NR 507 Week 3: Cardiovascular, Cellular, and Hematologic Disorders -
Discussion Part One
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Discussion
This week's graded topics relate to the following Course Outcomes (COs).
1 Analyze pathophysiologic mechanisms associated with selected
disease states. (PO 1)
2
Differentiate the epidemiology, etiology, developmental
considerations, pathogenesis, and clinical and laboratory
manifestations of specific disease processes. (PO 1)
3
Examine the way in which homeostatic, adaptive, and
compensatory physiological mechanisms can be supported
and/or altered through specific therapeutic interventions.
(PO 1, 7)
4 Distinguish risk factors associated with selected disease states. (PO 1)
5 Describe outcomes of disruptive or alterations in specific
physiologic processes. (PO 1)
6 Distinguish risk factors associated with selected disease states. (PO 1)
7 Explore age-specific and developmental alterations in
physiologic and disease states. (PO 1, 4)
Discussion Part One (graded)
A 17-year-old African American from the inner city complains of severe chest and
abdominal pain. Upon examination the attending physician performs and EKG, chest x-
ray, and an abdominal and chest clinical examination and finds nothing. Assuming, she is
drug seeking he sends her home. She comes back to the ER 4 hours later and now you
see the patient. She explains that she was running track this
,past afternoon at school and that despite being very hot (100 F) she pushed on.
Afterwards, she starts feeling extensive pain in her chest and abdomen. She has
jaundiced eyes, her blood pressure is 98/50, pulse is 112, T = 99.9 0F, R = 28. The pain
seems out of proportion to the physical findings.
What is your list of differential diagnoses in this case and explain how each of these fits with
the case patient as described above. Be sure to list at least four (4) pertinent differential
diagnoses. Indicate which of these you would select as the most likely diagnosis and explain
why.
Now, as she is in the ER she begins to exhibit stroke like features. ? Does this change your
differential?
How do you treat this patient now? Are they any preventative actions that could have been
taken?
Responses
Rechel DelAntar
5/15/2016 7:54:30 PM
Differential Diagnoses
Hello Professor and Class,
Differential Diagnoses
A case of a 17 year old African American from the inner city complaining of sever chest and
abdominal pain seen in the ER but was released after clinical examinations and tests reveal no
abnormalities with the assumption that the patient is drug seeking. She comes back 4 hours after
running track in school with symptoms of extensive chest and abdominal pain and jaundice and
expressed low-grade fever of 100F earlier. BP 98/50, tachycardic at 112 RR=28. Once n the ER,
patients symptoms have progressed to exhibiting stroke like features. Based on the patient’s
presentation and symptoms, patient may have:
1. Sickle Cell Disease – The term sickle cell disease (SCD) describes a group of inherited red blood cell
disorders. People with SCD have abnormal hemoglobin, called hemoglobin S or sickle hemoglobin, in their
red blood cells. In SCD, a person inherits 2 abnormal genes, one from each parent. In all forms, one of
the genes causes the production of hemoglobin S. In the case of Sickle cell anemia, a patient has 2
hemoglobin S, hemoglobin SS. Among all the types of SCD, sickle cell anemia is the most common
type (National Heart, Lung and Blood Institute, 2015). Normally, red blood cells are flexible and round,
moving easily through the blood vessels. In sickle cell disease, red blood cells become rigid and sticky
and shaped like sickles/crescent moons. These irregularities causes the cells to get stuck in small blood
vessels, which can slow or block blood flow and decrease oxygen supply to parts of the body. Pain is
the major symptom when the patient is in “crisis”. Pain develops when sickle-shaped red blood cells
block blood flow through tiny blood vessels to your chest, abdomen and joints. Pain is sporadic and
can last for hours or weeks. Continued poor oxygen supply to organs may eventually lead to organ
damage. Stroke is a common manifestation of the disease because of blood flow obstruction (Mayo
Clinic, 2014). This diagnosis fits the patient’s presentation and her experiencing signs of stroke is one
of the symptoms of the disease.
