Chronic obstructive pulmonary disease (COPD) is among the leading causes of death globally and is estimated to be the fourth leading cause of morbidity and mortality in 2030. Even though the obstruction of airways characterizes COPD, it is linked to metabolic disorders, which include obesity, cardiovascular disease, dyslipidemia, and diabetes mellitus, which significantly increase the symptomatic burden and deteriorate the health status. The prevalence of diabetes among patients with COPD is between 10 and 18.7% (Lipovec et al., 2016). It is essential to note that in COPD patients with mild-to-moderate airflow obstruction, cardiovascular diseases are the leading causes of death. Preventing metabolic disorders in patients with COPD compels a comprehensive understanding of the associated risk factors that could be genetic, or could be due to the interaction of lifestyle and other disease-specific determinants. This paper aims to examine the clinical findings of a female patient, M.K., and integrate her medical history, and physical examination results to determine possible diseases and come up with an effective mode of treatment.
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A diagnosis for chronic bronchitis was made for M.K.’s case because the patient met all the primary criteria for the condition in terms of the patient’s history, physical examination, and laboratory findings. Concerning the physical examination, M.K.’s symptoms for the disease, and include, the occurrence of chronic coughs that usually worsened in the morning (Lipovec et al., 2016). Moreover, other symptoms, such as excessive peripheral edema and distended neck veins, indicated the severity of chronic bronchitis. The diagnosis based on physical examination was also supported by her 22 years history of smoking. According to Widysanto and Mathew (2019), prolonged exposure to cigarette smoking is regarded to be a primary causative factor. On the other hand, the laboratory results suggested the occurrence of chronic bronchitis. M.K. clinical findings indicated abnormal arterial blood gases that were attributed to reduced lung sufficiency, and it resulted in the high partial pressure of carbon (IV) oxide that exceeded is the usual range of 38-42mm Hg, the low partial pressure of oxygen that was beneath the normal range of 75-100mm Hg (Ortiz-Prado, 2019). Lastly, the abnormally high hematocrit levels of 57% that surpassed the average level of 36-48% in females suggest decreased tissue perfusion that induces an increase in the production of erythrocytes in the red bone marrow as a compensatory mechanism.
Based on her diagnosis, there are several types of alternative treatments that can be administered. Furthermore, since chronic bronchitis cannot be cured, the necessary treatment employed aims to prevent complications from chronic bronchitis, and minimize the progression of the symptoms. In other words, the purpose is to reduce the overproduction of mucus and reduce coughs and inflammation (Widysanto & Mathew, 2019). These can be achieved by the implementation of both pharmacological and non-pharmacological interventions. However, smoking cessation has been identified as the most essential therapeutic intervention for chronic bronchitis. The medical agents that can be administered comprise bronchodilators, glucocorticoids, antibiotics, and phosphodiesterase inhibitors. Bronchodilators that are divided into short-acting beta2-agonists (albuterol, pirbuterol, and metaproterenol), long-acting beta2-agonists (salmeterol, vilanterol, and formoterol), and anticholinergics (ipratropium, revefenacin, and tiotropium) function by increasing the airway lumen, ciliary movement, and mucous hydration) (Widysanto & Mathew, 2019). Glucocorticoids, such as budesonide, fluticasone, and prednisolone, decrease mucous production and inflammation. Nevertheless, they should be administered for a short duration as long-term usage can result in adverse outcomes.
Third, macrolide administration reduces inflammation. Lastly, phosphodiesterase-4 inhibitors (roflumilast) have anti-inflammatory properties and prevent the hydrolysis of cyclic adenosine monophosphate, thus promoting the relation of the smooth muscles in the airway. On the other hand, the non-pharmacological methods include M.K. quitting cigarette smoking and participating in respiratory and chest physiotherapy.
In heart failure, the heart is unable to pump blood throughout the body efficiently. There are three types, and they include left-side, right-side, and biventricular heart failure. The left-sided one is the most common type and is caused when the left ventricle is too weak to pump blood throughout the body (Ortiz-Prado, 2019). On the other hand, right-sided heart failure is caused when the right ventricle is impaired; hence, it cannot efficiently pump blood to the lungs (Ortiz-Prado, 2019). Moreover, biventricular heart failure is caused when both sides of the heart are affected. With regard to M.K.’s case, she is probably suffering from right-side heart failure, and this is due to the fact that she is exhibiting symptoms of distended neck veins and excessive peripheral edema, which are unique to the condition.
