Healthcare Assignment Analysing Four Medical Case Scenarios

Question

Task: The healthcare assignment is based on the following case studies:
Case Study One
Mary-Lou is a 75-year-old widow, who lost her husband to cancer over a year ago. Her family and friends have noticed that she has been very teary, has low self-esteem, and has lost interest in the things she used to love, such as going to bingo with her friends and gardening. Her family initially put this down to the loss of her husband and thought it would pass with time. However, they are now getting really concerned as they have noticed that Mary-Lou’s mood is not improving still. When asked by her daughter if she is sleeping well, she says she has been drinking wine every night to help her go to sleep because it makes her feel happy and relaxed. What started as one glass a night has now increased to two or three glasses a night, and she has also started drinking during the day. Her daughter has noticed that her mum’s face always appears flushed and that she has had quite a few colds lately. Mary-Lou is also losing her balance and experiencing mood swings. Her daughter is worried that she is relying too heavily on alcohol and fears that she is starting to get short-term memory loss from the alcohol consumption. She has been forgetting things such as where she put her keys, whether she turned on the washing machine, and why she opened the fridge. Further, Mary-Lou tends to forget the topic of conversation when talking with her daughter on the phone and has also been getting disorientated and lost when she goes out on her daily walks. The other day, for example, a neighbor rang her daughter to tell her that she found Mary-Lou wandering around aimlessly, and when questioned what she was doing, Mary-Lou snapped and said she was trying to get home. Her daughter decided it was time to take Mary-Lou to the local GP to work out what was going on with her.

After listening to the signs and symptoms Mary-Lou was experiencing, the GP diagnosed her with depression and prescribed a SSRI to be taken daily. Based on the results of clinical and radiological assessments, the GP determined that she also had early onset Alzheimer’s disease. He prescribed a cholinesterase inhibitor and gave the family information on support groups and tips on what to do from here on in. He also prescribed a tranquiliser to be taken daily.

Question 1
Based on the description above
• Select/name one of the diseases/conditions Mary-Lou is suffering from and describe two signs and/or symptoms from Mary-Lou’s history that support your selection.
• Explain the pathophysiology of the condition you named

Question 2
Explain the mechanism of action of one drug type Mary-Lou is prescribed with and describe how these drug actions help mitigate some of her symptoms. In you answer, make references to the pathophysiology of the relevant disease and relate the chosen drug’s mechanism of action to the aetiology/pathogenesis of the disease.

Question 3
The following questions relate to a drug called MedZ:
a. MedZ contains 200 mg of the active ingredient in an intestine-solvent capsule. The active ingredient is effectively transported across the intestinal mucosa, which ensures that 78% of the drug is absorbed and enters the portal circulation. The drug undergoes a significant degree of first-pass metabolism, in which process 55% of the drug passing through the liver gets metabolized and therefore degraded to an inactive product. Calculate MedZ’s bioavailability and show your calculations.

When administered alone, 82% of MedZ is bound to plasma albumin. However, because of the higher plasma protein binding affinity of another drug, called MedY, when MedZ and MedY are administered together, the bound fraction of MedZ decreases to 35%.

i. Identify the type of drug interaction between MedZ and MedY in the present scenario and give your rationale
ii. Assuming that MedZ and MedY are administered together in an elderly patient, explain if the dose of MedZ should be decreased, increased, or left unchanged and give your rationale.

Mary-Lou’s family was happy with the management plan established by the doctor as Mary-Lou was progressing quite well. She was using notepads to jot down reminders, a pillbox to keep her medication organized, and a calendar to record appointments. Her family members were helping her with routine tasks such as cooking and paying bills. She was feeling much happier and did not have to rely on alcohol to go to sleep. One day she was feeling so good she decided to walk to her GP appointment alone. On her way there she stumbled over a branch and fell. She felt excruciating pain in her hip. A passer-by called an ambulance, and she was taken to the emergency department at the Royal Melbourne Hospital. An X-ray revealed that she had hip fracture and had to have surgery to repair it. Mary-Lou wondered whether this was linked to the pain she had been experiencing in her left knee for a while now. The specialist explained to Mary-Lou that the pain in her left knee was likely due to degeneration of her cartilage and said that the fracture might have been due to weakened bones. He told her he would like her to have a bone mineral density test to measure her bone density. The DEXA scan gave a T-score of 3.0. Mary-Lou is now given bisphosphonates and told to increase her daily intake of calcium.

