SUBJECT: HMCL223 Clinical Diagnostic …: HMCL223 Clinical Diagnostic Techniques TYPE: Case Study Assignment Exemplar TASK: 1. You are required to analyse the following case (including

© Endeavour College of Natural Health HMCL223_Assessment-Wk14_CaseStudyAssignmentExemplar Last Updated on 22-Jul-16 Version: 2.0 Page 1 of 23

SUBJECT: HMCL223 Clinical Diagnostic Techniques

TYPE: Case Study Assignment Exemplar

TASK:

1. You are required to analyse the following case (including the clinical diagnostic reports): o Comment on your interpretation of disease progression in a holistic manner including

predisposing, excitatory and sustaining factors in the case (consider all important aspects when interpreting the case).

o This interpretation will include comments on all of the pathology tests presented while considering sub-optimal & physiological optimal ranges.

2. After analysing the findings outline at least three further referrals for investigative pathology that is required to support your interpretation of the case.

Generate specific client instructions to the preparation for these diagnostic procedures:

o The type of test that is most relevant to your client & in context of supporting case

interpretation & discussion of suboptimal &/ or physiologically optiomal ranges specific for this client.

o The analyte that is going to be tested.

o Any drugs or supplements that needs to be stopped prior to the test that may impact on the results.

o Any specific instructions prior to testing i.e. time to tst, fasting etc…

o Include the completed Use the pathology referral request forms from Clinipath (WA only) or Healthscope that can be found within the Study Materials section of the HMCL223 LMS homepage. Please complete and include in the Appendix (pathology referral form is not included within the word count).

o Other suppliers or clinical diagnostic techniques – include the support material that outlines cost & delivery.

o If the client requires a referral to a GP to fulfil these referrals then include a referral letter in the Appendix outlinig the tests required & the reason (letter is not included within the word count).


3. Outline the cost & time involved for the client to fulfil these investigations:

o The pathology referral request forms from Clinipath (WA only) or Healthscope that can

be found within the Study Materials section of the HMCL223 LMS homepage include costings. Consideration of the time to complete the test needs to be discussed.

o If the client requires a referral to a GP to fulfil these referrals then outline the cost & time involved in fulfilling this method of diagnostic procedure (ring or email a local healthcare provider & explore costings in your local area). Please outline the wait time, the cost of the consult & how much will be covered by Medicare.

o Other suppliers of clinical diagnostic techniques outline the collection methods, the cost & the delivery time involed to complete the test & receive theresults. If this is a service provider please ring or email a local healthcare provider & explore costings in your area.

4. Outline the expected results of each test and explain how you will utilize these new diagnostic procedures to reinterpret the case. o Within this reinterpretation utilize specific components / examples from the case that

will support this.

o Outline additional questions and examinations (clinical examination findings) that are required to more clearly evaluate the interpretation of the case. This will require a thorough and comprehensive explanation of the biochemical/ hormonal/ pathological/ naturopathic diagnostic points.

5. Conclude with an analysis of the relevance of these interventions versus client compliance & create a definitive statement as to why or why not these tests are required. o Prioritize these referrals by considering the requirement to the management of the

case, if the investigation can be thoroughly explored with the questions & examinations outlined in the previous point. Consider the client’s outlay (time & money) to comply with these requests.


Case Study

Female: 37 years old







Pathology



1. Case Analysis

Well Developed

(15-11 marks)

Developed

(10-6 marks)

Poorly Developed

(5-0 marks)

Case was analysed & interpreted

accurately & concisely:

In a holistic manner Explored disease progressions

within the context of predisposing, excitatory & sustaining factors.

All important aspects were considered

All of the clinical diagnostic reports were discussed within the context of the case & the relevant symptoms presenting.

Clinical reports were discussed within the context of sub-clinical analysis & /or physiological optimal ranges.

Case was mostly analysed &

interpreted in:

In a holistic manner Moslty explored disease

progressions within the context of predisposing, excitatory & sustaining factors.

