NURSING 742: Biological Science for Practice Portfolio Case Studies

1. Immunisation (Measles) case study – (known also as Morbilli, Rubeola, or English measles)

The 2018/19 epidemic of measles, largely in unvaccinated children, caused at least 140,000 deaths globally¹ and 2,185 cases were reported in New Zealand (NZ).² Measles is highly contagious.^3-5 Of children infected, 15% require hospitalisation and 0.1% develop encephalitis with having permanent brain damage or die.⁶

Summer, aged two years, had returned to NZ with her parents at the beginning of 2025 after an 18-month round-the-world journey on a yacht that included visiting several Pacific Islands countries on their way back to NZ. Because of the travelling, Summer had not been vaccinated, although her mother planned to catch up on the required vaccinations after settling back into their home. Two weeks after returning home, Summer developed a cough, runny nose, inflamed eyes, sore throat, fever, a red, blotchy skin rash and earache.⁵ After attending the family’s general practice, Summer was diagnosed with measles and otitis media.

1. Staphylococcus aureus most commonly causes otitis media in children with measles.⁷ Explain how the measles virus increases the risk of otitis media caused by Staphylococcus aureus.
2. Despite measles being highly contagious, neither Summer’s parents nor other crew members developed the infection. Describe their most likely immune response that prevented them from developing this infection.
3. The proportion of children who have been immunised in NZ has fallen to 83% overall and only 69% for Māori children and the number of measles cases has been increasing since the last epidemic.⁸ Based on the R0, 92-94% of people need to be immune to achieve herd Immunity.^8,9

Explain what R0 is and the effect of the downward trend in vaccination rates in NZ on infection rates.

2. Viral (COVID) case study

The zoonotic COVID virus, or severe acute respiratory syndrome coronavirus (SARS), was most likely transmitted from bats to people and first detected in 2019, leading to the current global pandemic.¹⁰ The SARS virus is highly mutable with increasing numbers of variations in its main spike protein (antigen) leading to more variants, greater transmissibility and evasion from immune recognition.¹¹ The globally dominating Omicron variant was first identified in November 2021 and has over 60 mutations among the amino acids that make up the spike protein.¹² Despite this, Omicron infection is less severe and hospitalisations are about one-third (0.5%) of hospitalisations from the first Delta variant (1.3%),¹² and far lower for fully vaccinated people.¹³ However, people hospitalised over 60 years of age with pre-existing conditions have the greatest risk of severe disease requiring respiratory support and have the highest mortality rates.^14-16

Mr James, aged 76 years, resides in an aged-care facility, has been vaccinated against the delta and earlier omicron variant, and was admitted to hospital after having difficulty breathing. Mr James developed symptoms of COVID infection and tested positive 5 days before admission. On admission his respiratory rate was 30 per minute and shallow, his heart rate 110 beats/minute, O₂ saturation was 85% and his blood pressure had increased to 150/93 from 140/90 prior to admission.

Following guidelines,¹⁷ he was administered oxygen via a high flow nasal cannula circuit and positioned for maximal lung expansion to support his breathing and improve his arterial oxygenation levels, until his O₂ saturation levels improved. He was then started on remdesivir and enoxaparin.

Previous medications prescribed for Mr James include captopril, metolazone, simvastatin, dabigatran, and a Serevent inhaler to reduce the effects of historical smoking-related chronic obstructive pulmonary disease.

              Mr James’ latest arterial blood gas and blood test results.

1. Describe the two main routes of entry into Mr. James’ body cells that the Omicron variant of COVID-19 employs.
2. Explain how the virus has led to the respiratory symptoms Mr. James is experiencing.
3. Omicron has many sub-variants, including the currently circulating JN1 and KP.3.1.1.¹⁸ Explain how Mr James’ previous vaccination is expected to end the infection. (Include discussion of relevant antigen/s in your answer

3. Bacterial (Tuberculosis) case study

Sam aged 25 years has just arrived home after spending the last three years teaching at a boarding school in India and touring extensively around India during their school holidays. He moved back into his family home with his parents and 20-year-old sister and plans to apply for a teaching position in New Zealand. Shortly after arriving home, he complained of feeling very tired, had lost weight and developed an irritating productive cough. He consulted his family’s general practitioner (GP) about the symptoms and mentioned his recent return from India. Following best practice, the GP ordered blood tests, including an interferon gamma release assay (IGRA), a tuberculin skin test (Mantoux test) and a chest X-Ray.¹⁹ Sam was also given three containers for a sputum test on three consecutive days and instructions to seal and label the containers before delivering them for testing.

