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Question 1: In 400 words or less respond to the following statement
MrSeptica Sirs, 36 years of age, was admitted 3 days ago following a MVA with a haemo-pnuemothorax (treated with UWSD and now resolved), hypovolaemia (which has now resolved with appropriate IV fluids), IDC (removed yesterday), deep lacerations to knee (wound has been debrided in theatre and now dressed daily), head injuries treated with burr holes on Day 2. His temperature today at 1400hrs is 39.4°C.
Question 2: In 400 words or less respond to the following statement and provide supporting rationale.
Several weeks after the insertion of his tracheostomy tube, Mr Tic Tracky was diagnosed with pneumonia. He has a double cannula tube which comes with an outer and inner tube (which can be removed independently of the outer tube). You enter his room at 0800hrs and find him coughing weakly, he signals to you that he is having difficulty breathing (RR 34) and appears cyanosed. You would:
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Patients who are suffering with type II diabetes are studied to be at an elevated risk of acute renal failure, even if the risk factors are taken care of. This acute renal failure is more prominent in elderly patients and in those who are simultaneously suffering from other problems such as chronic disorders of kidney, congestive heart failure or high blood pressure.
In the event of acute renal failure, the basement membrane of the kidneys is damaged. The stiffening of the basement membrane causes changes in the pathology of cells of the mesangial and vascular region. The production of AGEs occurs; polyols collect through the aldose reductase reaction chain and the protein kinase C is stimulated. Other inflammatory pathways may also undergo activation due to the movement of the macromolecules causing secondary damage to the renal system. When the renal failure ensues in type II diabetes, glomerular hyperfiltration occurs causing intraglomerular hypertension. Next, in the course of renal damage microalbuminuria develops which eventually progresses to the condition of macroalbuminuria. Later, clinical deteriorations of the renal system may also cause albuminuria, edema, and nephrotic syndrome.(Evans & Capell, 2000)
Presence of microalbuminuria (30-300 mg albumin per day) can strongly confirm the presence of a cardiovascular disorder in patients with type II diabetes. The presence of protein in standard urinalysis tests depicts an already existing condition of macroalbuminuria.
Patients suffering from severe kidney disease show symptoms such as persistent fatigue, general ill feeling, the presence of headache, nausea, vomiting, poor eating, deep breathing pattern and swelling of the legs due to the presence of edema. The development of renal damage or subsequent renal failure is attributed to the presence of hypertension and poor control of blood sugar. In this case, consumption of unhealthy and fatty food, absence of a regular exercise and presence of urinary tract infection has played a significant role infurther damaging the kidneys. (American Diabetes Care, 2012)
Generally the renal damage in patients with type 2 diabetes progresses without any visible signs and symptoms of the condition. This patient has shown symptoms of urinary tract infection. In the last 4/7 days, she has complained of a decrease in urine output, drowsiness, fatigue and nausea all of which are indicative of acute renal failure.
Diabetic nephropathy occurs through a series of complex steps. Alterations in the hyperperfusion and hyperfiltration in the kidneys occur initially in the course of renal damage. This further helps in the progress to the release or outflow of albumin proteins from the capillaries in the glomerulus and bring about structural damage to the glomerulus such as thickening of the basement tissue, hypertrophy of the glomerulus, glomerulosclerosis, expansion of the mesangial cell and damage or destruction of the podocytes. These pathophysiologic mechanisms of the renal damage are responsible for signs and symptoms of acute renal damage. These clinical manifestations of the acute renal damage are a reduction in the rate of filtration of glomerulus and increase in the quantity if albumin being excreted. The most significant predisposing factors for acute renal damage have been reported to be poor control of glucose levels, increased blood pressure and cholesterol; all of which function in stimulating inflammatory mediators.