Most important aspects were considered

Most of the clinical diagnostic reports were discussed within the context of the case & the relevant symptoms presenting.

Moslty the clinical reports were discussed within the context of sub-clinical analysis & /or physiological optimal ranges.

Case was analysed & interpreted

intermittently or missing:

Symptomatlically & not in a holistic manner

Not explored or missing 1 or more aspects of predisposing, excitatory & sustaining factors.

Some or none of the important aspects were considered

Clinical diagnostic reports were not or poorly discussed within the context of the case & the relevant symptoms presenting.

Clinical reports were not discussed or poorly discussed within the context of sub-clinical analysis & /or physiological optimal ranges.

2. Referrals

Well Developed

(15-11 marks)

Developed

(10-6 marks)

Poorly Developed

(5-0 marks)

Client instructions: accurate &

concise information on:

Type of test, relevance to the client & in context of supporting case interpretation & discussion of sub-optimal &/ or physiologically optiomal ranges specific for this client.

The analyte & specific instructions to preparing for the tests including the use of drugs / supplements.

Three completed pathology referral request forms / other supplier request forms/ GP referral letter (in Appendix)

Client instructions: mostly accurate &

concise information:




Client instructions: intermittent or

missing information on:




3. Client Compliance Consideration

Well Developed

(10-7 marks)

Developed

(6-4 marks)

Poorly Developed

(3-0 marks)

Client Cost & Time Analysis

includes:

Clearly & concisely evaluated & quantified the cost & time involved in the requested referrals / investigations.

Client Cost & Time Analysis

includes:

Broadly evaluated & quantified the cost & time involved in the requested referrals / investigations.

Client Cost & Time Analysis includes:

Intermittent or missing evaluated & quantified the cost & time involved in the requested referrals / investigations.


4. Expected Results

Well Developed

(10-7 marks)

Developed

(6-4 marks)

Poorly Developed

(3-0 marks)

Analysis of expected results

thoroughly & concisely explored:

Diagnostic procedures are in context to the case (examples given) which clarifies relevance of use.

Supportive additional questions & examinations are explained in biochemical/ hormonal/ pathological & or naturopathic diagnostic points with a clear link to exploring the theory of case analysis explored with the diagnostic procedure.

Analysis of expected results mostly

explored:



Analysis of expected results

intermittently or did not explore:



5. Conclusion

Well Developed

(5-4 Marks)

Developed

(3-2 Marks)

Poorly Developed

(1-0 Marks)

Conclusion clearly & concisely

analyses:

Prioritization of the referrals by considering the findings as pivotal to the management of the case.

If the diagnostic technique could have gained similar outcomes from more rigorous case investigations (questioning & clinical examination findings)

Consider the client’s outlay (time & money) to comply with these requests.

Closing statement as to the requirement of the aforementaioned diagnostic procedures.

Conclusion mostly analyses:





Conclusion considers some points of:





No conclusion evident

Referencing & Word count

Well Developed

(5 marks)

Poorly Developed

(0 marks)

Within word count & correctly referenced using Harvard

Over word count & / or Incorrect use of Harvard & / or 1 or more references missing


HMCL223 Student Assignment Exemplar

CONTENTS

Case outline, disease progression theory of pathology ............................................ 14

Pathology Results .................................................................................................... 15

Investigative Pathology Further Referrals ................................................................ 16

Liver Function Test ............................................................................................... 16

Prognosis, Reinterpretation, Intervention .......................................................... 17

Homocysteine ....................................................................................................... 18


Complete Thyroid Profile ...................................................................................... 19


Other Investigations .............................................................................................. 20

Conclusion ............................................................................................................... 21

REFERENCE LIST................................................................................................... 22

Appendix .................................................................................................................. 23


Case outline, disease progression theory of pathology

Appendix provides a mind map outlining these.