The GP explained to Sam that tuberculosis is prevalent in regional areas in India²⁰ and that he wanted to rule out tuberculosis. While waiting for test results Sam was asked to stay at home, rest and isolate from other family members and visitors. The importance of good hygiene was stressed, such as using and safely disposing of tissues after coughing and sneezing and to wear a mask when with others.

One week later the GP telephoned to tell Sam that the Mantoux test was positive as were the acid-fast bacilli sputum smear tests. The chest X-ray confirmed active pulmonary tuberculosis. Under the Health Act of 1956 mycobacterium tuberculosis (Mtb) is a notifiable disease.^19,21 As required, both the laboratory and the GP advised the Medical Officer of Health of Sam’s diagnosis.

Sam became increasingly unwell over the following week and was admitted to hospital and placed in negative pressure isolation. Only family members were able to visit for the first two weeks of Sam’s treatment, after which time, Sam was considered non-infectious. However, it was essential that he continue to adhere to his prescribed medication regime.

(Reading Defence 6) and (Reading Defence 7) and (Reading Defence 8) will assist you with completing this case study.

1. Describe the formation of the granuloma in people where MTb infection might go undetected and untreated, and how the granuloma can contain the infection.
2. Best pharmacological treatment for Mtb is known as ‘quadruple therapy’. State the medications that make up this therapy, and their role in treating the infection.
3. Describe the potential complications for Sam if he does not complete his treatment and clear Mtb.

4a. Cardiovascular (Myocardial infarction) – Adult case study (Complete either 4a OR 4b)

Mrs Parks is 62 years old and has been admitted to hospital with a tentative diagnosis of a non-ST segment elevation myocardial infarction (NSTEMI). Further tests, including a 12-lead electrocardiogram (EGG) and echocardiogram, confirmed the diagnosis, revealed a partial blockage in her left anterior descending artery, ischemia in the Bundle of His and sub-endocardium of the left ventricle and a left ventricular ejection fraction of 45%. Cardiac surgery has been scheduled to insert a stent and re-establish patency in the affected vessel.

Mrs Parks seldom needs to see her general practitioner and has never been prescribed any long-term medications. She started smoking after leaving school, and although she has not managed to quit after several attempts, she has reduced her daily use to about 8 per day. Mrs Parks had a deep vein thrombosis following gynaecological surgery 7 years ago that was treated with heparin initially, followed by warfarin for 3 months.

Mrs Parks works as a mid-level manager in a popular inner-city restaurant and tends to drink 1-3 glasses of wine each day. She has a BMI of 23. She describes herself as usually fit and healthy and explained that she is ‘on her feet all day while at work’ and walks the family dog on her days off. She is supported by her partner of 10 years and has an adult daughter, who lives in the same city, and a son who lives overseas.

Currently her condition is stable. Her blood pressure is 150/90 mmHg, heart rate 90 beats per minute and respiratory rate is 18 respirations per minute. Mrs Parks’ clinical team are planning to commence her on metoprolol, atorvastatin and aspirin on discharge following surgery.

             Mrs Parks blood results are outlined below.

1. Reduction in LDL-cholesterol is associated with a lowered risk of cardiovascular events.²²a) Explain the underlying biological effects of lowered LDL-cholesterol levels that reduce Mrs Parks’ cardiovascular event risk.

b) In addition to her statin therapy, outline steps that Mrs Parks could take to improve her cholesterol levels, and how this benefits her risk profile, providing evidence for your answer.

2. Myocardial infarction can increase the risk of heart failure.²³ Referring to Mrs Parks’ current ejection fraction, describe the processes which can, over time, reduce stroke volume further, leading to heart failure.
3. Mrs Parks has expressed a little concern about the number of drugs she will be on after surgery. With reference to the underlying pathology of atherosclerosis, her history and risk of complications, explain why the suggested triple therapy is important.

