Case study 1
Depression is a mental health disorder that is associated with the functional deficiency of monoaminergic transmitters norepinephrine in the brain. Dopamine and serotonin play an essential role (Yang et al., 2018). The core pathophysiology is also found to be associated with the central noradrenergic system. The brain metabolism is impaired in the ventromedial prefrontal cortex and subcortical brain regions. The norepinephrine levels, dopamine, and serotonin levels are associated with the patients with depression resulting in the clinical and behavioural symptoms (Kraus et al., 2017).
Alzheimer’s disease is a neurovegetative disorder closely associated with the elderly. The neuron loss is largely seen in the amygdala, hippocampus, cortical associations, and entorhinal cortex (Lista & Hampel, 2017). The cognitive decline in the patients is associated with the activity of tau proteins that results in the neuron atrophy. This results in inflammation and development of amyloid plaques in the form of tangled bundles in the brain resulting in an increase in macrophage activity by activation of microglial cells. This accelerates the process of neuron decay and results in a cognitive loss in the patient (Dá Mesquita et al., 2016).
The drugs prescribed to Mary Lou are Fluoxetine/Prozac for the treatment and management of depression and cholinesterase inhibitors for Alzheimer’s disease.
The drug functions as a selective serotonin reuptake inhibitor (SSRI) and functions by delaying the absorption and reuptake of serotonin resulting in increasing the amount of time it can persist in the body (Cai et al., 2019). The drug is suitable for patients with depression as it helps in lasting the impact of serotonin in the body. Serotonin is an effective neurotransmitter that aids in the regulation of social behaviour and mood of an individual. Since, in the case of depression, the social behaviour and the mood of the patient is significantly impacted, this drug can assist in the management of same and help the patient cope better (Oronowicz-Ja?kowiak & Babel, 2019).
The drug delays the breakdown of the neurotransmitter, acetylcholine that is released in the synaptic clefts and therefore helps in the improvement of cholinergic neurotransmission (Lista & Hampel, 2017). In individuals suffering from Alzheimer’s, the nerve cell function is impaired due to damage, and therefore, the brain takes longer than usual for signal transmission. The Cholinesterase inhibitors assist in the increasing communication between the nerves and therefore assists the patient’s with Alzheimer’s disease (Lista & Hampel, 2017)
(A). Fluoxetine is absorbed well through the oral intake and his effectively bound to protein. The drug has a large volume distribution with a non-linear pharmacokinetic profile. The drug is metabolized to norfluoxetine after ingestion and is finally converted to hippuric acid. N-demethylation of the drug is essential for its metabolism and is carried out by enzymes CYP2D6, CYP2C9, and CYP3A4 after which the drug is eliminated through urine (Oronowicz-Ja?kowiak & Babel, 2019). The drug functions by inhibiting the presynaptic reuptake of the serotonin. The levels of hydroxy-tryptamine increases resulting in serotonin retention and limited reuptake. The interaction is mediated with several hydroxy-tryptamine receptors.
The drug also exhibits age dependent behaviour. The drug is known to be effective in adults for the management of depression by impacting serotonin reuptake in the body. However, in the adolescents, the Fluoxetine exposure results can increase of depression like behaviour (Cai et al., 2019). The pharmacokinetics of the drug, however, is independent of age (de Souza et al., 2016).
(B). The patients of Alzheimer’s disease who are being treated with Cholinesterase inhibitors and selective serotonin reuptake inhibitors can exert negative impacts of depression on cognition (Han et al., 2019). The Fluoxetine can alter the hepatic metabolism in the patients with Cholinesterase inhibitors by drug-drug interactions (Pasqualetti et al., 2015). An antagonistic effect can also be presented by certain selective serotonin reuptake inhibitors and worsen the cognitive symptoms of the patient (Pasqualetti et al., 2015).
Mary Lou is suffering from alcohol addiction. This can be derived as she has been increasing her wine uptake regularly and requires to sleep and manage her behaviour. These can be considered as the primary signs of alcohol addiction in Mary Lou. Further, the general practitioner has also prescribed additional medication to combat alcohol withdrawal for Mary Lou confirming the addiction. These are the essential signs that confirm addiction based on the clinical and behavioural assessments presented in the case study.
The pathogenesis of alcohol addiction is associated with neuroadaptation to reward system in the body. Alcohol intake is associated with the release of dopamine in the ventral tegmental area of the brain (Bach et al., 2019). This release triggers the nucleus accumbens region of the brain that makes the drinking behaviour “pleasurable” for the consumer. Regular use customizes the brain for reward system and eventually causes addiction. Dopamine is a neurotransmitter that is associated with reward-motivated behaviour. Alcohol functions by acting on multiple factors and receptors in the central nervous system including GABA, corticoid releasing factor, 5-HT, glutamate, and endogenous opioid systems (Bedse et al., 2019). Mary Lou is clinically depressed and has trouble sleeping. Release if dopamine by alcohol consumption triggers a reward system and helps her calm down and sleep. Mary also suffers from Alzheimer’s and depression signs and symptoms of which are overlapping with cute alcoholism. These overlaps include poor coordination, behavioural changes, and memory impairment (Bach et al., 2019). however, a distinct sign associated solely with alcoholism is the dependency on alcohol for sleep.