The normal function of the right ventricle constitutes the interaction of the preload, contractility, afterload, ventricular interplay, and cardiac rhythm. Overall, right-sided heart failure often develops as a result of the occurrence of cardiac or pulmonary disease or a combination of both that interferes with the preload, ventricular interplay, and rhythm and reduces contractility; thus, increasing afterload (Arrigo et al., 2019). When it comes to right ventricular failure in relation to cardiac disease, most right-sided heart failure is secondary to left-sided heart failure. According to Arrigo et al. (2019), the occurrence of left ventricular diastolic or systolic dysfunction and pulmonary hypertension is high among patients diagnosed with right-sided heart failure. Increased afterload is the primary pathophysiologic of ventricular failure in patients having an obstruction in the right ventricle outflow tract. Conversely, in patients with congenital heart disease, the chronic volume overload might trigger the dilation and failure of the right ventricle (Arrigo et al., 2019). Therefore, cardiac conditions affecting the right side of the heart decrease the contractility of the right ventricles or decrease preload due to reduced cardiac output, thereby leading to heart failure. Pericardial diseases can alter the ventricular interdependence and right ventricle preload, while abnormal heart rhythms might increase right ventricle dysfunction.
Right-sided heart failure can also be instigated by pulmonary disease. This phenomenon is commonly referred to as cor pulmonale (Arrigo et al., 2019). These changes can occur radically, for instance, in fulminant pulmonary embolism, or can be a result of longstanding respiratory conditions that alter the structure and function of the right ventricle. However, in the milieu of acute respiratory insufficiency in a previously healthy person, the failure of the right ventricle is often characterized by massive pulmonary embolism. The embolism brings about the distension and addition of more pulmonary capillaries that reduce vascular resistance, hence, increasing pulmonary pressure. Furthermore, chronic lung diseases, such as chronic obstructive pulmonary disease (COPD), are the primary precursors of respiratory insufficiency and cor pulmonary (Arrigo et al., 2019). COPD amplifies the right ventricle overload through several mechanisms, which comprised the rarefaction of the vascular bed, acidosis and hypercapnia, pulmonary hyperinflation, resistance in the airway, dysfunction of the endothelium, and hypoxia.
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M.K.’s recorded blood pressure is 158/98 mm Hg. According to the American Heart Association 2017 guidelines, this value suggests stage two hypertension as it exceeds the ≥140/90mm Hg limit (Whelton et al., 2018). To manage her hypertension, M.K. was prescribed Lotensin and Lasix. Though the treatment of hypertension primarily consists of medical agents that target the underlying disease(s), several medications are administered in different settings. Lasix, also referred to as furosemide, is administered either orally or as an intravenous solution. It is a type of loop diuretic that is often given to patients who have developed right-sided heart failure, and it is used as an alternative over thiazide diuretics in the treatment of hypertension. According to Whelton et al. (2018), loop diuretics are not recommended as the first-line of therapy; therefore, Lasix is used as a second-line of treatment. Lasix functions by increasing the secretion of water by interfering with the sodium and chloride reabsorption in the distal tubes and ascending Loop of Henle. It is essential to note that Lasix can be either used alone in the treatment of hypertension or in combination with other antihypertensive agents. In addition, hypertensive patients whose conditions cannot be adequately managed by thiazides might also not respond to Lasix when it is prescribed alone.
On the other hand, Lotensin, also known as Benazepril, is an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibition results in the reduced secretion of plasma angiotensin II that leads to a concurrent decrease in aldosterone secretion (Whelton et al., 2018). Consequentially, this will bring about an increase in the levels of serum potassium, although at a minimal level – hypertensive patients are characterized to have elevated serum potassium levels (Whelton et al., 2018). In the management of hypertension, Lotensin can be used either alone, or in combination with other antihypertensive agents. The administration of the ACE inhibitor, in conjunction with loop diuretics, which was the situation for M.K.’s case, gives a blood-pressure-lowering effect higher than that seen if either of the agents is used alone.
High blood pressure is a significant public health issue affecting the U.S. population as approximately 45% of the adult population is suffering from it (Centers for Disease Control and Prevention, 2020). Out of this, only 24% of the adults manage their hypertension; however, the other 45%, which includes 35 million people, has uncontrolled hypertension. The condition puts the affected individuals at risk for stroke and heart disease that is among the leading causes of death in the region. In 2017, approximately half a million deaths in the U.S. constituted hypertension as the primary cause, which can be equated to 1,300 deaths daily (Centers for Disease Control and Prevention, 2020). Moreover, it is estimated the U.S. spends about $131 billion every year to manage high blood pressure.
