Pathophysiology of Clinical Manifestation - Case Study Example

Clinical Assessment: Case study- Albert Name Course number University Date Word count: 2766 1a. What is going on here? Patient’s presentation Albert is a 65 year old man who has come to hospital complaining of cough and general discomfort. He coughs a lot and his chest sounds on the right side are reduced. At the same time he reports coughing up sputum of different colour. He has previously had bowel cancer two years ago which was treated successfully through surgery, and in his late twenties, he had an appendectomy. Conversely, Albert has experienced a recurrent upper respiratory tract infection for over a year now. Albert also has type 2 diabetes and at the time of examination his blood glucose is elevated at 15.2 mmol/L and in general, the patient seems depressed, appears to be apathetic and presents with malaise. Evident clinical manifestations – signs and symptoms Albert’s physical health is in distress, as indicated by the clinical symptoms and signs observed. Upon examination of his respiratory system, there is evidence of green sputum, reduced sound in upper right lobe of his lungs and the patient was taking 22 breaths per minute. Elevated blood glucose levels in diabetic patients have been linked to promoting respiratory infections (Garnett et al, 2013). In relation to this, his blood glucose level is elevated at 15mmol/L which is a clinical manifestation of hyperglycaemia. Examination of his musculoskeletal systems reveals slight muscle wasting in all limbs, and his feet are sensitive to touch though limb power is equal. This is a common clinical manifestation of diabetic neuropathy in many diabetic patients (Llewelyn, 2003). Albert also has a cataract on his right eye. The evident mental symptoms that were Albert displayed are related to a depressive state of mind. He responds with short answers and is apathetic, his affect is flat and he is quite irritable. On the other hand he reports that he is suffering from anorexia and has a poor sleep pattern. Diabetes can be said to be responsible for, and is often linked with poor mental health in vulnerable patients (Britbeff & Winkley, 2013). Conversely, these mental health problems interfere with a diabetic patient’s ability to practice optimal self-management, and this may explain the poor glycemic control in the case of Albert. His blood glucose is elevated at 15mmol/L, and his type two diabetes in poorly controlled. Besides, his children live away from him and his wife died two years ago. It is clear that the manifestation of a flat affect, apathy and poor sleep is an indication that Albert is not coping well with the negative events surrounding his life. Diabetes and depression have a causal relationship, meaning that diabetes can be the risk factor that brings about depression in a patient and on the other hand, depression may also be the reason patient developed diabetes (Egede & Ellis, 2010). At the age of 65 years, Albert is an aged man and it has been proven that diabetes type 2 to a large extent occurs with the increase in age. On the other hand, his diabetes is poorly controlled and this explains the occurrence of the acute complications he is experiencing such as the Upper respiratory tract infection and depression. Stress is a factor that contributes to suppressing the brains functionality in terms of mood and affect (Jacobs, 2004). Reflecting back on Albert’s case, he has too much on his plate than he can handle on his own. His children (who are his only close family) live far away from him, and they probably do not know about his psychological state. In addition, he has been through multiple infections for the last year, not forgetting the occurrence of bowel cancer two years ago. In the same period of two years he lost his wife to death, and now has to cope with ailing health. All this coupled with his inability to cope and lack of insight into the fatality of failing in self-management, pauses a great risk to his life. The following is a summary of the clinical manifestations in the case of Albert: Green sputum 22 breaths per minute Reduced sound in his right upper lobe of his lungs Elevated blood glucose level at 15mmol/L Slight muscle wasting in all limbs Reduced pedal pulses in both feet Malaise Apathy Depression Anorexia Poor sleep Irritability 1b. Pathophysiology of clinical manifestation In this section we focus on the pathophysiological process of anxiety which is a common clinical manifestation in patients like Albert, where it is co morbid. However, there is a general lack of research and information concerning the pathophysiology of anxiety (Shelton, 2004). Human beings strive to achieve balance in life, though the environment in which they live in has constant stressors that threaten this balance. The inability to manage ones emotional life, often results into physiological manifestations which represent anxiety, which is our highlight in this section. Anxiety is often viewed in terms of how the body reacts or responds to stressors, and these reactions are triggered by the brain, facilitated by a number of neurotransmitters. Anxiety is believed to occur as a result of disruptions in the modulation inside the central nervous system (Beesdo, Knappe, Dipl-Psych & Pine, 2009). The amygdala is the key starting point in relation to anxiety reaction of the body. This is so because it is composed of small neurons located at the foot of the brain which send signals of distress to the brain once they are triggered (Shelton, 2004). Once these signals are communicated to the brain (and specifically to the brain stem as well as the mid brain), the individual’s body responds with autonomic hyperactivity. This hyperactivity is what is observed in the clinical manifestations such as dizziness, sweating and irritability. In simple words, the body’s reaction to stressors is that of flight or fight (Beesdo et al, 2009). Here the sympathetic nervous system is also triggered, once the amygdale communicates to the hypothalamus which in turn activates the fight or flight action. Neurotransmitters in the brain are active in this process, and in this state the hormone adrenaline is released into the body in order to effect