1 the patient and their presenting symptoms.
Mr Pickles presents an interesting, complex and therapeutically challenging problem. In essence he is a gentleman with multisystem pathology who presents with an almost incidental finding which he was clearly reluctant to discuss.
It is a common finding amongst experienced healthcare professionals that in any consultation it is the last 30 seconds which is the most important. As the patient stands up to go, there is the just while I’m here moment when they can bring up an issue that really troubles them and may not be the real presented reason for the consultation. In this essay we shall discuss the various aspects of this situation and the measures we can take to try to help him. (Parker and Lawton 2003)
2.a holistic assessment of the pt, including any relevant medical social and psychological issues.
If we start with the initial presenting symptom under discussion – the impotence – it is easier to work backwards from that to discuss the possible pathophysiology that can be relevant.
Impotence is said to occur whenever the male fails to get an erection when it is required. This, in itself is neither unusual nor necessarily pathological. It becomes a significant symptom when the male repeatedly fails to get an erection that is sufficient for intercourse. It is quite possible to get full spontaneous erections and yet still be impotent. This is one of the major diagnostic features that distinguishes the psychogenic impotence from the purely physical. (Ackerman MD, Carey MP. 1995)
There are a number of obvious physical causes of erectile dysfunction that are relevant to Mr Pickles (see on), but equally there are a number of possible psychogenic causes that may be either primary factors or possibly secondary contributory factors in the aetiology of his problems.
The fact that he has recently undergone major cardiac surgery is a very relevant factor. Patients will frequently suffer from a major change in body perception when they have come to a close realisation of their own mortality. If we add to this the fact that, as the major breadwinner in the family, it is likely that Mr Pickles would have felt a major blow to his self-esteem when he was made redundant from a responsible high esteem job and forced to become a taxi driver with long working hours. This is quite apart from the anxiety and fatigue that such a job would engender.(Beck J. 1995)
It is possible that the medication that Mr Pickles is taking may have a bearing on his erectile dysfunction as the male erection is dependent on the hydrostatic pressure of the blood for its maintenance. Any medication that reduces the average blood pressure, will effectively reduce the capacity to acquire and maintain an erection. In addition to this the adrenergic beta-blocker group will also selectively block the sympathetic pathways that are vital to the neurovascular control of the mechanisms of erection.
Pathophysiology of diabetes and impotence
Both of these topics are huge subjects, so in this essay we will restrict out considerations to those aspects which are relevant to Mr Pickles and his problems.
We know that Diabetes Mellitus affects about 2% of the UK population with a specifically higher incidence in both the Asian and Afro-Caribbean communities(Nathan 1998). There is also a marked genetic component in the development of Diabetes Mellitus.
Mr Pickles has Type II diabetes mellitus which is associated with a number of factors including a high BMI and increasing age. At 56 yrs. old he is currently at the peak incidence age for Type II diabetes mellitus (Gregg et al. 2003).
Diabetes Mellitus is known to be associated with a number of complications. The prevalence and incidence of the complications, in general, tends to increase with the length of time that the patient has been diabetic. There is also an independent variable for complications that is directly proportional to the degree of control (as measured by the HbA1 levels). In general terms, the better the control the lower the incidence of complications (Kissebah et al. 1999)
As far as Mr Pickles is concerned, there are two major complications of Type II diabetes mellitus that are directly linked with impotence and they are cardio-(macro)vascular disease and neuropathy. (Wagner et al. 1998)
We can deduce that Mr Pickles has macrovascular disease by virtue of the fact that he his recovering from a CABG. And this may well be a very relevant factor in his erectile dysfunction but also there is the question of neuropathy which typically occurs in about 2.4% of the general population, but this figure rises to above 8% in the diabetic patient over the age of 60 yrs. ( Hughes 2002)
Impotence tends to occur, in varying degrees, in about 10-15% of men under 40 yrs. Its incidence increases with age to the extent that 40% of men at the age of 40 yrs report a degree of impotence and this prevalence rises to 70% at the age of 70 yrs. (Gregoire 1999).
If we add to this basic clinical picture the fact that there are other factors such as hypertension, smoking, cardiac neurosis, loss of self-confidence, depression and iatrogenic causes (medication etc.) all of which may well be relevant to Mr Pickles, then it can be seen that there are a plethora of potential causes of his erectile dysfunction. (Barnes, DE. 2004)
Both of the first two causes (hypertension and smoking) are independent risk factors for impotence, quite apart for the fact that they are also risk factors for the development of the macrovascular complications of Diabetes Mellitus (Bowering 2001)
Mr Pickles’ diabetic state has been recently well controlled (HbA1 of 6.5%). This is important as the incidence of development of diabetic complications is reduced by between 34-76% (depending on the particular study) for every 10% reduction in the average HbA1 reading. (Bowering 2001).
In addition to all of these considerations, atherosclerosis is also a major complication of Type II diabetes mellitus, which, presumably is relevant to Mr Pickles because of his CABG, and this may be a major factor in the development of his erectile dysfunction.
Management plan 3.a plan/strategy based on critical understanding of physiological and pharmaceutical issues.
Any management plan must firstly be based on an accurate diagnosis. At this point in time we do not have this luxury. As we have discussed, there are anyone of a huge number of possibilities in the aetiology of Mr Pickles’ erectile dysfunction problem.
When confronted with a problem such as this, any experienced healthcare professional may reasonably chose to manage the problem by making a rational judgement of the probabilities of any one particular cause being relevant. Implicit in such a management strategy is the fact that there are some causes that my be correctable (iatrogenic, psychological, and life style related) and there are some that may not (macrovascular damage, neuropathy and atherosclerosis).
