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Assignment 4: A discussion about the patient presented in your

viva voce

SEPTEMBER 12, 2016

Author Name

1.0 Introduction
The aim of this paper is to discuss the health condition of the patient admitted in the emergency
department of a public hospital. The patient Mr X is 60 years old living alone with his wife. He
mobilises through four wheel walker and is independent with activities of daily life (ADLs). The
main reason for admitting the patient was cellulitis for which he was admitted in 2014 as well.
On the arrival of the patient, he was bounded to bed, required full assistance for ADLs, swollen
legs, pain in both legs, 5 days of sleeplessness, and a fractured right hand. The past history of the
patient reveals that he is suffering from hypertension, type 2 diabetes, epilepsy, post fall head
injury, high cholesterol, and obesity. Before shifting to the private hospital, the patients
urinalysis is done and observation is taken. He is booked for X-Ray and blood test.
The paper discusses pathophysiology/ pharmacology of the patient in detail along with the
assessment and diagnostic of the test. It provides a critical analysis of the data and discusses
management of care of the patient. Some recommendations are also provided with respect to
needs of the patient and health disciplines.

2.0 Critical reflection

2.1 Pathophysiology/Pharmacology
The main reason for the admission of the patient is that he fell from the bed which lead to a
fracture in his right hand as well he had swollen painful legs and redness due to cellulitis. He
also had difficulty in sleeping for 5 days and upon arrival to the hospital, it was suggested that he
had an attack of gout (bone scan). Taking into consideration, the regimen he has been taking
some of the drugs can be related to his present medical condition and according to Belcastro,
DEgidio, Striano, & Verrotti (2013), it has been deduced that patients under sodium valproate
have increased uric acid level which can lead to an attack of gout.
One of the main complaints the patient presented was with cellulitis. The most obvious cause of
cellulitis, in this case, appears to be his old age and obesity. Among other causes of cellulitis
include a previous attack of cellulitis with an annual recurrence rate of 8 to 20%, venous
insufficiency, oedema and ulcerative condition of the skin. Cellulitis in 70 to 80 % of cases,
involves lower limb and is caused by Streptococci mostly present in the space between the toes
(Hirschmann & Raugi, 2012). Diabetes mellitus itself predisposes to multiple infections as

hyperglycemic environment predispose patient to low immunity (due to depression of humeral
immunity, decrease the function of neutrophils and suppression of antioxidant activity),
angiopathy, neuropathy and suppression urine antibacterial activity (Alves and Casqueiro, 2012).
Diabetes is also considered to be a risk factor for the development of cellulitis especially of the
lower limb caused by fungal infection (tinea pedis and toenail onychomycosis) (Bristow &
Spruce, 2009).
Valproic acid can lead to hyperinsulinemia and insulin resistance, hyperleptinemia and leptin
resistance thus increasing the chance for development of diabetes mellitus (Belcastro, DEgidio,
Striano, & Verrotti, 2013). Rosuvastatin is associated with the development of diabetes because
as it inhibits HMG-CoA reductase, it causes variation in insulin signalling, decreased insulin
secretion, decreased adipocyte differentiation and other mechanisms. But diabetes due to
Rosuvastatin occurs only in those individuals who are already prone to develop it (Robinson,
2015). The other causes for diabetes of Mr X are his overweight which resulted due to insulin
resistance, derangement in fatty acid metabolism, mitochondrial stress, endoplasmic reticulum
dysfunction and involvement of pro-inflammatory cytokines (like Tumor Necrosis Factor and
interleukin-6) (American Diabetes Association, 2010)
It was also found that Valproic acid also alters the level of antioxidants disturbing the balance of
the oxidative state in the body (Ponka-Ptorak et al., 2011). One of the cause for Mr X
hypertensive condition could be Valproic acid as it is associated with changing in circular
markers which can lead to an acceleration in the process of atherosclerosis (Chuang et al., 2011).
Valproic Acid, on the other hand, also causes a gain in weight. This weight gain occur as a result
of multifactorial involving metabolic and endocrinological disturbances and increase the number
of circulating long chain free fatty acid (Jimnez, Greenberg, & Mills, 2011). Rosuvastatin
improves glucose intolerance and insulin resistance thus is beneficial for diabetics but it also
mobilises fat from viscera to subcutaneous tissues (Neto-Ferreira et al., 2013).
Mr X, when admitted, was having faecal and bowel incontinence as well. Urinary and faecal
incontinence incident increases with age with its increased incidence among individuals who are
more dependent on others than those who are not that much dependent on others (National
Institutes of Health State-of-the-Science Conference Statement, 2008). The cause of incontinence
in an older individual is due to degenerative changes as well as problems that start to develop
with advancement in age like cognitive impairment, infection and multiple drug regimen. This