Question 4
Name the disease affecting Mary-Lou’s left knee and describe two characteristic clinical manifestations of this pathology. Explain the aetiology and pathophysiology of the disease.

Question 5
Considering Mary-Lou’s T-score, identify the disease she suffers from, briefly describe the pathogenesis of this disease, describe the mechanism of action of bisphosphonate administration, and explain the benefits of this treatment in her present condition.

Question 6
Discuss why Mary-Lou’s fracture may take longer to heal than it would for someone who was half her age. In your answer, you are expected to name and discuss three physiological factors that are needed for healing to take place and explain how each of the factors you identified is affected by ageing.

Case Study 2
Hilda Wilde is a 45-year-old woman, who was diagnosed with asthma as a child. She recalls her first asthma attack being horrendous; chest tightness, breathing difficulty, wheezing, feeling anxious, and sweating profusely. She was rushed to hospital and spent many days in hospital as a child until she managed to work out the triggers and control them early. The triggers for her asthma were cold temperature, pollen, smoky environment, and respiratory infection/cold, which continue to be the triggers throughout her adult life. She also developed hay fever and an allergy to penicillin in her 20’s, which didn’t surprise her as her mum also had these conditions. One cold spring day, Hilda is outside gardening as she is finding herself stressed by the current coronavirus and gardening usually relaxes her. Hilda is making good progress on weeding when she starts to experience those dreaded sensations she knows only too well; tightness in the chest, shortness of breath, and dizziness. She starts to wheeze and cannot stop coughing. Her husband notices Hilda is struggling and brings Hilda’s inhaler (Ventolin) for her. However, Hilda’s wheezing and shortness of breath does not ease off, even with her inhaler. She finds it hard to talk or get up and walk. Her lips start to turn blue. Hilda’s husband calls an ambulance, and Hilda is taken to hospital where she is given corticosteroids. She is told she has to stay in hospital a few days so that her condition can be monitored. However, Hilda is worried about staying in hospital due to the novel coronavirus outbreak. Her GP has previously told her that if she contracts the virus, she is at a greater risk of developing more serious symptoms, such as pneumonia or acute respiratory distress. The hospital staff have assured her that they take all the necessary precautions: all coronavirus-affected patients are isolated in private rooms, and all healthcare staff practice proper hand hygiene and appropriate use of PPE.

A few days later, Hilda’s asthma is under control, and she is now discharged from hospital. She is told to take her preventer medicine every day, even when she is feeling well. She is also told to follow routine practices and precautions to lessen her risk of contracting coronavirus.

Question 1
Choose one of Hilda’s triggers and explain how it contributes to the pathophysiology of her asthma.

Question 2
Hilda has been told to take her ‘preventer’ medication everyday.
a. Name the broad drug category preventer medications belong to, describe their mechanism of action, and explain their benefits in Hilda’s case.
b. Describe the method and one benefit of topical administration of preventer medications.

Question 3
Hilda has been advised to get the AstraZeneca vaccine to reduce the risk of contracting coronavirus. She is hesitant as she has heard that the Pfizer vaccine is ‘better’. She doesn’t understand the doctor’s explanation of the two vaccines. Using terms a patient can understand, describe one difference and one similarity between the mechanism of action of the Pfizer and AstraZeneca COVID vaccines.

