1. Question 1 Answer 

a. Based on the presented clinical picture of the patient it can be evaluated that she is suffering from two identified diseases namely alcoholism and depression. 

b. Depression- Low self-esteem and teary (Mulhall et al., 2018)

Alcoholism- It can be identified by frequent mood swings and loss of memory (Ghosh et al., 2016). 

c. Pathophysiology 

Depression- Flagship characteristics of depression are circadian rhythm changes that occur in the disturbed secretion of melatonin and disturbed sleep. The pineal gland, situated in the middle of the brain in between two cerebral hemispheres, secretes melatonin, identified as the precursor of sleep (Yang et al., 2018). Through regulating the circadian rhythm of the body, controlling the pattern of development of clock genes in the suprachiasmatic nucleus (SCN) and altering the primary serotoninergic neurotransmitter genes associated with depressed mood, melatonin has a depressive impact (Kraus et al., 2017). Such symptoms are evident in Mary’s case. 

Alcoholism- Alcohol impairs almost all organ system in the human body and might cause death and coma when taken in high doses. It affects various brain neurotransmitter processes, like GABA, opiates, serotonin, dopamine and glutamate. Increased amounts of opiates enable the euphoric impacts of alcohol, while sedative effects and anxiolytic are triggered by its effects on GABA (Stickel et al., 2017). A receptor for glutamate is blocked by alcohol. Long-term absorption contributes to even more glutamate receptors becoming synthesised. The nervous system exhibits heightened excitability as alcohol is eliminated. People who consume alcohol for a longer period are more likely than people who have been drinking for a shorter time to have "alcohol withdrawal syndrome" (Milivojevic & Sinha, 2017).

2. Question 2 answer 

The chosen drugs are diazepam and Fluoxetine

Diazepam- 

Action mechanism- Diazepam is a tranquilliser of benzodiazepines with anticonvulsants, sedatives, muscle relaxants and amnesiac properties. In different areas of the brain and spinal cord benzodiazepines, such as diazepam, bind to receptors (Jacob et al., 2020). The inhibition effects of gamma-aminobutyric acid (GABA) are enhanced by this interaction. The functions of GABAs include CNS engagement in sleep induction. Hypnosis, recollection, depression, neuronal excitability and epilepsy modulation are often associated.

Use- A benzodiazepine is an anxiolytic, anticonvulsant, sedative, amnesic, long-acting effects and muscle relaxant. Its acts are controlled by enhancing the function of gamma-aminobutyric acid. It is used as an anticonvulsant, and in the control of alcohol withdrawal syndrome, hypnotic in the short-term control of insomnia, as a muscle relaxant and premedicant and in the management of acute and severe anxiety disorders (Dhaliwal & Saadabadi, 2019).

Fluoxetine

     Action mechanism- Fluoxetine is an effective inhibitor of serotonin reuptake (SSRI) and expends its therapeutic action by suppressing the neurotransmission serotonin synapses reabsorption, as the name implies. As a consequence, in different areas of the brain, concentrations of 5-hydroxytryptamine (5-HT) is raised (Lyte et al., 2019). In comparison, for 5-HT transporters, fluoxetine has a strong affinity, a poor affinity for noradrenaline transporters, and no affinity for the dopamine transporters, suggesting that it is preferential for 5-HT (Lyte et al., 2019).

Use- Fluoxetine is an antidepressant of the 2nd generation, listed as a selective inhibitor of serotonin reuptake (SSRI). Fluoxetine is suggested for acute and preventive care with major depressive disorder, antisocial personality disorder (Micheli et al., 2018). Fluoxetine can also be used to relieve depression associated with resistant depression in conjunction with other benzodiazepines.

