1.1. Heart rate is a prognostic marker for longevity. It is not only a sign of the body activity but also a reflection of various medical problems. The lower the rate is (within the defined norm), the better the cardiovascular system of the body functions. 160 beats per minute is an increased heart rate, especially for an old person who is 76 years old. Hence, it will definitely have a negative impact on Mr. Roberts’ state.

Heart rate is quite influential for the myocardial oxygen supply and demand. The point is that primarily heart is the highest oxygen-consuming organ. Arteries extract 70-80% of oxygen (Ramanathan & Skinner, 2005). Such number is three times higher than oxygen consumption in the rest of the body. Growing indicators of the oxygen consumption have to be met by coronary blood flow in case of some sport exercising. In such case, oxygen supply and demand would match. However, it can also happen that coronary blood flow increases independently of exercising. Hence, the coronary arteries splint the heart and lead to the diastole decrease.

Myocardial oxygen supply depends on the diastolic perfusion pressure, O2-carrying capacity, and coronary vascular resistance. In its turn, coronary vascular resistance is predetermined by external compression and intrinsic regulation. As for the myocardial oxygen demand, contractility, heart rate, and wall tension are the major determining factors. Hence, changes in myocardial oxygen demand are reflected in the heart rate, overall cardiac work, and metabolic heart demands. The increase of the heart rate leads to the diastole decrease together with decrease of the myocardial perfusion, which occurs during diastole. These processes are very likely to increase the myocardial ischemia, worsen the coronary constriction, and lead to the coronary artery stenosis (Bertrand, n.d.).

Ischemic heart disease is one of the most common heart failures associated with increased heart rate. In addition, both features are common for the improper coronary blood flow. Many factors predetermine coronary blood flow. Ramanathan and Skinner (2005) have emphasized perfusion, pressure, extravascular compression, metabolic, endothelium-mediated, and neurohumoral regulation as the processes that are closely interconnected with heart rate. The increased heart rate is a sign of the increased coronary blood flow and serious failures of metabolic regulation. In addition, it is the evidence of the severe coronary stenosis and reduced diastolic duration. Some other results of the abnormal oxygen distribution can be diabetes, hypertension, and atherosclerosis.

As far as the main symptoms of the coronary ischemia and atherosclerosis are stable angina and acute MI, UA, and AMI, these syndromes can possibly be observed in Mr. Robert. Asymptomatic ischemia as well as a symptomatic one, which is often associated with coronary narrowing, is preceded by the increased heart rate. However, according to Bertrand (n.d.), in case of the increase from 60 to 80 beats per minute, the situation with Mr. Robert demands peculiar attention. The heart rate is very high even though it is important to remember that the normal heart rate is individual for each person. With regard to the fact that ischemia development risk increases with the heart rate increase, it is important to understand that 160 beats per minute is a great risk. However, the rate definitely needs to be compared to the previous indicators. Thus, limiting the increase of the heart rate is an effective mean of ischemia prevention. According to Bertrand (n.d.), such strategy lets ?-blockers provide benefits to the coronary artery disease while their reversion has a destructive effect on the ventricular function. To sum it up, it is obvious that the increased heart rate is the sign of the coronary artery disease and abnormal myocardial oxygen distribution.

1.2. When dealing with the radial artery, it is important to remember that it is of great significance not only in terms of taking pulse but also for indicating the systolic blood pressure. As the major artery on the forearm, it supplies the blood from lungs. However, it is not the only artery on the hand. Hence, it does not endanger the patient strongly if the first aid is provided in time. As for John’s case, the loss of the big blood volume is the main danger for the patient. Such considerable blood loss has to be recognized as early as possible in order to avoid the shock with its consequences and provide effective actions.

The injured artery causes the decrease of the systolic pressure. Moreover, it reduces the delivery of the oxygen to the organs of the body. In fact, the blood that is carried away from the heart in order to bring oxygen to the body parts is lost. Consequently, neither the heart nor the organs that had to be supplied with it can function properly. Quite often, the reactions of the organism can include the hypovolemic shock, anemia, hemorrhage, pains, and loss of consciousness among others (Stainsby, MacLennan, & Hamilton, 2000).