It is reasonable, in such circumstances, to discuss the situation openly with Mr Pickles and discuss with him the various treatment options. Patient empowerment and education is a vital strategy to adopt in circumstances such as this as Mr Pickles is far more likely to comply and respond if he understands the rationale behind the treatment plan.(Howe and Anderson 2003)
We would suggest that an appropriate strategy would be to initially tackle the situation on two fronts. The psychological aspects of the erectile dysfunction are probably best discussed with an experienced psychologist or councillor who has expertise in this particular area.
This is important because there is a considerable skill in eliciting the relevant factors from the patient. Many patients are reticent about talking openly about their imitate sexual details and there has to be a careful build up of trust and empathy on both sides. Factors such as good eye contact and a non-judgemental body stance are essential on the part of the healthcare professional if the optimal result is to be obtained
Not only can the issues that are relevant be explored, but also any one of a number of psychological treatment techniques can be employed. This is a matter of considerable clinical judgement and skill and therefore probably best done by an experienced healthcare professional in that area.
The pharmaceutical area can also be addressed as Atenolol is clearly not the best anti hypertensive to use as, not only will it reduce the blood pressure (which it clearly is important to do) but it also produces a counter productive beta-blockade which will not help the erectile dysfunction problem.
The difficulty is that, after the CABG, Atenolol does have a degree of action on the suppression of ectopic electrophysiological foci in the myocardium which is a recognised complication of the procedure. It also is thought to have a cardioprotective effect post-myocardial infarction. It is probably a good idea to change his anti-hypertensive medication, but in the circumstances, it is probably better to seek the advice of the surgical team who performed the CABG. before making the transition.
The question of Viagra has been raised by Mr Pickles. This is not as straight forward as it might initially appear. Viagra has been shown to work well in these circumstances. It has the downside that it allows sexual intercourse which is associated with increased peaks of blood pressure. As Mr Pickles is still in the postoperative recovery phase (16 weeks) it would again be sensible to consult with the surgical team as to their advice on the issue.
The other problem with Viagra is that if it transpires that the long term aetiology is actually psychological rather than purely physical, then the prescription of Viagra will often breed a feeling of psychological dependence which may firstly be both inappropriate and unnecessary and secondly, very hard to break. It is probably therefore inappropriate to consider such options at this stage in the management.
4.legal and professional accountability should be discussed.
The legal and professional issues are largely covered in the making of a management plan. In any area of professional competence, the best defence against criticism or censure, is the fact that a healthcare professional works from a rational evidence-based plan. It is for this reason that we have set out the rational and reasoning for the plan that we have chosen to adopt. It is actually quite permissible (legally) for a healthcare professional to be wrong on any given issue, as long as they have come to a reasoned and rational decision based on the facts that were placed before them. And behaved in a way that the majority of their professional colleagues believe is reasonable in the circumstances. It is, of course, central to these considerations, that all actions are carefully and fully recorded in the patient’s notes
5.a critical discussion of influences on prescribing decisions.
The area of prescribing for Mr Pickles is clearly important. To some extent, we have covered the reasoning behind the change of prescription earlier in this essay. There is a common misconception amongst many members of the public (and indeed many of the less experienced healthcare professionals) that the solution to every problem comes in the form of tablets on a prescription. The whole area of patient empowerment and education is often filled with issues of lifestyle change, healthy living, self care and positive thinking which can frequently be more effective that simply giving the patient a prescription. (Boule NG et al. 2001)
In the context of the NHS, it is a common observation that sometimes a prescription is given because it is the most expedient short-term measure in a given situation, (Dawes RM et al. 1974), however, time invested in an explanation to a patient as to why other measures might be equally as important is rarely time wasted., (Corrigan B. 1974)
Future management 6.consider your future prescribing activity based on experience gained from this case study.
In any professional area of activity, the author likes to use the mechanism of reflective practice to allow a critical assessment of a past course of action to modify future actions when faced with a similar situation. (Gibbs, G 1988)
On careful reflection of this case, I believe that I may have acted rather rashly in stopping the Atenolol as a first choice. On reflection, I believe that the Atenolol did need to be changed for any one of a number of other anti-hypertensive agents but I feel that, in retrospect, I would have been wiser to take advice from the surgical team before I made that decision.
Further reflection and discussion with other healthcare professionals (Marks-Moran & Rose 1996), suggested that another appropriate course of action would have been to stop the antihypertensive medication altogether for a short period.
This is on the grounds that his hypertension was not severe and was hitherto well controlled. If the erectile dysfunction was simply a reflection of the fact that the medication was holding his blood pressure down to a level where erection could not easily occur, a few days off the medication may allow a transient increase in his blood pressure to the point that erection could occur. As long as one was careful to monitor his blood pressure to ensure that it did not rise too far, I have been advised that this would represent a reasonable therapeutic trial to establish whether the underlying causes were mainly physical or physiological.(Wagner G et al 1998). On the face of it, this does seem reasonable but I believe that I would have to take further advice before I was fully comfortable with that decision.
It follows from what has already been discussed, that I also feel that I may have been too quick to consider the pharmacological interventions before making a complete holistic assessment of the patient. There are clearly a number of lifestyle adjustments that may be relevant here such as weight loss and increasing exercise and looking for a new focus in life (to minimise any element of depression) which would be comparatively easy to achieve with appropriate empowerment and education of the patient. (Funnell R et al 2004)
All in all, this is not a straight forward case. There are many elements which require careful and considered assessment. I believe that it is one of those cases that helps to point out that although there is a huge emphasis to be placed on modern scientific understanding and application of medical principles, there is also a very large element of human understanding and caring that is so very important to the successful management of patients such as Mr Pickles (Waterlow J. 1998)
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