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Clinical Case Scenario Assignment - Case and Analysis - Medical Science

Unit Learning Outcomes -

1 - Explain the importance of homeostasis in maintaining health.

2 - Identify the structure and function of bacterial, viral and human cells and tissues.

3 - Describe the structure and function of the integumentary, cardiac, pulmonary, haematological, musculoskeletal, neurological, and endocrine systems.

4 - Identify physiology underpinning vital sign measurement in the identification of normal body systems.

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1. A doctor tells the nursing and midwifery students that it is important to monitor patients' blood pressure when they are receiving Verapamil (a calcium channel blocker). Explain why, with reference to the physiology of cardiac and smooth muscle.

Case 1 - Importance of B.P monitoring while on Verapamil (a calcium channel blocker) with reference to the physiology of cardiac and smooth muscle.

Analysis - There calcium channel blockers are classified into Diphenylalkylamines; Benzothiazepines, and Dihydropyridines. Verapamil is classified under Diphenylalkylamines (Whalen, Finkel, & Panavelil, 2014). The intracellular concentration of calcium maintains smooth muscle tone and helps in the contraction of myocardium.

Calcium channel blockers blocks the incoming calcium which generally enters the muscle cells through special voltage sensitive calcium channels by binding to L-type calcium channels in coronary and peripheral arteriolar vasculature's smooth muscle (Whalen et al., 2014). All these mechanisms lead to the relaxation of vascular smooth muscle which results into the dilation of arterioles. Moreover, Verapamil has two important features viz. negative iotropic and negative dromotropic effects (Whalen et al., 2014). These entire cause significant dose dependent lowering of blood pressure values which at times can lead to some serious condition, hence proving the importance of blood pressure monitoring in patients on Verapamil.

2. Communication between cells is key to organism-level regulation of the internal environment to maintain health, that is, nearly constant internal conditions (homeostasis). Outline and compare the intercellular communication pathways that function to provide homeostasis.

Case 2 - Intercellular communication pathways that function to provide homeostasis.

Analysis - Intercellular communication is defined as the exchange of information among the various cells of the body whereas Homeostasis is defined as the maintenance of stable internal state of the body. Intercellular communication is required at a sophisticated level for multi-cellular organisms to coordinate their responses (Bradshaw, & Stahl, 2016). There are various modes of communication which are autocrine; paracrine; endocrine; neurocrine, and lumencrine communications (Aykan, 2012).

The stimuli which get transmitted across the cell membrane pave the way for intercellular communication. Receptors are responsible for producing a variety of responses like covalent modifications; post-translational modifications (PTMs), and limited proteolysis (Bradshaw, & Stahl, 2016). The various modes of intercellular communication help in homeostasis.

Autocrine communication through activity of growth factors explicitly stimulates the cell via receptors which regulates functioning of normal cells like macrophages, vascular smooth muscle cells, and others in either good or bad way. Paracrine communication is vital as it binds to and affects neighboring cells through growth factors. Intercellular communication also takes place through tunneling nano tube like structures. Endocrine communication involves communication system. Lumencrine communication involves open cell types like prostrate (Aykan, 2012).

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3. During exercise, the blood flow to the active skeletal muscles is increased by autoregulation. Explain how this works and explain what other controls operate on blood flow.

Case 3 - Autoregulation and other controls operate on blood flow.

Analysis - An average human being consumes 0.15 and 0.4 liters of oxygen per minute while on rest and most of it is being consumed by brain, heart, liver, and kidney. The skeletal muscle consumes very less of oxygen. It is only when the skeletal muscles are contracting; they require more blood (Joyner, & Casey, 2015).

During exercise, the active skeletal muscles contract which enables increased flow of blood. The controls are

1) Fraction of cardiac output - As per Fick principle, oxygen consumption is directly proportional to blood flow and arterial-venous O2 difference (Joyner, & Casey, 2015). Exercise leads to increase in stroke volume, and fall in mixed venous oxygen saturation,

2) Peak values - Pertaining to peak value of skeletal muscle blood flow, active muscle mass (AMM) and mean arterial pressure (MAP) are dependents. There is a modest rise in MAP with the onset of exercise. 40-50% of lean body mass in young humans is AMA. (Joyner, & Casey, 2015).

3) Sympathetic nervous system control - There is an increase in the cardiac output due to stimulation sympathoadrenal system.

4) Local blood flow - The hemoglobin, and hematocrit counts are important determinants.

4. A patient's wound overwhelms the clotting mechanism and leads to serious haemorrhage and drop in blood pressure. Explain the compensations that the body has to maintain cardiac output.

Case 4 - Compensations body does in response to hemorrhage to maintain cardiac output.

Analysis - Cardiac Output is directly proportional to Heart Rate, and Stroke Volume. The body would first compensate by increasing the heart rate which would maintain cardiac output despite hemorrhage associated decrease in Stroke Volume. This would enable patient to retain perfusion and blood pressure. A second compensatory mechanism would be rise in systemic vascular resistance to maintain blood pressure.