4b. Cardiovascular (Kawasaki) – Paediatric case study

Liang, aged 18 months, and his sister Mei, aged four years, live with their parents in Auckland. Liang’s parents migrated from Hong Kong six years ago and both children were born in New Zealand. Liang’s mother took Liang to their general practitioner after he developed a high temperature of 38.4°C, a fever (hot and sweaty), became unusually irritable and was reluctant to eat and drink. The general practitioner (GP) prescribed paracetamol for Liang and asked his parents to return to the practice if his fever continued over the next 2 to 3 days. Three days later Liang’s took him back to the practice as the fever continued and Liang had developed a red swollen tongue, puffy red eyes, and a maculopapular rash over his body.

Based on the progressive symptoms and blood test results,²⁴ the GP suspected Kawasaki Disease and immediately arranged for Liang to be admitted to Starship Hospital for further investigations and treatment. Accompanied by his parents, Liang was assessed on arrival by a paediatric cardiologist registrar. A blood test, an electrocardiogram (ECG) and echocardiogram were carried out.

Following a full physical examination and test results, Liang was diagnosed with Kawasaki Disease.

Liang’s blood results are outlined below.

1. Discuss the effects of Kawasaki Disease on the cardiac arteries.
2. About three weeks after presentation to hospital, Liang experienced peeling of the skin on his fingers and toes. Describe this phenomenon and explain why it occurs
3. Explain best management and treatment for Liang including long-term care.

5. Acid Base case study

Mrs. McCauley is 77 years old and has developed peripheral vascular disease impeding the blood flow to her lower right leg. She is currently undergoing femoral bypass graft surgery to restore blood flow and perfusion to her lower leg. This is a long procedure and periodically the anaesthetist conducts a blood gas analysis to check on Mrs. McCauley’s ventilatory status.

Mrs. McCauleys latest blood test results show:

1. State the type of acid-base imbalance.
2. Explain the origin of the acid-base imbalance and include the bicarbonate equation with the direction of the chemical flow in your answer.
3. Is there any compensation occurring? If so, describe the type of compensation?
4. Briefly explain how this acid-base imbalance could be corrected.

6a. Renal (Acute Kidney Injury) – Adult case study (Complete either 6a OR 6b)

After working through the on-line course content the following readings (Reading Renal 3) and (Reading Renal 4) will help you complete the case study about Mr Johnson who has an acute kidney injury (AKI).  

Mr Johnson lives independently and alone after his wife passed away 2 years ago. Mr Johnson had just celebrated his 90th birthday with two elderly friends and family. He completed the celebration with opening and sharing a 10-year-old prized bottle of Scottish whisky. The following morning, he called his daughter to say he was feeling terrible, had a dreadful headache, his mouth felt as ‘dry as a bone’, and he was unable to pass urine. When Mr Johnson’s daughter arrived at his house, she noticed he was also quite confused and decided to take him to hospital (as it was Sunday, and his general practice was closed). After being assessed and having a full blood screen he was diagnosed with acute kidney failure (AKI) and admitted to hospital.

Mr Johnson is reasonably healthy and plays the occasional game of golf with his friends. Although he does not have any chronic medical conditions, he has been prescribed atorvastatin to reduce his slightly elevated low-density lipoprotein (LDL) cholesterol, and a beta blocker for his elevated blood pressure to lower his risk of having a cardiovascular event. Mr Johnson had taken Ibuprofen 2-3 times in the night and again in the morning for his headache, when he also had his usual atorvastatin and beta blocker.

Currently his blood pressure is 100/65 mmHg, respiratory rate 20 per minute, heart rate 85 beats per minute temperature 37°C and he has mild peripheral oedema. Based on Mr Johnson’s presentation and blood test results (outlined below), he was diagnosed with AKI.