A 37-years-old female, financial consultant, presents with hypertension and 30kg weight

gain within a year. She is stressed, anxious, possibly depressed, has a poor nutrient diet,

migraines, deep vein thrombosis (DVT), low libido, a history of preeclampsia, gestational

anaemia, cesarian, depression, smoking and hysterectomy. A familial predisposition to

hypertension and cancer exists.

Predisposing Factors Sustaining Factors Excitatory Factors

Smoking Stress Stress

Lack of exercise and sedentary life

Malabsorption Anxiety

Stressful job Food Allergies: yeast Depression

Hormonal imbalances Lack of exercise and sedentary life

Insomnia

Coagulation, heart & blood vessel disorders (DVT)

Diet Fatty food intolerance

Inconsistent weight. Altered HPAT-axis or HPG-axis

Under-nutrition

Familial history of hypertension

Hypertension

Table 1 - Predisposing, sustaining, excitatory factors to hypertension and obesity

Obesity can result in hypertension (McCance et al. 2010, p.1152). Hypertension, smoking

and obesity, increased her risk to develop DVT (27yr; on anticoagulants since) (Douketis

2014). With increased stress, prior intense exercise, decreased rest and unmanaged

stressed response, fatigue, along with her sustained hypertension, her menstruation

disorders may have been due to dysregulating one of the hypothalamic–pituitary–

adrenal/thyroid/gonadal axes, which excite and sustain obesity, fatigue any psychological

symptoms. Physical inactivity, along with sleep deprivation, depression, anxiety and stress

have contributed to her excess weight gain and hypertension (Akabas et al. 2012, pp.18-

19,28-30). Physical inactivity and poor diet increase susceptibility to Non-alcoholic-fatty-

liver-disease (NAFLD) (Day 2002). Anticoagulants, dehydration, anxiety, stress,

hypertension, fatigue and hormonal irregularities contribute to migraines (associated with


NAFLD), while symptoms are exacerbated by low nutrient intake and are correlated with

cardiovascular and nervous system symptoms, palpitations, breathlessness, panic attacks

and low energy (Celikbilek et al. 2014; Mayo Clinic 2013; Mayo Clinic 2015). Hypertension

can result in palpitations, shortness of breath and headache (Walker et al. 2014,

pp.607,609).

Medically Diagnosed

Currently Previously Upon examination

DVT, Hypertension Post-natal depression, hysterectomy

(intact ovaries), two C-sections, pre-

eclampsia

BMI: 33.35 -

obesity class 1

Table 2 - Medically Diagnosed

Pathology Results

Haemoglobin levels are all within range except for her MCHC which may be sub-optimally

low, perhaps due to anaemia and present as fatigue, but this alone is insufficient as MCV,

haemoglobin and haematocrit are within range (Pagana & Pagana 2014, p.447; Vaucher

et al. 2012).

WBC are within range. Signifying decreased possibility of inflammatory disorders,

metabolic disorders, paracytic infections or allergic reaction, but alone aren’t definitive

(Pagana & Pagana 2014, pp.526-532).

Lipid profile tests indicate total cholesterol, LDL, triglycerides and HDL are within range

and according to calculations based on Pagana & Pagana (2014, p.156) she has a 1% 10-

year CHD risk, contesting metabolic syndrome, dyslipidemia and CHD (Akabas et al.

2012, p.16; Kazaks & Stern 2013, p.54). Prior elevated LDL and total-cholesterol may be

attributed to hypothyroidism, pregnancy, chronic liver disease, Cushing syndrome (Walker

et al. 2014, p.453). With a history of DVT, LDL target should be below 2.0mmol/L.

Table 3 - Ratios

Ratios

LDL/HDL 1.6 HDL/LDL 0.59 Total-cholesterol/HDL 3 CHD Risk Low

The phase in menstruation cycle of the collected FSH and LH sample isn’t identified.

Ovulation day isn’t identified due to hysterectomy. FSH is within range. Only if collected


during the luteal phase is LH within range. A LH/FSH ratio of less than 2 is normal,

signifying smaller degree of PCOS implication (Banaszewska et al. 2003). Low LH could

indicate thyroid disorders, stress or malnutrition, while increased LH may indicate PCOS,

low estrogen (Pagana & Pagana 2014, p.350; Poppe et al. 2007).

