Clinical Case Study

Introduction

This paper purposes to serve as a clinical case study investigation of various concepts by focusing on a patient, Alan, 56 years old who has presented to his general practitioner (GP) with different symptoms, a life style, and a family history that may indicate a multi-morbidity condition. As such, this discussion aims to find out, monitor, manage, and offer treatment for the case involved. This will be done by carrying out a differential diagnosis, initially based on the symptoms and a physical examination, and then an analysis of the multi-morbidity case clinical results to determine the medical and health conditions of the case and then consequently present an effective management and treatment array for the diagnosed conditions.

Case Study

This current discussion is based on a 56 year old male adult, Alan. The name is a pseudonym and has been anonymized to be concurrent with the principles of general principles of medical practice as outlined in the (Nursing and Midwifery Council.

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Medical History

Further analysis and examination of Alan’s clinical history has revealed that he smokes regularly and is a social drinker as well; nevertheless he has greatly reduced these tendencies lately. The family history of the patient further brings to light that his family has a history of diabetes and that his own mother passed on as a result of end stage liver failure. However, Alan had not been previously really aware of this condition. Finally, physical examination of the patient reveals that Alan is 180 cm tall and currently weights 100 kg. The previous results show that Alan has lost up to 17 kg, which is unexpected. The blood pressure was recorded to be 140/90 mmHg. Further, there was no evidence of jaundice or pruritis.

Symptoms

Alan has presented to his general practitioner with several complaints which include; having a dull pain in his right upper quadrant, fatigue and tiredness most of the time, excessive thirst, urinary frequency and malaise. These symptoms indicate that Alan is suffering from a variety of health conditions. Accordingly, the initial diagnosis section will present some of the possible medical conditions that the patient may be suffering from.

As reported by his clinical history, Alan’s lifestyle may also result in various health conditions, especially those of the liver and lung duct systems.

Alan may have inherited a type of diabetes from his family lineage. A possibility could be the type 2 diabetes, especially because of the extreme thirst which indicates dehydration (Earlstein, 2017). The patient may also have other conditions, since this is a multi-morbidity case. As such, the specific laboratory results will be able to finally detect what exactly Alan is suffering from.

The physical examination results indicate two significant changes; weight loss and blood pressure. Alan has lost a total of up to 17 kilos within a very short period of time,

A combination of RUQ tenderness, excessive thirst, fatigue, and urinary frequency may indicate the presence of various conditions which include; hepatitis, pyelonephritis, kidney stones and other acute abdomen conditions. Mr. Alan may be suffering from one of these acute abdomen conditions or any other condition depending on the life factors and family history. The excessive thirst indicates dehydration which in turn may show that Alan is suffering from some specific type of diabetes. Additionally, Alan’s symptoms also show hemoptysis and pyrexia. Therefore when taking the laboratory tests, it is prudent that the general practitioner also checks for such health conditions.

Tests Requested

The general practitioner then ordered for a range of tests to specifically determine Alan’s conditions. First of all the GP took a midstream urine specimen and then conducted a urine dipstick. The general practitioner further ordered for blood tests which included: Full blood count, ESR, Prothrombin time, Urea & Electrolytes, Liver function test, Lipid profile, HbA1c, Hepatitis B & C serology which can be used to diagnose liver diseases and other conditions (Ginès, 2005). The tests were to confirm the specific conditions that Alan might be suffering from and the results are as discussed below.

The urinalysis test was carried out by using a sample or specimen of Alan’s urine. The urinalysis results were negative for leucocyte esterase while positive for glucose (2+). Therefore, the urine wasn’t sent for further analysis through culture. Since the urine was negative for leucocyte esterase, it means there were no blood cells in the urine hence no indication of any urinary tract infection. The presence of elevated glucose levels in the urine on the other further confirms the previous speculation of Alan having diabetes (Fonseca, 2008).

A specimen of Alan’s blood was taken for blood sugar levels and liver function tests. The glycated hemoglobin (HbA1c) tests for the average blood sugar level, the erythrocyte sedimentation rate (ESR) tests for any inflammation, while the lipid profiling tests are used to check if there are any damages to the liver and confirm the cause. A summary of these and the respective reference ranges is as shown below:

According to the glycated hemoglobin (HbA1c) results, the average blood sugar levels for the past few months for Alan is 53 mmol/mol; 7.0%. These results are higher than the normal blood sugar level of 11.1mmol/L and which are always below 5.7 percent. As such, given the symptoms that were previously described by Alan, this test confirms that he has diabetes, which is most likely the type 2 diabetes since it has developed when he is an adult and his sedimentary lifestyle (Boyer, et al., 2014).