Mr Johnson’s blood and urine test results are outlined below:

1. Mr Johnson’s glomerular filtration rate (GFR) is 45 ml/min/1.73m².
   a) Explain the effect of acute kidney injury on Mr Johnson’s GFR and
   b) Explain the major local compensatory mechanisms expected to normalise GFR.
2. Mr Johnson’s beta blocker was temporarily stopped after his admission to hospital. Discuss the rationale for this clinical decision.
3. Management of AKI is aimed at supporting renal function.^26-29 It is expected that Mr Johnson will make a full recover following commencement of intravenous fluids (IV) and frequent measurement and readjustment based on urine output and vital observations.

Explain the expected movement of fluid between intracellular and extracellular compartments that will lead to a reduction in peripheral oedema.

6b. Renal (Nephrotic Syndrome) – Paediatric case study

Working through the course content and the following article  (Reading Renal 5) will help you complete the case study.

Michael, aged 5 years, was taken to the family general practitioner (GP) after his parents noticed he was passing unusually light, foamy urine, felt too tired to go to school, seemed to be developing puffy eyes and that his shoes suddenly seemed to be far too small for his feet. Michael was otherwise healthy and had transitioned easily between kindergarten and school 4 months ago. He had no pre-existing health conditions or family history of renal disease. The GP noted that Michael’s blood pressure was elevated (125/90 mmHg) and a urinalysis showed the highest level of proteinuria. Results from an urgent blood test (outlined below) indicated that Michael had a serious renal condition, and the GP arranged an urgent follow up at Starship hospital.

Based on Michael’s blood test results and blood pressure the consulting paediatric renal specialist suspected nephrotic syndrome and admitted Michael to hospital for an ultrasound and renal biopsy and treatment.

Michael’s mother is 6-months pregnant with their second child and both she and Michael’s father are distraught about the tentative diagnosis and also worried about the implications for their second child. It is explained to them that nephrotic syndrome can be hereditary or idiopathic (with no known cause) and in rare cases can be either due to an underlying infection, related to an allergy, or congenital (presenting in the first few weeks of life).^30,31 It is also explained that the treatment is very effective, and most children respond well and lead healthy lives.

Two of the most common presentations are focal segmental glomerulosclerosis (FSGS) and minimal change disease (MDC). Based on laboratory results a diagnosis of idiopathic nephrotic syndrome consistent with MCD was made. No biopsy was undertaken, as this is not usually carried out unless patients do not respond to treatment.³² Following this diagnosis, treatment was initiated.

Michael’s blood and urine test results are outlined below:

7. Explain the structural renal changes resulting from MCD, and how these result in a reduced GFR.
8. Explain the relationship between nephrotic syndrome and the elevated cholesterol levels seen in Michael’s lab results.
9. Michael is started on a regimen of corticosteroids as part of his treatment. Discuss their biological or mechanism of action and expected reduction of his symptoms.

7. Type 1 Diabetes case study

Christian, aged 7 years, has been admitted to Starship Children’s Hospital with diabetic ketoacidosis (DKA) and a tentative diagnosis of Type 1 diabetes. Christian’s parents moved to Auckland from Denmark when Christian was 2-years old (his mother is Danish, and father is originally from Dunedin). Both parents work for an information technology business and are distressed about Christian’s diagnosis and the implications for his care and impact on their family. Christian has an identical twin (Daniel) and a 9-year-old sister (Freja).

Although Christian is usually very healthy, 4 weeks ago his mother took him to their general practitioner (GP) after he developed a cold, a sore throat, and blisters in his mouth. After the GP checked his temperature, throat, mouth and auscultated his chest, she felt he probably had a common coxsackievirus viral infection. The GP advised Christian’s mother to keep him home for the rest of the week to recover and advised on good hygiene and distancing to reduce the spread of the infection. Christian had recovered by the weekend and had been well until about a week ago when he complained of being really tired, lost his usual hearty appetite and clothes seems to have become loose on him.

In response to several questions from Christian’s parents about Type 1 diabetes, the attending clinician explained that Type 1 diabetes is more common in Scandinavia^33,34 and New Zealand^35,36 and that enteroviruses (including the coxsackievirus) commonly cause infection in young children,^37-39 and can trigger Type 1 diabetes.^40-42 There is a genetic link although concordance for identical twins is much lower for Type 1 compared with Type 2 diabetes.^43,44

Christian’s blood test results after admission.

