Case Study Report Part A: Co-morbidities Essay Example

Introduction

Out of four adolescents in Australia, one is either obese or overweight. In 2012 and 2013, approximately 1.8 million hospital admissions had an association with cardiovascular disease (CVD), chronic kidney disease (CKD), or diabetes (Willcox, 2015). Chronic illnesses include arthritis, chronic respiratory conditions, asthma, human deficiency virus, heart disease, and hypertension. A chronic illness refers to an illness having a duration that exceeds one year besides requiring ongoing attention from healthcare personnel. A chronic illness also exhibits the potential to disrupt the daily activities of an individual. Apart from the physical medical conditions, chronic illnesses also include addition disorders and substance use problems, mental illnesses, cognitive impairment disorders, dementia, and developmental disabilities. The assessment discusses about Angela, a 69-years old woman living in Australia that presents multiple concurrent chronic conditions (MCC). Angela presents a 24-year history of smoking even though she no longer smokes. Besides the smoking condition, Angela suffers from arthritis, Chronic Obstructive Pulmonary Disease (COPD), and hypertension that limit her physical mobility. The report provides an assessment of the potential impact of the illnesses on Angela’s condition.

Pathophysiology and Clinical Manifestations of Hypertension, COPD, and Arthritis

Arthritis

Pathophysiology

Rheumatoid Arthritis (RA) emanates from the complex interaction of three different scientific domains. The first domain is the complex environmental stimulus and genetic predisposition to the condition. The second domain is the self-amplifying and self-perpetuating intra-synovial immune response. The final domain is tissue injury that emanates from inflammatory effector molecules, degradative enzymes, and pro-inflammatory cells. In individuals with arthritis, the process is arthrotropic and yields a pathologic laceration in the synovium, cartilage destruction at the joint margin, and hallmark bone erosions. The histopathology of arthritis involves the synovial lining, microvasculature, and the interstitium. The synovial lining comprises of both Type A and Type B cells. Type A cells are macrophage-like whereas Type B cells are fibroblast-like. The onset of the process entails the proliferation of the synovial lining that result in its increase in mass and cell number. The interstitium also exhibits a nodular and diffuse inflammatory cell infiltrate that comprises of CD4+ and CD8+ lymphocytes, antigen presenting cells, and dendritic cells (Choy, 2012). The histologic appearance turns out to be dramatic in some patients by revealing the focal aggregation of B and T cells and the presence of germinal centers that are similar to the ones seen in lymphoid tissues. At the end of the process is the classic erosion at the cartilage and bone margin with the effect extending to other distant structures such as the ligaments, tendons, and musculoskeletal structures (McInnes & Schett, 2011).

Clinical Presentation

Symmetrical synovitis is the main characteristic of RA. It entails multiple diarthrodial joints among other articular features. RA patients observe a slow onset of the inflammation of joints that lasts from weeks to months. Some patients reveal the waning and waxing course also called palindromic rheumatism. This occurs several years prior to the presentation of the permanent features of RA. The patient also presents systemic symptoms such as weakness, fatigue, and malaise besides joint inflammation. Joint manifestations occur in RA patients in the form of strange stiffness that occurs either in the morning or in the periods following inactivity. The patient also presents pleuropulmonary manifestations such as abnormalities in the lungs and pleura following a chest radiograph. RA also presents cardiac manifestations such as the increase in posterior pericardial effusion. Approximately 1% of RA patients also present Pseud-Felty’s and Felty’s Syndrome that associates the condition with splenomegaly and leukopenia. Clinical manifestations include the presentation of sjogren’s disease, rheumatoid nodules, and other articular manifestations (McInnes & Schett, 2011).

