Case Study-Primary Dysmenorrhoea

Primary dysmenorrhea is a lower abdominal or pelvic pain that can radiate to back and thigh without any underlying disease. It occurs before or during menstruation or both.

Case study- monitoring the diabetic patient

Monitoring should include:

• Twice daily glucose monitoring at different times of the day,
• Six monthly HbA1c and blood pressure monitoring.
• Annually lipids, U&Es, microalbuminuria and review with clinician.

Case Study-Treatment Goals for a Diabetic patient

Goals include:

• Lifestyle changes- weight loss, smoking cessation and regular exercise.
• Blood pressure should be <135/75 mmHg
• Total cholesterol should be <5.00mmol/L
• Blood glucose control that is HbA1c<7.0%
• Antiplatelet therapy.

Case Study- Insulin Types and Forms of Availability

Devices include:

• Vial + syringe
• Continuous subcutaneous infusion
• Penfill cartridge + injection device
• Flexpen (ready filled) - Innolet device has a larger dial on it.

Types of insulin:

• Short acting: soluble/aspart/lispro/glulisine.
• Intermediate acting: isophane/biphasic isophane/biphasic aspart/biphasic lispro.
• Long acting: protamine zinc/glargine/detemir.

Most come in highly purified animal and human sequence versions. Animal sequence versions are used in patients having higher titers of antibodies to human version.

Case Study- Insulin use in diabetic regimen

If fasting glucose is >6mmol/L then add intermediate acting insulin 6-10 units at bedtime, increase by 1-3 units every 3 days until target blood glucose is reached.

If fasting glucose is within range but daytime glucose levels are high, then add intermediate acting insulin 6-10 units at breakfast, increase by 1-3 units every 3 days until target blood glucose is achieved.

Case Study-Treatment Options For Diabetes

The aim of treatment is to bring the HbA1c to target value of 6.5% in a diabetic patient, and to educate the patient in terms of lifestyle modifications such as diet, exercise and to monitor their own plasma glucose levels to reach the target range. The treatment option should be according to patient’s acceptance and cost effective. The following steps are recommended if HbA1c is not below 7.5%:

• Take metformin, if it does not control HbA1c alone, and add sulfonylurea as well. If any of these drugs not accepted by the patient due to unwanted side effects such as nausea or hypoglycemia, thiazolidinedione can be added in place of any of these drugs. A rapid acting insulin secretagogue can be added if the patient has erratic lifestyle, as it requires once daily dosing.
• Add insulin or a thiazolidinedione (if insulin is not accepted by the patient). Exenatide may be considered if the criteria is met, that is BMI >35kg/m², on a cost effectiveness basis.
• Intensify insulin regimen overtime and take with pioglitazone if thiazolidinedione was effective previously or high dose insulin alone is ineffective.

Case Study- HbA1c in Diabetes

Red blood cells are composed of haemoglobin. When glucose is present in the blood it sticks to haemoglobin and forms glycosylated haemoglobin (HbA1c). The normal value of HbA1c is 3.5-5.5%, in diabetes HbA1c of 6.5% is indicative of good control. The blood glucose level of 6.5 mmol/L is equivalent to 7% HbA1c. This patient has HbA1c of 9% which is equivalent to 13mmol/L of blood glucose level is not indicative of a good diabetes control.

Case Study- Macrovascular and Microvascular Complications of Diabetes

• Macrovascular complications are related to cardiovascular system. The patient has a controlled blood pressure and cholesterol levels.
• Microvascular complications are due to high blood glucose levels for a longer period of time, which is demonstrated through HbA1c levels. The microvascular complications involve neuropathy, nephropathy and retinopathy. The patient has developed neuropathy, if it is not treated amputation will be required.

Case Study-Clinical issues for diabetic patient

He has diabetes not well controlled due to the presence of neuropathy and high blood sugar levels. The weight is needed to be controlled by diet and exercise to avoid insulin resistance otherwise injections will be used  to treat the patient.