2. Hemochromatosis - causes your body to absorb too much iron from the food you eat. Excess iron is
stored in your organs, especially your liver, heart and pancreas. Too much iron can lead to life-
threatening conditions, such as liver disease, heart problems and diabetes. Symptoms include
abdominal pain, weakness, fatigue, heart failure such as chest pain and liver failure (National Institute
of Diabetes and Digestive and Kidney Disease, 2014). Although some of these symptoms are similar to
the one in the case study, hemochromatosis occurs mostly among Caucasians and the pain in this
disease is more chronic and not severe which does not fit the profile of the patient.
3. G6PD – Glucose-6-dehydrogenase Deficiency is a hereditary type of hemolytic anemia in which red
blood cells break down when the body is exposed to certain drugs or the stress of infection. It is
common between Mediterranean and African origin and is characterized by abnormally low levels of
glucose-6-phosphate dehydrogenase, an enzyme involved in the pentose phosphate that is especially
important in the red blood cell. G6PD deficiency is the most common human enzyme defect. There is no
, specific treatment, other than avoiding known triggers. Symptoms include jaundice, fever, fatigue,
tachycardia and abdominal pain from splenomegaly and hyperbilirubinimia (US National Library of
Medicine, 2016). Although some of the symptoms fit the case study, patients with G6PD do not
experience chest pain. Also the pain experienced in patients with this disease are not as severe as the
one described n the case study. This disease also does not lead to stroke like symptoms.
4. Heart Failure - often referred to as congestive heart failure (CHF), occurs when the heart is unable to
pump sufficiently to maintain blood flow to meet the body's needs. There are different types of heart
failure, there is right sides or left sided heart failure referring to the side of the heart being affected.
There is also systolic or diastolic heart failure. When the condition is severe, blood backs up to the
lungs causing elevated pulmonary pressure and congestion leading to right sided heart failure (cor
pulmonale). Backward failure of the right ventricle leads to congestion of systemic capillaries. This
generates excess fluid accumulation in the body causing congestion in other organs. Symptoms include
chest pain, shortness of breath, tachycardia, jaundice and coagulopathy (from impaired liver function
from congestive hepatopathy), abdominal distention and pain (McDonagh, T., 2011). Although some of
the symptoms are the same as the case study, these symptoms do not occur suddenly. Heart Failure
occurs over time and would not have allowed the patient to be able to run track because at this stage of
symptomatology, the patient would have been very debilitated that ambulating short distances would
render them dyspnic.
5. Leukemia - is a clonal malignant disorder of leukocytes in the blood and blood-forming organs. The
common feature of all forms of leukemia is an uncontrolled proliferation of malignant leukocytes,
causing an overcrowding of bone marrow and decreased production and function of normal
hematopoietic cells. There are different types of leukemia, Acute myeloid leukemia (AML) and acute
lymphocytic leukemia (ALL) progress much faster and symptoms may worsen more quickly than with
the chronic leukemias (CML and CLL) (Mc,Cance, K.L., et. al., 2013). Symptoms include fever, fatigue,
weakness, abdominal pain, easy bruising and petechiae. Although some symptoms match that of the
patient in the case study, leukemia does not show symptoms of chest pain or jaundice as well as stroke
and does not for the case study.
References:
Mayo Clinic. (2014). Diseases and Conditions: Sickle Cell Anemia. Retrieved from
http://www.mayoclinic.org/diseases-conditions/sickle-cell-anemia/basics/symptoms/con-
20019348.
McCance, K.L., Huether, S.E., Brashers, V.L. and Rote, N.S. (2013). Pathophysiology:
The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby.
McDonagh, T. (2011). Oxford textbook of heart failure. Oxford: Oxford, University Press.
National Institute of Diabetes and Digestive and Kidney Disease. (2014).
Hemochromatosis. Retrieved from http://www.niddk.nih.gov/health-
information/health-topics/liver-disease/hemochromatosis/Pages/facts.aspx.
National Heart, Lung and Blood Institute. (2015). What is sickle cell disease?
Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/sca.