Hypertension

Pathophysiology

Just like arthritis, the pathogenesis of hypertension is complex and multifactorial. Many factors modulate the blood pressure of an individual. These include vascular reactivity, humoral mediators, vascular caliber, circulating blood volume, elasticity of the blood vessel, cardiac output, blood viscosity, and neural stimulation. In the pathogenesis of the condition, multiple factors such as genetic predisposition, excess intake of dietary salt, and adrenergic tone interact to yield hypertension. Currently, no specific mechanisms that cause hypertension even though genetic predisposition is a major contributing factor to the condition. However, it is evident that an immunological basis provides an insight into the onset of hypertension among humans and other animals. An association exists between the renal infiltration of immune cells and hypertension. Moreover, a negative association exists between blood pressure and pathologic and pharmacologic immunosuppression. T lymphocytes and cytokines derived from T-cells also contribute towards hypertension. Prior to the onset of hypertension is the oxidation of lipids that forms isoketals that act as neoantigens. The presentation of isoketals to T-cells results in the activation of the T-cells as well as the infiltration of critical organs such as vasculature and kidney. The result is severe or persistent hypertension that causes the damage of end organs (Alexander, 2017).

Clinical Presentation

During the initial stages of hypertension, the patient exhibits almost no visible symptoms thereby giving hypertension the name of a silent killer. It is only after the blood pressure reaches a very high level of approximately 180/110 mm of Hg or when there is an organ damage that symptoms start appearing. Headache is one of the symptoms that patients suffering from hypertension present. The characteristic aspect of such headaches is the fact that they only appear when the blood pressure of the patient rises. Other symptoms include pain in the backside of the neck, feeling hot and flushing, nausea and occasional vomiting, drowsiness, dizziness, severe hypertension that causes severe and sudden nosebleeds, irregular heartbeat, shortness of breath, and eye damage characterized by double or blurred vision (Mandal, 2014).

Chronic Obstructive Pulmonary Disease (COPD)

Pathophysiology

Smoking suffices to be the leading cause of COPD. In a study conducted on the incidence of COPD among patients, it was evident that 85% of the patients turned out to be initial smokers as compared to 15% non-smokers. Individuals from developing countries have also exhibited high prevalence of COPD. As opposed to smoking witnessed among most patients, individuals from poor households in developing countries develop COPD because of the exposure to indoor air pollution following the regular use of biomass fuel. As a result, COPD cases caused by indoor air pollution from biomass fuel accounts for approximately 30% to 50% of all COPD cases in India, a developing country. However, individuals require at least 25 years of exposure to such fumes to develop COPD. For cigarette smokers, they need to smoke for at least 10 pack years to develop COPD. The at-risk professionals include drivers, mechanics, and employees in factories that manufacture fertilizers, organic compound dyes, rubber products, explosives, petroleum refining, ammonia, and plastics. Farmers exposed to funguses and grain dusts are at risk of developing COPD. The other risk factors include outdoor air pollution, old age as a result of physiological obstruction, and genetics. Through elastin proteolysis, the elastic recoil lung pressures drop accompanied with the narrowing of air vessels. This produces air trappings in lungs and reduced flow of air in bronchioles (Brashier & Kodgule, 2012).

Clinical Presentations

Patient living extremely sedentary lifestyles provide the first indicator for COPD. In most cases, such patients record few complaints but adjust their lifestyles in a number of ways such as increased inactivity without knowing the cause of their conditions. Even though such patients could complain about fatigue, they do not know that the fatigue emanates from a respiratory problem. Patients that generally complain about chronic cough and dyspnea are the other group of patients that present a high likelihood of having developed COPD. It is only during exertion that it becomes possible to notice dyspnea. The insidious onset of mucoid sputum in the morning and throughout the day in volumes that do not exceed 60 ml is the other presentation of COPD. Finally, episodes of purulent sputum, increased cough, fatigue, wheezing, and dyspnea occurring without fever present the symptoms of COPD. Such patients face the risk of incorrect diagnosis since a combination of dyspnea and wheezing could lead to the false diagnosis of asthma in the place of COPD. The other illnesses that present similar manifestations thereby presenting the risk of incorrect diagnosis include bronchiolitis, bronchiectasis, and heart failure (Han et al., 2015).