Hypovolemic shock is the reaction of the human body on the loss of the 20% of blood. Firstly, it is characterized by the organs failure and loss of plasma and cells. In separate cases, due to hypovolemic shock, the organs even stop working (Heller, 2014). Hence, it is crucial to understand that the blood loss can become a serious trauma for the human body. Among the main responses of the human body to the blood loss and hypovolemic shock, one can point out anxiety, confusion, general weakness, pale skin, rapid breathing, and unconsciousness. The more blood is lost, the more serious the reaction is. The most serious complications can cause kidney or brain damage, heart attack, gangrene of the limbs, or even death (Heller, 2014). As far as John has lost 25% of blood, it is obvious that the consequences will be very severe and will demand rapid reaction from the medical workers. Long-term detention of the hospital visit increases the possibility of hypovolemic shock and makes the risks to life grow considerably.

The transportation of the patient to the hospital is an important aspect. It is necessary to keep John in warmth and comfort not to allow hypothermia leading to an inadmissibly low body temperature (Heller, 2014). He can lie flat with legs put 12 inches higher than the body and head in order to improve the circulation of blood (Heller, 2014). The main aims of the medical treatment in such case include increasing the blood pressure and replacing the fluids in the body. Hence, dopamine, dobutamine, epinephrine, and norepinephrine are commonly used in such situations (Heller, 2014). However, what is the most important after the delivery of the patient to the hospital is that all medical professionals including surgeons, anesthetists, hematologists, and blood bank staff have to interact very tightly in order to save a patient (Stainsby et al., 2000). Stainsby et al. (2000) also emphasize that secure hemostasis, renewal of circulating volume, and efficient blood component replacement are the main aims of the medical workers who have to work with a patient with considerable blood loss.

Depending on the state of the patient, the responses of the medical staff can vary. The tests can include physical examination, blood chemistry tests, or kidney function test (Heller, 2014). In other cases, the tests are not the priority and should be conducted after the life of the patient is not under threat. However, there are some common rules related to the doctors’ responses. These demands include circulating volume restoration as the first task; contacting the clinician in charge, blood bank, anesthetist, and hematologist; stopping the bleeding; conducting laboratory investigations; and providing the patient with sufficient amount of the corresponding blood (Stainsby et al., 2000). Hence, the reaction of the body to the considerable blood loss can be more or less rapid and endangering. However, timely aid is the prerequisite of successful recovering.

2.1. To begin with, one should pay particular attention to physiological aspects of Mr. Black’s work. Taking into account the fact that he is a truck driver, it is obvious that he has mostly sedentary lifestyle with not much walking. Hence, the pain in the lower leg while walking is the reaction to the actions that are not so common for the veins and joints of the 56-year-old man. The analysis of Mr. Black’s problem should start with the immobility of the lower legs during his work. He obviously sits in a car, making only slight moves with his feet all day long at work. Hence, one of the first assumptions should be the common disease of the drivers called thrombosis. The types of thrombosis include deep vein, cerebral venous, cavernous sinus, and portal vein thrombosis (Wedro, 2015).

The legs have both superficial and deep veins. Their main difference from the arteries is the complete absence of the muscles within their walls. For this reason, veins cannot pump blood to the heart with their own strength. Only physiological activity is helpful to do so. Blood can be returned to the heart due to the work of the large body muscles that affect the veins. However, this can happen only in case of the normal and regular activity. Mr. Black’s work does not provide his body with normal activity and his muscles on the legs with enough motion to move the blood in the veins. As for the seldom pedestrian walks, they become an exception to the common schedule and lead to unsuccessful attempts of the muscles to push the blood clots that have appeared due to immobility.

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In addition to immobility, the reasons of the DVT can include traumas, obesity, bruises, hypercoagulation predetermined by genetic predisposition, cancer, increased amount of the red blood cells, smoking, and some other exterior influences (Wedro, 2015). As for the advice to the patient, it is necessary to be more active and take low doses of heparin or enoxaparin as prophylaxis. In order to make the immobile work less harmful for health, it is necessary to get up earlier and walk for at least an hour before sitting at the wheel.

The blood clot, or thrombus, can appear in the deep or superficial veins system. However, the diagnostics of the superficial thrombosis is a bit easier due to more obvious swelling of the superficial veins. Moreover, thrombophlebitis does not evoke pain while walking as it happens with Mr. Black. The deep veins are not visible without any special facilities. However, additional symptoms that accompany pain usually are swelling, tenderness, and warmth (Wedro, 2015). DTV is not dangerous while the throbs do not move. However, it can become a threat to the human life if this clot of platelet, cells, and fibrin starts moving to the heart.

