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Part 4: Integrated Summary Top 4 Final Hypothesis (3 likely and a Zebra) …

- - - - ● Signs & Symptoms: chest pain, fatigue, tachycardia, arrythmia, signs of infection: fever, diarrhea, body aches, shortness of breath, headache, swelling in legs (Gilotra, n.d.)
        
        ● Assessment & Exam Findings: fever, sweats, body aches, headache, sore throat, swollen/tender lymph nodes, chest discomfort, dyspnea, productive cough, nausea, diarrhea, tachycardia, lower extremity edema, diminished breath sounds, crackles, tachypnea, decreased O2 saturation
  - - - ▪ How does the pathology of the condition crossover to other body systems or impact the body as a whole (example: inflammatory meditators)
        
        Inflammatory Mediators: Myocarditis initiates the production of proinflammatory mediators, including cytokines and chemokines. These molecules not only act locally within the heart but also enter the systemic circulation. This can lead to a cascade of events throughout the body (Cooper L., 2022).
        
        Cardiovascular System: The heart muscle inflammation can weaken the myocardium, reducing its contractility. This leads to impaired cardiac output and potentially results in heart failure. Consequently, peripheral tissues and organs receive less oxygen and nutrients, affecting their function (Cooper L., 2022).
        
        Respiratory System: Severe myocarditis can lead to pulmonary congestion and edema, affecting gas exchange in the lungs and causing respiratory distress (Cooper L., 2022).
        
        Renal System: The systemic inflammation and reduced cardiac output may decrease blood flow to the kidneys, potentially leading to reduced glomerular filtration rate and fluid retention (Cooper L., 2022).
        
        Hepatic System: Liver congestion and dysfunction can occur due to the backward transmission of elevated venous pressure, causing hepatomegaly and altered liver function (Cooper L., 2022).
        
        Nervous System: Reduced cardiac output may result in reduced cerebral perfusion, leading to symptoms like dizziness, syncope, and even cognitive impairment (Cooper L., 2022).
        
        Immunological Impact: Myocarditis can stimulate the immune system, sometimes causing autoimmune reactions in other body tissues and contributing to systemic inflammation (Cooper L., 2022).
        
        Musculoskeletal System: Patients often experience fatigue and muscle weakness, which can impact their daily activities (Cooper L., 2022).
        
        Gastrointestinal System: Reduced cardiac output can affect blood supply to the gastrointestinal tract, leading to abdominal discomfort, nausea, and vomiting (Cooper L., 2022).
        
        Endocrine System: Stress from myocarditis and the inflammatory response can disrupt hormonal regulation, potentially causing endocrine imbalances (Cooper L., 2022).
- - - - ▪ How does the pathology of the condition crossover to other body systems or impact the body as a whole (example: inflammatory meditators)
        The local activation of the inflammatory system in the alveoli leads to systemic inflammation and possible complications such as bacteremia, sepsis, cardiovascular complications secondary to hypoxia, deep vein thrombosis (DynaMed, 2023). Systemic response leads to tissue injury and multiorgan dysfunction with some patients (Ramirez, 2023).
  - - - ● Signs & Symptoms:
        Patients with community acquired pneumonia typically present with fever, cough, productive cough, shortness of air, difficulty breathing, chest pain, presence of leukocytes, imaging revealing lung infiltrate, with elderly patients showing non-typical symptoms such as confusion, malaise, diarrhea, and myalgia (DynaMed, 2023).
        
        ● Assessment & Exam Findings
        Patient presents with positive symptoms of dyspnea, diminished breath sounds upon auscultation, shallow breathing, thick yellow green sputum, pale, diaphoretic, drowsy, confused, tachycardic, crackling sounds on one side, diminished breath sounds, elevated white blood cells count, clammy skin, fatigue, low oxygen saturation.
        Negative symptoms include no retractions, no tracheal deviation. Skin ecchymosis usually caused by microvascular injury related to trauma. Negative for accessory muscle use.
  - - - Lifestyle changes:
        Encourage smoking cessation
      - Medications:
        Antibiotics
      - Procedures:
        Bronchoschopy
      - Treatment :
        Antibiotic treatment recommended with amoxicillin being the first line if patient has not contraindication for at least 5 days.
      - Education
        Annual influenza vaccination
        Pneumoccocal vaccination
- - - - ▪ How does the pathology of the condition crossover to other body systems or affect the body as a whole: The ongoing inflammation and destruction of the bronchioles can lead to injury to blood vessels, hemoptysis, and hemodynamic instability during exacerbations (Amati F et al. 2019). Due to the cough, many patients endorse urinary incontinence (Barker, A. 2023,a). Patients with bronchiectasis are more frequently deficient in vitamin D than patients without this diagnosis, and decreased bone mineral density, with osteopenia or osteoporosis, is more commonly found in patients with bronchiectasis, notably, in those younger than the age of 45 (Amati F et al. 2019; Barker, A. 2023,a).
  - - - Medications
        
        Decongestants and antibiotics such as macrolides that kill bacteria and reduce bronchial inflammation (ALA, 2022)A trial of inhaled antibiotics such as tobramycin or gentamicin for patients colonized with P. aeruginosa who have 3 or more exacerbations in 1 year, or severe exacerbations, can lessen the bacterial load in and arrest the ongoing deterioration of the bronchioles (Barker,A.2023,c).
        