TSH is with range and therefore doesn’t directly implicate thyroid disease related

symptoms. This alone doesn’t rule out thyroid disorder associated symptoms, such as

obesity, history of menstruation disorders, dry skin, palpitations, anxiety, depression,

insomnia; as T4 T3 can be within or out of range and thyroid autoantibodies still present

(Degner et al. 2014; Kronenberg 2008, pp.378-384,386). Prior suboptimal TSH may be

due to early autoimmune thyroiditis (transient thyrotoxicosis) (Kronenberg 2008,

p.364,390).

Fasting glucose levels are within range, signifying absence of hypoglycemia, diabetes

mellitus, metabolic syndrome or Cushing’s disease (Pagana & Pagana 2014, p.256).

Excess thirst and sweat may have other sources. Though insulin resistance may maintain

pancreatic beta-cell secretion and normal glucose levels her blood glucose levels are

within range (Kyrou et al. 2010, pp.209-210).

Investigative Pathology Further Referrals

This section provides diagnostic tests required to assess client pathophysiology and

establish a baseline prior to treatment, to which we can reassess progress after 3-4

months of treatment by retesting and measuring outcomes against goals and proving

client reflection. Baselines are the analytes for each diagnostic investigation.

LIVER FUNCTION TEST

Analyte Expected result

Aspartate aminotransferase (AST)

Moderately Increased

Alkaline phosphatase (ALP) Within range (or possibly elevated)

Alanine aminotransferase (ALT)

Increased

Total Bilirubin Increased

Albumin Decreased


Gamma-glutamyltransferases (GGT)

Increased

Total Protein Decreased

Table 4 - LFTs

Reasoning: Due to anticoagulants, fatty food intolerance, nausea, vomiting, bruising,

impaired sulphation pathway, amalgam fillings (contain mercury) migraines, fatigue

(sluggish liver due to toxic load, decreased blood oxygen carrying capacity) and

impairment from smoking (also increases ammonia), alcohol, dyspnoea, sleep

disturbances and obesity which will help assess function and structure of the liver

(Celikbilek et al. 2014; Hechtman 2012; Walker et al. 2014, pp.959-961; Pagana & Pagana

2014, pp.39-40,47-49,119-126,246-248,424-432).

Instructions

Specimen/Method Preparation Avoid on day of test and day before

Serum blood test from vein in arm obtained in the morning (8:00am)

Overnight (>8-hour) fasting required

Analgesics, caffeine, NSAIDs, diuretics, antibiotics, vitamins and supplements

Caution Daily anticoagulant dose should be administered after blood specimen collection and greater than 12-hours before;

Table 5 – Instructions (Pagana & Pagana 2014, pp.40,48-49,119-126,247,424-432)

Prognosis, Reinterpretation, Intervention

Due to reasoning above, these enzymes are expected to be elevated. This will indicate

increased circulating liver enzymes, which can signify fatty liver deposits, impaired

detoxification, cirrhosis, increased toxins and inflammation (McCance & Huether 2014,

p.1413,1460-1461; Pagana & Pagana 2014, pp.39-40,47-49,119-126,246-248,424-432).

Characteristic of visceral fat is the release of adipokines and fatty acids (FA) to the liver,

which then enters circulation, impacting hepatic function, which increases liver FA deposits

resulting in fatty liver (NAFLD) and possibly insulin resistance and hypoglycemia

(Grossman & Porth, 2014, p.1253). Mitochondrial dysfunction results in increased reactive

oxygen species or extensive lipid peroxidation in response to an increased hepatic supply

of free-FA due to obesity resulting in non-alcoholic-steatohepatitis, oxidative damage and

inflammation (cytokine production) contributing to insulin resistance (Day 2002). Lack of


exercise and diet increase susceptibility to NAFLD/NASH and greatly influence FA supply,

fat distribution and oxidative stress (Day 2002).

