Case Study 1: Gastrointestinal Function

Constipation and its risk factors

Constipation occurs when bowel movements become less frequent and stools become difficult to pass. It happens most often due to changes on the diet, routine, or because the inadequate intake of fiber (Sumida et al., 2017). It is a common condition because almost every individual goes through it at some point in their lives. Though, it is not severe at some point, still causes discomfort to people because everyone feels better and relieved when their bowel movements are back on the right track. Some of the risk factors of developing constipation includes a change of diet. When a person changes abruptly from one diet to another, the body takes quite some time to adapt to new foods. This, therefore, causes constipation. Another risk factor is the lack of enough water in the body. Notably, the presence of dehydration makes the bowel movement much tougher, which is a clear symptom of constipation. Another risk factor is the tendency to reject the urge to poop. When an individual rejects the call to poop, it can result in the accumulation of stool in the body, and simultaneously causes constipation.

According with W. G. (2019), other risk factors we can also mention are:

• Being an older adult.
• Being a woman.
• Being dehydrated.
• Eating a diet that’s low in fiber.
• Getting little or no physical activity.
• Taking certain medications, including sedatives, opioid pain medications, some antidepressants or medications to lower blood pressure.
• Having a mental health condition such as depression or an eating disorder.

Recommendations that can be given to a patient who is suffering from constipation are:

• Include plenty of high-fiber foods in your diet, including beans, vegetables, fruits, whole grain cereals and bran.
• Eat fewer foods with low amounts of fiber such as processed foods, and dairy and meat products.
• Drink plenty of fluids.
• Stay as active as possible and try to get regular exercise.
• Try to manage stress.
• Don’t ignore the urge to pass stool.
• Try to create a regular schedule for bowel movements, especially after a meal.
• Make sure children who begin to eat solid foods get plenty of fiber in their diets.

Symptoms of constipation present in H.R case study and those that are not present

Symptoms of constipation present in the H.R case study are; delay of bowel movements where she went a whole week with a single bowel. Another symptom is the presence of hard stool, which comes out with a lot of strain, it often takes her 10 minutes at a minimum to initiate a bowel movement, and she’s feeling bloated. Patient’s suffering from constipation usually have hard stools like in this case. There are some symptoms not present in this case study as of; the feeling of fullness even after having a bowel movement, presence of rectal blockage, incomplete stool emptiness from the rectum, while needing help doing so using your hands to press the abdomen  inserting a finger to remove the stool from the rectum (Hawkins, 2016).

Is there a possibility of anemia?

From the case presented by H.R., there is no proof of anemia because no single symptom is given that resembles those of anemia. But patients with constipation can develop anemia; how? due to the presence of anal or rectum fissures.  This condition is most commonly caused by constipation when passing hard stools. In addition, bleeding from the rectum is present and anal fissures may also cause pain during and immediately after bowel movement; symptoms the patient does not refers at this time (W. G., 2019).

Another way that the anemia could be present in the patient, but is not related to the constipation, it’s the fact that she is taking over the counter medications; like aluminum hydroxide tablets to help with the relieve of the heartburn. One of the effects of this medication is to decrease PH in the stomach, relieving heartburn, but if taken for long time periods could cause anemia due to a decrease in the absorption of vitamin B12 and iron (W. G., 2019). Hence, constipation appear to be present due to the aluminum ions causing the relaxation of the gastrointestinal track smoothing the muscle, which can postpone the gastric emptying and cause constipation.

Case Study 2: Endocrine Function

The race and ethnic group where diabetes mellitus is common and its symptoms in C.Bs case

There are 17 million Americans (5.9% of the population) who have diabetes mellitus (DM), with up to 6.4 million not yet diagnosed and almost 1 million new cases added yearly. Of these cases, 90% to 95% of the cases are type 2 diabetes. At every age group, African Americans have one of the highest incidences of diabetes in the United States, with over 20% of African Americans between 60 and 74 years old having the disease. Therefore, is most prevalent among Native Americans in the southeastern United States, with 27.8% of the population affected. On average, Native Americans, including Alaska Natives, are 2.2 times as likely to have diabetes as non-Hispanic whites of similar age (Bergenstal, 2017).

In the case of C.B, she has some symptoms which are comparable with diabetes mellitus type 2. Patient has a history of having high blood sugar levels three years ago with not follow-up; also, an elevated fasting blood sugar of 141 mg/dL (Fasting blood sugar test; If it’s 126 mg/dL or higher on two separate tests, you have diabetes). Another symptom she reported is the fact of been very thirsty lately and getting up more often at night than usual to urinate. She has gained weight and finally as a result of her uncontrolled diabetes, she has suffered of a multiple genitourinary infection.