Case study 1 Part 2
Cartilage degeneration in the joints can occur due to synovial dependent processes or synovial independent processes. The synovial pannus acts by invading the cartilage at the circumference of the inflamed joints in an individual. The cartilage destructive and pro-inflammatory cytokines are often released along with the cartilage degrading proteases by the hemosiderotic synovium (Mathiessen & Conaghan, 2017). The pathogenesis of osteoarthritis is associated with the degradation of cartilage along with remodelling in the bone structure. The chondrocytes of the cartilage cells are affected by the inflammat0ory response in the surrounding cells. The disease is, therefore, called an osteo-degenerative disease and is closely linked with aging. The subsequent loss of cartilage is called as chondropenia (Kraus & Hsueh, 2019). Proteases play an important role in the pathophysiology of the condition as they are associated with the matrix degradation in the affected individuals. collagenase-1 or MMP-1 is the essential enzyme that is associated with collagen degradation in the affected individuals. The other enzymes that play a role in the pathophysiology of the disease include aggrecanase that is responsible for proteoglycan fragmentation (Kraus & Hsueh, 2019). When the cartilage in the joint is damaged it can result in severe pain and inflammation and is common in adults aged above 45 years. The common signs and symptoms associated with this damage also known as articular damage include inflammation, stiffness, range limitation, and difficulty in mobility.
The major difference in the pain caused by osteoarthritis and rheumatoid arthritis is that osteoarthritis is caused by the mechanical wear of the joints where as, rheumatoid arthritis is an autoimmune disorder. The patients with rheumatoid arthritis can develop symptoms at any point in life, in contrast to osteoarthritis that is associated with the health condition of the elderly. The pain in rheumatoid arthritis may appear rapidly in the patient where as symptoms of osteoarthritis appear slowly in the patient. The pain induced by rheumatoid arthritis is the patient results in painful, swollen, and stiff joints (Woo et al., 2017). On the other hand, osteoarthritis results in pain in the patient with tender pain in the patient. The pain in osteoarthritis presents asymmetrically in the body and results in stiffness in joints within a few minutes of walking or movement (Chen et al., 2017). On the contrast, the patients with rheumatoid arthritis present with a symmetric pain accompanied by swelling. The autoimmune disease, rheumatoid arthritis results in pain and swelling due to inflammation in the cartilage due to immune response. Pain in osteoarthritis is caused by worn joints that result in mechanical irritation and inflammation in cartilage resulting in joint pain and swelling (Pennati et al., 2017).
Figure 1: Difference in osteoarthritis and rheumatoid arthritis in contrast to the normal joint.
The process of bone healing is inclusive of processes that involve inflammation, bone production, and bone remodelling. The process of inflammation starts immediately after the fracture and lasts for several days. The bleeding and clotting at the site of fracture are observed causing initial stability in the structure for the production of new bone. The second process is bone healing which begins when the blood is clotted through the process of inflammation (Pennati et al., 2017). This results in the replacement of the affected site by the fibrous tissue. And soft callus that is a form of cartilage. The soft callus is eventually replaced by the hard bone in the process of healing. The third process is bone remodelling that is the final phase of bone healing in the body (Ackerman et al., 2018). The bone structure hardens and compacts in this process and returns to its normal shape. The process of blood circulation is enhanced in this area allowing for complete healing of the fractured bone. Age impacts the process of bone healing. Therefore, the age of Mary will affect this process. Healing would have been faster in younger age. It has been studied that the inflammation process of the bone healing is impacted by age (Clark et al., 2017).
The complications of hip fracture that are prevalent in the elderly include bedsores due to prolonged bed rest required for healing and development of blood clots in the lungs or legs (Withrow et al., 2016).
The T-Score in DEXA scan is used as a measure of the bone mineral density assessment score. The test is done for the diagnosis of osteoporosis. A T-score of a healthy adult is above -1.0 for the normal bone density. A T-Score between -1 to -2.5indicates low bone mineral density is osteopenia in the patients. Where as, a T-Score of lower than -2.5 is indicative of osteoporosis (Ono & Takayanagi, 2017). Osteoporosis is a health condition where the bones become fragile and are more prone to fractures. The condition is caused when the skeleton fails to achieve optimal strength during the growth and developmental phases. The condition is also caused when there is excessive bone resorption causing loss of bone mass and resulting in the disruption of skeletal architecture (Ono & Takayanagi, 2017). The deficit in the process of bone formation can also result in osteoporosis.
Bisphosphonate is helpful for the patients with osteoporosis as it helps in the inhibition of the none resorption by osteoclasts. The chemical possesses structural similarity to pyrophosphate and therefore possesses high affinity in the human body system (Withrow et al., 2016). The drug inhibits the osteoclast mediated resorption and binds to hydroxyapatite in the bones for action. The drug is also known to function by altering the osteoclast activity by limiting the osteoclast progenitor cell development and also by promoting apoptosis of the osteoclasts assisting in keeping the bone structure dense (Ghiasi et al., 2017).
