Introduction
This study presents a case of a 45-year-old female, measuring 167.5 cm and weighs 102 kg, with a long history of smoking and poor diet for about 22 years. She suffered from Type II diabetes mellitus associated with primary hypertension. She is receiving some current medications that include Lotensin and Lasix for treating the hypertension, and concurrent Glucophage for treating the Type II diabetes mellitus. Lately, she has been diagnosed of having chronic bronchitis.
The patient experienced some symptoms of chronic bronchitis, which included chronic persistent cough, which is more severe in the mornings. Cough is associated with sputum and light-headedness. For managing this condition, the most important milestone recommended for such patient is to stop smoking. Other recommendations include avoidance of any respiratory irritants and performing regular exercise known as pulmonary rehabilitation to strengthen the muscles of respiration. The patient may be prescribed certain medications such as a central cough suppressant and a bronchodilator for short-term symptomatic relief of cough. However, antibiotics usually have no role in treating chronic bronchitis, unless there is a concurrent lung infection identified by the color of sputum or associating fever (Grouzard, Rigal, & Sutton, 2016).
The patient is suspected to have congestive heart failure. She suffered from some manifestations such as congested neck veins, too much peripheral edema, and increased urination especially at night. Some risk factors that may contribute to the development of congestive heart failure include cigarette smoking, COPD, high blood pressure and Type II diabetes mellitus. These factors may lead to development of atherosclerosis of the coronary arteries. So, hypoxic injury leads to necrosis of myocardial fibers and affection of the contractile properties of the heart by causing ischemic heart disease. Cardiac output depends on two variables: heart rate and stroke volume. Stroke volume depends on three factors: the preload, contractility, and the afterload. Affection of the preload by impaired ventricular filling due to COPD, affection of contractility by the ischemic injury of myocardial fibers, and affection of the afterload by systemic hypertension; all these factors can lead eventually to the development of congestive heart failure, with failure of compensatory mechanisms (Figueroa & Peters, 2006). The subsequent systemic venous congestion, which resulted from right sided heart failure, leads to elevation of the systemic venous pressure and capillary pressure. This elevation results in congested neck veins, too much peripheral edema, and increased urination especially at night; the symptoms experienced by the patient (Abastar, 2015).
The patient blood pressure measures 158/98 mm Hg, so she is experiencing stage 1 of hypertension. Treatment of this stage of hypertension requires both lifestyle modifications and administration of anti-hypertensive drugs. Lifestyle modifications include eating a low-fat, low-sodium diet, losing weight, regular exercise and not smoking. The patient is receiving Lotensin and Lasix. Lotensin is classified as one of the category of the angiotensin-converting enzyme (ACE) inhibitors. It is classified as the drug of choice for treating hypertensive patients who have associated diabetes mellitus; many studies revealed that ACE inhibitors can modulate the pathogenesis of diabetes because they have a favorable effect on both macrovascular and microvascular complications caused by diabetes mellitus. Lasix belongs to another category of anti-hypertensive drugs, as it is a loop diuretic, which may be used as a first line of therapy for most hypertensive patients. Usually, hypertension is controlled by a combination of two or three drugs from different categories of anti-hypertensive drugs (Beckerman, 2015).
In the United States, hypertension is considered a very important health problem. It is classified as a major contributor to heart disease and a leading cause of death. According to the National Center for Health Statistics, 1 in every 3 American adults suffers from high blood pressure and the percent of adults aged 20 years and over with hypertension is 33.5% (2013-2014). In 2016, the number of deaths from essential hypertension and hypertensive renal disease was 30,221deaths, with crude death rate of 9.5 per every 100,000 population. In 2011, the economic burden caused by hypertension was great, as the total costs associated with treating hypertension in the US were $46 billion in health care services, medications, and missed days of work (Statistics, 2017).
The lipid panel of the patient shows high cholesterol measuring 242 mg/dL, high LDL measuring 173 mg/dL, low HDL measuring 32 mg/dL and very high triglycerides, which were 1000 mg/dL. This condition is known as hypertriglyceridemia, and it puts the patient at a risk of developing atherosclerosis, atherothrombosis and thromboembolism, with subsequent increased risk of having severe complications such as heart attack or stroke. Therefore, hypertriglyceridemia is considered a prothrombotic state. The prothrombotic state has the following criteria: raised concentrations of fibrinogen, attenuation of fibrinolysis and activation of the platelets. Besides, the patient in this case is considered at high risk for cardiovascular complications because of the accompanying diabetes mellitus. So, she should be maintained on Antiplatelet therapy and monitored for increased risk of bleeding (Dabrowski, 2015).
Hypertension and diabetes mellitus are two diseases that are strongly correlated for each other, as each one affects the other and increases its complications. In this case, many clinical findings correlate the two diseases. Morbid obesity, as BMI is about 60, is considered a risk factor for both diseases, and also has a deteriorating effect on their courses. Hypercapnia (increased PaCO₂) can result from COPD and obesity hypoventilation syndrome, and hypoxemia (decreased PaO₂) can result from obstructive sleep apnea syndrome that is common with diabetes ( Zammit, Liddicoat, Moonsie, & Makker, 2010). These disturbances of intermittent hypoxemia promote oxidative stress, tissue injuries, vascular inflammation and endothelial dysfunction causing cardiovascular morbidity and mortality ( Dewan, Nieto, & Somers, 2015).
In this case, the value of glycosylated hemoglobin (HbA1c) is 7.3 %. Glycosylated hemoglobin is beneficial in that it can give an idea about the average level of blood glucose for the past 2 to 3 months, so provides an idea about long term control of blood glucose level. In normal individuals without diabetes, the normal range for the glycosylated hemoglobin level is between 4% and 5.6%. In diabetics, the target level is usually less than 7%. So, the value in this case indicates uncontrolled diabetes over the past 2 to 3 months. Uncontrolled blood glucose level for a long period increases the risk for developing microvascular complications of diabetes such as affection of retinal blood vessels (diabetic retinopathy), affection of blood vessels supplying nerves (diabetic neuropathy), affection of renal glomeruli (diabetic nephropathy) and affection of vasa vasorum; small blood vessel of the adventitia of larger blood vessels (MedicineNet, 2002).
Conclusion
This case study presents the co-relation between some important, common diseases in affecting each other. Also, it pays the attention for the importance of healthy lifestyles in preserving health and avoiding complications of existing diseases.
Cigarette smoking is considered an important risk factor for COPD, hypertension and Type II diabetes mellitus. Besides, it has a negative effect on diet and other systems of the body such as gastro-intestinal tract and urinary system.
Obesity is considered an important risk factor for respiratory disturbances, hypertension and Type II diabetes mellitus. Also, it leads to worsening of all the previous diseases and affect many other systems of the body.
There is a strong relation between the pathophysiology of different diseases, so good control and treatment of one disease may have a positive impact on another one. This is evident with angiotensin-converting enzyme inhibitors; they are mainly used for treating high blood pressure, but at the same time they have a beneficial effect on the pathophysiology of the microvascular complications of diabetes. That is why they are considered treatment of choice when the two conditions are associated.
Chronic diseases represent major health problems, as they are major causes of morbidity and mortality, besides they have a large economic burden. Therefore, more attention should be given to prevention programmes in all levels of prevention. Living with chronic diseases requires good understanding of the disease and its complications. So, health education is very essential to make the patients understand the importance of healthy lifestyles and the need for compliance with instructions and medications.
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