How would C.Bs glycemic values be if she develops a bacterial pneumonia?

I will expect for glycemic values to be high. Infection in this case pneumonia; causes a stress response in the body by increasing the number of certain hormones such as cortisol and adrenaline. These hormones work against the action of insulin and, therefore the body’s production of glucose increases, resulting in high blood sugar levels. When the blood sugar is high, white cells are unable to “mop up” bacteria because they cannot move around at their normal speed, and do not reach the infection site quickly enough to engulf and kill the present bacteria (Pippitt et al., 2016). Hence, some of the reasons of an uncompensated diabetes is the infection. 

Initial therapy non-pharmacologic and pharmacologic

In my opinion the best initial non-pharmacological therapy could be:

• Dietary interventions: Nutritional interventions are important in achieving optimal glycemic control in patients with DM. Most patients with this condition become obese overweight and the weight loss achieved through dietary restriction of energy, helps them with the diabetes management. Blood glucose response to individual food items varies according to glycemic index (GI) and the glycemic load (GL) in the diet.
• Physical activity: This one improves insulin sensitivity, bodyweight, cardiovascular risk factors, physical fitness, lipid level, blood pressure and overall their wellbeing, reducing the risk of cardiovascular morbidity and mortality.
• Restorative sleep: Sleep deprivation and poor quality of sleep results in an altered metabolic and hormonal function, leading to the development of DM. People who sleep less than 6 hours per night are at risk of developing diabetes, therefore it is advised having at least 7 hours of uninterrupted sleep per night. Various mechanisms are described in the development of diabetes in people with sleep deprivation. During this stage brain glucose use is reduced, causing a hormonal deregulation, resulting overall in higher Growth Hormone (GH) levels and evening cortisol levels that may contribute to the development of DM (Pippitt et al., 2016).
• Diabetes education: Patients with newly diagnosed diabetes should participate in a comprehensive diabetes self-management education program, which includes individualized instruction on nutrition, physical activity, optimization of metabolic control, and prevention of complications.

            Pharmacologic therapy should be initiated along with consultation on lifestyle modifications, focusing on dietary changes and other lifestyle contributors to hyperglycemia. Weight loss and maintenance underpins are effective diabetes therapies that can reduce the risk of weight gain, associated with sulfonylureas and insulin.

 In the absence of specific contraindications, I will suggest metformin as an initial therapy; it can be given beginning with 500 mg a day with the evening meal and, if tolerated, add a second 500 mg dose at breakfast time. The dose can be increased slowly (one tablet every one to two weeks) as necessary reaching a total dose of 2000 mg per day. Metformin is the medication preferred as initial therapy, because of the glycemic efficacy, absence of weight gain and hypoglycemia, together with general tolerability, and the favorable cost (Pippitt et al., 2016).

References

Bergenstal RM, Gal RL, Connor CG, et al., (2017) Exchange Racial Differences Study Group. Racial differences in the relationship of glucose concentrations and hemoglobin A1c levels. Ann Intern Med; 167:95–102

Hawkins, A. T., Olariu, A. G., Savitt, L. R., Gingipally, S., Wakamatsu, M. M., Pulliam, S., … & Bordeianou, L. (2016). Impact of rising grades of internal rectal intussusception on fecal continence and symptoms of constipation. Diseases of the Colon & Rectum, 59(1), 54-61.

Marín-Peñalver, J. J., Martín-Timón, I., Sevillano-Collantes, C., & del Cañizo-Gómez, F. J. (2016). Update on the treatment of type 2 diabetes mellitus. World journal of diabetes, 7(17), 354.

Pippitt, K., Li, M., & Gurgle, H. E. (2016). Diabetes mellitus: screening and diagnosis. American family physician, 93(2), 103-109.

Sumida, K., Molnar, M. Z., Potukuchi, P. K., Thomas, F., Lu, J. L., Matsushita, K., … & Kovesdy, C. P. (2017). Constipation and incident CKD. Journal of the American Society of Nephrology, 28(4), 1248-1258.

1. G. (2019). Who Gets Constipation? What Are the Causes? What Is an Evidence-Based. Gastrointestinal Emergencies: Evidence-Based Answers to Key Clinical Questions, 185.