Further, the erythrocyte sedimentation rate (ESR) test is used to determine if there is any inflammation related conditions such as rheumatoid arthritis (RA) or any other type of arthritis, systemic lupus erythematosus (SLE) and cancers. The normal ESR results for the adult men under the age of 50 years is usually averagely below 15 mm/hr. While for Alan’s case, the ESR results showed 22 mm/hr which is out of the reference range. This indicates that he has high levels of inflammation. However, the ESR test only give information about inflammation and indications about various conditions but can’t specifically confirm a condition (Marmarelis et al., 2014).

Further the doctor ordered the Alanine aminotransferase and Aspartame aminotransferase which are blood tests to check for any liver damages (Boyer and James, 2001). Liver damages can be caused as a result of various reasons which include; exposure to hepatitis virus, drinking of a lot of alcohol or having a family history of liver disease, such as Alan’s mom who died of liver failure. The results of this test for Alan were also out of range which might indicate any of the above. Since Hepatitis was ruled put, therefore Alan might be having a different liver condition.

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Since Alan’s results are very high and given the presence of inflammations, alongside his smoking and drinking habits, Alan therefore has a liver cancer (Reau, et al., 2012). To confirm this, the Gamma-Glutamyl Transpeptidase (GGT) and Alkaline phosphatase: (ALP) tests were ordered by the doctor. According to the results, both GGT and ALP were increased confirming liver disease (Snyder et al., 2016).

The liver function tests carried out show the existence of liver problem. To confirm the liver disease or any genetic condition, further tests need to be carried out. These include imaging tests and tissue analysis tests. Imaging tests such as ultrasound, MRI and CT Scan can show the existence of liver damage. Taking a tissue sample (biopsy) from the liver and analyzing it in the laboratory will also help in the diagnosis of liver disease.

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Treatment and Management

The diagnosis has presented that Alan has type 2 diabetes and liver disease. Consequently, the treatment and management of diabetes includes insulin therapy, blood sugar monitoring and partaking activities that help keep the blood sugar closer to normal. These include; healthy eating, regular exercise, and possibly diabetes medication such as Metformin, DPP-4 inhibitors which help reduce the blood sugar levels, and Sulfonylureas which help the body to secrete more insulin. Also, lifestyle modifications including stopping alcohol use will help with management of the liver disease. A medical program that includes careful and regular monitoring of the liver function is also prudent to the management of liver disease.

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Conclusion

In conclusion, this current discussion has managed to successfully examine the results of Alan’s case and determine that according to the symptoms, as previously, speculated, he is suffering from type 2 diabetes. Further analysis of the results also indicates that he has a liver disease. Both of these conditions are concurrent with Alan’s family history of diabetes and liver disease, in which his mother previously passed on due to liver failure. To this end, a treatment and management plan for the two conditions has also been presented.

References

  • Boyer, David S, and Homayoun Tabandeh. Diabetic Retinopathy: From Diagnosis to Treatment. , 2014. Internet resource.
  • Boyer, James L. Liver Cirrhosis and Its Development: Proceedings of the Falk Symposium 115 Held in Basel, Switzerland, 22-24 October, 1999 (part Ii of the Basel Liver Week 1999 ; Xi International Congress of Liver Diseases). Dordrecht: Kluwer, 2001. Print.
  • Earlstein, Frederick. Type 2 Diabetes: Facts, Diagnosis, Symptoms, Treatment, Causes, Effects, Prognosis, Research, History, Myths, and More!, 2017. Print.
  • Fonseca, Vivian A. Diabetes: Improving Patient Care. Oxford: Oxford University Press, 2008. Print.
  • Ginès, Pere. Ascites and Renal Dysfunction in Liver Disease: Pathogenesis, Diagnosis, and Treatment. , 2005. Internet resource.
  • Marmarelis, Vasilis Z, and Georgios Mitsis. Data-driven Modeling for Diabetes: Diagnosis and Treatment. , 2014. Internet resource.
  • Reau, Nancy, and Fred Poordad. Primary Liver Cancer: Surveillance, Diagnosis and Treatment. New York: Humana Press, 2012. Internet resource. Sara Zareei, Massoud M.A. Boojar, Massoud Amanlou, Inhibition of liver alanine
  • aminotransferase and aspartate aminotransferase by hesperidin and its aglycone hesperetin: An in vitro and in silico study, Life Sciences, Volume 178, 2017, Pages 49-55, Snyder, Rich S. What You Must Know About Liver Disease - a Practical Guide to Using Convent. , 2016. Print.

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