Case Study- Osteoporosis Falls Prevention

Lifestyle modification including cessation of smoking, regular exercise, calcium and vitamin D supplementation is necessary to ensure a healthy life style.

The Patient risk of fall includes:

• Polypharmacy: taking four or more drugs at a time, especially sedating and blood pressure lowering medicines,
• Visual impairment,
• Depression or cognitive problem,
• Postural hypotension,
• Balance, gait or mobility issues (including stroke, Parkinson’s disease or joint disease).

The Environmental risk of fall includes:

• Inaccessible lights and windows,
• Slippery floors,
• Steep stairs,
• Lack of safety equipment such as grab rails,
• Loose fitting footwear or clothing,
• Lack of lighting particularly on the stairs.

Older people who fall should be called to specialist fall service, who:

• Have had previous fragility fracture,
• Scared of fall,
• Lives in unsafe housing conditions,
• Attended accident and emergency department following a fall,
• Called an ambulance following a fall,
• Two or more patient’s risk factors,
• Have had frequent falls,
• Falls in a hospital, nursing or residential area.

Interventions to prevent risk of fall and damage associated with it as follows:

• Improve vision, if possible,
• Prevent postural hypotension,
• Reduce the medications especially the sedatives to prevent falls if possible,
• Improve the residential place,
• Treat osteoporosis,
• Occupation therapy to help maintain the balance,
• The use of hip protectors in the hospital or community services,
• Rehabilitation by physiotherapy to regain confidence.

Monitoring the patient with the use of alendronate 70 mg weekly

      Monitoring should include:

• DEXA scan annually.
• An endoscope to check for stricture formation if difficulty in swallowing.
• U and E: especially plasma calcium and creatinine.

Case Study- Osteoporosis Treatment Options

• Bisphosphonates: available as daily, weekly or monthly preparations, taken on an empty stomach to avoid chelation with the metal ions in the food. It improves bone mineral density by 3 % per year when taken with calcium supplements.
• Calcitonin: available as nasal spray, but requires dietary calcium intake.
• Calcitriol: oral, but need to monitor plasma calcium and creatinine.
• Hormone Replacement Therapy: reverses the urogenitory symptoms but increases the chances of breast cancer.
• Strontium ranelate: must be taken on an empty stomach to avoid chelation with the metal ions in the food.
• Teriparatide: only by injection.
• Raloxifene: does not alter menopausal vasomotor symptoms.

Case Study- Goals of Therapy

The goals of the therapy are to increase the bone mineral density and reduce the likelihood of fracture.

Case Study-Osteoporosis Tests

Bone Mineral Density (BMD) using dual energy X-ray absorptiometry (DEXA) of the head of the femur (on the hip) is performed. The World Health Organization defines osteoporosis if the BMD is 2.5 or more below the adult female mean value. The difference of which is T-score. The T-score of -1 and -2.5 is considered as osteopenia. Other test for detecting osteoporosis is ultrasonography of the heel is performed.

Case Study- Osteoporosis Risk Factors

Mrs. Patel has a low body mass index (<21) and she is on long term steroids.

Other risk factors include poor dietary intake of calcium, lack of weight bearing exercises, excessive alcohol intake, premature menopause (before the age of 45), poor absorption of food consumed, occasional fractures, 3 or more episodes of amenorrhea before menopause, hyperparathyroidism, family history (maternal side).

Case Study-Osteoporosis

Osteoporosis is characterized by micro architectural deterioration of bone tissue and decreased bone mass, with increased bone fragility and risk of bone fracture.

Additional Information with the use of HRT

• To use barrier methods of contraception, as she can still conceive for upto 2 years after her menstruation stops.
• The risk of osteoporosis is decreased while using HRT.
• The risk of thromboembolism, endometrial and breast cancer is increased while using HRT.