Weight loss via dietary intervention (i.e. anti-inflammatory diet) and exercise, has shown to

resolve liver biochemistry and reduce liver size, fatty liver deposits, fibrosis and

steatohepatitis (Kronenberg 2008, p.1573; Hickman et al. 2002).

HOMOCYSTEINE

Reasoning: Due to palpitations, shortness of breath, fatigue, swollen feet, cold

extremities, sweat, insomnia, hypertension, obesity, DVT, physical inactivity, smoking,

malnutrition, increased LDL and total-cholesterol which increase her risk for

atherosclerosis, coronary, peripheral and cerebrovascular disease, therefore it is essential

to differentiate between these “red-flag” conditions and refer if necessary (Walker et al.

2014, p.581).

Instructions


Serum blood test from vein in arm obtained in the morning (8:00am)

Overnight (>12-hour) fasting required

NSAIDs, anticonvulsants, antiepileptics, theophylline, nitrous oxide, folic acid, OCP, tamoxifen, smoking, vitamin B’s

Table 6 - Instructions: (Pagana & Pagana 2014, p.303)


Due to above reasoning homocysteine levels may be elevated. This could indicate

cystinuria, malnutrition, Vitamin B6, B12 or folate deficiency; cardiovascular,

cerebrovascular or peripheral vascular disease, since it contributes to arterial and venous

thrombosis and atherosclerosis (Kumar et al. 2010, p.122; Pagana & Pagana 2014,

pp.303).

Folate and Vitamin B12 are required for the conversion of homocysteine to methionine and

Vitamin B6 is required for metabolising homocysteine to cysteine, therefore reducing

circulating homocysteine levels; while increased homocysteine may interact with

dyslipidemia and hypertension increasing coronary risk (Gropper & Smith 2013, p.201-


202; McCance & Huether 2014, p.989,1049). Due to these deficiencies phase-II

detoxification may be compromised as homocysteine is an intermediate in methyl and

sulfur group metabolism (Pizzorno & Murray 2013, p.496).

Intervention via combination of folate, Vitamin B12 and B6 should correct homocysteine

levels and remethylation pathways, improve phase-II detoxification and possibly reduce

CHD risk (Pizzorno & Murray 2013, p.496,500-501).

COMPLETE THYROID PROFILE

Analyte Expected Results

TSH As presented or suboptimal upper-end

FT4 Out-of-range below; Sub-optimal low;

FT3 Out-of-range below; Sub-optimal low;

rT3 Determined by T4 to T3 conversion; Nutrient deficiencies

Thyroid Autoantibodies: Antithyroglobulin Antibody (TgAb)

Elevated

Thyroid Autoantibodies: Antithyroid Peroxidase Antibody (TPOAb)

Elevated

Table 7 Thyroid Profile (Pagana & Pagana 2014, p.102-105, 486-489,497-500,506-508)

Reasoning: To rule out Hashimoto thyroiditis and due to her symptoms: weight gain, prior

menstruation disorders, dry skin, palpitations, anxiety, depression, swelling, fatigue, cold

peripheries, insomnia, decreased appetite (Degner et al. 2014; Kronenberg 2008,

pp.364,378-384,386,390-391; Walker et al. 2014, p.741).

Instructions


Serum blood test from vein in arm (preferably morning)

No fasting required Avoid these drugs on the day of the test and previous day: aspirin, anticoagulants, fibrinolytic, heparin, beta-blockers, antibiotics, OCP, estrogens, androgens, furosemide, opioids, anti-seizure.