Co-morbidity, Chronicity, and Complexity

Co-Morbidity

Comorbidity refers to the occurrence of two or more illnesses or disorders in one person concurrently or one after the other. It also entails the interaction between the illnesses in the individual that could yield an adverse course for both conditions in the patient. For instance, comorbidity has shown increasing prevalence between mental and physical illnesses. In a study that measured comorbidity across chronic physical conditions, mental disorders, intellectual impairment, and psychological wellbeing, 27.7% of the cases indicated at least one of the five identified chronic physical conditions within the past one year. Of all the conditions, high blood pressure or hypertension turned out to be the most common. The other conditions and illnesses that exhibited high incidence among the selected individuals include asthma, cancer, and diabetes. Only 0.7% of the respondents reported epilepsy. The study revealed an association between chronic physical conditions and common mental disorder (CMD). Among the patients that presented severe CMD symptoms, 37.6% also presented a chronic physical condition. However, only 25.3% of patients that presented no or few CMD symptoms presented a chronic physical condition. For instance, individuals that presented severe CMD symptoms presented double likelihood of having asthma as compared to those that had few or no symptoms (Rai et al. 2014).

In medicine, chronicity refers to the state of being chronic or lasting for a long duration. As a result, a chronic illness turns out to be the identity of the patient in the society due to its long lasting nature contrary to episodic or acute illnesses. It is clear that medical success is the main contributor of chronic illnesses. Patients suffering from acute illnesses have been able to have increased life expectancies because of successes in medicine. Increased life expectancy has increased the vulnerability of individuals to disease and accident events that have contributed massively towards the development of chronic conditions and illnesses. Controlling tobacco smoking and other illnesses such as hepatitis B, elevated blood cholesterol, and hypertension would have a significant contribution in the reduction of the global incidence of chronic conditions. Out of seven individuals, one presents a disabling condition or illness that limits his or her ability to perform a specific activity. The elderly, minorities, and individuals from lower socioeconomic groups exhibit higher incidences of chronic conditions and illnesses (Ornstein et al., 2013).

Complexity

Complexity in illnesses and conditions refers to the state of the illnesses being complex or multifactorial. As a result, complex illnesses and conditions refer to illnesses and conditions caused by different factors thus the alternative name ‘multifactorial’. Examples of such diseases include obesity, diabetes, and heart diseases. As opposed to certain illnesses such as sickle cell anemia and cystic fibrosis that emanate from the mutation of a single gene, complex illnesses such as diabetes, obesity, and heart diseases do not have a single genetic cause. As a result, they emanate from multiple genetic, environmental, and lifestyle factors. Research has revealed that complex conditions and illnesses cluster in families. However, the specific pattern of inheritance of the conditions among family members is unclear. As a result, it is difficult to determine the risk of an individual to either pass on or inherit the disorder. It is also difficult to study and treat complex conditions because of the unclear identification of all the factors that cause the conditions. Therefore, researchers are still identifying and studying all genes associated with the conditions before determining the effective ways of treating or preventing the disorders (U.S. Department of Health and Human Services, 2017).

Discussion

The Chronicity and Complexity of Agnes’ Situation

It is clear that Angela suffers from arthritis, COPD, and hypertension. Apparently, the above illnesses are both complex and chronic. The complexity of the illnesses emanates from the fact that they are multifactorial implying that they are caused by different factors. To begin with, Angela developed COPD primarily out of her smoking habit that lasted for 24 years. Even though she no longer smokes, Angela developed COPD since the period of active smoking exceeds 10 pack years. As a grandmother aged above 60 years, it is clear that physiological obstruction associated with old age also escalated Angela’s condition. Angela’s presentation of increased discomfort when mobilizing especially from the spine is the main indicator of arthritis. It is evident that Angela developed arthritis from the third domain that involved tissue injury emanating from inflammatory effector molecules, degradative enzymes, and pro-inflammatory cells during her period of active smoking. This reveals an interaction between arthritis and COPD. Angela’s condition also reveals the interaction between arthritis and hypertension because of the weakness that has limited her mobility thereby compelling an increasing in the weight of her body. Weight increments have a positive association with hypertension. Furthermore, increased inactivity is one of the clinical presentations of COPD. This also implies a direct relationship between COPD and arthritis that has further worsened Angela’s situation.