Non hormonal treatments-menopause

       Non hormonal treatments include:

• Clonidine: for hot flushes.
• Selective serotonin reuptake inhibitors (SSRIs): for hot flushes.
• Gabapentin: for hot flushes, paraesthesia, aches and pains.

Hormonal treatments for menopause

Due to the presence of estrogen there is increased risk of breast, endometrial and ovarian cancer, venous thromboembolism and stroke, but there are decreased chances of vaginal atrophy, vasomotor instability and osteoporosis.

The use of transdermal formulations is preferred because of decreased systemic side effects as the drug may not undergo the first pass effect in liver, but patient’s preference is important.

• For localized (urogenital) effect: vaginal preparations are preferred having less systemic side effects.
• Without uterus: oral or non-oral estrogens without progesterone are used to avoid endometrial cancer.
• With uterus and perimenopausal: sequential HRT is used to allow a bleed.
• With uterus and postmenopausal: continuous combined HRT is used.
• High dose progestogen (medroxyprogesterone) is useful for vasomotor instability without any cardiovascular conditions.

Case Study- Menopause Cause

Reduction in the circulating estrogen levels. Serum Follicle Stimulating hormone (FSH) will be greater than 30IU/L.

Case Study- Hot Flushes

Menopause- hot flushes, night sweats, sleep disturbance, vaginal dryness and discomfort.

Monitoring of Hypothyroidism

Symptomatic improvement occurs in 2-3 weeks with the use of levothyroxine, but it takes around 6 weeks to bring TSH levels to normal. TSH monitoring is done every six weekly with the change of levothyroxine dose. Once TSH comes within range, thyroid profile test is conducted once yearly. The use of hormone replacement therapy and oral contraceptives raises the total T4 levels, so free T4 is also measured if the patient is taking any of these medicines. The usual dose of levothyroxine is 100-200 micrograms daily.

Hypothyroidism

Primary hypothyroidism is due to autoimmune disease (Hashimoto’s disease) in which the body produces antibodies against the thyroid gland. Possible causes are:

• Congenital- poor production of thyroid gland.
• Enzymes defect in thyroid gland.
• Dietary iodine deficieny
• Surgical removal of thyroid gland.
• Over treatment with antithyroid medicine.
• Radioactive iodine therapy.
• Lithium and amiodarone.

Secondary hypothyroidism results from an underproduction of thyroid hormones characterized by deficient thyroid stimulating hormone (TSH) stimulation by pituitary gland.

Case Study on weight gain

Hypothyroidism- low metabolic rate leading to weight gain, even on a calorie controlled diet, hair thinning and feeling cold.

Case Study- Pyridostigmine Use in Myasthenia Gravis

Pyridostimine is less powerful and slower in action than neostigmine but it has longer duration of action. It has mild gastrointestinal side effects, but antimuscarinic drug is still required for stomach cramps. The total daily dose of 450 mg should not be exceeded as it leads to acetylcholine receptor downregulation. Immunosuppressant therapy is required at a daily dose of 360 mg. it is only available as a tablet, unlike neostigmine which is available as a tablet and an injection.

case study- Myasthenia Gravis

 

• The presence of acetylcholine receptor antibodies.
• Edrophonium test: in which edrophonium chloride is injected intravenously to prevent acetylcholine degradation, hence the level of acetylcholine increases at the neuromuscular junction.
• Nerve conduction study: conducted for fatigue, in which repetitive neuronal stimulation is done. It results in decrements of muscle action potential due to impaired nerve to muscle conduction.

Case Study: Muscle Weakness

ANS: MYASTHENIA GRAVIS

It is an autoimmune disease which is characterized by muscle weakness that starts with exercise and resolves at rest.Ptosis (drooping of eyelids) is common characterized by blurred vision due to affected eye muscles that control the eye movements. Antibodies target the acetylcholine receptors by altering or destroying them at the neuromuscular junction, hence contraction of the muscles does not take place, and there are fewer acetylcholine receptors available so the muscles receive fewer nerve signals.

acetylcholine