Case Study 3
Bruce is a 47-year-old journalist, who decides he needs to visit his doctor due to some gastrointestinal symptoms. At first it just started out as a bit of abdominal pain and cramping, followed by diarrhea so at first Bruce just thought he had a stomach bug. But weeks went by and the diarrhea just increased in frequency, and instead of feeling better, he started to feel really fatigued. This had been going on for 8 months before his wife finally convinced him to make an appointment with a doctor, who then referred him to a gastroenterologist. A couple of months later when he finally goes to his specialist appointment, Bruce admits after questioning that he has had bleeding with his stool, but he didn’t want to tell the doctor as he was embarrassed and didn’t want to get checked for hemorrhoids. The gastroenterologist also asks many questions about Bruce’s diet and his weight and discovers that Bruce has lost 15 kg in the past year despite eating a lot of hot chips and mashed potatoes – the only thing Bruce feels doesn’t make his diarrhea worse. The gastroenterologist then tells Bruce he would like to perform a colonoscopy to investigate further. After the colonoscopy, the surgeon tells Bruce that they found a number of polyps in his bowel, which is not necessarily a cause for concern as many polyps are benign, but they will have to wait on the results of the biopsies to make sure none of them were malignant. A week later the surgeon calls Bruce; unfortunately, it is bad news – the biopsy shows evidence that the growth is malignant and anaplastic and that they can’t rule out metastatic growths. Bruce is called back in for follow-up tests, and they find that there is an abnormal growth in his liver also. Bruce is now sent to an oncologist, who recommends that he has surgery to remove any remaining polyps, a portion of his bowel, and the abnormal growth from his liver. Based on the advice from his oncologist, Bruce also decides to undergo chemotherapy treatment. Whilst doing some routine checks after his treatment, Bruce is informed he has neutropenia.

Question 1
Describe two similarities and two differences between hyperplasia and cancer.

Question 2
On follow-up examinations, Bruce is found to have a brain tumour. Biopsy results reveal that the cancer cells taken from his brain tumour have the morphological characteristics of colorectal cancer. Considering brain cells are permanent cells, explain the most likely reason for this finding.

Question 3
Explain why patients who have leukaemia may have excessively high numbers of white blood cells in their blood, yet they are immunocompromised.

Bruce’s friend Greg has been trying to support him throughout his journey. Greg is a 42-year old ITspecialist, who suffers from type II diabetes mellitus, which has been under control using an oral anti-hyperglycaemic medication and a reasonably healthy diet. Rather disturbingly, however, Greg has been experiencing numbness and some awkward tingling in his left foot recently.

Question 4
Assuming that Greg’s present symptoms are associated with his underlying disease, name the condition responsible for his numbness and tingling, and explain the link between type II diabetes and the condition you identified.

Question 5
Greg takes an oral anti-hyperglycaemic medication. Explain why insulin administration is not recommended in his condition.

Question 6
Explain how glucose uptake of Greg’s (i) endothelial and (ii) resting skeletal muscle cells changes when he is experiencing a hyperglycaemic episode and give your rationale.

CASE STUDY 4
Maria is a 67-year-old retired, obese woman, who lives with her husband Max. She enjoys sitting down to a movie every night with a bottle of Shiraz and a large packet of salt and vinegar chips or tub of cookies and cream ice cream. She has always loved a glass or two of wine with dinner, but now figures she can have a few more since she no longer has to get up for work. Maria doesn’t like to exercise, her only form of exercise is walking around Coles on Friday whilst doing her weekly shopping. Her sister has asked her to join her walking group on numerous occasions, but Maria would rather stay home and bake. Maria’s mother moved in with her many years ago, when her father passed away from a heart attack at the age of 60. Her mother isn’t in the best of health, she has type II diabetes and hypertension, which she controls with medication.

One day Maria decides to visit her neighbour, taking with her a batch of freshly baked cookies. Whilst walking to her neighbour’s house, she notices that she is short of breath and is feeling a slight pain in her chest, but when she sits down, she feels fine, so she dismisses it once again, putting it down to her poor fitness. However, on her way home she begins to feel light-headed and weak, and feels like she is going to be sick. She notices that she has been feeling like this quite a lot lately, even when resting in the evening, so she decides to make an appointment with her GP for later in the week.

At the medical clinic the GP looks at Maria’s medical history. She was diagnosed with hypertension four years ago and has tried many different medications to treat the hypertension. She was currently taking beta blockers. The GP worries about Marias latest symptoms so writes a referral for her to see a cardiovascular specialist for an ECG and a coronary angiogram to determine why Maria has been short of breath and unwell. One day, whilst waiting for her results, Maria starts to feel more nauseous and dizzier than usual. She starts to feel clammy and sweaty, and her face seems gray in colour. The chest pain returns, but now feels like a crushing pain, and she can’t breathe. Her husband, Max, dials 000, and she is rushed to hospital. An ECG shows that Maria has ST elevation, and a blood test indicates that she has high levels of myocardium-specific troponin in her blood. Maria is given heparin intravenously as well as an anti-platelet and fibrinolytic drug. She is taken into surgery, where a coronary angioplasty is performed.