the actions of the sympathetic nervous system. On the other hand, within the central nervous system there is a corticotrophin-releasing factor (CRF) that plays a significant role in how the responses to stressors are coordinated internally and externally. Once the body perceives a stressor, a number of hormonal responses are involved in trying to protect the entire body system from the threat. For instance, the CRF is released and consequently, corticotrophin is released and the stress hormones of glucorticoid and epinephrine are also released (Shelton, 2004). This poses a threat to the body because glucorticoids give undue feedback to the hypothalamus and as a result, the release of the CRF is reduced. Conversely the neurotransmitter Amniobutyric acid (GABA) hampers with the release of the CRF, thus disrupting the CRFs role in moderating the endocrine responses to stress (Gilhotra & Dhingra, 2010). The locus caeruleus (LC) is activated by glucorticoids, a process which also plays part in triggering the amygdale through the help of norepinephrine. As a result, the amygdala is directed to release more and more CRF, which consequently activates a higher release of glucorticoids (Shelton, 2004). During this process the central nervous system is exposed to the glucorticoid hormones, which are a danger factor to the body. This is because the hormone glucorticoid is responsible for depleting the norepinephrine neurotransmitter. Norepinephrine plays a significant role in promoting attention and motivation in individuals, and its reduction exposes an individual to mood disorders. This type of disorder is clearly manifest in Albert, given the flat affect and malaise. In summary, the pathphysiological process of anxiety involves the alteration of the neurotransmitters such as GABA, CRH, norepinephrine and serotonin. Conversely it also revolves around amygdala hyper activation (Pasquini & Berardelli, 2009). 2. What else do I need to know? a.) What further information is required at this point? To further understand this case, it important to realize that the patient is under a lot of physical and mental distress. On the other hand, he is frail and his muscles may be degenerating due to age (Kim, Kalantar-Zadeh & Kopple, 2013). However, despite his frail physical health, here is need on information regarding the management of disease in this patient who has major physical and mental illness. There is need to comprehensively understand the patients mental state, in regard to the physical health as a causative factor. Consequently, the clinical manifestation of reduced pedal pulses in both feet calls for further information in order to identify the path physiology and then define a holistic treatment plan. b.) Other assessments/investigations need to be performed or recommended in order to complete the clinical picture? In his medical history, Albert had bowel cancer two years ago, which was successfully treated through surgery. Therefore it is imperative to carry out certain tests in order to establish if there has been a reoccurrence of the bowel cancer, which has been known to reoccur in the first two years after successful surgery (Scholefield & Steele, 2002). At this point we aim at identifying any cases of metastatic or secondary bowel cancer which is common in patients who have had bowel cancer even though successfully treated (Bowel Cancer Australia, n.d). To begin with, a chest CT scan is necessary in order to investigate whether the bowel cancer has by any chance spread to the lungs, as well as get a clear picture on the health status of his lungs. Conversely, liver biopsy is necessary to rule out bowel cancer in the liver. Colonoscopy will aid in identifying any metachronous cancers that may have occurred after surgery. Conversely, a virtual colonoscopy, best known as a CT Colonography is very helpful in identifying any case of secondary cancer in his colon and cancer (Bowel Cancer Australia, n.d). Conversely, an MRI scan may be necessary in order to have a clear picture on the health of his body organs. On another note, we investigate whether the poor glycemic control has contributed to the recurrent respiratory infections. Hyperglycaemia is one of the risk factors associated with respiratory tract infections in diabetic patients (Garnett et al, 2013). On the other hand, it has been noted that diabetic patients are at a higher risk of respiratory tract infections, and this is in some way attributed to unhealthy lifestyle and advanced age (Thomsen & Mor, 2012). Diabetic neuropathy is asymptomatic in many diabetic patients hence the need for careful investigations, and in Albert’s case, a nerve biopsy may be necessary (Bansal, Kalita & Misra, 2006). Therefore, whole body CT scan or MRI is very effective in investigating the health of his body organs, and provide an avenue for the provision of holistic care. c.) Aspects of the patient’s health history need further information to inform the comprehensive clinical assessment? In order to have a complete picture into the comprehensive clinical assessment for Albert, a look into his mental, social, spiritual and physical health is imperative. Researches into the causal factors for diabetes have shown a significant relationship between mental well-being and diabetes (Robinson, Luthra & Vallis, 2013). To begin with, diabetes has been seen to bring about a disruption in the quality of life for patients with diabetes. In the case of Albert, we seek to establish how he is coping with the disease mentally, socially and physically. Management of diabetes is not an easy task, and inadequate glycemic control often times leads to morbidity and in extreme cases mortality (Britneff & Winkley, 2013). Albert displays the characteristic of a patient who has a challenge coping with the disease and this is manifested in the mood changes and negative feelings of helplessness coupled with irritability. Stress and lack of an appropriate social support network has a negative impact on how an individual manages glycemic levels. Life events like the death of a spouse have a significant impact on the social and mental health of an individual and they are sources of stress. Social support is very important in promoting diabetic