* Glutamic Acid Decarboxylase

1. Explain the main reasons why the prevalence of type 1 diabetes is higher in Scandinavian^33,34 and New Zealand^35,36 populations compared with most non-European populations.
2. Christian’s parents ask if Daniel can be tested for autoantibodies for type 1 diabetes.
   a) Explain why Daniel might have autoantibodies consistent with type 1 diabetes (include discussion of the immune system in your answer).
   b) Discuss the implications of a positive autoantibody result.
3. Following best practice, Christian is commenced on IV sodium chloride, potassium 20 mmol/500ml and 0.07 units of insulin/kg/hour.⁴⁵ Prior to discharge, Christian’s parents will meet with the dietitian who will discuss optimising Christian’s nutritional intake including that of carbohydrates.

Discuss the main recommendations for carbohydrate intake for Christian and their rationale.

8. Type 2 Diabetes and Diabetes-related Complications case study

Globally, the incidence of type 2 diabetes in children and youth (15 – 25 years) has increased from 117 to 184 per 100,000 between 1990 and 2019 and is higher for non-European youth.^46,47 In New Zealand (NZ) there has been a 5% annual increase since 1995 in youth developing type 2 diabetes, and females have almost twice the rate of males.⁴⁸ The incidence is higher for Pacific (5.9/100,000) and Māori (4.1/100,000) children compared with 1.5/100,000 European children.⁴⁹

Sefina is a 19-year-old young Samoan women diagnosed with type 2 diabetes at 13-years. She is the youngest of six children, lives at home with her parents and three siblings and works 32 hours per week as an assistant librarian. Her maternal grandmother and paternal aunt have type 2 diabetes and her mother had gestational diabetes when pregnant with Sefina.

Sefina was diagnosed with type 2 diabetes after a urinary tract infection and the family’s general practitioner noticed that Sefina had acanthosis nigricans and organised an HbA_1c diabetes screen. Sefina also displayed several risk factors for type 2 diabetes, including an elevated BMI (36 kg/m²), blood pressure (130/85 mmHg), HbA_1c (76 mmol/mol), low-density-lipoprotein cholesterol (LDL-C, 3.2 mmol) and microalbuminuria (43 mg/L). Sefina found it difficult to exercise and was embarrassed to join a gym or exercise class. Puberty may have accelerated Sefina’s development of type 2 diabetes, as the onset of puberty is a risk factor.^46,49,50

At diagnosis, Sefina was commenced on metformin, that was gradually increased to 1,000 mg twice daily, to reduce her HbA_1c level⁵¹ and risk of diabetes-related complications.^51,52 Within 6 months of commencing metformin Sefina’s HbA_1c decreased to 64 mmol/mol.^53,54 Sefina and her family have worked hard to improve their lifestyles to help Sefina manage her cardiometabolic risk factors. Neither Sefina nor any family member’s smoke. The family are supported by their general practice with regular 3-monthly consultations and support phone calls with the ‘diabetes nurse’. Sefina and her mother have had additional consultations with a hospital-based dietitian to improve the family’s nutritional intake. Currently, Sefina’s BMI is 34 kg/m², blood pressure 125/82 mmHg, and Sefina disembarks early from the bus and walks the last two kilometres home.

Sefina’s current blood and urine test results are outlined below.

1. Sefina was diagnosed with type 2 diabetes around the time of menarche. Explain how puberty drives the development of type 2 diabetes in at-risk youth.
2. A key longitudinal cohort study of youth with type 2 diabetes, showed that 55% develop renal disease, 51% retinopathy and 32% neuropathy within 14 years from diagnosis.⁵⁵ Referring to Sefina’s results above discuss management of the major risk factors to reduce progression of renal disease for Sefina.
3. A randomised controlled trial (RCT) among 82 youth with type 2 diabetes, compared exenatide, a glucagon-like peptide-1 receptor agonist (GLP-1RA), with placebo added to first-line therapy, including metformin, for 79%.⁵⁶ HbA1c reduced by 3.6 mmol/mol in the treatment group compared to 4.9 mmol/mol in the control group resulting in a 8.7 mmol/mol statistically significant difference.⁵⁶ Referring to this paper, and (Supplementary Figure 3), 40% of the intervention participants compared with 12% of control participants reached target HbA1c levels <55 mmol/mol after 12 weeks.
   a) Explain the biological action or mechanism of action of a GLP-1RA drug.
   b) Based on this RCT,⁵⁶ calculate and interpret the number of youth with type 2 diabetes who need-to-be-treated with a GLP-1RA agonist added to first-line therapy, to achieve target HbA1c levels and explain the clinical implications for Sefina.