Question 1
Before her current problems, Maria was prescribed a beta blocker for her hypertension. Explain the benefits of beta blocker administration in the treatment of hypertension with specific emphasis on how this treatment reduces blood pressure

Question 2
A couple of weeks before her current episode, Maria noticed that ‘she was short of breath and was feeling a slight pain in her chest, but when she sat down for a few minutes, she felt much better and the pain disappeared.’ Name the condition Maria was most likely experiencing and explain its pathogenesis.

Question 3
Considering her clinical symptoms and laboratory findings, name the disease Maria is suffering from when admitted to the hospital and explain the benefits of heparin administration in her present state.

Answer

Healthcare AssignmentCase study 1
Ans 1)
The disease from which Mary Lou is suffering from is Alzheimer’s. First sign is she is now forgetting things like where to keep her keys and whether she switched on the washing machine. The second evidence is one day she was wandering aimlessly and when she was asked what she was doing there. She snapped and told she was just trying to get home. These two evidences support the selection.

The beta amyloid deposition as well as the neurofibrillary tangles generally leads to the loss of the synapses as well as the neurons. This generally results in the gross atrophy of the impacted areas of the brain. This generally initiates at the mesial temporal lobe( Selkoe, 2019 ).

Ans 2)
Most of the uses of cholinesterase inhibitors are generally based on the mechanism which is common of the actions which are initiated by the inhibition of the acetyl cholinesterase. Also, extensive use of the enzyme can also lead to the accumulation of the neuro transmitter’s acetylcholine as well as will enhance the simulation of the postsynaptic cholinergic receptors. These can be considered as the medications which will prevent the breakdown of the acetylcholine in the body. The cholinesterase inhibitors will stop the action of the acetyl cholinesterase. The acetyl cholinesterase can be considered as the enzyme which will break down the acetylcholine to any of the inactive form. The people having the Alzheimer’s disease have some of the nerve cells which are very less active. This also means it will take very long for the brain signals to be sent. The goal of the cholinesterase inhibitors is to enhance the communication which is present between the nerve cells and also to improve the symptoms of the Alzheimer. The donepezil, the rivastigmine as well as the galantamine help in the prevention of an enzyme which is called as the acetylcholineseterase from getting broken into acetylcholine. These also mean there will be a high concentration of the acetylcholine. This will also lead to a better communication between the nerve cells. This can also help in the Alzheimer’s disease for some time.

Ans 3)
a) Active ingredient = 200 mg
78 % of 200 = (78/100)*200 = 156
Drug pass through liver = 55 % of 156 = (55/100)*156 = 85.8

b) 1) When the MedZ as well as the MedY are administered together, the bound fraction will be decrease.
2) The doses must be increased.

Ans 4)
The name of the disease is Osteoarthritis which is the progressive destruction of the articular cartilage can be considered as one of the hallmark of the osteoarthritis as well as the rheumatoid arthritis. It is attributed as the different class of catabolic factor which include the proinflamatory cytokines, the aggrecanases, the matrix metalloproteinases as well as nitric oxide. The primary osteoarthritis can be caused due to the breakdown of cartilage which is a rubber material which reduces friction in the joints.

The osteoarthritis pathogenesis will involve the degradation of the cartilage as well as the remodelling of the bone because of an active response of the chondrocytes in the articular cartilage as well as the inflammatory cells present in the tissues present. There are basically four stages of osteoarthritis. The first stage is the minor. Here, the minor wear and tear of the joints take place. There will be very little or no pain in the area which is affected. The stage 2 here will be the mild. There are more noticeable bone spurs. The affected area feels stiff after the sedentary period. The third stage is moderate. Here, the cartilage in the affected area starts to erode. The fourth stage is severe. Here, the cartilage is almost completely gone.