        Inhaled medications through nebulizer to thin mucus secretions, relax muscle, and widen airway: bronchodilators, steroids, saline (ALA, 2022)
      - Lifestyle Changes: stop smoking cigars and avoid second hand smoke, decrease sodium intake, stay hydrated (ALA, 2023). Regular exercise; avoidance of all lung irritants such as dust, fumes, household cleaners and indoor fires (Barker,A.2023,b).These strategies will help thin secretions and help to prevent further damage to the bronchioles.
      - Procedures: Surgery such as resection when the disease process is localized to 1 or 2 lobes. Lung transplantation in extreme cases with excessive bleeding or bronchiectasis spread in both lungs (ALA, 2022; Barker,A.2023,c).
      - Treatment: 1. Airway clearance/Bronchial hygiene by numerous means:directed cough, forced expiration, chest physiotherapy, flutter-valve devices, chest wall oscillation vest. These measures help to control breathing, increase delivery of oxygen into the alveoli, and loosen/break up mucus to clear it from the bronchioles (ALA, 2022; Barker,A.2023,b).
      - Education: Flare-ups may occur and require 1-2 weeks antibiotics; take prescribed medications and perform mucus clearance daily (ALA, 2022). Yearly vaccines against influenza, Covid and RSV help protect against common respiratory illness which can deteriorate bronchiectasis. Frequent hand washing and avoidance of persons who are ill will also help to avoid exacerbations of bronchiectasis (Barker,A.2023,c).
  - - - ● Signs & Symptoms: Cough, sputum, dyspnea, rhinosinusitis, pleurisy, crackles, decreased sense of smell, dullness on percussion (Barker, A. 2023,a; Amati F et al. 2019)
        
        ● Assessment & Exam Findings: Patient has fever, anorexia, malaise, cough, dyspnea, sputum, nasal stuffiness (Barker, A. 2023,a; Amati F et al. 2019).
      - Bush, A., & Floto, RA. (2019). Pathophysiology, causes and genetics of paediatric and adult bronchiectasis. Respirology. 24: 1053–1062. https://doi.org/10.1111/resp.13509
        Amati F., Simonetta E., Gramegna A., Tarsia P., Contarini M., Blasi F., & Aliberti S. (2019). The biology of pulmonary exacerbations in bronchiectasis. Eur Respir Rev. 28(154):190055. doi: 10.1183/16000617.0055-2019. PMID: 31748420; PMCID: PMC9488527.
        Barker, A. (2023). Clinical manifestations and diagnosis of bronchiectasis in adults. UpToDate. Retrieved October 20th 2023 from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-bronchiectasis-in-adults?search=bronchiectasis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H5990869 a
        
        References
- - - - How does the pathology of the condition crossover to other body systems or impact the body as a whole: Blood in the pleural space causes alveolar hypoventilation, V/Q mismatch and autonomic shunting which affects the functional capacity of the lung. A large hemothorax can exert pressure in the vena cava and pulmonary parenchyma causing impaired preload and increased pulmonary vascular resistance (Gomez & Tran, 2023).
      - Positives: Patient presents with dyspnea, tachycardia, fever, hypoxia, ecchymosis to thoracic area and presents with symptoms of pneumonia which is the most common complication of undiagnosed Hemothorax.
      - Negatives: Patient does not have tracheal deviation, breath sounds are diminished bilaterally, symmetrical chest rise
  - - - Education: Boating safety and recognizing signs & symptoms of blunt force trauma in case of future accidents.
      - Medications: Antimicrobials targeting common oropharynx pathogens such as aerobic Staphylococcus and Streptococcus. -3rd generation cephalosporins, metronidazole, beta-lactam/beta-lactamase inhibitor combination (Iguina & Danckers, 2023)
      - Procedures:
        
        Video-assisted thoracoscopic surgery: for advanced empyema; allows for direct visualization and evacuation of infected pleural space (Iguina & Danckers, 2023)
        
        Open thoracostomy and decortication: debridement of scarring and fibrous tissue from persistent empyema (Iguina & Danckers, 2023)
        
        Tube thoracostomy for drainage of purulent empyema fluid; in place until drainage less than 50 mL in 24 hours or lung re-expansion seen on chest XR (Iguina & Danckers, 2023)
        
        Intrapleural medications: combination of fibrinolytic and mucolytic agents to improve fluid drainage (Iguina & Danckers, 2023)

                                                                          American Lung Association. (2022). *Treating and managing bronchiectasis.* American Lung Association. https://www.lung.org/lung-health-diseases/lung-disease-lookup/bronchiectasis/treating-and-managing                                                        Barker,A. (2023). Bronchiectasis in adults: Maintaining lung health. *UpToDate*retrieved October 2, 2023 from https://www.uptodate.com/contents/bronchiectasis-in-adults-maintaining-lung-health?search=bronchiectasis%20treatment&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#*. **b**                                                                                       Barker,A. (2023).Bronchiectasis in adults: Treatment of acute and recurrent exacerbations.*UpToDate*retrieved October 2, 2023 fromhttps://www.uptodate.com/contents/bronchiectasis-in-adults-treatment-of-acute-and-recurrent-exacerbations?search=bronchiectasis%20oxygen&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5#H3464359806 **c**