Discursion involving Inflammation Tissue Repair and Wound Healing

1) Inflammation, Tissue Repair, and Wound Healing
Case study on a 6-year old
Six-year-old, Carlton, suffered a deep gash on his foot when playing with his mom along the beachside. His mom washed the injured foot and took him home. The next day, Carlton’s foot worsened, with the gash growing pink, inflamed, warm and painful. So his mom put gauze on the wound before taking him to their community healthcare center.
· What is the physiologic mechanism causing the wound to become red, hot, swollen, and painful? How is this different than the inflammatory response that might occur in an internal organ?
An injured tissue starts healing instantly. Tissue destruction directly injures numerous soft tissue cells which leads to metabolism alteration, with chemical mediator liberation initiating inflammatory reaction (Tissue Response to Injury, n.d). The body’s intrinsic defense mechanism mediates acute inflammatory reaction against pathogen invasion at the skin’s entry portal or systemically in case of infection of internal organs, propagating inflammation. Acute inflammatory reaction leads to the creation of a harmful microenvironment through increased leucocyte and plasma movement (particularly granulocytes) between the blood and injured tissues, for localizing and destroying specific pathogens and initiating healing. It propagates inflammation, which forms part of a complex vascular tissue reaction to all harmful stimuli (like damaged cells or invading pathogens). As such, acute inflammation represents a stereotyped primary cellular and biochemical reaction occurring only in vascularized tissues where microbial pathogens and other harmful stimuli cause cell invasion, injury, or death. Further, its mediators include a torrent of biomedical occurrences furthering and maturing acute inflammatory reaction involving the immune and vascular systems, and several cells in the affected tissue. Acute inflammation’s key signs on the skin include swelling, redness; warmness; function loss; and pain. Acute internal organ inflammation might not produce all aforementioned key signs (e.g., pain may occur only if the inflamed spot has sensory nerve endings). Meanwhile, systemic inflammation impacts all body organs, manifesting as general infection (marked by pyrexia, cardiovascular and hematological changes, intensified metabolic functioning, and impaired renal, brain and liver function) (Berg, 2014).
· What are the immunologic events that are happening at the local level during Carlton’s acute inflammatory response?
Leukotrienes, cytokines and histamine are the chemical mediators vital to limiting exudate extent and, hence, extent of swelling, following injury. Histamine, which is secreted by damaged mast cells, results in vasodilation, increasing cell permeability because of endothelial cell swelling and separation. Prostaglandins and leukotrienes cause margination, where leukocytes (macrophages and neutrophils) stick to cell walls. Further, they improve local cell permeability, thereby impacting fluid, neutrophil, and protein passage across cell walls through diapedesis for forming exudate within extravascular spaces. Hence, active hyperemia and vasodilation prove critical to plasma (exudate) formation and to the supply of neutrophils to damaged regions. With increased swelling and extravascular pressure, lymphatic and vascular flow decreases. The extent of swelling is associated directly with vessel damage levels. Cytokines, especially interleukin and chemokines, largely regulate leukocyte traffic, facilitating phagocyte attraction to the inflammation site. In response to chemokine presence, leukocytes and macrophages move to the inflammation site in a matter of some hours (Tissue Response to Injury, n.d).
2) Steroids are often given for severe inflammatory pain associated with rheumatoid arthritis. For acute surgical pain, however, these drugs are rarely used, even though inflammation is probably the major cause of postoperative pain. Explain the rationale for the contrasting approaches.
Clinicians are usually warned to cautiously utilize topical steroids in post-surgical inflammation management owing to risks of cataract, intraocular pressure elevation, steroid dependency, and fungal or viral infection exacerbation. Such complications commonly result in premature discontinuation of treatment or, at the very least, a lowering of concentration or dosage. Sometimes, clinicians totally avoid steroid treatment, treating a potentially chronic or recurring problem sub-optimally. But topical steroids are an irreplaceable inflammation treatment, being the main anti-inflammatory, broad-spectrum ophthalmic product on hand. Steroids’ action mechanism impacts inflammatory reaction at all levels, thus being instantly effective among individuals suffering from ocular inflammation. On the cellular level, steroids suppress key inflammatory cell proliferation (including lymphocytes and mast cells), besides stabilizing extracellular membranes. Meanwhile, corticosteroids, on the biochemical level, hinder histamine production, enhancing its breakdown. Ideal steroids are anti-inflammatory and broad-spectrum, with site-specific, targeted, swift reaction (Lane, 2007).
3) Discuss why you feel sequence in physical examination is essential. Be sure to thoroughly support your answer.
History-taking and physical examination are embodiments of the age-old patient care and healing skills. Effective gathering of nuanced, sensitive patient history and a correct and comprehensive examination improves the clinician-patient relationship, sets clinical thought direction, and focuses patient evaluation. These steps influence the subsequent stages of the treatment process, guiding clinician choices. With increased patient volume and shorter encounter times, clinicians must establish a timely working diagnosis. Increasing healthcare expenses and the current state-of-the-art technological equipment necessitates selectiveness when it comes to utilizing healthcare tools and using specific patient evaluation findings as the basis for testing decisions (Bickley & Szilagyi, 2012). Thus, physical exam and patient medical history prove crucial to diagnosis, frequently offering more insights as compared to broad testing. The former provides important evidence to narrow down the list of potential causes of the patient’s condition while the latter can offer clues to the underlying diagnosis; both, combined, narrow down the clinician’s diagnostic workup, eventually resulting in a timely, accurate diagnosis (Muhrer, 2014).
Physical exams also play a vital role in the limiting of avoidable, extensive diagnostic testing, ensuring decreased patient as well as clinician cost. Performing too many tests may prove stressful to patients as well as providers, potentially generating unanticipated key positive findings or red herrings typically unrelated to the original issue. Attempting an evaluation of incidental findings may be nonproductive as well as time-consuming whilst not facilitating determination of the actual cause of the patient's symptoms. The above issue is exacerbated by steep healthcare bills which increase patient stress (Muhrer, 2014). Depending largely on rough imaging may result in grave mistakes when physicians fail to take physical findings into account. Clubbing, tremors, rebound tenderness and other such key signs undetectable in scans may indicate a major underlying disorder. For preventing such errors, the practice of conducting physical patient examinations must be revived (Muhrer, 2014).


References
Berg, R.H. (2014). Communicable Medical Diseases: A Holistic and Social Medicine Perspective for Healthcare Providers. Balboa Pr.
Bickley, L., & Szilagyi, P. G. (2012). Bates' guide to physical examination and history-taking. Lippincott Williams & Wilkins.
Lane, S. S. (2007). New thinking in the treatment of postoperative inflammation. Retrieved May 14, 2018, from https://www.healio.com/optometry/cornea-external-disease/news/online/{8f41d77a-e214-4109-89b9-5f172d41529a}/new-thinking-in-the-treatment-of-postoperative-inflammation
Muhrer, J. C. (2014). The importance of the history and physical in diagnosis. The Nurse Practitioner, 39(4), 30-35.
Tissue Response to Injury (n.d.) Retrieved 14 May 14, 2018 from http://highered.mheducation.com/sites/dl/free/0078022649/998035/Prentice15e_Chap10.pdf