Ans 5)
As we know the t score when is less than or equal to -2.5 in any bone will indicate osteoporosis. Here the t score is -3.0 so it will be osteoporosis. The pathogenesis of the osteoporosis can be considered as a multifactorial and will also take into the account the genetics. Also, the systemic factors like the deficiency and excessive hormones as well as the environmental factors and the interaction will also be considered. Mechanism of action: the bisphosphonates will inhebit the osteoclastic bone resorption by the mechanism which will differ from the antiresorptonagent [2, 4]. The bisphosphonates will attach to the hydroxyapatite binding site on both the surface on the surface which undergoes the active resorption. Inspite of a lot of differences present between the random control trials as well as the observational studies, the overall bisphosphonates licensed has also proved to reduce the fracture risk by the inhibition of the bone resorption. It also helps in reduction of the pain in the bone metastasis and also will decrease the mortality. The bisphosphonates can be considered as the potent inhibitors of the bone resorbing cell and also have clinical benefits in a variety of metabolic bone disorder.

Ans 6)
When an old person suffers from bone fracture, the body here will detect a lot of resources towards the fracture. Also, the bone will be considered as already involved in the loosing cycle of the removal of bones as well as the replacement of the bone. Here, more bones will be removed than they being replaced. Also, on the basis of observations the stem cells number is the bone marrow decline significantly when the age of the person increases. The fracture will take longer to heal because the stem cell number drops. The factors which influence the healing can be local as well as systematic. The first factor is the degree of the local trauma and the bone loss, the second factor is the type of bone which is affected and the third factor is immobilization degreeand the local pathologic conditions. The bones will become more brittle and can also break easily. The height can also decease because the trunk as well as the spine becomes short. The second factor is because the bone will lose calcium as well as other minerals. Aging is natural as the age - related diseases such as the degree of immobilisation.

Case study 2
Ans 1)
The trigger chosen here is pollens. When the rain drops are crashed in the air borne pollens, then the pollen grains are generally broken down into the tiny particles. These particles usually get further as well as deeper into the lungs as compared to the large pollen grains. This also triggers and also worse the asthma response.

Ans 2)
a) The category Metered dose inhalers are for the preventer medications. People, who are having a health condition such as asthma, use a device called as the metered dose inhaler. It will spray the medicine through the mouth and it will reach the air ways. When the inhaler is not used in a correct manner, the medicine may not also enter the mouth and some of the medicine may also remain at the back of the mouth. In both the cases it may not reach the air ways where it is not required. There are three main parts in a metered dose inhaler. The first is the mouth piece cover, the mouth piece and the medicine container. First step will be to remove the mouth piece cap. The second step will be to shake the inhaler. It is important to stand or sit up straight and then breath in deep and breathe out deep to empty the lungs. After shaking of inhaler, the mouth - piece must be taken in the mouth and a tight seal will be formed. Breathe in and inhale the puff into the mouth. Keep breathing in slowly and inhale in the medicine. It is also recommended to hold the breath for 10 counts after inhaling. Next step will be breathing out slowly through the mouth. When 2 puffs are required, it is required, wait for some time before the second puff. Next step will be rinse out the mouth with water and then spit out the water. It is also important to keep the inhaler clean to make it work properly. A proper use of the inhaler will help in controlling the symptoms of the lung condition( DeGrandi, 2018 ). There are multiple advantages of metered dose inhalers. The first advantage is it is portable as well as convenient. The second advantage is it is non - breathe active. The third advantage is it is more cost effective than the dry powder inhaler. There will be no preparation required with no preparation.

b) The tropical can also be applied directly to the skin. A thin layer of the cream can also be applied which can be spread evenly on the surface which is affected. It can also be spread gently on the skin and is not smoothed or rubbed. The tropical administration will also involve the application of drugs primarily to elicit the local effect. This can be at the site of application as well as for avoiding the systemic effect. One of the major benefits is there are few risks of the gastrointestinal difficulties. As it is very well known, different individual will absorb medication at different rates. The oram medication will be able to cause a variety of digestive side effects. The patients who generally experience the side effects can also opt to terminate the medication as well. The drug system which is tropical will be able to overcome the limitations and will also help in improving the recovery process of the patients.

Ans 3)
Both the vaccines will use different type of study protocol, different type of methods as well as different type of end points and they are also performed in different geographic locations across the globe. The astra Zeneca’s can be easily transported and can be stored upto 6 months between 36 * F to 46 * F and Pfizer can be used at -4* F and 94 * F. no vaccine cause blood clots.