The following statistical article (Numbers needed to treat) will help you answer this question and address this concept in assignment 1, as well as reviewing Lecture 5.

9. Asthma case study

Nikau is a 7-year-old boy of Māori ethnicity, who lives with his parents and two older primary school-aged siblings in South Auckland. Both his parents work in Manakau city, and Nikau’s auntie looks after the children after school until his mother returns from work. Though neither of his parent’s smoke, his auntie is a regular smoker but only smokes or vapes in the house when the weather is bad. His paternal grandfather and two of his teenage cousins have asthma.

Nikau has visited his local Whānau Ora community clinic with his mother, Marama, because his wheezing and coughing has recently worsened, especially at nighttime. Their rental house has been mildly affected by recent flooding and gets quite damp, but his parents have tried to keep Nikau’s room warm using a portable gas heater. Marama reports that Nikau was quite often wheezy as an infant, mainly associated with colds or flus, but his symptoms had greatly reduced over the COVID years with the various precautions in place. He has never taken regular medications for asthma. Nikau explains that lately he has been getting breathless during sports and physical education at school. He has played Rugbytots since preschool, and this winter he has started Junior Rugby League, which he loves.

On clinical assessment by the family’s usual general practitioner (GP), Nikau is 126 cm tall and weighs 28 kg. His peak expiratory flow rate (PEFR) is 220 L/min (93% of age-height predicted), forced vital capacity (FVC) is 1.74 L (100% of predicted), his forced expired volume in 1 second (FEV1) is 1.36 L (89% of predicted), and FEV1/FVC is 78% (normal ≥80%) Nikau reports that it feels ‘hard to breathe’, and auscultation reveals a clear wheeze. After two puffs of salbutamol (Ventolin) his FEV1 increased to 1.60 L (an 18% improvement) and wheezing was reduced.

Their GP prescribes Nikau with two inhalers, 50 µg fluticasone propionate (Flixotide Junior) 1 puff, twice daily and salbutamol (Ventolin) for use before rugby or other sports and when needed. Nikau is referred for an appointment with the practice nurse who will arrange regular follow-up care according to NZ Guidelines.⁵⁷

1. Eicosanoids are lipid-based signalling molecules, the most prominent in allergic responses being cysteinyl leukotrienes and prostaglandin D2.⁵⁸ Explain the role of leukotrienes and prostaglandins in an acute asthma exacerbation.
2. Some individuals with asthma develop irreversible structural changes to airways known as remodelling.^59-61 Describe these chronic changes and their effects, referring to evidence that suggests that they can begin at a young age.
3. Marama asks whether regular medicine is necessary and wonders if Nikau can just use his Ventolin (SABA) when he is symptomatic. Explain the benefits of inhaled corticosteroids, over SABA therapy alone, and how regular use of these may help Nikau in the long term.

10a. COPD (Chronic Bronchitis) – Adult case study  (Complete either 10a OR 10b)

Mrs Brooks, aged 70 years of Māori ethnicity, is a retired office manager from Wellington, who lives alone after her husband passed away last year. She was diagnosed with chronic bronchitis, a chronic obstructive pulmonary disease (COPD), 10 years ago and has experienced several exacerbations since, including two in the last 12 months and a prolonged one during the previous winter. During these exacerbations she frequently needed to take Ventolin (salbutamol) in addition to Seretide (fluticasone/salmeterol) medication, and a course of antibiotics were required during both recent exacerbations. She has smoked for most of her adult life, and although she has not been able to stop for any length of time, she has greatly reduced her cigarette use to about five per day.

