Comprehensive Clinical Case Study: John Smith's Healthcare Over 8 Days

This case study meticulously follows the medical journey of John Smith, a 62-year-old male, over eight days, detailing his progression from initial health concerns to multiple diagnoses. The study begins with interpreting his blood test results, assessing his risk of atherosclerosis, and discussing the steps involved in its development. It then explores his acute coronary syndrome, including his chest pain, ECG results, and the effectiveness of various medications. The case progresses to left-sided heart failure, analyzing the events leading to the diagnosis and the efficacy of his treatment. Further complications such as shock, diabetes, and lung cancer are addressed, with detailed examinations of his blood glucose levels, body-size analysis, and the effects of chemotherapy. The study also investigates deep vein thrombosis and its related risks, as well as the development of COPD. The case concludes with an overview of his overall prognosis, considering his multiple health concerns, treatments, and the impact of a respiratory infection. The assignment requires interpreting clinical presentations, analyzing diagnostic results, and discussing the rationale behind various treatments and their effectiveness.

Workbook Case: Day 1
John Smith is a 62 year old male. He lives on his own, and has two adult children, who have been
telling him for some time that they think he needs to get healthier. He doesn’t exercise, and his
weight gain has increased a lot since he retired several years ago. He has been a smoker for many
years.
Two weeks ago, he finally went to his doctor for a general check-up, as the death of one of his long-
time mates only about 3 months ago had left him getting quite concerned about his own health.
During the consultation, John’s height was 175cm, weight 160kg, blood pressure 150/90, and body
temperature 37.6oC. The doctor asked John to have a blood test and return for a follow-up
appointment.
Today (Case Day 1), John has returned to his doctor to discuss results of his blood test. The findings
were:
LDL: 5.6
HDL: 0.4
TG: 5.7
Total cholesterol: 9.4
1. Interpret John’s blood test results.
2. Interpret all aspects about John that relate to the development of atherosclerosis.
3. Discuss the steps involved in the development of atherosclerosis, ensuring that you relate
this to John’s blood test.
4. If John is currently developing atherosclerosis, discuss where this may be developing in his
body, ensuring that you interpret the potential consequences in these locations. Based on this,
discuss the prioritisation of monitoring these locations.

Clinical Case Report: Day 2
John is usually tired during most days. Last night, he didn’t sleep well, waking several times during
the night panicking and struggling to breathe. By mid-morning, John watching morning TV shows and
is tired, but thinking constantly about his doctor’s appointment yesterday. The doctor had discussed
lots of health concerns, and John’s been getting more worried. He was given prescriptions for
medications, but didn’t feel like going to the chemist (pharmacy) yesterday as he felt he was too
overwhelmed. The medications are:
• Lipid lowering
• ACE inhibitor
As he gets up and starts getting ready to go to purchase his medications, he’s becoming increasingly
anxious. He starts getting chest pain, so sits back down to watch TV and try to relax, hoping that will
make the pain will go away. After about 20 minutes, he still has the pain, so calls an ambulance
which arrives within about 8 minutes. The paramedics found his blood pressure to be 175/95, heart
rate at 125 beats per minute, respiratory rate 28 breaths per minute, and body temperate 37.5oC.
His immediate treatment includes glyceryl trinitrate and aspirin, and his pain quickly stops.
Upon arrival at the hospital, the ECG is shown here, and blood tests reveal:
• No increase in cardiac troponin or cardiac lactate dehydrogenase
• Blood glucose level: 14 mmol/L
Because he’s in the high risk group, he was scheduled as a priority for angiogram; during the
angiogram, a 95% occlusion was found high in his left anterior descending coronary artery, near to
the aorta, which was treated successfully using angioplasty. Results from blood tests later that
evening show:
• Increased cardiac troponin and increased CKMB
• Blood glucose level: 9.4 mmol/L
Since his angioplasty, he is now being treated with the following medications:
• Aspirin
• GTN
• Lipid lowering
• ACE inhibitor
• Non-selective β-blocker

1. Discuss the clinical relevance of his stress in the morning in relation to his chest pain.
2. Interpret his clinical presentation, including his chest pain, ECG and blood test results.
3. Compare the purposes of his treatment with the medications glyceryl trinitrate and aspirin;
discuss the potential benefit of both medications in relation to his case.
4. What is the purpose for him being administered the ACE inhibitor and non-selective β-
blocker since his angioplasty?
5. Although the blockage in his coronary artery has been treated, discuss reasons why he
remains on a lipid lowering medication.

Clinical Case Report: Day 3 [John Smith]
John remains in hospital, and is feeling very weak and unwell. He has been told this morning that he
is suffering from left-sided heart failure. His urinary output is extremely low, and at times he finds it
difficult to breathe. John is now coughing regularly throughout the day, and the lower parts of his
legs and feet are swollen. Today’s observations include a blood pressure of 135/85, heart rate at 85
beats per minute, and body temperate 36.5oC.
Today’s blood test results include:
• Increased cardiac troponin, increased CKMB, and increased cardiac lactate dehydrogenase
• Blood glucose level: 17 mmol/L
1. Refer back to the question on John from yesterday, relating to question 2, which stated
“interpret his clinical presentation, including his chest pain, ECG and blood test results”. Use today’s
blood test results to briefly extend or confirm your interpretation of his case.
2. Interpret the events from John’s clinical case that led to the diagnosis of left-sided heart failure.
3. How effective has his treatment with the ACE inhibitor been? What has led you to this conclusion?
Mid-afternoon, John suffered from an episode of shock, which was detected as his blood pressure
dropped down to 80/40mmHg, he lost consciousness, and his skin was cool. He was quickly treated
using oxygen and medications, and recovered reasonably well.
By the end of the day, his medications are:
• Lipid lowering
• ACE inhibitor
• Cardioselective β-blocker
• Diuretic
• Digoxin
4. You note that the β-blocking drug has changed from yesterday to today. Discuss the importance of
this for John’s case.
5. Which type of shock is most likely to have occurred for John, and why.