Case study 3
Ans 1)
Before the cancer cells which are formed in the tissue of the body, the cells will go through the abdominal change which are also called as the hyperplasia as well as the dysplasia. Also, in hyperplasia the number of cells in an organ increase but the tissue will appear normal if it is observed by a microscope. But in dysplasia, the cells appear abnormal under the micro scope but they are not cancer cells. They are not cancer cells but may become cancer cells. The hyperplasia is when the cells multiply with the normal physiological process and the cancer cells are abnormal under the microscope examination.

Ans 2)
The result of biopsy tells the doctors to determine whether the cells are cancerous. Also, when the cells are determined as cancerous, then the biopsy test will reveal from where the cancer originated. This also means it will tell which type of cancer it is. This test also helps the doctor to determine the aggressiveness of cancer. This means it will tell the grade of the cancer. One more important factor will be whether the cancer cells are at the margins or are present at the edges of the biopsy sample. Also, a positive as well as an involved margin will mean there are cancer cells which are present in the margin. Also, the biopsy can also tell the doctors on how aggressive a cancer appears as well as to what extent of the disease it may be. This refers to the stage of the cancer as well as to the grade of the cancer. The test can also help in determining what type of cancer cells are there inside the tumor. The diagnosis is made just by removing a piece of the tissue for study in pathology lab. The tissue piece is also called as the sample or the specimen. The test will help in determining what the pathologist will find about the specimen. All the features mentioned above reflect the characters of a colorectal cancer. Also, the features are as follows: the first feature is there is a persistent change in the bowel habits, the second feature is diarrhea or constipation, the third feature is there will be a change in the consistency of the stool, the fourth feature is there is rectal bleeding or there is blood in the stool. Also, the patient feels an abdominal discomfort like cramps, gas or feels pain. The patient also feels the bowel does not empty completely. All the reasons explain the reason for the findings( Thébaud, 2019 ).

Ans 3)
The people who have CLL can also have high white blood cell count since the excess number of the lymphocytes since the leukemia cell do not fight with the infection the way the normal white blood cells do. The Leukemia will also involve the white blood cells. As we know the white blood cells are the potent infection fighters because they will grow normally as well as will divide in an orderly manner. This will be as per the body requirement. Also, the people having leukemia, with them the bone marrow will produce an excess amount of white blood cells which are abnormal. These cells also do not function properly. The people who have developed acute leukemia, there the white blood cells will multiply very quickly in the bone marrow. Over a given period of time, they will crowd out the healthy cells. This can also lead to an unexpected as well as an excessive bleeding or infection. These are a few reasons why people who have leukaemia can have an excessive high number of cells in their blood and still they are immunocompromised.

Ans 4)
A high level of blood sugar can lead to diabetic neuropathy. This can lead to the damage to the nerves which send signals from the hands as well as from the feet. A Diabetic neuropathy can also lead to numbness as well as tingling in the fingers, in the toes, in the hands as well as in the feet. There is another symptom which is burning, sharp as well as aching pain. This is called as the diabetic nerve pain. It is a matter of concern where around 70 % of the people having diabetes will be able to develop some of the symptoms of neuropathy. This can be considered as a side effect of the given disease. The diabetic neuropathy will begin in the toes and they work their way towards the head. The first symptom will be numbness and tingling in the toes or the fingers. This can also resemble the feel of pins as well as needles when the foot which has fallen asleep will began to wake up.

Ans 5)
When long lasting insulin is taken it is not necessary to check the blood sugar. But when the short acting or the meantime insulin is taken, the blood sugar must be checked prior to the meal. Then the insulin must be given before the meal. And when the meal is skipped, insulin must not be administered. When insulin is not administered properly i.e., it is given in too less, in too large or is given at the wrong time can also result in transient as well as a serious hypo as well as hyperglycaemic excursion, a severe hypoglycaemia as well as a DKA. The type 2 diabetics will obtain injections when their disease can’t be controlled by the diet, by the exercise as well as by the oral medication. The insulin will not be taken orally since it is a protein which will be broken at the time of digestion.

