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Constantina Case Study: Adult Female Marathon Runner

Question

Task:
Question 1 (8 marks total)

A. Endometrial tissue contains glandular structures relevant to Constantina’s reproductive function.Note the role of this glandular tissue in reproductive function, including any likely changes fromnormal in the secretion and resultant effects for Constantina.

B. Considering Constantina and her current circumstances, describe the role of oestrogen and discusshow the levels of this hormone may vary from normal.

Question 2 (8 marks total)
A. Describe the role of the kidneys in maintaining fluid balance with reference to the role of antidiuretichormone (ADH). Is Constantina at risk of not maintaining homeostatic fluid mechanisms? Why/whynot?

B. What is a urinalysis and what is its significance for this case? With respect to the specific gravity (SG)component of Constantina’s urinalysis result, and using your knowledge of normal kidney function,would you expect this result? Why/why not?

Question 3 (8 marks total)
A. What is gut motility? Is it likely that Constantina’s gut motility has increased or decreased fromnormal? Discuss EITHER peristalsis OR segmentation in your response.

B. Why is it important for Constantina to maintain adequate protein intake? Discuss its importance incellular recovery in your response.

Question 4 (8 marks total)
A. Constantina has used Voltaren Emugel (containing a NSAID) to ease her aching muscles. Identify theroute of administration and discuss how the drug is likely to be absorbed after administration and itslikely bioavailability. Justify your answer by discussing whether the drug would be subjected tohepatic first pass.

B. What is the importance of the half-life of a drug? Assuming 100% absorption and the half-life of anNSAID is 8 hours, calculate the % amount of drug that is likely to be present in the blood after 24hours.

Question S (8 marks total)
A. Consider Constantina’s blood pressure result and discuss whether the mean arterial pressure islikely to be varied from normal. In your answer you must include reference to a possible change inblood viscosity and briefly mention the consequences of any change in BP upon kidney function.B. Discuss the role of the renin-angiotensin-aldosterone system in the maintenance of blood pressurein Constantina’s circumstance.

Answer

The essay based on the Constantina case study aims to critically discuss the clinical information as obtained from a 38-year-old adult female marathon runner namely Constantina after she presented herself to a GP clinic in post-training run condition.

The reproductive function for Constantina may be discussed in the light of endometrial tissue that contains glandular structures that have a major role in the secretion of glycogen that results in the augmentation of the blood flow in the spiral arteries concerning increase in the progesterone level (Lessey & Young, 2019). It is noted in the research of Brame, Macedo and Klein (2017) that high-intensity workout in women results in the low level of progesterone and inturn causes the low secretion of glycogen from the glandular structure of endometrial tissue and may cause poor maintenance of endometrium tissue and menstrual imbalance. Concerning to Constantina case study, Constantina is involved in the strenuous exercise which has decreased the secretion of progesterone and led to poor function of glandular tissue in the release of glycogen thus negatively affecting the reproductive function and menstrual cycle.

The reproductive function is also related to the release of oestrogen that has a major role in the maintenance of reproductive function, increasing cholesterol level and increasing bone strength (Vellanki, K., & Kramer, 2019). Oestrogen level tends to rise in the follicular phase of the menstrual cycle that causes the release of luteinizing hormone and follicle-stimulating hormone and maintain the growth of the endometrium, however, Nagai et al. (2016) suggested that with excessive exercise the secretion of oestrogen may vary from normal and cause its low secretion. Thus, it can be said that Constantina performing strenuous exercise three days per week can lower the release of oestrogen hormone from normal that has resulted in amenorrhea and poor reproductive function.

Further focusing on the Constantina case study, it is noted that Constantina experience lethargy and a decrease in the intake of fluids which can be related to the function of the kidney. It plays a crucial role in maintaining the fluid balance through regulating the concentration of urine and its excretion through reabsorption of body fluids concerning the Antidiuretic hormone. The anti-diuretic hormone acts to retain water inside the body through increased re-absorption of water by acting of late distal tubules of kidneys and collecting duct (Cuzzo & Lappin, 2019). It phosphorylates aquaporin-2 that tends to upsurge the water movement through the osmotic gradient and maintain haemostasis. In the given Constantina case study, Constantina is at risk of not maintaining fluid mechanism as her water intake has been reportedly lower than usual thus accentuating the chances of dehydration. It is further evident from her physical examination illustrated within the Constantina case study that shows dryness of lips, dark circles under eyes and poor skin turgor and the high specific gravity of urine that reflect signs of dehydration and therefore, the loss of body fluid in Constantina is not been replenished that cause fluid imbalance.

For Constantina, a urinalysis was conducted that aimed to test the urine sample and is significant for diagnostic purposes. Urinalysis is the examination of the appearance, content and concentration of urine is performed for the detection and management of a wide array of disorders such as kidney ailments, urinary tract infections, diabetes (Free, 2018). In Constantina case study, the specific gravity (SG) of urine is reported to be 1.035 thus depicting value on the higher range. Therefore, it is indicative of poor kidney functioning with respect to the dysfunction of renal tubules and ADH hormone release. The prevention of water reabsorption causes an increase in expel of urine and a high concentration of solute thus leading to excessive loss of water and dehydration (Perrier et al., 2017). Hence, Constantina being at the risk of not maintaining fluid mechanism, high SG is expected in the urinalysis.