US National Library of medicine. (2016). Glucose-6-phosphate dehydrogenase
Deficiency. Retrieved from https://ghr.nlm.nih.gov/condition/
glucose-6-phosphate-dehydrogenase-deficiency.
Rechel DelAntar reply to Rechel DelAntar 5/16/2016 10:59:33 PM
RE: Differential Diagnoses
The signs and symptoms of sickle cell disease are caused by the sickling of red blood
cells. Painful episodes can occur when sickled red blood cells, which are stiff and inflexible, get
stuck in small blood vessels. These episodes deprive tissues and organs of oxygen-rich blood and
can lead to organ damage, especially in the lungs, kidneys, spleen, and brain. A particularly
serious complication of sickle cell disease is high blood pressure in the blood vessels that supply
the lungs (pulmonary hypertension). Pulmonary hypertension occurs in about one-third of adults
with sickle cell disease and can lead to heart failure. The rapid breakdown of red blood cells may
also cause yellowing of the eyes and skin, which are signs of jaundice. Since sickle cell is
, inherited, genetic counseling is an important part of managing this disease (National Heart, Lung
and Blood Institute, 2015). Health maintenance for patients with sickle cell disease starts with
early diagnosis, preferably in the newborn period and includes penicillin prophylaxis, vaccination
against pneumococcus bacteria and folic acid supplementation. Treatment of complications often
includes antibiotics, pain management, intravenous fluids, blood transfusion and surgery all backed
by psychosocial support. Blood Transfusions are often necessary in cases of severe anemia.
Currently, Stem cell transplantation is the only cure for SCD patients (Sickle Cell Disease
Association of America, 2016).
References:
National Heart, Kung and Blood Institute. (2015). How is Sickle Cell Disease treated.
Retrieved from https://www.nhlbi.nih.gov/health/health-topics/topics/sca/treatment.
Sickle Cell Disease Association of America. (2016). About Sickle Cell Disease.
Retrieved from http://www.sicklecelldisease.org/index.cfm?page=about-scd.
Instructor Brown reply to Rechel DelAntar
5/17/2016 7:02:48 PM
RE: Differential Diagnoses
What part of the Heart failure causes the chest pain?
Rechel DelAntar reply to Instructor Brown
5/19/2016 4:04:11 PM
RE: Differential Diagnoses
Hello Professor and Class,
Heart failure (HF), often referred to as congestive heart failure (CHF), occurs when the
heart is unable to pump sufficiently to maintain blood flow to meet the body's needs. Heart
failure is caused by many conditions that damage the heart muscles which include Coronary
Artery Disease, heart attack (MI), Cardiomyopathy and hypertension. In these cases, there is a
decrease in blood supply to the myocardium either due to blockage from thrombus or damage
to the heart muscles from infections, alcohol abuse or drug abuse and increased work load of
the heart due to elevated pressures such as in hypertension. Decrease blood flow to the heart
causes decreased oxygenation to the myocardium causing symptoms of chest pain (national
Heart, Lung and Blood Institute, 2015).
Reference:
National Heart, Lung and Blood Institute. (2015). What is Heart Failure? Retrieved from
https://www.nhlbi.nih.gov/health/health-topics/topics/hf.
Alice Jeffries
5/16/2016 3:36:45 AM
Discussion Part One
Dr. Brown and class,
The four differential diagnosis are below. While working in Arizona on a cardiac
floor, we had a patient who was regularly admitted with sickle cell disease. She
was a young lady as described in the case study. She was often treated like a
drug seeker, which was so sad because she would not get treatment until she
was in crisis. I believe the case study diagnosis is sickle cell disease. Because
the risk of stroke in children with SCD is higher than children without SCD due
to the change in shape, stiffening and distorted red blood cells, and the changes
in the vascular system that causes narrowing of arteries (Adams, 2014), the
signs of stroke would not change my initial diagnosis. The increased velocity of
blood going through areas of stenosis increases the risk of stroke by 39% for
each 10 cm/sec above the median velocity (Adams, 2014). Blood transfusion
can be used to halt an impending stroke in adolescents with SCD (Adams,
