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A 36-year-old female has brought her mother to your medical office. Lately she has noticed her mother's eyes look like they are protruding. What can you tell her and her mother? What are possible causes and the most likely cause? Do you think the doctor will order laboratory blood tests? If so, which ones? How would the results be interpreted?

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Jean Keeling
Jean KeelingLv2
28 Sep 2019

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Related questions

Personal Information

Name: Mrs. Paula Johnson

Age: 65 years old

Gender: Female

Description

Mrs. Paula Johnson is a 65-year-old white woman with a previous history of a sedentary lifestyle, hypertension, hypercholesterolemia, and diabetes mellitus type II. She is a heavy smoker since she was 20 years old. She was brought to the emergency room because her family found her unresponsive on the floor. She was diaphoretic. Her family thought she had her diabetes decompensated. Mrs. Johnson’s daughter indicated her mother was complaining of nausea and epigastric pain the day before. Also, her blood pressure was high.

On the physical examination we found:

Remarkable Signs on Physical Exam by Regions

Chest: Palpitation

Remarkable Signs on Physical Exam by Systems

Integumentary system: Profuse diaphoresis, coldness, and pallor

Respiratory system: Tachypnea

Cardiovascular system: Weak pulse, tachycardia, and hypotension

Nervous system: Unconsciousness. No other neurologic signs.

Lab Tests

Complete blood count (CBC)

Cardiac enzymes

Glucose level

Lipid panel

EKG

Cardiac catheterization

Diagnosis

Silent myocardial infarction

Other Diagnoses

Essential hypertension

Dyslipidemia

Diabetes mellitus

Supporting Material

Mrs. Johnson has been diagnosed with silent myocardial infarction. As we learned last module, the first step in pathophysiology is observation of noticeable changes, but what do we do when the patient does not outwardly experience symptoms? Chest pain is a scary symptom that usually alerts the physician and patient. However, if the patient or the physician is not alerted, the medical practitioner has to dig deeper to understand the cause or set of causes that contribute to the condition.

What are your initial reactions related to the case?

What is a heart attack?

Considering Mrs. Johnson’s case, why does she have an increased risk of having a heart attack?

What is tissue perfusion? Which of the patient’s conditions can alter tissue perfusion? How?

What is hypertension? How does hypertension alter tissue perfusion?

Describe pneumonia. What risk factors does the patient have for pneumonia?

Based on “Morgan: A case of Diabetes” by Lisa Rubin and Clyde Freeman Herreid (National Center for Case Study Teaching in Science)

The Patient:

Morgan Water is a 27-year old Native American that lives on a reservation in Oklahoma. Nearly ¼ of Morgan’s tribe has diabetes but she has no direct family history of diabetes, heart disease, or other serious conditions. She is however obese (BMI = 32) and leads a sedentary lifestyle. Morgan has been suffering from an increasing persistence of symptoms including unusual thirst, dizziness, blurred vision, and numbness in her right foot. The symptoms have been developing over several months but as she is planning her wedding she attributed them to nerves. She is finally persuaded to see her family doctor. Her non-fasting blood glucose level was elevated so the doctor has her return the next morning for a fasting blood sample so they could more accurately measure her blood glucose and insulin. Her blood results are below:

Test

Morgan’s values

Normal range

Pre-Diabetic range

Diabetic range

Plasma glucose, mg/dl

260

70 -139

140 - 199

≥ 200

Fasting glucose, mg/dl

140

≤ 99

100 - 125

≥ 126

A1C, %

7.6

~ 5

5.7 – 6.4

≥ 6.5

Fasting Insulin, mIU/ml

34

2 - 10

10 - 20

≥ 20

Question 1:

Based on her history and blood results, what do you think is the most likely diagnosis for Morgan?

A. Type I Diabetes Mellitus

B. Type II Diabetes Mellitus

C. Pre-Diabetes

D. Cardiovascular Disease

Question 2:

What is the cause of Morgan’s disease?

A. It is an auto-immune disorder that destroys the β-cells of her pancreas so she produces less

insulin than normal.

B. She has a genetic mutation that results in less insulin receptor being produced than normal.

C. She has developed insulin resistance, where her insulin receptors do not recognize the insulin her

body produces, likely due to her obesity.

D. There is no known cause, it can happen spontaneously.

Morgan is worried that she will have to spend the rest of her life giving herself injections but her doctor does not prescribe insulin injections.

Question 3:

Why would injections of insulin not help Morgan if she has hyperglycemia?

A. Her body is already producing excess insulin but not responding to it.

B. Her problem is with her insulin receptors responding to insulin.

C. Excess insulin will only exacerbate her insulin resistance.

D. All of the above.

Question 4:

Given Morgan’s metabolic state, which of the following pathways would you expect to be active in Morgan’s cells (select all that apply)?

A. Glycolysis

B. Gluconeogenesis

C. β-oxidation

D. Amino acid degradation

E. Protein synthesis

Case Study 1: Case Presentation

John, a healthy twenty-eight year old electrical engineer, was driving home from work one evening when he experienced sudden stabbing pain in his right pectoral and right lateral axillary regions. He began to feel out of breath and both his respiratory rate and heart rate increased dramatically. As luck would have it, John passed a hospital each day on his way home and was able to get himself to the hospital’s emergency room. The emergency room physician listened to John’s breathing with a stethoscope and requested blood gas analysis and a chest x-ray. John answered a few of the doctor’s questions. The doctor noted that John had no history of respiratory problems but was a heavy smoker.

