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

Comprehensive Case Study on COPD, Heart Failure, Hypertension,

And Diabetes Mellitus

M.K is a 45-year-old female, weighs 225 pounds and 5’5” in height. Her medical history shows her to be a smoker for 22 years, just about half of her life. In addition, she lacks proper nourishment to sustain a healthy lifestyle. More importantly, M.K has a history of Type II diabetes mellitus accompanied by primary hypertension. Recently, she experienced a myriad of health problems including chronic cough with sputum in the mornings, light-headedness, distended neck veins, excessive peripheral edema, and nocturnal polyuria.  With the above symptoms, M.K. was diagnosed with chronic bronchitis. She is taking Lasix and Lotensin for her hypertension, and Glucophage for her Type II diabetes mellitus. Her recent blood pressure reading with laboratory results were as follows: BP 158/98 mm Hg, Hematocrit 57%, HbA1c 7.3%, PaCO2 52 mm Hg, PaO2  48 mm Hg, Cholesterol 242 mg/dL, HDL 32 mg/dL, LDL 173 mg/dL, and Triglycerides 1000 mg/dL.

Based on the given information, M.K suffers from chronic bronchitis. According to MedlinePlus, chronic bronchitis is one type of COPD (chronic obstructive pulmonary disease) causing the inflamed bronchial tubes to produce an increased amount of mucus, leading to coughing and difficulty breathing. The most prominent cause of M.K’s chronic bronchitis can be attributed to her 22 years of smoking cigarettes. M.K. is at high risk of acquiring many other health conditions such as heart failure, hypertension, and Type II diabetes. Contributing to these possible health problems are M.K’s age, history of smoking, her being overweight, and her poor diet. According to Leontil, lifestyle choices that affect the development of type 2 diabetes include: lack of exercise, unhealthy meal planning choices, and being overweight or obese.

What clinical findings correlate with M.K.’s chronic bronchitis?

M.K. presents with a chronic productive cough, hypoxemia PaO2 48mmHg (below the normal values of 75-100 mm Hg), hypercapnia PaCO2 52mmHg (exceeds the normal limit range of 38-42 mmHg), hematocrit level of 57% (higher than the normal range of 35-47%), and peripheral edema which would suggest there is right sided heart involvement.

What type of treatment and recommendations would be appropriate for M. K.’s chronic bronchitis?

According to UCSF Health Care Specialists, the following therapy is essential for M.K’s condition to relieve symptoms, prevent complications and slow the progression of the disease. First therapy includes the use of bronchodilator medications to help relieve symptoms of chronic bronchitis by relaxing and opening the air passages in the lungs. This can be taken orally or inhaled by way of aerosol sprays. Examples of these medications are Vospire, AccuNeb albuterol, and formoterol. The next therapy consists of using steroid medications, such as prednisone, which can help alleviate symptoms of chronic bronchitis. Antibiotics, such as ceftriaxone, can also be added to help fight respiratory infections associated with his chronic bronchitis. Expectorants like Guaifenesin can further help by liquefying secretions. It is also essential to administer H2 blockers (ranitidine) to eliminate stress ulcers. Part of her therapy is receiving the flu and pneumonia vaccine annually every five to seven years to prevent infections.

M.K. may find it increasingly difficult to breath on her own because of her chronic bronchitis. She will need oxygen therapy to treat her hypoxemia, and as her disease progresses, she may require supplemental oxygen which comes in various forms and can be delivered through different devices. In addition to oxygen devices, M.K. may also need lung volume reduction surgery. This procedure includes removing small wedges of damaged lung tissue. An important part of her treatment is pulmonary rehabilitation. This includes education, nutrition counseling, learning special breathing techniques, quitting smoking, and starting an exercise regimen. Further lung damage can be caused if she continues to smoke. She will be advised to have regular physical activity as this can actually improve her health and overall well-being.

What type of heart failure would you suspect with M.K.?

In M.K’s case, due to her severe smoking-induced bronchitis cause the heart right lower chamber or ventricle which leads to pulmonary hypertension. I suspect that she would have a right sided heart failure. The pathogenesis of right sided heart failure is due to fluid buildup in your body. Blood backs up in the body’s veins and causes swelling in the legs, ankles, and swelling within the abdomen such as the GI tract and liver. Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure and when the left ventricle fails, increased fluid pressure is, in effect, transferred back through the lungs, ultimately damaging the heart’s right side and when the right side loses pumping power, blood backs up in the body’s veins, this usually causes swelling or congestion in the legs, ankles and swelling within the abdomen such as the GI tract and liver (causing ascites) (Types of Heart Failure, 2017).  According to Bullock, Cor pulmonale is RHF (Right Heart Failure) that results from lung disease and over 50% of cases in the United States are caused by emphysema and chronic bronchitis.

What stage of Hypertension is M.K. experiencing?

Hypertension is defined as an abnormal elevation of the systolic arterial blood pressure with age-related differences (Bullock, 2000). The normal blood pressure is 120 over 80 mm of mercury (mmHg), but hypertension is classified as having higher than 130 over 80 mmHg. There are two stages of hypertension. Stage 1 hypertension is when the systolic pressure is 140 and 159 mmHg and when diastolic pressure is 90 and 99 mmHg. Stage 2 hypertension occurs when systolic reads at 160 mm Hg or higher, and diastolic is 100 mmHg or higher. M.K. experienced stage 1 hypertension because blood pressure was at 158/98 mm Hg.

According to Orenstein, with Stage 1, prehypertension, and the use of one of a number of drugs that are known to not only reduce blood pressure but also to reduce the risk of heart disease and stroke. The number of drugs include: thiazide diuretics, ACE inhibitors, angiotensin receptor blockers, beta blockers, and calcium channel blockers.