Case Study 2
The two triggers associated with the asthmatic condition of Hilda include pollens and smoky environments. Asthma is a respiratory disorder that causes respiratory distress in the patient by hindering the air passage (Capraij et al., 2019). The allergens like pollen and smoke dust can trigger the immunogenic response in the respiratory pathway and result in inflammation of the respiratory tract. Bronchoconstriction may occur as a consequence of this inflammation. The Antigen presenting cells (APCs) in the respiratory pathway trigger this reaction as they consider the allergens as antigens. The smooth muscle contractions are observed in the respiratory pathway in an asthmatic attach causing bronchospasm in the respiratory tract. The mucus is secreted and the airway is narrowed (King et al., 2018). As a consequence, the airflow is further hindered. Tissue remodelling, bronchoconstriction, and bronchospasms cumulatively result in difficulty in gaseous exchange in the patient. Hyperresponsiveness and hyper mucus secretion are also associated with excessive hindrance in breathing and contribute towards asthmatic attack (Capraij et al., 2019). This immunogenic response is triggered by certain compounds or particles that may be recognized as antigens in the respiratory tract of the patient triggering an inflammatory response. As the air passage is narrowed, and the availability of the oxygen to the lungs is hindered, the respiratory rate of the patient increases to meet the oxygen distress generated. The patient may develop symptoms like dyspnea and hypoxia in extreme conditions (King et al., 2018).
The two signs and symptoms presented by Hilda include difficulty in breathing and cyanosis or lips turning blue. Hilda is facing extreme difficulty in breathing (King et al., 2015). Asthma results in respiratory distress as the airway is blocked and the patients are not able to get adequate oxygen. In asthma, the respiratory pathway for the air is restricted due to an inflammatory reaction resulting in contraction of smooth muscle cells. The inflammation also causes hyper mucus secretion in the respiratory pathway and prevents effective air exchange in the body, as a consequence, the amount of oxygen required by the body is not met and to compensate for same, shortness of breath with respiratory distress is observed with increase in respiratory rate and heart rate (King et al., 2018). As the oxygen saturation levels of the body are further depleted, cyanosis or colour change in lips of Hilda is observed. Cyanosis occurs when the oxygen amount bound to hemoglobin in the body is critically low. The concentration of hemoglobin that is devoid of oxygen increases n the body due to hypoxia or critically low oxygen saturation levels. Clinically evident cyanosis often occurs when the oxygen saturation levels of the body are below 85%. Hilda is exhibiting signs of hypoxia or extreme deterioration in oxygen levels due to her asthmatic attack evident through extensive breathlessness and cyanosis (Hikichi et al., 2018).
Ventolin belongs to a class of salbutamol that is prescribed to patients with respiratory distress. Salbutamol functions by selectively blocking the beta 2-adrenergic receptors (Moore et al., 2019). The drug is highly selective and is effective for patients with health conditions like asthma and COPD. The drug functions as a bronchodilator. The R-isomer of the drug assists the patients by relaxing the smooth muscle cells of the respiratory pathway and facilitating the air movement in the smooth muscle cells. The action of the drug on the beta 2-adrenergic receptors results in the activation of adenyl cyclase and therefore increase the concentration of cyclic AMP in the cells. In the cascade initiated by the drug, the calcium concentration is decreased in the intracellular compartments of the smooth muscle cells and therefore it results in the relaxation of smooth muscle cells (Vet et al., 2020). The respiratory pathway is relaxed by salbutamol administration from the trachea to the terminal bronchioles assisting in immediate assistance to the patient under respiratory distress. The drug is helpful for Hilda ss it helps in the relaxation of the respiratory pathway irrespective of the spasm causing or the irritant. The drug also assists in the reduction of inflammation by acting on mast cells (Moore et al., 2019). Hilda is undergoing an exacerbation of an asthmatic attack. Therefore, administration of salbutamol will assist her in the easing of the respiratory pathway and promote breathing (Vet et al., 2020).
The two measures that will minimize the chances of contraction of coronavirus in Hilda are isolation of the infected patients in the private rooms with the practice of proper hand hygiene in the clinical setting. COVID-19 is a communicable infectious disease that is caused by the novel coronavirus. The disease results in acute respiratory distress and can serve to be fatal for patients with existing respiratory health problems like asthma and COPD (Guan et al., 2020). It is therefore important to take essential precautions to prevent the infection of coronavirus. The virus exhibits high infectivity and therefore it is important to use essential security interventions lie PPE kits and maintain proper hand hygiene (Novel, 2020). The virus fails to survive the soap based hand wash and therefore frequent hand washes and maintaining the distance from the infected individuals is crucial (Novel, 2020). Patients with pre-existing respiratory conditions like asthma and COPD are at higher risks of developing serious secondary problems like pneumonia and chronic hypoxia on contraction with the novel coronavirus.
To break the chain, it is important to practice social distancing and prevent direct contact with people. The disease is also associated with several asymptomatic cases and therefore, it is important to take the necessary precautions These precautions include wearing of the mask, maintaining social distancing and keeping the hand sanitized with regular hand washing to prevent contamination (Guan et al., 2020).
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