Based on her lipid panel, it can be said that M.K. is at risk for dyslipidemia. Dyslipidemia is described as a condition characterized by abnormal levels of cholesterol and other lipids in the blood. For instance, the normal total cholesterol level is that which is below 200 mg/dL, and M.K.’s cholesterol is seen to supersede the standard (Hormone Health Network, 2018). Second, is the high-density lipoprotein (HDL) in which M.K.’s 32 mg/dL is below the recommended standards for women (above 50 mg/Dl). There is also an abnormality in her low-density lipoprotein (LDL) readings, which is above the standard value of below 70 mg/dL for individuals with diabetes. Finally, her triglycerides levels exceed the recommended amount of below 150 mg/dL. Overall, it is seen that the clinical findings align with the characteristics of the disease, which are, high levels of LDL and triglycerides, and low levels of HDL (Hormone Health Network, 2018). When LDL levels are very high, fatty deposits, also referred to as plaques build up inside the arteries. Over time, they harden the arteries, thus resulting in atherosclerosis, which increases the risk of peripheral artery disease, cardiovascular disease, or heart attack (Hormone Health Network, 2018). It is essential to note that several studies have established a connection between high lipid panels and obesity and insulin resistance (Bora et al., 2015). Therefore, this suggests that her high cholesterol levels were probably due to her already existing obese and diabetic condition.
Lowering the levels of cholesterol can be achieved by both pharmacological and non-pharmacological methods. M.K. should be administered additional medications, such as statins (Lipitor, Crestor, Livalo, or Zocor) (Hormone Health Network, 2018). They are the first-line of treatment among patients with dyslipidemia. Statins function by inhibiting the enzyme in the liver that triggers the production of cholesterol. As a result, the levels of LDL will decrease while that of HDL will increase slightly. They can also reduce the level of triglycerides, only if they are not severely elevated (Hormone Health Network, 2018). In addition, they can prevent the growth of plaques or reduce their size. On the other hand, non-pharmacological methods comprise M.K. practicing healthy dietary habits, exercising to lose weight, and quitting cigarette smoking.
Diabetes mellitus often occurs alongside high blood pressure; therefore, it can be said that M.K.’s abnormally high blood pressure insinuates the former. This can also be inferred for vice versa, and it is mainly because diabetes mellitus and hypertension have common underlying causes and risk factors. In M.K.’s scenario, these risk factors include her cigarette smoking history, poor diet, and obesity. Moreover, other clinical findings suggest diabetes are high glycated hemoglobin levels.
According to Horowitz (2019), M.K.’s glycated hemoglobin (HbA1c) of 7.3% levels suggests diabetes. HbA1c is a unique portion of hemoglobin A that is present in both healthy individuals and those with diabetes mellitus. It requires the presence of glucose and is formed through non-enzymatic action; hence, it is stable. Therefore, HbA1c can be perceived to be a reflection of the average blood glucose level throughout the entire red blood cell span, which is approximately 120 days in healthy individuals (Horowitz, 2019). To understand the principle of the HbA1c test, it is essential to consider the characteristics and functions of this type of hemoglobin. In homeostatic conditions, that is when the blood glucose level is average, some of the hemoglobin binds to the glucose, and this leads to an HbA1c level of approximately 5%.
However, in the case of a patient with diabetes mellitus, M.K., there is an increased glucose level in the blood circulation that is hyperglycemia. Therefore, more hemoglobin present in the red blood cells will attach themselves to the glucose available, hence forming numerous HbA1c. Since the lifespan of the red blood cells is 120 days, HbA1c will persist for that period. It is also due to this reason that the HbA1c is regarded to be more effective than the measurement of the blood glucose level, which reflects this level at the time of the test rather than the past 3-4 months (Horowitz, 2019). It is recommended for HbA1c levels in stable diabetic patients to be monitored at least twice per year. On the other hand, unstable patients are advised to perform four visits. One limitation of the HbA1c test is that it cannot indicate the glucose level throughout the day, which is often required among diabetic patients (Horowitz, 2019).
M.K. is suffering from COPD, which is characterized by her chronic bronchitis, and metabolic syndrome that is reflected by the presence of obesity, hypertension, dyslipidemia, and hyperglycemia. These conditions can be regarded to stem up from her extensive history of cigarette smoking and poor dietary habits. At the current health state that M.K. is in, she seems to have a poor prognosis as she is at high risk of suffering from a heart attack or stroke. Although not mentioned in the above discussions, M.K.’s high hematocrit levels might be due to her smoking. Therefore, she must drink plenty of fluids. Moreover, even though they are both severe and incurable conditions, M.K. can focus on reducing the severity of symptoms, and this can be achieved by taking extra medication, for instance, statins to manage her dyslipidemia. On the other hand, she can work on reducing her weight and practice good dietary habits. It is suggested that she be subjected to radiographic techniques to evaluate the state of her lungs and heart. This is because the extensive smoking might have resulted in the thickening of the lungs, which is reflected by the high hematocrit levels.
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