 Low levels of HDL significantly increase the risk of heart disease and are associated with diets high in saturated fats, refined carbohydrates, and refined sugars, especially high fructose corn syrup.

Inactivity, obesity and cigarette smoking also reduce HDL levels.

12 Elevated LDL levels are the result of inactivity, obesity, and type II diabetes.

13 LDL levels also increase from diets high in refined carbohydrates, sugar, saturated animal, trans, and hydrogenated fats.

14 Conditions that can cause high triglycerides include hypothyroidism, diabetes, liver and kidney disease, corticosteroids, and diets high in refined carbohydrates and sweets as well as excess fat intake.

Other medications may need to be prescribe such as beta blockers which will slow heart rate and decrease blood pressure, which decreases the heart’s demand for oxygen. Aspirin can reduce the tendency of your blood to clot, which may help prevent obstruction of your coronary arteries. Cholesterol-modifying medications can decrease the amount of cholesterol in the blood, especially low-density lipoprotein (LDL, or the “bad”) cholesterol, these drugs decrease the primary material that deposits on the coronary arteries. Possible medications including statins, niacin, fibrates and bile acid sequestrants.

Another of patient’s abnormal labs is her HbA1c of 7.3%. In patients with HbA1c < 7.3%, postprandial glucose makes the major contribution to the overall hyperglycemia, whereas the contribution of fasting glucose becomes progressively predominant in patients with HbA1c > 7.3%. As a consequence of these observations, initiation of anti-diabetic treatments or implementation of second-line therapies should be aimed at reducing either postprandial excursions or fasting hyperglycemia according to whether HbA1c levels are found respectively below or above a cut-off value of 7.3%.

8 Normal ranges for hemoglobin A1c in people without diabetes is about 4% to 5.9%.

People with diabetes with poor glucose control have hemoglobin A1c levels above 7%.

The goal for people with diabetes, with their doctor’s help, is to establish stable blood glucose levels resulting in hemoglobin A1c levels that are at least below 7% to reduce or stop complications of diabetes (for example, diabetic nerve, eye, and kidney disease).

In summary, Chronic obstructive pulmonary disease is associated with important chronic comorbid diseases, including cardiovascular disease, diabetes and hypertension. Lung function impairment is associated with a higher risk of comorbid disease, which contributes to a higher risk of adverse outcomes of mortality and hospitalizations. Appropriate treatment plans should be aimed towards progression and prevention of these diseases.

References

4 American Thoracic Society.

http://www.aafp.org/afp/1998/0515/p2365.html

Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease.

http://www.aafp.org/afp/1998/0515/p2365.html

Am J Respir Crit Care Med.

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1995;152(5 Pt 2)

http://www.aafp.org/afp/1998/0515/p2365.html

14 American Diabetes Association.

“Diagnosing Diabetes and Learning About Prediabetes.”

15 www.cdc.gov/bloodpressure/facts

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