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5. You see a patient with a goiter. You run some tests and find the patient is iodine deficient. Explain how iodine is used in the production of thyroid hormones. Also, explain how a goiter might form as a result of iodine deficiency (be sure to include the role of TSH in your response).

Case 5 - Iodine, thyroid hormones and its role in goiter

Analysis - The iodine through small intestine is transported to the thyroid through plasma. Iodine gets concentrated and oxidized here and then gets incorporated into thyroglobulin (Tg). This later on turns into T3 and T4 (Rousset, Dupuy, Miot, & Dumont, 2015).

The enlargement the thyroid gland beyond normal proportion is termed as 'Goiter'. TSH, Thyroid stimulating hormone is a glycoprotein which is produced by the thyrotroph cells of the pituitary glands. It acts as a signal when the thyroid level is too low, thereby increasing the thyroid level. An abnormal growth in size stimulated by TSH results in goiter (Sarapura, & Samuel, 2017).

6. When patients who are receiving glucocorticoid therapy need to stop taking it (e.g., Prednisone), the doctor will prescribe a series of doses of tapering size to gradually lower the dose rather than suddenly stop it. Explain this dosage strategy in terms of the negative feedback control of cortisol secretion.

Case 6 - Reasons for gradually reducing the dose of prednisone in terms of the negative feedback control of cortisol secretion.

Analysis - Adrenal cortex secretes Cortisol. There is a loop which is negative feedback to the anterior pituitary and hypothalamus which controlling the Cortisol secretion. This feedback loop keeps the level of Cortisol in blood under check (Starr, 2005).

Prednisone is similar to Cortisol but the fact that Cortisol is produced naturally and prednisone is synthetic. While on prednisone, the adrenal gland produces lesser Cortisol. Sudden withdrawal may not give adrenal gland to restore its normal functioning. Hence, the dose is reduced gradually rather than stopping it abruptly.

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7. What does it mean to say that the pancreas is both an endocrine and an exocrine organ? Consider the cells involved and the secretion pathways.

Case 7 - Pancreas as a two in one organ with reference to the cells involved and the secretion pathways.

Analysis - Pancreas is a two in one organ. On hand, pancreas acts as an exocrine organ secreting digestive juices in the duodenum. Although pancreatic enzymes like amylase and lipase are secreted in active form, proenzymes like trypsinogen are activated in duodenum. On the other hand, it is an endocrine organ as it secretes insulin, glucagon, and somatostatin. Moreover, two fused organs are there viz. dorsal and ventral pancreas embryologically (Banasik, & Copstead, 2018).

8. Explain how skin helps to thermally regulate body temperature (be sure to discuss the entire homeostatic feedback mechanism).

Case 8 - Skin, thermoregulation, and homeostatic feedback mechanism

Analysis - Heat is produced in the body as a by-product of cellular metabolism. The heat of the body is dissipated through skin. Homeostasis is the maintenance of the equilibrium of our body in all aspects.

A feedback mechanism comprises a receptor, a control center, and an effector which is generally the recipient of the external messages. The receptor after sensing changes in the internal environment transmits the message to the control center, brain. The brain interprets the message and passes on the information to the effector. An effector is generally an outer part of the body like skin or blood vessels or blood. An effector after receiving information from the control center produces a response to the given condition (Peate, & Nair, 2015).

There are two types of feedback system. One is negative which reverses the changes to the set level. Most of our body system is based upon this. The second one is positive feedback system which enhances an output to maintain homeostasis. When there is a lowering of body temperature, the hypothalamus would receive an input from the skin which would in turn send an output to skeletal muscles via nerves to start shivering, thus raising the body temperature (Peate, & Nair, 2015).

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9. Explain what dual innervation means with regard to the autonomic nervous system. Using the cardiovascular and respiratory systems as examples, explain how dual innervation regulates the function of each system.

Case 9 - Dual innervation pertaining to autonomic nervous system using the cardiovascular and respiratory systems

Analysis - The ANS has sympathetic and parasympathetic divisions. Both these innervate most of the organs of the body. In case of Cardio-vascular system, the heart rate is slowed down by the vagal parasympathetic innervation. The heart rate on the other hand is increased by the sympathetic innervation. Although there are two innervations, one system predominates the other. In the case of cardio-vascular system, the vagus nerve is the dominating factor (Whalen et al., 2014).

Regulation of many functions of airways is done through innervation. Human airways are innervated by Efferent and afferent autonomic nerves . In respiratory system, parasympathetic nervous system is the dominating neural pathway (Van der Velden, & Hulsmann, 1999).

10. A newborn infant is found dead, abandoned by the road. Among the many questions that the police would like answered is whether the infant was stillborn. Explain how the medical examiner could determine this with reference to the respiratory system and the tests involved.

Case 10 - Medical examination to determine if the abandoned child was stillborn with special reference to respiratory system

Analysis - Autopsy is the gold standard in the given scenario to find the exact cause. The basic test is to place the lungs in water to see if these float or not. In case it was not a stillbirth, the infant must have breathed which could have trapped some air as the lungs got inflated.

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