It is obvious that the diagnosis of DVT cannot be based solely on the assumptions and needs special tests that follow the physical examination. The blood tests and ultrasound are the effective means of diagnostics. Ultrasound is an effective mean to define whether the clot exists, where it is situated, and its sizes. D-dimer test is an effective chemical test that is also quite helpful in diagnosing the patients with thrombosis (Wedro, 2015). Diagnostics can also be based on venography and some other approaches.

After the confirmation of the diagnosis, Mr. Black must get the recommendations about the treatment. In case it is DVT, depending on the number, size, and position of the clots, it is necessary to define whether it is complicated or not. During three months, it may be recommended to have the regular ultrasound examination and intake such medications as warfarin or heparin. Such anticoagulant medicines are used to block blood clotting, but they are time-consuming, as they are prescribed as a two-step procedure (Wedro, 2015). In contrast, factor X is a more immediate procedure to thin the blood. Apixaban, rivaroxaban, dabigatran, and edoxaban are used for the latter procedure. However, the therapy is not always appropriate. Hence, placing a filter in the inferior vena cava also becomes an option. Finally, surgery for removing the clot is the last possible option.

3.1. Heart murmurs are not rare among the neonates and infants. Fortunately, they are not always the sign of a disease and disappear with age, usually till adolescence. Very often, they are estimated as innocent instead of pathological, which means that they are not the symptoms of the heart disease. In the current case, it is important that the murmurs are acyanotic, not accompanied by other symptoms, and can be the result of the normal blood flow from the heart and blood vessels (Gandhi, 2014). However, it does not mean that a harsh, loud, systolic murmur best heard at the left lower sternal border can be neglected. The lack of symptoms is not the evidence that the heart of the child is healthy. Especially, the harsh sound and pale skin should raise serious worries among the healthcare workers.

Cyanosis usually is the sign of pathological heart failures. Hence, the fact that it was not developed is important evidence that the murmurs are not pathological. Being the evidence of insufficient saturation of tissues with oxygen, it is the obvious visual sign that the blood does not circulate properly and the heart does not work properly. Even though on the current stage the murmurs seem to be asymptomatic, systolic, and acyanotic, it is disturbing that the sounds are harsh. The innocent murmurs usually are sensitive to the change of the position, short, soft, single, and sweet instead of harsh. Hence, it is necessary to change the position of the child to check the nature of the sounds. Moreover, the neonate has to be under regular control in order to check whether the pale skin color may further develop into cyanosis. However, even if cyanosis does not develop further, it is necessary to re-examine the child with the help of echocardiography in case the murmurs become continuous.

Very often, murmurs are the signs of heart disease. In 50 % of cases, they are pathological and lead to serious complications with the health of a child (Gandhi, 2014). However, in order to mark the murmurs as pathological, it is necessary to provide thorough investigation. They can be accompanied by a number of different symptoms. The symptoms of the heart disease among the neonates include poor feeding without gaining weight properly, breathlessness, blue episode and sweating, tachypnea, tachycardia, hepatomegaly, poor peripheral pulses, low oxygen saturation, and faltering growth (Gandhi, 2014). As far as these symptoms are not observed, one can think that the current situation is not an example of the heart disease. However, it is necessary to analyze the murmurs in terms of intensity, systolic and diastolic timing, transmission, and quality. The given case shows harsh, loud, systolic murmurs best heard at the left lower sternal border. Hence, such diagnoses as VSD, Still’s murmur, HOCM, and TR are not appropriate because of the loud and harsh nature of sounds that does not characterize innocent murmurs (Gandhi, 2014). With regard to the nature of the murmurs, the diagnosis of Still’s murmur, which is characterized by the musical quality and lack of some extra clicks, is inappropriate. Still’s murmur is a result of the blood flow in aorta and the left ventricular outflow tract. However, such blood flow does not cause paleness and harsh sounds.

Nevertheless, it is impossible to make the right conclusion with the help of only physical examination. A thorough investigation is necessary in order to define the real reasons of the murmurs. In case the murmurs estimation shows that they are grade 3 and accompanied by some other symptoms, the healthcare workers should definitely estimate them as potentially life-threatening. Hence, it is necessary to refer to echocardiography in order to identify cardiac defects or anatomical abnormalities. Femoral pulses palpation and pulse oximetry are also common approaches to examine the possible heart defects and estimate the possible consequences of the health state of the child

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