Lotensin and Lasix are M.K.’s current medications for her hypertension. The generic name for Lotensin is Benazepril and is used to treat high blood pressure (hypertension). Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. Benazepril is an ACE inhibitor and works by relaxing blood vessels so that blood can flow easier. Lotensil prevents the kidneys from retaining sodium and water by deactivating angiotensin-converting enzyme which is the enzyme in charge of activating inactive angiotensin I into active angiotensin II. Angiotensin II raises blood pressure since it activates the retention of sodium and water thereby constricts the arteries. Lasix, also known as furosemide, is a loop diuretic meaning it inhibits the reabsorption in a specific part of the kidney tubule called the loop of Henle. Lasix blocks sodium and chloride from being reabsorbed from the tubules back into the bloodstream. Overall, diuretics help the kidneys remove sodium and water from the body, leading to a decrease in blood volume resulting in lower blood pressure because the heart has less to pump with every beat.

According to Bullock, hypertension is the most common disease in the United States, affecting 20% to 30% of adults and it is a direct risk factor for, and contributor, to heart and vascular disease; especially myocardial infarction, congestive heart failure, and cerebrovascular accident.

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?

M.K’s lipid panel are as follows: 32 mg/dL HDL which is lower than normal, LDL 173 mg/dL higher than the normal range, and high cholesterol of 242 mg/dL. With these laboratory values, she is of higher risk for CAD (Coronary Artery Disease). According to Lewis, elevated LDL level has a strong and direct link with CAD. On the other hand, increased in HDL levels put you on a lower risk level of CAD. High triglyceride levels are associated with the progression of CAD. Cholesterol blocks arteries in a procedure called atherosclerosis. Narrowed arteries in your heart can then expand surprising blood clots, inflicting coronary heart attacks.

M.K. requires medication such as diuretics, calcium channel blockers, angiotensin II receptor blockers, angiotensin converting enzyme. A statin drug such as Lovastatin, Pravastatin, or Simvastatin should also be considered. The statins prevent the synthesis of cholesterol in the liver by blocking hydroxymethylglutaryl coenzyme A reductase. These medications reduce the risk of cardiovascular diseases and reduce mortality. It is also essential to give her baby aspirin which can further decrease blood pressure. MK’s poor diet and being overweight, correlate for both hypertension and type II diabetes mellitus.

HbA1c lab value

The value of HbA1C 7.3% is high (normal range is between 4 and 5.6 %). This means that this patient has been suffering from hyperglycemia (uncontrolled type 2 diabetes) 8-12 weeks (3 months) prior to the test. The rationale behind this: HbA1C test measures the amount of glycated hemoglobin in the blood, hemoglobin in the blood is present in red blood cells. Once this hemoglobin binds with plasma glucose, it forms glycated hemoglobin. Consequently, the rise of plasma glucose levels results in an elevation of the glycated hemoglobin levels. Similarly, since degradation of red blood cells that release hemoglobin takes around 8-12 weeks (around 3 months), the levels of glycated hemoglobin in the blood are considered a reflection of the plasma glucose levels for the past 3 months.

Conclusion

M.K is suffering from chronic bronchitis, based on her history, sign and symptoms and some of her clinical findings. Her very long history of smoking is the contributing factor for her chronic bronchitis. Her chronic bronchitis correlates with her clinical outcomes of abnormal partial blood gases in the artery by the low partial blood pressure of oxygen and the high partial blood pressure of carbon dioxide. Her physical conditions together with clinical findings indicates that she is currently experiencing stage 1 hypertension and is susceptible to right-sided heart failure. She takes Lotensin and Lasix to control her hypertension and to inhibit the threat of a stroke or heart attack. Her lipid panels indicates that she is at high risk of developing other complications such as hyperlipidemia, atherosclerosis, and heart diseases. These can be treated by using “statins”, which limits the cholesterol in the liver and absorbing it in the blood. Her HgA1c level is high and her type 2 diabetes mellitus is not under control, which shows that glucose level in body is abnormal and may prompt heart failure because of increased glucose carrying capacity of blood vessels. Because of this, it is critical that her doctor should increase the current Glucophage dosage, prescribed additional medication or order new medication to control her level. It is recommended that M.K should stop smoking, ensure balance diet and exercise, follow her therapy to relieve symptoms, prevent complications and slow the progression her disease.

Reference

Bullock, B & Henze, R. (2000). Focus on Pathophysiology. Lippincott Williams & Wilkins

Leontil, L & Hess-Fischl, A. (2019).Type 2 Diabetic Causes. Retrieved from

https://www.endocrineweb.com/conditions/type-2-diabetes/type-2-diabetes-causes

Lewis, S. Heitkemper, M. Dirksen, S. O’Brien, P. Bucher, P. (2007). Medical-Surgical Nursing:

St. Louis, Mosby Elsevier.

Lotensin. Retrieved from https://www.webmd.com/drugs/2/drug-6883/lotensin-oral/details

MacGil, M. (2018). Everything you need to know about hypertension. Retrieved from

https://www.medicalnewstoday.com/articles/150109.php

Medline Plus. Chronic Bronchitis. Retrieved from

https://medlineplus.gov/chronicbronchitis.html

Orestain, B. (2009). Understanding the stages of hypertension. Retrieved from

https://www.everydayhealth.com/hypertension/understanding-the-stages-of-hypertension.aspx

Types of heart failure. Retrieved from

https://www.heart.org/en/health-topics/heart-failure/what-

is-heart-failure/types-of-heart-failure

UCSF Health Care Specialists. Chronic bronchitis, Retrieved from

https://www.ucsfhealth.org/conditions/chronic_bronchitis/treatment.html