Gastrointestinal motility is another aspect that is crucial to the maintenance of good health in an individual. In simple terms, gut motility refers to the contractions and relaxations of the muscles in the gastrointestinal (GI) tract, which causes movements inside the digestive system in addition to transiting of the contents inside it known as peristalsis (Beckett et al., 2017). Wood (2019) has stated that in dehydration, the intestine absorbs a large amount of water from food digested making its excretion difficult and obstruction in peristalsis movement which can be facilitated by high water volume. As noted, the issue of dehydration in Constantina it can be said that peristalsis movement is likely to decrease from normal.

The main function of the protein in the diet is to maintain the daily caloric intake, repair cells and tissue and promote the growth of the muscle and body. Constantina is a marathoner that is essentially an endurance type of sport that can result in damage to tissue and pain. Eddens et al. (2017) have noted that the intake of protein diet is essential to repair the damaged tissue and maintain the integrity of cells by anabolising into amino acids and promoting cellular recovery. Therefore, she needs to maintain protein intake to meet her daily caloric intake and aids in the cellular recovery process by fostering restoration of muscles and thereby facilitating regaining strength (Cintineo et al., 2018).

In the Constantina case study, it is noted that Constantina is reported with huge muscle soreness and pain. To ease her aching muscles, Constantina resorted to using the Voltaren Emulgel that contains an NSAID. The NSAID component and the active ingredient in this emulgel are diclofenac that in turn acts by relieving pain and reducing the inflammation. The route of administration is topical through the skin and is likely to undergo systemic absorption from the GI tract and undergo hepatic first pass. Therefore, diclofenac sodium’s relative bioavailability was 6% of the systematic exposure suggesting 94% lower compared to oral diclofenac and is proportional to the size of the area that has been treated, further depending on the total applied dose as well as the extent of skin hydration (Gopalasatheeskumar et al., 2017).

In this context, it would be pertinent to mention the importance of the half-life of a drug. As per definition, it refers to the time taken for the concentration of the drug in the plasma or in other words the total amount of drug inside the body to undergo reduction by 50% (Binder & Skerra, 2017). In taking medications and stopping, this half-life of the drug is crucial apart from two other vital factors of strength and duration and aims to reveal whether the accumulation of the drug might occur owing to multiple dosing routine. Assuming 100% absorption and half-life of an NSAID 8 hours in 8 hours, 50% of the drug will be absorbed and in the next 8 hours remaining 50% accounting to 25% will be absorbed (16th hours). Further, after 24 hours, half of 25% which is 12.5 % will remain in the blood.

Further, on examining the blood pressure of Constantina, it was found to be 87/58 mm of Hg. The normal blood pressure is usually between 110/70 mm of Hg to 120/80 mm of Hg. Therefore, in the scenario of Constantina case study, it was aberrant. The normal range of mean arterial blood pressure (MABP) lies between 70-110 mm of Hg and in this case; it underwent a deviation, exhibiting lower value. The research by Zimmerman et al. (2017) has stated that in a situation of an increase in the viscosity of blood, there is an increase in the total peripheral resistance (TPR) thereby obstructing the flow of blood. The dependence of MABP with cardiac output and TPR, suggests an increase in the systolic blood pressure for maintenance of the blood volume. Therefore, low BP in the Constantina case study leads to a decrease in blood viscosity due to lowering in the TPR. It causes an increase in the flow of blood and the lowering of MABP. Larsson et al. (2018) have also indicated that with the decrease in the MABP, there will be a decrease in the volume of blood and cause obstruct in the flow in the glomerulus. Hence, it alters the reabsorption function of the kidney.

For Constantina, a sudden drop in BP causes the release of renin from the kidney as it activates the renin-angiotensin-aldosterone system (RAAS). It leads to the formation of angiotensin I through stimulation of the angiotensinogen which further converts to angiotensin II. It releases aldosterone hormones which have a direct function in the kidney (Ghazi & Drawz, 2017). It acts by increasing the absorption of sodium and release it into the blood circulation. Therefore, the findings obtained from the Constantina case study analysis clarifies that in order to maintain the blood pressure in Constantina’s situation, the release of aldosterone hormone increases the sodium level and blood volume that eventually increases the blood pressure.

Lastly from the above discussion based on the Constantina case study, it can be concluded that the medical history, as well as the physical examination and pathological tests in the form of urinalysis conducted upon Constantina, revealed vital information about the issue of dehydration and hypotension. The performance of these routine pathological tests might be beneficial to streamline treatment protocols in an effective way of fostering her health and wellbeing.