patients adherence to treatment (Rogers et al, 2012). Therefore we explore the type of social support Albert receives from his family and friends. Family is an important source of support and encouragement for an individual, and this aids in lightening the burden of managing the disease (Delamater, 2006). Another very important aspect we look into is the physical health which involves physical exercise and work out. Exercise plays an important role in glycemic control since it enhances the body’s sensitivity to insulin, improves the heath of the cardio-respiratory system and has a profound positive effect on the psychosocial health of a patient with type II diabetes (Riddel & Perkins, 2009). In addition Pandey (2011) looks into alternative therapies for diabetes management and highlight the importance of exercise like yoga, which bears a spiritual, psychological and physical approach, which is useful in improving overall well-being. An individual’s lifestyle behaviour is very important while it comes to managing a life threatening disease. Self-destructive behaviour is a negative coping behaviour often displayed by patients. Apathy is one manifestation of depression and is very harmful in diabetic patients since the patient does not initiate effort to take care of him/herself. Diabetic patients who also have depression suffered an increased risk of diabetic related complications such as neuropathy, retinopathy and micro vascular problems (Egede & Ellis, 2010). Albert is already experiencing some of these complications given the fact that he has had recurrent respiratory tract infections, and the slight wasting of his limb muscles may be an indication that he is not very far from diabetic neuropathy. 3. What does this all mean? a.) Overall clinical impression Looking at the whole process the patient in question is under distress due to a number of factors. He is in physical distress, given the discomfort of having to manage a recurrent infection, yet he has to deal with another life threatening condition. The patient displays poor glycemic control and his health is deteriorating at an alarming rate. However, given his age it is evident that the death of his wife has taken toll on him and he has not been able to cope with the whole situation. In relation to this, a number of studies assert that stressful or traumatic life events have the potential of disrupting an individual’s quality of life (Egede & Ellis, 2010; Britneff & Winkley, 2013). On the other hand, the patient does not have reliable insight regarding his condition and as a result, he has poorly controlled diabetes, which has affected the quality of his physical health. Looking at his medical history, Albert had bowel cancer two years ago, and this is another traumatic life event that could be responsible for driving him deeper into depression. He appears to have lost meaning of life, and therefore no longer bothers about self management. Albert is a typical case of an elderly patient whose family is away and they are not aware of the mental and emotional state of their parent. Unfortunately, this lack of family support as well as the lack of a strong social network has sent him into depression. His mental health has suffered as a consequence of his physical health while the reverse is also true. Patients will experience despair, anger and grief which further elevate the progression of their physical and mental health Rapaport, Cohen, & Riddle (2000). This is evident in the clinical findings where the impression is that the patient has depression, lung infection and diabetes. This is evidence that the patient is coping negatively, and since his family is not around to support and encourage him on the importance of self-management, he has responded with despair and consequently sank into depression. The clinical assessment tool was very useful in determining the cause of clinical investigations in Albert’s case. Understanding his medical history provided much needed information thus reducing the amount of time that would have otherwise been spent in conducting tests, to determine his diagnosis. Conversely this informed the decision making process for patient care since learning about existing and past medical problems, provided insight into the direction that treatment should take. On the other hand, the information taking session for the clinical assessment tool created a very good avenue for the nurse to develop an empathetic understanding of the patient. This in turn formed a foundation for establishing a therapeutic relationship with him, which may be an important starting point for providing holistic support, which involves medical and psychosocial support. References Bansal, V., Kalita, J. & Misra, U. K. (2006). Diabetic Neuropathy. Postgraduate Medical Journal, 82(964), 95-100 Doi: 10.1136/pgmj.2005.036137 Beesdo, K., Knappe, S., Dipl-Psych & Pine, D. S. (2009). Anxiety and Anxiety Disorders in Children and Adolescents: Developmental Issues and Implications for DSM-V. The Psychiatry Clinics of North America,32(3), 483-524 Bowel Cancer Australia (n.d). Advanced Bowel Cancer. Retrieved 6 June 2014, from http://www.bowelcanceraustralia.org/bca/index.php?option=com_content&view=article&id=151&Itemid=567 Britneff, E. & Winkley, K. (2013).The role of psychological interventions for people with diabetes and mental health issues. Journal of Diabetes Nursing, 17, 305-10 Delamater, A. M. (2006). Improving Patient adherence. Clinical Diabetes, 24(2), 71-7 Egede, L. E. & Ellis, C. (2010). Diabetes and depression: Global perspectives. Diabetes research and Clinical Practice, 87, 302-312 Garnett et al. (2013). Metformin reduces airway glucose permeability and hyperglycaemia-induced Staphylococus aureus load independently of effects on blood glucose. Thorax, doi: 10.1136/thoraxjnl-2012-203178 Gilhotra, N. & Dhingra, D. (2010). 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I. (2004). Diagnosis and Management of Anxiety Disorders. Journal of the American Osteopathic Association, 104(3), 2-5 Thomsen, R. W. & Mor, A. (2012). Diabetes and Risk of Community-Acquired Respiratory Tract Infections, Urinary Tract Infections, and Bacteremia. The Open Infectious Diseases Journal, 6(1), 27-39 Read More