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Diagnosis on the basis of Vitals
The case study selected for this assignment is case number 3.
QUESTION 1:
The three possible differential diagnosis for this case are:
Essential hypertension
Thyrotoxicosis
Post exercise state
QUESTION 2:
The most likely diagnosis for this patient is hypertension. According to Bickley, Szilagyi and Bates (2009), normal pulse rate for healthy young adult is 60-100. This patient has a pulse rate corresponding to upper normal limit. According to Madhur et al. (2014), a blood pressure of 150/120 mmHg, as in this case, is classified as stage 2 hypertension.
According to Dreisbach et al. (2015), hypertension is a multi factorial disorder. Few factors are:
Characteristics of vessels
Fluid volume in the body
Humoral mediators
Cellular viscosity of blood
Neural stimulation
In this patient, the raised blood pressure is the result of essential hypertension while in response to the vessel wall stiffening, the heart rate is normal. Similarly, the respiratory rate is rarely affected because the gaseous chemistry of the blood remains unchanged. However, long standing hypertension and LVH is deleterious for health and can lead to heart failure.
It is also noteworthy that hypertension has a genetic preponderance as well. According to Foëx and Sear (2004), the two main factors contributing to hypertension, either simultaneously or individually are increased cardiac output and an increase in peripheral vascular resistance. In geriatric population, the vessel compliance is increased which decreases the elasticity of the vessel due to vessel wall stiffening. There is another reason why patients develop hypertension is because of the autonomic dysfunction either due to coexistent co-morbidity or due to mediator release. Alpha adrenoceptor stimulation leads to increased vascular tone which ultimately increases the total peripheral resistance. The constant rapid and forceful contraction leads to the hypertrophy of the endocardium of the heart giving rise to left ventricular hypertrophy. In some cases, there is involvement of renin-angiotensin system. There is one other reversible cause of hypertension called as renal artery stenosis in which the renal artery is blocked which leads to increased vascular resiatance. This raise leads to hypertension.
There is a concomitant increase in the pulse rate when the heart contracts rapidly but in patients who have stiffening of the arterial walls, it is for this reason that there is a very slight affect on the pulse rate. The slight change is evident in this patient with borderline pulse rate. Further, the breathing rate remains unchanged because the cellular chemistry is not changed but hypertension may lead to increased pulmonary perfusion. When the cardiac contractility is increased for chronic period then it may lead to failure of the myocardial muscles which ultimately leads to pooling of blood in the vessels. This pooling causes pulmonary edema along with edema in the periphery.
According to Graff et al. (2013), hyperventilation leads to decreased cardiac contractility while in greater quantities of oxygen, there is constriction of the diameters of great vessels which leads to increase in the systemic blood pressure.
References
Bickley, L., Szilagyi, P. and Bates, B. (2009). Bates' pocket guide to physical examination and history taking. 7th Edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Foëx, P. and Sear, J. (2004). Hypertension: pathophysiology and treatment: Table 1. Contin Educ Anaesth Crit Care Pain, [online] 4(3), pp.71-75. Available at: http://ceaccp.oxfordjournals.org/content/4/3/71.full [Accessed 9 Mar. 2016].
Graff, B., Szyndler, A., Czechowicz, K., Kucharska, W., Graff, G., Boutouyrie, P., Laurent, S. and Narkiewicz, K. (2013). Relationship between heart rate variability, blood pressure and arterial wall properties during air and oxygen breathing in healthy subjects. Autonomic Neuroscience, [online] 178(1-2), pp.60-66. Available at: http://www.sciencedirect.com/science/article/pii/S1566070213000957 [Accessed 9 Mar. 2016].
Madhur, M. et al.(2014). Hypertension: Practice Essentials, Background, Pathophysiology. [online] Emedicine.medscape.com. Available at: http://emedicine.medscape.com/article/241381-overview [Accessed 9 Mar. 2016].
