HSE706 Research In Clinical Exercise Physiology

Question: Case Study Jake has just changed school and his teacher has advised his mum to see the GP. He has been very tired and sleepy during class. He has also been going to the toilet more frequently than the other pupils and this is especially noticeable in the afternoons after lunch. She also feels that over his first month at school he has lost weight and his new uniform seems much baggier than when he first started. His mum has also noticed that he is complaining of genital itching and she has not changed her washing powder. She has noticed that he is going to the toilet more, but she thought this was connected to the itching, and he has been drinking more as he is complaining of being thirsty. The only main change has been moving to a new area and starting a new school. Until his teacher got in touch with the additional information she had assumed it was just down to the stress of the relocation due to Jake’s Dads new job. The GP does some point of care testing and takes a finger prick of blood to test on a blood glucose monitor and does a dipstick of a urine sample requested at the appointment. These results are shown below:- · Blood glucose 22.1 mmol/l · Urinalysis of dipstick shows; Glucose ++ / 500 mg/dl / 28mmol/l and a small amount of Ketones 15mg/dl The doctor sends Jake to Accident and Emergency and orders a full blood count and also a urinalysis 1. Comment on all results that are of concern (blood and urine) and offer a diagnosis for Jake. You should represent and analyse this data appropriately. 2. Discuss the pathophysiology underlying cellular changes that account for Jake’s health status. You should also explain some of his signs/symptoms. Jake is admitted to hospital and an oral glucose tolerance test (OGTT) is requested. This is performed the following morning. Table 1:- OGTT Results 6 months later Jake attends an appointment with his consultant to monitor the control of his condition. His results were as follows:- · HbA1c of 9% or 75 mmol/mol · Urinalysis. Shows the presence of protein, leucocytes, nitrite’s and glucose. Flame photometry results:- · Na+ 200 mmol/l · K+ 5 mmol/l 3. Discuss these results and make a suggestions on what needs changing to optimise Jake’s health status. Answer: 1. Jake’s laboratory results are not within the normal range. According to Rao and Raju (2016, pp.2757-2761), random blood sugar of 22 mmol/L is higher than the normal random blood sugar of 7.5 mmol/L in a healthy individual. This should not be the case in a normal individual because insulin helps to lower blood sugar level by allowing movement of glucose from the blood to cells for use. Glucose in urine of 28 mmol/ liter is also higher than the normal value of between 0 and 0.8 mmol/L (Gu et.al 2016, pp.7191-7197). This is because nearly all glucose is reabsorbed in the proximal convoluted tubule of the kidney after being filtered by the glomerulus. This should, therefore, lead to the absence or very little amount of glucose lost in urine. Jake has also been going to the toilet more often than normal, a condition known as polyuria (Mahon.et.al 2018). This is as a result of glucose loss in urine therefore, water follows passively leading to large volumes of urine loss. He has also been feeling thirsty most of the time, a condition called polydipsia (Coleman.et.al 2016). The patient has to take too many fluids to compensate for fluids lost in urine. Basing on the signs and symptoms of Jake, a diagnosis of Diabetes mellitus type 1 can be made. This is due to the presence of polyuria, polydipsia, the presence of glucose in urine and random blood sugar of 22 mmol/L. Type one diabetes is also of early onset. 2. Pathophysiology of type 1 diabetes mellitus According to Zaccardi et.al (2016, pp. 63-69), type 1 diabetes mellitus is an autoimmune disease that occurs in individuals who are genetically susceptible and may be precipitated by environmental factors. In these individuals, the immune system is triggered to develop an autoimmune response against pancreatic beta cell antigen which resembles viral proteins. Antibodies are therefore produced leading to the destruction of beta cells which produce insulin. Some individuals with diabetes mellitus type 1 may remain in a prediabetes state for a long time before developing diabetes mellitus. When islets cells of Langham’s are destroyed, it results in very low or absence of insulin in the body. Blood glycogen increases and there is an impaired uptake of glucose by muscles and adipose cells. There is also an absence of inhibitory stimuli to hepatic glucose production, lipolysis, and ketogenesis. This further increases the glucose amount in the blood. Osmotic diuresis, dehydration, and diabetic ketoacidosis result. Muscle wasting is also observed in people with diabetes due to impaired uptake of amino acids for protein synthesis and failure to inhibit protein degradation. The main classical symptoms of diabetes are polyuria, polydipsia, unexplained weight loss and fatigue. Polyuria or excessive urination is due to excessive accumulation of glucose in the blood. When too much glucose accumulates in the blood, the kidneys try to reabsorb as much as possible but when it can’ t it eliminates through urine. When glucose is lost through urine, it creates a concentration gradient which leads to water loss from tissues. Fluid loss increases causing dehydration. The body, therefore, compensates by the urge of thirst in order to take more fluids. Weight loss result due to loss of glucose and calories through urine. The body, therefore, cannot use glucose for energy production but shifts to using of fats and structural proteins for energy production. This result in weight loss despite food intake. Fatigue is also one of the symptoms. Cells are unable to take glucose in order to convert to energy, therefore, decreased energy levels. The patient gets tired easily even after carbohydrate consumption. Itching may be a result of yeast overgrowth around the genital areas. High glucose level provides a favorable environment for microorganisms to multiply and therefore the usual normal flora becomes a problem (Hessler et.al 2016, pp. 750-758). 