Caution: Daily anticoagulant dose should be administered after blood specimen collection and greater than 12-hours before;

Table 8 - Instructions: (Pagana & Pagana 2014, p.102-105, 486-489,497-500,506-508)



Due to above reasoning TgAb and TPOAb could be elevated and may accompany

hypothyroid symptoms (Kronenberg 2008, p.387). Prior transient thyrotoxicosis may have

led to thyroid cell destruction (Kronenberg 2008, p.390). TgAb, TPOAb and activate T-cells

destroy thyroid cells and target thyroid TSH-receptors destroying these minimising TSH

thyroid stimulatory effect (Crowley 2013, p.682). Feedback mechanisms may increase

TSH and lower thyroid hormones (Crowley 2013, p.682). TPOAb can cross the blood brain

barrier leading to inflammation and pathogenesis of anxiety, depression and mood

disorders (Degner et al. 2014). Decreased carbohydrate, protein and lips metabolism due

to decreased thyroid hormones reduce basal metabolic rate leading to weight gain

(Tortora & Derrickson 2012, p.698). Permeation of mucopolysaccharides into tissues can

result in dry skin, oedema, fluid retention and anemia (Walker et al. p.743). Cholesterol

levels may increase due to protein under-stimulation, and reduced glucose and FA

utilisation for ATP production (Tortora & Derrickson 2012, p.699). Aminotransferases may

be raised due to impaired clearance (Kronenberg 2008, p.380).

Intervention with selenium, iodine, supplementation will improve thyroid function, increase

and hormones, protect thyroid tissue, improve T4 to T3 deiodination, decrease thyroid

autoantibodies and therefore improve pathophysiological function denoted above leading

to weight loss and decreased symptom (Kohrle 2013).

OTHER INVESTIGATIONS

Baseline Hormone Profile (female) (serum). This will help obtain significant hormone

imbalances that may be contributing to her weight gain (i.e. PCOS), low libido, disturbed

sleep and point to an aetiology for her prior menorrhagia and dysmenorrhea (Reid &

Evans 2011, p.71).

Adrenal Hormone Profile test to assess her adrenal function due to her ongoing stress,

anxiety, insomnia, headaches, depression and fatigue as increased cortisol may lead to

adrenal hypertrophy or adrenal exhaustion, while reduced DHEA-S also results in fatigue,

weight gain and impaired cognitive function (Reid & Evans 2011, p.93).


Conclusion

Obesity can trigger hypertension and many of her symptoms, including psychological. The

hypothesis was that there is a main aetiology governing this pathology. Dysregulation of

the hypothalamic–pituitary–adrenal/thyroid/gonadal axes were investigated as sources of

her presenting case. While differentiation is crucial as there is a crossover amongst these

axes defining the variables of elevated TgAb and TPOAb gave justification to presenting

complaints. Therefore, complete thyroid profile was applicable to assess, antibodies, HPT-

axis dysregulation and manage the client respectively.

Due to parameters involving her history and symptoms (see Homocysteine section), of

impact of cardiac health or CHD risk assessment via pathology test, such as CRP,

fibrinogen or homocysteine would be essential. Therefore, homocysteine could provide

markers for these conditions but also provide a route for naturopathic therapeutic planning

and co-management (referral).

Liver function tests were chosen due to obesity, mercury exposure and allergies which

may have been impacted liver functions. Assess of the liver would guide intervention by

also focusing on supporting the liver function, detoxication, protecting it and minimising

insulin resistance.

Client compliance, in term of cost and time were considered when selecting diagnostic

investigations. All tests can be performed on the same morning. A referral has also been

appended.

Referral prioritisation Diagnostics Reasoning

1st Homocysteine Hypertension and Cardiovascular Health

2nd Thyroid Hormone Profile Hypertension, Weight Gain and relative symptoms

3rd Liver Function Test Impact of obesity on liver function and physiology

Possible further investigations

4th Adrenal Hormone Profile Adrenal cortex impact and contribution to disease state


5th Baseline Hormone Profile Prior cause of menorrhagia and dysmenorrhoea

Table 9 - Referral prioritisation

REFERENCE LIST - removed


Appendix

Documents

SUBJECT: HMCL223 Clinical Diagnostic …: HMCL223 Clinical Diagnostic Techniques TYPE: Case Study Assignment Exemplar TASK: 1. You are required to analyse the following case (including