dilemma of incontinence has not only effect on the personal life of a person but also increases the
incidence of falls and mortality (Farage, Miller, Berardesca, & Maibach, 2007). The other cause
of Mr X urinary and bowel incontinence is his diabetes mellitus. Diabetes results in degeneration
of nerves known as neuropathy which affects somatic as well as autonomic nervous system and
is more affected by poor glycemic control, long duration of diabetes and psychosocial
disturbances. The cause of faecal incontinence is due to reduced tone of anal sphincter and
impairment of sensation and rectal passivity and urinary incontinence occurs due to bladder
dysfunction. Bladder dysfunction can be due to neuronal dysfunction, urothelial dysfunction and
detrusor smooth muscle dysfunction (American Diabetes Association, 2010).
The patient also complained of sleep difficulty for 5 days. One of the causes of sleeping
difficulty of Mr X is Olmetec (Olmesartan) which is an angiotensin receptor blocker.
Angiotensin receptor blockers like Losartan, Olmesartan cause insomnia to patients who are
using them (Jimnez, Greenberg, & Mills, 2011).
2.2 Investigation
Upon admission of Mr X, history, vitals and laboratory analysis were done which lead to the
formation of the management plan. Mr X had a blood pressure of175/85 at the time of admission
for which he was prescribed Amlodipine and 187/95 even on the second day. 75% patient with
high blood pressure require combination therapy which n case of Mr X was provided by
Amlodipine and Olmesartan. this combination therapy is also necessary as Mr. is having
increased weight which is also one of the factors which causes the much more increase in blood
pressure than a patient who are not obese. For this combination any two drugs from these five
classes can be chosen: diuretics, Calcium Channel Blockers (CCBs), Angiotensin-Converting
Enzyme Inhibitor (ACE) inhibitors, Angiotensin Receptor Blockers (ARBs), b-blockers
(American Diabetes Association, 2010). The combination of Amlodipine and Olmesartan results
in significant reduction in blood pressure in an additive manner. This combination is more
efficacious as ARBs decrease the sympathetic tone which in turn does not increase heart rate as
seen with CCBs. ARBs also decrease the incidence of peripheral oedema which is usually a side
effect of CCBs by causing vasodilatation (Chrysant, Melino, Karki, Lee, & Heyrman, 2008).
Amlodipine and Olmesartan also decrease the incidence of end organ dysfunction than either of
the drug alone (Gradman et al., 2010). The doctor also directed for ambulatory blood pressure
monitoring (ABPM) which means that blood pressure is checked at regular interval. For ABPM