3. Oral glucose tolerance test is the amount of glucose in blood two hours after 75 mg of glucose intake. In a healthy individual, the glucose level should be less than 11.1 mmol/L after one hour and less than 7.8 mmol/L after two hours. Jake had an oral glucose tolerance test and his results after one hour were 9.8 mmol/L blood glucose and 12.0mmol/L after 2 hours. This is higher than normal. People with diabetes have lower glucose tolerance due to low levels of insulin in their bodies. Their cells, therefore, are not able to take glucose for energy production and other functions hence accumulation in the blood (Farrar et.al 2015). According to diabetes prevention programme (2015, pp. 51-58), HbA1c (glycated haemoglobin) is a test of plasma glucose concentration within three months. This test is used to monitor how blood glucose have been managed for the last 3 months. Higher levels of glycated haemoglobin show poor control of blood sugar. In well-controlled diabetes, the glycated haemoglobin should be below 6.5%. From Jake results, his glycated haemoglobin is 9% which is higher than normal hence poor control. Sodium levels of 200 mmol/L are higher than the normal range of between 135 mmol/L and 145 mmol/L. This is as a result of fluid and electrolytes imbalance. When fluid loss is higher than fluid intake, hypernatremia may result. This is important in order for the body to reabsorb more fluids. Potassium levels of 5 mmol//L are within the normal range of between 3.5mmol/ L and 5.0mmol/L. What needs changing Jake needs to use insulin injections preferably up to six times a day depending on blood glucose level. This will replace the function of the pancreas of insulin production, therefore, blood glucose levels will be lowered. Excess glucose is converted to energy, glycogen for storage and amino acids for protein synthesis (Beck et.al 2017, pp.371-378). Jake also needs to take in more fluids to control the fluid and electrolyte imbalance. Increased fluid intake reduces sodium levels to normal. Jake also should avoid food rich in sodium such as canned meat, fish and poultry. Exercising is also important to lower sodium levels as sodium is used by nerves and muscles. He should take a balanced diet meal three times in a day and snacks in between as insulin use has a high risk of causing hypoglycemia. Meals should contain enough carbohydrates for energy production to prevent protein metabolism for energy production. This will help the patient to add weight (Lais et.al 2016, pp. 26-32). References Beck, R.W., Riddlesworth, T., Ruedy, K., Ahmann, A., Bergenstal, R., Haller, S., Kollman, C., Kruger, D., McGill, J.B., Polonsky, W. and Toschi, E., 2017. Effect of continuous glucose monitoring on glycemic control in adults with type 1 diabetes using insulin injections: the DIAMOND randomized clinical trial. Jama, 317(4), pp.371-378. Coleman, S.K., Rebalka, I.A., D’Souza, D.M., Deodhare, N., Desjardins, E.M. and Hawke, T.J., 2016. Myostatin inhibition therapy for insulin-deficient type 1 diabetes. Scientific Reports, 6, p.32495. Diabetes Prevention Program Research Group, 2015. HbA1c as a predictor of diabetes and as an outcome in the diabetes prevention program: a randomized clinical trial. Diabetes care, 38(1), pp.51-58. Farrar, D., Duley, L., Medley, N. and Lawlor, D.A., 2015. Different strategies for diagnosing gestational diabetes to improve maternal and infant health. Cochrane Database of Systematic Reviews, (1). Gu, X., Wang, H., Schultz, Z.D. and Camden, J.P., 2016. Sensing glucose in urine and serum and hydrogen peroxide in living cells by use of a novel boronate nanoprobe based on surface-enhanced raman spectroscopy. Analytical chemistry, 88(14), pp.7191-7197. Hessler, D., Fisher, L., Polonsky, W. and Johnson, N., 2016. Understanding the areas and correlates of diabetes-related distress in parents of teens with type 1 diabetes. Journal of pediatric psychology, 41(7), pp.750-758. Lais, L.L., de Lima Vale, S.H., Xavier, C.A., de Araujo Silva, A., Aydemir, T.B. and Cousins, R.J., 2016. Effect of A One-Week Balanced Diet on Expression of Genes Related to Zinc Metabolism and Inflammation in Type 2 Diabetic Patients. Clinical nutrition research, 5(1), pp.26-32. Mahon, M., Amaechi, G., Slattery, F., Sheridan, A.L. and Roche, E.F., 2018. Fifteen-minute consultation: Polydipsia, polyuria or both. Archives of Disease in Childhood-Education and Practice, pp.edpract-2018. Rao, R. and Raju, G.B., 2016. Random blood sugar levels and pseudocholinesterase levels their relevance in organophosphorus compound poisoning. International Journal Of Community Medicine And Public Health, 3(10), pp.2757-2761. Zaccardi, F., Webb, D.R., Yates, T. and Davies, M.J., 2016. Pathophysiology of type 1 and type 2 diabetes mellitus: a 90-year perspective. Postgraduate medical journal, 92(1084), pp.63-69.

HSE706 Research In Clinical Exercise Physiology

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