3. Question 3 answer 

Yes, form the clinical picture it can be said that Mary-Lou is suffering from alcohol addiction. With time her dose in increasing and affecting her nervous system and impacting other organs too making her feel disoriented (Ceccanti et al., 2018). This is turning from short term addition to long term adverse health effects as Mary started with one glass of wine per night but the dose has increased to further three or more glasses. This majorly affects the brain of the patient. Psychological dependence shows that Mary does not get enough sleep without taking alcohol.  Further, Her daughter states she forgets topic on the phone calls, reason for going to fridge and others factors depicts the alcohol dependence and its impact on the patient's brain by impacting the memory (Khosravani et al., 2019). Further, the most common symptom is blackouts and acute intoxication. According to Palpacuer et al. (2018), with excess alcohol dependence, the patent might suffer memory loss, difficulty in learning, speech impairment, neuropathy which is evident symptoms in Mary’s case. 

The physical dependency symptoms can be characterized by improper coordination in walking, moving and balance. Park et al. (2017) put forth that chronic alcohol addiction is correlated with the disturbed gait of the individual along with imbalance of the body and are important sequels for the determination of addiction.  

4. Question 4 answer 

Many drugs show excessive side effects among the old age individuals as compared to the young ones. This is generally due to hindered capacity of the older adults as they show increased medication responsiveness (Jansen et al., 2016). Hence, it is necessary to reduce the MedX dose for Mary. The four age-related complications include- 

a. Increased Sensitivity to Drugs- Problems with reduced body size, changed body shape (more weight, less water), and reduced kidney and liver functioning allow certain drugs to persist at dangerously elevated levels and over longer periods in older people's bodies than in younger generations (Jansen et al., 2016). 

b. Metabolism-Older people typically have a lower metabolic rate. This adds to reduced medication bioavailability. Lower dosages could therefore perform well. In elderly adults, the rate of opioid synthesis is decreased, so free plasma levels in them is high relative to adolescents (Barardo et al., 2017). Basal metabolic rate is greater in younger individuals than in older persons.

c. Excretion of drugs- by the age of 60 and above the kidney shows inefficiency in releasing toxins out of the body and many drugs can have harmful impacts in turn (Patel & Lewis, 2018). Further, giving higher doses of drugs the older adult becomes susceptible to adverse kidney reactions and can suffer co-morbidities. 

d. Owing to a loss of intestinal blood supply and decreased gastric acidity, medication intake is decreased in elderly persons. Therefore, a lower dose is required. The diffusion rate is lowered because the concentration of free plasma is greater than in adults (Drenth et al., 2020).

Case study 1, part 2- Musculoskeletal disorders

5. Question 5 answer 

Crepitus is when two rough surfaces in the human body come into direct contact, the sound is produced, for example, in rheumatoid arthritis or osteoarthritis when the cartilage between joints erodes and the surfaces scrape against one another in joint, or if the two damaged surfaces of the skull fractures rub together (Osias et al. 2018). The cartilages get closer through arthritis, and deterioration of the cartilages progresses, which also leaves the bone exposed and leads to inflammation (Osias et al., 2018). Because of this, irritation develops as the bones press against each other and stiffness contributes to joint movements becoming difficult. 

Sign and symptoms- 

1. Cracking or popping sound while bending the elbow or knee  
2. Crunching sensation or crackling sounds while moving the joints such as shoulders 
3. Continuous or occasional swelling surrounding the joints
4. Mobility is affected by the increasing inflammation  
5. Redness might be present in rare cases on the joints (Silva et al., 2018) 

6. Question 6 answer

It is different from other joint diseases learnt in the module as crepitus is a disorder as which causes a sound reflex of crackling or crunching that is correlated or related to the existence of air in the subcutaneous tissue. Also, some inflammatory diseases are characterized by bone-to-bone friction although this rarely happens in other joint disorders (Silva et al., 2018). The sound is the product of irregular air, bone or bone connexions. Another example is where fluid leaks from the sinuses and a nasal bone fracturing can be felt through the skin overlying it but the sound is not commonly felt. Crepitus also stems from previous injury or arthritis to the joint. Even so, the surrounding air in the tissue that may be due to an injury or certain forms of infectious diseases may often lead in a crackling or cracking sensation and an irregular sensation in the joint (Ju et al., 2019).

