Chronic Medical Conditions and Health Surveillance - Essay Example

?Chronic Medical Conditions and Health Surveillance This case study is based on a 76 years old female who has sustained a fall. This essay criticallyanalyses the different aspects of the patient’s history and physical examination and discusses the underlying pathophysiology and probable diagnoses. It also sheds light on the available lifestyle modification strategies and pharmacological interventions for this patient and the different referral options which can be utilized in such a case scenario. Critical Analysis of the Patient’s History: The history obtained by the patient revealed that the patient is a known hypertensive and experienced an episode of high blood pressure resulting in a nosebleed while she was away on a holiday trip. In order to control her blood pressure, she was started on an antihypertensive. The patient then sustained a fall which was not accompanied by any episodes of altered consciousness. Falls are a commonly encountered issue amongst the elderly and studies have revealed that they amount to almost 60% of the hospital admissions in the UK National Health Service (NHS) amongst the elderly (Oliver, 2007, p. 173). In order to decipher the cause of the fall, a focused history regarding the events preceding and following the fall should be obtained. In the case of this patient, she reports that the fall occurred when she stood up from a chair and was preceded by an episode of feeling ‘giddy’. Since she denies any aura, alteration of consciousness, post-ictal events, persisting weakness or loss of function in any part of the body after the fall, and this is verified by her husband who was present at the time of the incident, most common neurologic causes of the fall such as stroke or seizures can be ruled out. Similarly, as she denies any chest pain or palpitations, cardiac causes such as arrhythmias and angina/myocardial infarction also become unlikely as the cause of the fall. Keeping in mind that paramedics have limited time available to obtain a detailed history, as opposed to a history taken in other health care setting, while taking history for a patient who has sustained a fall, the DAME classification system is recommended to be followed in order to elucidate a cause for the fall. The DAME classification system covers the commonest causes of falls amongst the elderly, whereby D refers to Drugs and alcohol; A refers to age-related physiological changes, such as impaired balance and postural instability, reduced vision and increased reaction time; M refers to medical causes and E refers to environmental causes (Oliver, 2007). Drugs/medications are amongst the top causes of falls amongst elderly especially due to the multiple co-morbidities that are commonly found amongst elderly patients, the problem of poly-pharmacy leading to drug interactions is quite common in this population of individuals. Therefore, obtaining a careful drug history and ruling out any drug over dosage, interactions and adverse effects leading to a fall is important in elderly patients. A critical analysis of the patient’s medication history reveals that the patient was started on Atenolol, at a starting dose of 400mg BID, which amounts to 800mg of Atenolol per day. Atenolol belongs to a class of anti-hypertensives termed as beta blockers, and is one of the most commonly prescribed drugs from this class (Carlberg, Samuelsson, & Lindholm, 2004, p. 1684). Atenolol is a cardio-selective beta blocker, i.e. it only acts on beta-1 receptors, which are the predominant type of receptors in the heart. Such beta blockers spare the beta-2 receptors, which are the predominant type of receptors located in the lungs and the vascular smooth muscle and are thus free from side effects such as bronchospasm, which were previously commonly encountered with the use of non-selective beta blockers (Medic8, 2010). Previously, beta blockers such Atenolol were considered to be the first-line agent in the management of hypertensive patients, but more recently, the use of these agents as the drug of choice for hypertension is under debate (Carlberg, Samuelsson, & Lindholm, 2004). Recent NICE guidelines suggest the use of calcium channel blockers or thiazide diuretics as the first line agents in the management of hypertensive patients aged greater than 55 years (NICE Clinical Guidelines 34, 2006). Moreover, on patients who are already on either one of the aforementioned drugs and still have elevated blood pressures, the addition of an Angiotensin Converting Enzyme (ACE) inhibitor is the next appropriate recommended step in management (NICE Clinical Guidelines 34, 2006). The addition of a beta blocker to a calcium channel blocker is not a recommended management strategy for hypertensive patients specially those who fall in the elderly age group. The initial recommended starting dose for Atenolol is 50 mg once a day. The patients should be then monitored for response for atleast a week after which a consideration for dose escalation is to be made. The recommended maximal dose of Atenolol is 100 mg per day (RxList, 2010). There are several document adverse effects of Atenolol. The Atenolol related adverse effects pertinent to this patient include bradycardia, postural hypotension, dizziness and altered glucose metabolism (Medic8, 2010) as all of these can lead to falls. There are several important points regarding this patient’s drug history which warrant discussion. Firstly, the patient was started on a dose of Atenolol which is almost 8 times higher as compared to the maximal recommended dose. Such high doses can have potentially hazardous ill effects and could lead to severe reductions in blood pressure. Moreover, it is recommended, that in elderly patients, the starting dose of any drug, in particular drugs which are excreted via the hepatic or renal route, should be adjusted and drugs should be prescribed with caution, starting with the lowest recommended therapeutic dose. This is because the hepatic, renal, or cardiac functional reserve in elderly patients is reduced and thus drug elimination is altered. Therefore, the renal and hepatic functions should be assessed before starting any new drug in this age group of patients. In addition, since most elderly patients are on other drugs due to concomitant illnesses, there is a potential for drug interactions (RxList, 2010). In the case of the patient in question, the patient was already on Amlodipine, which is a Calcium channel blocker. It is a documented fact that calcium channel blockers have an additive effect when prescribed along with Atenolol (RxList, 2010) . The drug interactions between Amplodipine and Atenolol can result in bradycardia and heart block (RxList, 2010). Thus, keeping in view the preceding discussion, the most likely explanation for the patient’s fall was postural hypotension or bradycardia both of which could have resulted from the high dosage of Atenolol prescribed to the patient and the potential interaction between the two anti-hypertensive drugs being used by the patient, i.e. Atenolol and Amlodipine. Other important details of the history which are necessary to obtain in order to ascertain the cause of the fall include the patient’s past medical history. It is important to ask the patient whether any similar episodes were encountered in the past. Moreover, a recent history of palpitations and blackouts should be obtained as the presence of these would supplement the proposed diagnosis. Moreover, since the patient is a known hypertensive who had been using Amplodipine previously for the control of her blood pressure, a history of the patient’s compliance with medication and blood pressure control on the prior medication is also important. This is important to determine the cause of the patient’s elevation of blood pressure which occurred while she was away on the holiday. Non-compliance and non-adherence to medical treatment regimes is a commonly encountered problem especially amongst the elderly population and those with chronic health conditions. Non-compliance with the prescribed regime can result in inadequate control of blood pressure and is an important factor to consider since if this is the underlying cause of the patient’s inadequate control, then dose escalation or addition of a new drug to the treatment regime is not required. The past medical history will also reveal whether the patient has had any prior episodes of fall and if so, what were the underlying causes. If a history of recurrent falls is present, it is likely that the underlying cause of the falls is common for all events and then the management plan should focus on eliminating that cause. Physical Examination: The physical examination performed on the patient revealed normal temperature, respiratory rate, capillary refill, oxygen saturation, GCS and ECG. Two important clinical findings on examination were a heart rate of 62/min and a blood pressure of 119/70 mmHg. The heart rate of the patient does not fall in the bradycardiac range (i.e. Read More