Ans 6)
The glucose will largely enter the endothelial cell by the membrane of the GLUT family of the facilitative membrane transporter. The glucose metabolism by the glycol sis will then be regulated by the three enzymes which are rate limiting. These enzymes are: hexokinase, the phosphofructokinase as well as the pyruvate kinase. When the endothelium will be exposed to the hyperglycemia, an array of the negative intracellular events will promote the endothelial dysfunction. In any of the diabetic patient, the response of the coronary circulation will be exposed to the increasing amount of the acetylcholine in the given paradoxical constriction instead of the vasodilation. When under the resting conditions, the skeleton muscles will depend on the insulin for the promotion of the glucose intake. When the insulin is binded to the membrane receptor it will trigger a cascade of the intracellular reaction which isacuminating in the activation of the glucose transporter 4 among the other outcomes. The increasing skeleton muscles glucose uptake during the exercise will be caused from the coordination of rise in the rate of the glucose delivery, the surface membrane transport of glucose as well as the intracellular substrate flux by the glycol sis.

Case study 4
Ans 1)
The beta blocker will act by blocking the effect of the hormone epinephrine which is called as the adrenaline. The beta blocker makes the heart to beat very slow and lesser force will be applied. This is very much helpful in lowering the blood pressure. The beta blocker will also help in widening the veins as well as arteries for improving the blood flow. Beta blockers such as the propranolol as well as the atenolol can be very much effective in the hypertension. For the secondary prevension of the myocardial infarction, the evidence will be best suited for timolol. Sotalol can be considered as the best antiarrhythmic in the beta blockers. The beta blockers also help in reducing the speed as well as force of the heartbeat. This also helps in lowering the blood pressure. These will work by preventing the hormone adrenaline by binding to the beta receptors. The beta blockers will be available for the administration in three forms. The first is oral, the second is intravenous and the third is ophthalmic. The administration route will depend on the acuity of the illness, the type of the disease as well as the chronicity of the disease. The beta blocker which is called as the beta - adrenergic blocking agent can be considered as the medications which will help in reducing the blood pressure. The beta blockers work by just blocking the affects of the hormone epinephrine. This is called as adrenaline. The beta blocker makes the heart to beat slow which lowers the blood pressure. On an average, beta 1 blocker will lower the BP by -10 point of systolic as well as -8 point of the diastolic pressure in the people having a mild to moderate high blood pressure( Na, 2018 ).

Ans 2)
She is having ST elevation as well as she was having high levels of myocardium specific trooping. The ST segment elevation will occur because the ventricle can be considered at rest and are then repolarized. Also, the depolarised region will be able to generate the electric current which is travelling away from the recording electrode. Because of the same, the baseline voltage which is before the QRS complex will be in depression. The pathophysiology can be caused by the acute, total occlusion of the epicardial coronary artery which is generally due to the atherosclerotic plaque or the erosion as well as the subsequent thrombus formation. The non - ischemic cause of the ST segment elevation will contain the left ventricular hypertrophy, the pericarditis, the ventricular rhythms, the hypothermia, the hyperkalemia as well as other electrolyte imbalances. The ST elevation can also be there in all or some of the leads of ECG. It can also be linked with the myocardial infarction.

The electrocardiogram will remain an indispensable tool which is used for diagnosis of the heart disease. The disease such as arrhythmias as well as the myocardial. The elevation of the ST segment can be considered as a hallmark of the acute myocardial infarction. It also will help in identifying the patients who are in a critical condition.

Ans 3)
She has high levels of myocardium-specific trooping in her blood. The heparin can be considered as an anticoagulant. This is also considered as a blood thinner. This helps in the prevention of the formation of the blood clots. The Heparin can be used for the treatment as well as the prevention of the blood clots which are caused by different medical conditions and any type of the medical procedures. It can also be used before the surgery for reducing the risk of the blood clots. Heparin can also be used for the prevention of the blood clots from forming in the people. This is for the people who have certain medical condition or the person who are undergoing certain medical process which will increase the chances that the clots will form. For the method of administration to be intermittent, the frequency will be the initial dose. There will be 10,000 units of recommended doses. For the method of administration as intravenous injection, the frequency of dose will be every 4 to 6 hours and the recommended doses are between 5000 to 10000 units. For the method of administration to be continuous intravenous infusion, the frequency will be the initial dose and the recommended dose will be around 5000 units by the intravenous injection. For the method of administration to be infusion, the frequency will be continuous and the recommended doses will be around 20000 to 40000 units of dose per 24 hours. It can be used for the prevention or the treatment of certain blood vessels, the heart as well as the lung condition. It can also be used for the prevention of the blood clotting in the open - heart surgery, the kidney dialysis as well as the blood transfusion.

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