7. Question 7 answer 

a. According to Clark et al. (2017), the increase in chronic inflammation is the major cause of delayed healing of fractures among older aged individuals. Next, the bone of the younger individuals are much thicker and stronger and are oxygen-rich which increases the healing capacity as compared to the older adults.  

b. The fracture would take a long time to heal because of the three identified physiological factors- 

i. Regeneration of cartilage is slow

Due to injuries, culminating in osteochondral defects or focal chondral, or as more dispersed cartilage deterioration in a systemic organ disorder such as cartilage damage and this may grow. With growing age, deterioration of cartilage structure and consistency is very evident (Qasim et al., 2020). There is a range of disorders ranging from focal cartilage abnormalities with underlying cartilage and chronic inflammatory cartilage focal lesions, and dispersed lesions. Such disorders with age affect the healing capacity of the fractures in older adults.  

ii. Bone mineralisation

People, particularly females after menopause, loss bone density or mass as they age. Calcium and other nutrients are lost to the bones. Bones called vertebrae to make up the spine. Gel-like padding (called a disc) in between each bone. The loss of calcium in bones does affect their functioning and makes them weak and commonly in females (Allen & Moe, 2020). 

iii. Poor cellular differentiation

Age-related changes that can adversely impact fracture healing are seen by immune cells ad stem cells involved in fracture healing. This results in increased oxidative disruption, and reduced ability for osteoblastic and chondrogenic progression with age (Wang et al., 2018).

c. Risk of falls and injuries and blood clots are collated with hip fractures in elder individuals. 

8. Question 8 answer 

Mary is suffering from a fracture.  

Pathogenesis- Pathological hip fracture, a crack in the proximal (topmost) end of the femur. This can occur at any age in the individual’s life but they are most likely to affect elderly individuals due to delayed healing (Guerado et al., 2016). Significant impact crashes, and fragile bones or bone failure (osteoporosis) are common causes. With age, the likelihood of hip fractures from falls and bone deterioration increases. The mineralization deficiency has also been suggested as a cause of "bone weakness," rendering an "osteoporotic" hip fracture vulnerable to elderly people. According to recent research, however, the issue of mineralization in the elderly is not a normal reduction of the volume of calcium in the bone, but an erratic distribution of its mineralization (Guerado et al., 2016). In the periosteal, tissue minerals concentration is slightly higher and declines from that to the endosteum; it declines from the femoral neck to the proximal portion of the neck of the femur and therefore varies radially. In addition, tissue differences are subject to major changes in bone elasticity in the axial direction of the femoral spine. 

Bisphosphonate administration- Bisphosphonate therapy decreases the risk of fracturing by the reduction of bone resorption. Bisphosphonates (BPs) are formulations of inorganic pyrophosphate, where the two phosphates become bound by carbon instead of oxygen. As a consequence, in order to attenuate their physicochemical effects, BPs have two side chains that can be altered (Seo et al., 2016). BPs possesses a higher calcium affinity, and they specialise in the bloodstream at sites of successful bone remodelling in the skeleton. During the anabolic process of remodelling, all groups of BPs become lodged in new bones by attaching to bone hydroxyapatite, whereby they remain inert (Seo et al., 2016).

Case study 2 - Neoplasm and microbiology case study

9. Question 9 answer 

Tumours are mass or accumulation that proliferates abnormally. Tumours may be malignant or benign tumours depending on their bioactivity.

Malignant- Malignant cells are considered cells that have the capacity to invade the surrounding tissues. They are generally referred to as cancerous tumours that cause unregulated tumour growth and metastasis (Kleinovink et al., 2017).