high tech instruments in spite of traditional sphygmomanometer are used and an automated
office BP is measured (OBrien et al., 2013).
X-ray and bone scans were done to assess fracture as well as features of gout. For gout, X-ray is
proven to be helpful for diagnosis and can be used to differentiate gout from arthritis
(Chowalloor, Siew, & Keen, 2014). It holds 93% more diagnostic specify value than= clinical
diagnosis of gout which is just 37 % (Rettenbacher et al., 2007). As per research, it has been
concluded that plain radiographs are less sensitive than other scanning modalities in detection of
gout (Perez-Ruiz, Dalbeth, Urresola, de Miguel, & Schlesinger, 2009). Bone density scan
revealed arthritis in multiple joints include intratarsal and tarsometatarsal joints of both feet and
in the second MCP joint of the right hand bilateral acromioclavicular joints which probably be
caused by gout as it affects toes of feet (arthritis research UK, 2016). DXA scan is done in
conditions of fracture, diabetes, hypothyroidism and inflammatory conditions of the joint
(Arthritis Research UK, 2016). For the diagnosis of gout, doctor directed for bone density scan
which can be used for diagnosis of gout (Christensen, Sheta, Morillon, & Hansen, 2016). He
also had increased creatinine levels. Causes of increased creatinine include increased intake of
cooked meat, proteins or supplement having creatinine as their ingredient (Samra, 2012).
2.3 Recommendations
After dealing with the emergency situation doctors recommended some strategies for Mr X to
follow them so his condition can be stabilised further. Mr X was advised to regularly monitor his
Blood pressure at his home. This monitoring of Blood Pressure is under Ambulatory Blood
Pressure Monitoring (ABPM). It eliminates the visual errors, is more standardised, increases
accuracy and prevent office-induced hypertension and give an accurate diagnosis of hypertension
as the patient may have nocturnal hypertension or daytime hypertension. This protocol comprises
of taken blood pressure reading 2 times a daily for 7 days continuously and taking the mean of
duplicate reading. The strategy of monitoring for a diabetic is beneficial as diabetic patient show
more hypertensive nocturnal BP or no dipping BP. For an elderly patient, they show fluctuation
in their BP status having hypertension interspersed with hypotension, ABPM gives a better
insight of this variability and helps planning for medication BP recorded in the patients home is
a significantly better predictor of future cardiovascular risk than is office BP (OBrien et al.,

He was also encouraged for mobility as he was fully dependent on 2 to 3 persons for his daily
activities. These mobility strategies can assist him re-gaining his functional capabilities and with
weight reduction can add more benefit to his mobility status. As well as reduced hospital stay
also allow regaining functional status (Wolinsky et al., 2011). This can also improve the quality
of life of Mr X and will allow him to regain his confidence (Hudakova & Hornakova, 2011). He
also abstained from high purine diet because he was having high creatinine level due to increased
intake of cooked meat, proteins or supplement having creatinine as their ingredient (Samra,
2012). The strategy of drinking a plenty of water is too clear urate levels from the body and
prevent the conversion of urate into crystals and inhibit its deposition in the joint and kidney. He
must be encouraged to reduce weight under the guidance of a physiotherapist as it can also help
him get rid of urate levels (arthritis research UK, 2016). Mrs X was advised to buy an electric
bed for Mr X as they allow its occupant more independence and prevent their dependence on
others as well as decreases chances of bed sores.
2.4 Conclusions
According to the case study, Mr X was already suffering from a number of diseases namely
Diabetes, Obesity, Epilepsy, high cholesterol, arthritis due to gout, previous history of falls and
cellulitis with great dependency on people around him for assistance in daily workouts. He was
admitted because of fall which fractured his right hand, cellulitis and sleeplessness for 5 days. In
light of all above discussion, it was concluded that multiple drugs and metabolic disorder point
out to his condition. The cause of his gout effect was ruled out to be Valproic acid. Diabetes
showed a link with Valproic acid, Rosuvastatin and obesity. The cause of his cellulitis pointed
towards his old age, diabetes and obesity. He was overweight as well which are related to
Valproic acid and Rosuvastatin consumption. He was having faecal and urinary incontinence
which occurred due to neuropathy caused by diabetes and old age neuronal dysfunction. Upon
investigation, the doctor noticed increased creatinine levels and arthritic changes in multiple
joints. The intervention included Ambulatory Blood Pressure Monitoring, increased water intake,
low purine diet, physiotherapy, and follow-ups with a general physician and physiotherapist. To
prevent further hazard his wife was advised to buy an electric bed and move to single story

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