Question

Below are symptoms of a patient related to the Renal System. Each person needs to answer all of these and then reply substantially to their teammates. As a team you should come to a final conclusion on all 3 questions in regards to the Patient and the symptoms. *Only the people in your group/team can see your discussions. Based on the symptoms answer the following questions:

1. Identify all anatomical structures related to and/or that are being affected based on the patient case information. (i.e. tissues, organs, vessels, brain components, membranes)
2. Explain how the anatomical structures and their physiological function/dysfunction are interrelated normally and what is going wrong with the structures in this current patient case information.
3. Identify and explain possible a diagnosis and what can be done to fix or reverse the current situation described in the patient case information. Please be specific and detailed.

Patient Case (Initial Review): (More information may be coming on June 8th)

You are an ER Doc in a rural town and you just walked in to a room with a patient named Frank. Frank is in serious condition. Upon entering the room and performing a quick physical exam you identify the following physical symptoms:

• Cough
• Mucus
• Cyanosis
• Swollen Liver
• Edema
• sPO₂ of 70%

You ask for lab tests and get the following lab results:

• pH 7.32
• PaO₂ 35 mmHg
• PaCO₂ 80 mmHg
• HCO₃^- 40 mM

Further Question(s)/Information:

• After further analysis the Doctor thinks this patient has emphysema.
• What are your thoughts on this diagnosis and how would emphysema explain the lab tests and physical symptoms above?
• What would be the plan to fix this?

Answer 1

I agree with the diagnosis of emphysema. But I would prefer to use the term chronic obstructive pulmonary disease.

Explanation:

• The patient has cough and mucus production- this suggests the respiratory system is involved.
• Cough is produced due to airway inflammation.
• This inflammation is secondary to exposure to noxious fumes and gases ( example - cigarette smoke)
• Mucus production is also due to airway inflammation.
• In COPD there is increase in the density of sub mucosal glands of the airways.
• The airway is also lined by mucus secreting cells called goblet cells.
• This patient also has
  • Swollen liver
  • Edema feet
• These symptoms are suggestive of right heart failure.
• This patient has suffered from right heart failure because:
  • This patient must have been having respiratory problems from a long time.
  • In COPD, there is airflow obstruction due to inflamed airways and bronchoconstriction.
  • This has lead to hypoxia in the lungs ( due to less oxygen reaching the alveoli)
  • In the lungs ( unlike the systemic circulation) , hypoxia causes vasoconstriction.
  • Due to vasoconstriction, the pressure inside the pulmonary arteries increases.
  • The increase in the pulmonary arteries pressure, also increases the resistance to blood flow in the pulmonary arteries.
  • The right heart pumps blood into the pulmonary artery.
  • As the resistance to the flow to blood in the pulmonary arteries increase, the right heart finds it difficult to pump blood into the lungs.
  • This leads to increase in the end systolic volume and pressure in the right ventricle.
  • As a result, the right is unable to accomodate the blood entering into the right atrium ( via superior and inferior vena cava )
  • As a result, there is congestion of blood in the liver ( as the hepatic vein drains into the inferior vena cava)
  • Plus, there is edema in the lower limbs ( transudation secondary to increase in hydrostatic pressure in the veins of the legs
• The lab test can be explained as follows:
  • In COPD, there is expiratory airflow obstruction.
  • This leads to incomplete exhalation.
  • This leads to air trapping
  • Air- trapping leads to dilatation of alveoli ( airspaces)
  • Due to dilatation of the airspace there is breakdown of the interalveolar wall.
  • This leads to emphysema formation.
  • Emphysema formation has the following effects
    • Due to breakdown of the interalveolar wall the surface area available for gas exchange reduces. This leads to hypoxia
    • This explains the low pO2 levels
    • The lungs become hyper inflated.
    • The hyperflated lung flattens the diaphragm.
    • This makes it difficult for the diaphragm to function and therefore accessory muscle of respiration need to be used by the patient.
    • A point comes when then muscles fail to function.
    • This is termed as respiratory pump failure
    • As a result, the patient hypoventilates.
    • This leads to CO2 retention.
    • That is why this patient has high pCO2
  • The high PCO2 has causes acidosis. That is why the pH is lower than normal (7.35 - 7.45).
  • This is called respiratory acidosis.
  • The patient has high bicarbonate levels ( normal - 24 )
  • This means the patient's kidney is trying to retain bicarbonate in the nephron.
  • This is an attempt to increase the pH of the body.
  • However the pH has not gotten corrected completely.

This can be fixed in the following ways:

• The Patient should be first started on supplemental oxygen therapy ( nasal prongs or face mask)
• With help of pulse oxymeter the oxygen should be treated. The target SPO2 should be 90%.
• Make sure that supplemental oxygen ( FIO2 ) is not too high.
• Because, given high FIO2 in patient of COPD can lead to cessation of respiratory and it would further aggregates the hypoxia.
• If supplemental oxygen fails to correct the problem, the next best thing to do is to start the patient on non- invasive mechanical ventilator. This will provide the patient with pressure support and oxygen also.
• The patient should be given inhaled bronchodilators. This will relieve the bronchospasm, reduce the work of breathing and improves hypoxia.
• Intravenous steroids ( example hydrocortisone) should be given to reduce the inflammation.
• Antibiotics to reduce the infection.
• Diuretics to reduce the edema and the blood volume. This will help reduce the work load on the heart.

Chronic obstructive pulmonary disease is a preferred term because no patient has purely emphysema component or chronic bronchitis in the lungs. Majority have a combination of both.