Anaplastic- Typically, malignant tumours contain undifferentiated cells and this characterization of the cells is referred to as Anaplasia. A malignant neoplasm resulting from the unregulated multiplication of cell populations of epithelial origin or exhibiting such epithelial features is a generic term for anaplastic carcinoma (Battistella et al. 2017).

Metastatic- Metastatic tumours are ones that may migrate to distant locations and internal organs where malignancy progresses and starts to infiltrate again (Ramirez et al., 2018).

Prognosis of malignant tumours: The prognosis for malignant tumours is low. They propagate or proliferate to remote locations and propagate across the body if detected late. They will not be healed by mere surgical intervention, but cancer treatments such as radiotherapy, chemotherapy etc. are needed to eradicate the surviving malignant cells because they may have the potential to attack again while they persist (Kleinovink et al., 2017). If not detected diagnosed and treated early systematically, malignancy can be lethal.

The difference from benign, differentiated, localized growth- Cells which do not infiltrate or grow rapidly is benign tumours. They remain in a localised position. The cells resemble and are well distinguished from their originating tissue are known as the differentiated ones (Song et al., 2016). They have easy prognosis as compared to other cells.  It is possible to treat benign tumours if excised by surgery.

10. Question 10 answer

Cancer is one of the most widespread forms of chronic illness. Cancer is a disease in which unregulated tumour growth occurs and it can be malignant and there is a risk of progressing to other parts of the body. The causes of cancer may be influences associated with obesity, exposure to Ultraviolet ( UV exposure, some cancer-causing or biomedical substances, such as hereditary defect inheritance, and both of these aspects may lead to cancer by a genetic mutation that controls cell proliferation and regular working gene expression in our body and unregulated cell growth. Metastatic is the mechanism in which cancer cells exit the primary tumour mass and migrate through lymphatic and blood channels to form new complexes in other body sites, rendering them more invasive and metastasizing with the following characteristics (Little et al., 2016).

Resisting cell death- By resolving cell death (configured cell death) by reconditioning the genes regulating cell death and its associated enzyme called caspases, they can avoid apoptosis and this lack of control over the cancerous cells allows them to expand or live for a prolonged period and enhances invasiveness, induces angiogenesis, provides more time for alterations, etc (Little et al., 2016).

Altered metabolism- Tumor cells use glucose and other substances for their development by angiogenesis throughout tumour formation (tumour cells display a high degree of glycolysis) and both of these factors make them increasingly invasive (Faubert et al., 2020).

11. Question 11 answer

Bruce's case study is characterised as colonic cancer, which is the production of intestine polyps, according to the details provided. Polyps bleed further into digestive tract causing inflammation and constant loss of blood or iron and are the cause for fatigue. Anaemia (iron deficiency anaemia) may be caused by this lack of iron, and fatigue (weakness) is the most frequent characteristic of anaemia. Without an adequate amount of iron, red blood cells in the body can not contain enough of a component that helps them to hold oxygen (haemoglobin) (Ruiz et al., 2019). As a consequence, anaemia with iron deficiency can leave Bruce feeling fatigued or even shortness of breath.

The cause for the elevated risk of infection is the lack of essential intestinal flora (bacteria) attributable to excessive bleeding from the intestine, that certainly benefits combat few pathogenic bacteria and even neutropenia. That means reducing the number of neutrophils. About 61% of our white blood cells are macrophages which are the scavengers of the body; blood loss will primarily contribute to neutropenia, thus increasing the risk of infections (Piovani et al., 2020).

12. Question 12 answer

The modes of reducing the chances of Bruce includes the two following:  

Wearing PPE kits hat is personal protective kits- According to WHO (2020), using gloves, sanitizing hands and wearing masks are the most successful ways of eliminating the transfer of the virus from person to another along with social distancing.  

Susceptible host- Persons undergoing chemotherapy are vulnerable to weaker immune system in the case of immunosuppressed cases, (neutropenia) immunotherapy; improving immunity in addition to chemotherapy is effective in avoiding the infection (Lee et al., 2020)