Reference
Beckett, E. A., Young, H. M., Bornstein, J. C., & Jadcherla, S. R. (2017). Development of Gut Motility. In Pediatric Neurogastroenterology (pp. 21-37). Constantina case study Springer, Cham. Retrieved from https://doi.org/10.1007/978-3-319-43268-7_3

Binder, U., & Skerra, A. (2017). PASylation®: a versatile technology to extend drug delivery. Current Opinion in Colloid & Interface Science, 31, 10-17. Retrieved from https://doi.org/10.1016/j.cocis.2017.06.004

Bramer, S. A., Macedo, A., & Klein, C. (2017). Hexokinase 2 drives glycogen accumulation in equine endometrium at day 12 of diestrus and pregnancy. Reproductive Biology and Endocrinology, 15(1), 4. Retrieved from Retrieved from https://doi.org/10.1186/s12958-016-0223-4

Cintineo, H. P., Arent, M. A., Antonio, J., & Arent, S. M. (2018). Effects of protein supplementation on performance and recovery in resistance and endurance training. Frontiers in nutrition, 5, 83. Constantina case study Retrieved from https://doi.org/10.3389/fnut.2018.00083

Cuzzo, B., & Lappin, S. L. (2019). Vasopressin (antidiuretic hormone, ADH). In StatPearls [Internet]. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK526069/

Eddens, L., Browne, S., Stevenson, E. J., Sanderson, B., van Someren, K., & Howatson, G. (2017). The efficacy of protein supplementation during recovery from muscle-damaging concurrent exercise. Applied Physiology, Nutrition, and Metabolism, 42(7), 716-724. Retrieved from https://doi.org/10.1139/apnm-2016-0626

Free, H. M. (2018). Urinalysis in clinical laboratory practice. Crc Press. Retrieved from https://books.google.co.in/books?hl=en&lr=&id=ipxGDwAAQBAJ&oi=fnd&pg=PT11&dq=Free,+H.+M.+(2018).+Urinalysis+in+clinical+laboratory+practice.+Crc+Press&ots=wWf8iUwdAu&sig=WmMnaDceVrHxJliPg7_Xvp1RsB4&redir_esc=y#v=onepage&q=Free%2C%20H.%20M.%20(2018).%20Urinalysis%20in%20clinical%20laboratory%20practice.%20Crc%20Press&f=false

Ghazi, L., & Drawz, P. (2017). Advances in understanding the renin-angiotensin-aldosterone system (RAAS) in blood pressure control and recent pivotal trials of RAAS blockade in heart failure and diabetic nephropathy. Constantina case study F1000Research, 6. Retrieved from https://dx.doi.org/10.12688%2Ff1000research.9692.1

Gopalasatheeskumar, K., Komala, S., Soundarya, R., Parthiban, S., Bharathi, B. D., & Elango, S. (2017). Review on Emulgel Formulations with Non-Steroidal Anti-Inflammatory Drugs for Topical Administration. Pharma Science Monitor, 8(1). Retrieved from https://www.academia.edu/34559197/review_on_emulgel_formulations_with_non-steroidal_anti-inflammatory_drugs_for_topical_administration

Larsson, J. S., Krumbholz, V., Enskog, A., Bragadottir, G., Redfors, B., & Ricksten, S. E. (2018). Renal blood flow, glomerular filtration rate, and renal oxygenation in early clinical septic shock. Critical care medicine, 46(6), e560-e566. Retrieved from doi: 10.1097/CCM.0000000000003088

Lessey, B. A., & Young, S. L. (2019). Structure, function, and evaluation of the female reproductive tract. In Yen and Jaffe's Reproductive Endocrinology (pp. 206-247). Content Repository Only!. Retrieved from https://doi.org/10.1016/B978-0-323-47912-7.00009-3

Nagai, S., Ikeda, K., Horie-Inoue, K., Shiba, S., Nagasawa, S., Takeda, S., & Inoue, S. (2016). Constantina case study Estrogen modulates exercise endurance along with mitochondrial uncoupling protein 3 downregulation in skeletal muscle of female mice. Constantina case study Biochemical and biophysical research communications, 480(4), 758-764. Retrieved from https://doi.org/10.1016/j.bbrc.2016.10.129

Perrier, E. T., Bottin, J. H., Vecchio, M., & Lemetais, G. (2017). Criterion values for urine-specific gravity and urine color representing adequate water intake in healthy adults. European journal of clinical nutrition, 71(4), 561-563. Retrieved from https://doi.org/10.1038/ejcn.2016.269

Vellanki, K., & Kramer, H. (2019). Amenorrhea and Estrogen Disorders in Women with Kidney Disease. In Endocrine Disorders in Kidney Disease (pp. 127-138). Springer, Cham. Retrieved from https://doi.org/10.1007/978-3-319-97765-2_10

Wood, J. D. (2019). Normal Anatomy, Digestion, Absorption. In Adult Short Bowel Syndrome (pp. 1-16). Academic Press. Retrieved from https://doi.org/10.1016/B978-0-12-814330-8.00001-9

Zimmerman, R., Tsai, A. G., Vázquez, B. Y. S., Cabrales, P., Hofmann, A., Meier, J., ... & Intaglietta, M. (2017). Post-transfusion increase of hematocrit per se does not improve circulatory oxygen delivery due to increased blood viscosity. Constantina case study Anesthesia and analgesia, 124(5), 1547. Retrieved from Retrieved from https://dx.doi.org/10.1213%2FANE.0000000000002008

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