After viewing the chest radiograph, the doctor informed John that he had experienced a spontaneous pneumothorax, or what is commonly called a collapsed lung. The doctor explained that a hole had opened in John’s right lung and that this hole had allowed air to leak into the cavity surrounding the lung. Then, as a result of the lung’s own elastic nature, the lung had collapsed. The doctor said he could not be certain of the cause of the pneumothorax, but smoking cigarettes had certainly increased the likelihood of it happening. He told John he was fortunate the pneumothorax was small, which meant that relatively little air had escaped from the lung into the surrounding cavity, and it should heal on its own. He instructed John to quit smoking, avoid high altitudes, flying in nonpressurized aircraft, and scuba diving. He also had John make an appointment for a re-check and another chest x-ray.

Case Background

Spontaneous pneumothorax occurs when a blister on the surface of the lung opens, allowing air from the lung to move into the pleural cavity. This occurs because alveolar pressure is normally greater than the pressure in the pleural cavity. As air escapes from the lung, the lung tissues will recoil, and the lung will begin to collapse. The lung will continue to collapse until the difference between the alveolar pressure and pleural pressure disappears or until the collapsing of the lung causes the opening to seal.

The pneumothorax decreases the efficiency of the respiratory system, which in turn results in decreased blood oxygen concentration, increased respiratory rate, and increased heart rate. If the pneumothorax is small, the air that escapes into the pleural cavity can be reabsorbed into the lung once the opening has sealed shut. If the pneumothorax is large, a needle or chest tube may have to be inserted into the pleural cavity to draw the air out and allow for the reexpansion of the lung.

Questions

Define the following terms and explain how they may have been affected by John’s spontaneous pneumothorax.

Visceral pleura

Parietal pleura

Pleural cavity

As a result of a pneumothorax, the lung tissues recoil, and the lung collapses. Explain how recoil and collapse are prevented in a healthy lung?

How does elastic recoil function in breathing?

Why was John instructed to avoid high altitudes and flying in nonpressurized aircraft?

Case Study 2: The Case of the Coughing Housewife

Jessica, a fifty-nine year old mother of four, moved from a ranch in Colorado to Los Angeles, after the death of her husband, to be closer to her oldest son and his family. She has been in Los Angeles for 18 months and has noticed that she is experiencing shortness of breath which has worsened over the last six months. For the last week, she has been coughing and bringing up yellow mucus. She also noticed swelling in her ankles so she decided to visit a physician about her condition.

Jessica's family and medical history include a negative history of asthma or allergies, lack of occupational or home exposure to asbestos, a previous smoking history (one package of cigarettes per day between the ages of 16 and 52), episodes of bronchitis, treated with antibiotics on an outpatient basis, and a positive history of heart disease (father at 52 and brother at 56). Jessica has no history of serious illness, including heart disease, and her weight is within five pounds of her "desired" weight. She usually coughs in the morning to "clear her throat", but there is usually only a small amount of white mucus.

Her nurse practitioner conducts a general physical examination with the following results. Jessica's skin is normal (no rashes or cyanosis) and her nervous system is functioning normally. Her body temperature was 98.4oF while her pulse was regular at 95 beats per minute with an occasional premature beat. Jessica's blood pressure was within normal limits, however her jugular veins were slightly distended. Her respiratory rate was 28 breaths per minute; she breathed with pursed lips and used her accessory respiratory muscles more than would be expected. Jessica presented with a barrel chest and mild dyspnea when climbing onto the examination table. When listening to her breathing, the nurse practitioner noticed that Jessica had prolonged expiration accompanied by expiratory wheezes. Evaluation of her abdomen indicated no masses or tenderness, but she presented with both hepatomegaly and splenomegaly. All of her extremities were normal with the exception of bilaterally pedal edema.

Based on these results, the nurse practitioner suspected a pulmonary disorder and, after consultation with a physician, ordered laboratory tests (blood and sputum), spirometry and chest x-rays. The results of the laboratory tests were as follows: plasma bicarbonate = 38 mEq/L, hematocrit = 49%, white blood cell count = 9000, pH = 7.38; PaCO2 = 56, and PaO2 = 54. Analysis of the sputum sample indicated the presence of epithelial cells, polymorphonucleocytes and gram positive diplococci. Jessica's 1 second forced expiratory volume (FEV1) was 1.5 L/sec and her forced vital capacity (FVC) was 4 L. These values were 40% and 83% of normal, respectively. Results of the chest x-ray indicated scarring and hyperinflation of the lungs.

The results of these tests coupled with the physical examination and history lead to a diagnosis of emphysema. Jessica was prescribed antibiotics for the infection and oxygen by nose as well as a b2-agonist nebulizer as an acute treatment and requested to stay for observation and stabilization. After Jessica's condition was stabilized she was discharged and given a prescription for an inhaler containing a b2-agonist to be used as needed. She was also encouraged to exercise regularly and follow the nutritional guidelines she was given. Jessica was also informed that if the symptoms either worsened or did not lessen within the next week, to return and her treatment would be reevaluated and would possibly include nocturnal oxygen and an inhaler containing corticosteroids.

Answer the following questions about this case

Define the bold terms in the text. (8 points)

What risk factors and symptoms did Jessica present with prior to the physical examination that suggested a pulmonary disorder?

How did the physical examination, chest X-ray and spirometry confirm this hypothesis?

Identify muscles involved in respiration and how these muscles are responsible for the process of ventilation.

How will the b2-agonist in the inhaler help with the respiratory problems Jessica presents with?

Why is it important that a b2-agonist and not simply an b-agonist is used in the inhaler?

If her condition does not progress, why would corticosteroids be used in the inhaler?

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