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.