Clinical Case Report on John Smith, Day 4.
Over the series of blood tests that John Smith has been having, his blood glucose levels remain high.
Today’s blood test results show:
• Increased cardiac troponin, normal CKMB, increased cardiac lactate dehydrogenase
• Blood glucose level: 15 mmol/L
His waist circumference is 110cm, and height and weight were provided on Day 1 (height 175cm,
weight 160kg). His body temperature is 36.3oC, blood pressure of 125/80, heart rate of 75 beats per
minute. He is now passing large volumes of urine, although has swelling in his lower legs. By the end
of the day, his medication list is:
• Lipid lowering
• ACE inhibitor
• Diuretic
• Digoxin
• Insulin
1. Provide a full body-size analysis for John. Include what conditions are now added to John’s
diagnosis, with an explanation of the evidence that confirms those conditions.
2. Reflect back on the blood glucose results that have been occurring over the last several days
for John, including those aspects that may have contributed to his blood glucose results.
3. Discuss the urinary volume that would be expected for someone with diabetes, and why this
volume occurs. How does that compare with John’s urinary volume over recent days, and now the
change in volume today? In your answer, include an explanation of his medications that influence
urinary volume.

Case on John Smith, Day 5
Over the last couple of days, John has commented to you a couple of times that he’s annoyed that
since he’s been in hospital, it is no longer easy for him to have a cigarette whenever he feels like it.
He has been a smoker for many years, and it is appropriate to investigate the possibility of lung
cancer. John’s chest X-ray reveals a mass growing in his lungs, which is confirmed to be cancer. He
immediately starts on chemotherapy.
1. Seeing as John already has lung cancer, is there any benefit in him quitting smoking now?
2. After being on chemotherapy, it is anticipated that John will start to lose his appetite.
Describe the main pathophysiological reasons why he might not feel like eating (ie focus on the
effects of chemotherapy directly on the body, rather than his emotional response to his disease).
3. One of the potential side effects of chemotherapy that John may experience is anaemia.
Explain how chemotherapy can lead to anaemia. Include information that links anaemia with his left-
sided heart failure.

Clinical Case Report on John Smith: Day 6
Although redness and swelling in his lower legs has previously noted over several days, today he
complains of severe pain in his right calf. You observe that his right calf is very warm and much more
swollen than the left leg, although his body temperature is 37.3oC.
1. Interpret all aspects of John’s case that are consistent with his diagnosis of deep vein
thrombosis.
2. Compare John’s very warm leg with his overall body temperature.
3. Compare John’s “much more swollen” right leg with his left leg.
4. Discuss why John is at risk of developing another condition, related to his deep vein
thrombosis.

Case of John Smith: Day 7
After having been diagnosed with DVT yesterday, John is today struggling with his breathing.
Although he does not have a pulmonary embolism, he has laboured breathing and severe dyspnoea,
his respiratory rate is 28 breaths per minutes, he coughs a lot which brings up mucus, and has a
barrel chest. His heart rate is 110 beats per minute, oxygen saturation SaO2 is 91%, and he is now
diagnosed with COPD. John is constantly tired, even though he doesn’t get out of bed much at the
moment.
1. How may his previous smoking have contributed to the development of lung diseases,
particularly COPD?
2. Which disease/s within COPD does John most likely have? For each disease that you
consider, ensure that you link with the evidence that supports your diagnosis.
3. Discuss which aspects from John’s case today demonstrate that he is attempting to
compensate for his respiratory condition.
4. Interpret his new diagnosis of COPD, in relationship to his left-sided heart failure, including
whether having left-sided heart failure may have contributed to development of COPD. Discuss
whether you think he is likely to also develop right-sided heart failure?

Clinical Case Report: Day 8 John Smith – final day
Since John has been in hospital over the last 7 days, he has been diagnosed with multiple health
concerns, and has recently been treated using the following medications: lipid lowering, ACE
inhibitors, diuretics, β1 blocker, digoxin, insulin, chemotherapy, heparin and bronchodilators.
Over the time that John Smith has been in hospital, he has been visited regularly by his adult
children. Today you notice that his daughter is sitting beside him, and she is coughing and blowing
her nose, and you are concerned that he may catch this respiratory infection from her.
1. Reflecting back on John’s case over the last week, discuss specific aspects about him that
may contribute to malnutrition.
2. Reflecting back on John’s case over the last week, discuss specific aspects about John that
increases his risk of suffering from respiratory infection.
3. Discuss what a respiratory infection would do to his blood glucose level, and how that
should be managed.
These two questions are the final questions on John, and ask you to consider specific aspects of his
overall health.
4. Reflecting back on John’s case over the last week, discuss specific aspects that contribute to
his oedema in all body regions/organs, ensuring that you include the lungs. In your answer,
comment on his overall prognosis. Also include discussion of the relevant medication/s for this (see
list above).
5. Reflecting back on John’s case over the last week, discuss specific aspects about his lung
function and diseases, including other lung disease/s he is at risk of developing. In your answer,
include the effects on his breathing, and comment on his overall prognosis. Also include discussion
the relevant medication/s for this (see list above).