Mrs Brooks is currently consulting with her general practitioner (GP) while experiencing another exacerbation following an upper respiratory viral infection. She complains of gasping for breath during light exertion such as when quickly standing and walking to answer the telephone. She has regular bouts of productive coughing, including prolonged episodes over the previous three winters, and on some days had found it difficult to dress and stay up for the day. On examination, Mrs Brooks had a pronounced wheeze and fits of coughing with clear sputum. She also has moderate to severe peripheral oedema in her lower legs, ankles and feet, and a slight cyanosis, particularly in her face and nose.

Mrs Brooks’ BMI is 34 kg/m², blood pressure 140/85 mmHg, temperature 36.1 and post-bronchodilator FEV1/FVC 66%. Her regular medications include captopril, atorvastatin, aspirin and a Seretide inhaler. After the examination, she was prescribed an Ultibro Breezhaler (glycopyrronium/indacaterol) instead of Seretide,^62,63. and referred to a new community smoking cessation programme. Her GP will telephone over the next few days to check on her progress and arrange further follow up if required.

Mrs Brook’s blood and respiratory recent test results.

COPD; Chronic Obstructive Pulmonary Disease.

1. Describe the pathological changes to the bronchiole epithelium in chronic bronchitis, explaining how some of these changes increase Mrs Brooks’ susceptibility to respiratory infections.
2. Explain how severe chronic obstructive pulmonary disease (COPD) can result in lower limb oedema.
3. Exercise is an important component of pulmonary rehabilitation recommended for people with COPD.^62,63 Describe the characteristics (e.g. type and duration) of exercise that have been shown to be effective for people with COPD and explain how exercise is likely to benefit Mrs Brooks.

10b. Respiratory (Cystic Fibrosis) case study – Paediatric (complete either 10a or 10b)

Tiara, aged 3 years, of Māori ethnicity, and living near Pukekohe, was diagnosed with cystic fibrosis as an infant following positive screens completed as part of the NZ Newborn Metabolic Screening Programme (NMSP). At the time, the family’s midwife let them know of this result and they had an appointment with a nurse specialist at Middlemore Hospital to explain the condition and its management, after which her parents attended genetic counselling. Genetic testing, completed as part of Tiara’s newborn screen, indicated that she has the F508del mutation.

Tiara’s dad, Matiu, is a farm hand on a mixed-stock farm in the Franklin district and Tiara’s mother, Stella, is a primary school teacher but is currently on maternity leave. Tiara has 3 other siblings, 2 older and 1 younger. Following Tiara’s diagnosis, all underwent additional sweat testing, but none tested positive for the condition. Many of their extended whanau live in the South Auckland area and one of her first cousins and two 2^nd cousins also have cystic fibrosis. Whilst none of the family smoke, some of the farm workers who are regular visitors to the home smoke and vape.

Because of distance from community health services the family had home district nurse and physiotherapy visits when Tiara was very young, and for respite care when Tiara’s younger brother was born. Now, Matiu and Stella help Tiara take her nebuliser and apply chest physiotherapy twice most days. Tiara is currently smaller than her siblings were at her age, 94 cm in height, and weighing 13.7 kg, approximately in the 50^th percentile for BMI.

The family live close to a popular kindy which prides itself on being an Enviroschool. The youngsters learn about sustainability, nature and caring for their own plants and pets. Tiara desperately wants to go to kindy, like her older sister (aged 4.5 years), and Matiu and Stella are considering this.

1. 1. Cystic fibrosis is a multisystem disease caused by disrupted anion (chloride and bicarbonate) cellular transport.^64,65 List three organ systems commonly affected by cystic fibrosis. For each, briefly describe the pathological changes and associated clinical problems.
   2. Exercise intolerance is a common clinical feature of cystic fibrosis.⁶⁶ Explain how cystic fibrosis pathology makes aerobic exercise difficult for Tiara.
   3. Tiara had newborn screening for cystic fibrosis as part of the newborn screening programme (Guthrie heel-prick test).⁶⁷ Describe what this screening entails and why measurement of immunoreactive trypsinogen (IRT) can be used as an initial (Tier 1) test to identify most infants who have cystic fibrosis.