Conclusion

Arthritis, hypertension, and COPD are examples of complex chronic illnesses. The illnesses are complex because they have different causative factors. The chronicity of the illnesses emanates from the fact that they last for long durations as opposed to episodic and acute illnesses. Arthritis causes tissue injury thereby resulting in the inflammation and weakening of tissues. Consequently, weakness and fatigue are some of the clinical presentations of arthritis. Smoking and other air pollutants cause elastic proteolysis that leads to the narrowing of air passages and air trappings in the lungs thereby resulting in the development of COPD in a patient. The different factors that cause hypertension include vascular reactivity, humoral mediators, vascular caliber, circulating blood volume, elasticity of the blood vessel, cardiac output, blood viscosity, and neural stimulation. Clinical presentations of hypertension include headaches, pain in the backside of the neck, feeling hot and flushing, nausea and occasional vomiting, drowsiness, dizziness, severe hypertension that causes severe and sudden nosebleeds, irregular heartbeat, shortness of breath, and eye damage characterized by double or blurred vision. In the case, Agnes presents arthritis, hypertension, and COPD characterized by weakness and fatigue, weight gain, discomfort when moving, limited ability to exercise, and breathlessness when walking.

References

Alexander, M.R. (2017). Hypertension: Pathophysiology. Retrieved from: http://emedicine.medscape.com/article/241381-overview#a3

Brashier, B. B., & Kodgule, R. (2012). Risk factors and pathophysiology of chronic obstructive pulmonary disease (COPD). J Assoc Physicians India, 60, 17-21.

Choy, E. (2012). Understanding the dynamics: pathways involved in the pathogenesis of rheumatoid arthritis. Rheumatology, 51(suppl_5), v3-v11.

Han, M. K., Dransfield, M. T., Martinez, F. J., Stoller, J. K., & Hollingsworth, H. (2015). Chronic obstructive pulmonary disease: definition, clinical manifestations, diagnosis, and staging. UpToDate. Retrieved from https://www-uptodatecom. ezproxy1. library. arizona. edu/contents/chronic-obstructive-pulmonary-diseasedefinition-clinical-manifestations-diagnosis-andstaging, 1-150.

Mandal, A. (2014). Hypertension Symptoms and Effects. News Medical. Retrieved from: http://www.news-medical.net/health/Hypertension-Symptoms-and-Effects.aspx

McInnes, I. B., & Schett, G. (2011). The pathogenesis of rheumatoid arthritis. New England Journal of Medicine, 365(23), 2205-2219.

Ornstein, S. M., Nietert, P. J., Jenkins, R. G., & Litvin, C. B. (2013). The prevalence of chronic diseases and multimorbidity in primary care practice: a PPRNet report. The Journal of the American Board of Family Medicine, 26(5), 518-524.

Rai, D., Stansfeld, S., Weich, S., Stewart, R., McBride, O., Brugha, T., … & Papp, M. (2014). Comorbidity in mental and physical illness. Adult Psychiatric Morbidity Survey 2014.

U.S. Department of Health and Human Services. (2017). What are complex or multifactorial disorders? Genetics Home Reference. Retrieved from: https://ghr.nlm.nih.gov/primer/mutationsanddisorders/complexdisorders

Willcox, S. (2015). Chronic diseases in Australia: Blueprint for preventive action.