I.

INTRODUCTION
Type 2 diabetes is a chronic condition that affects the way your body metabolizes
sugar (glucose) — an important source of fuel for your body. With type 2 diabetes, your
body either resists the effects of insulin — a hormone that regulates the movement of
sugar into your cells — or doesn't produce enough insulin to maintain normal glucose
levels. Type 2 diabetes mellitus (T2DM) accounts for around 90% of all cases of
diabetes. T2DM is most commonly seen in persons older than 45 years, but it is
increasingly seen in children, adolescents, and younger adults due to rising levels of
obesity, physical inactivity, and energy-dense diets. There's no cure for type 2 diabetes,
but losing weight, eating well and exercising can help manage the disease.

Hypokalemic periodic paralysis is a condition that causes episodes of extreme

muscle weakness typically beginning in childhood or adolescence. Most often, these
episodes involve a temporary inability to move muscles in the arms and legs. Attacks
cause severe weakness or paralysis that usually lasts from hours to days. Some people
may have episodes almost every day, while others experience them weekly, monthly, or
only rarely. Attacks can occur without warning or can be triggered by factors such as
rest after exercise, a viral illness, or certain medications. Often, a large, carbohydrate-
rich meal or vigorous exercise in the evening can trigger an attack upon waking the
following morning. The relationship between serum potassium, mortality, and conditions
commonly associated with dyskalemias, such as heart failure (HF), chronic kidney
disease (CKD), and/or diabetes mellitus (DM) is largely unknown. Diuretics and renin-
angiotensin-aldosterone system inhibitors were related to hypokalemia and
hyperkalemia respectively.Potassium

Potassium is the major intracellular cation. It helps establish the resting membrane
potential in neurons and muscle fibers after membrane depolarization and action
potentials. In contrast to sodium, potassium has very little effect on osmotic pressure.
The low levels of potassium in blood and CSF are due to the sodium-potassium pumps
in cell membranes, which maintain the normal potassium concentration gradients
between the ICF and ECF. The recommendation for daily intake/consumption of
potassium is 4700 mg. Potassium is excreted, both actively and passively, through the
renal tubules, especially the distal convoluted tubule and collecting ducts. Potassium
participates in the exchange with sodium in the renal tubules under the influence of
aldosterone, which also relies on basolateral sodium-potassium pumps.

A urinary tract infection (UTI) is an infection in any part of your urinary system —
your kidneys, ureters, bladder and urethra. Most infections involve the lower urinary
tract — the bladder and the urethra. Women are at greater risk of developing a UTI than
are men. Infection limited to your bladder can be painful and annoying. However,
serious consequences can occur if a UTI spreads to your kidneys. Hypokalemia is
commonly found in patients with urinary tract infection (UTI) in our clinical
observation.Urinary tract infections are more common, more severe, and carry worse
outcomes in patients with type 2 diabetes mellitus. They are also more often caused by
resistant pathogens. Various impairments in the immune system, poor metabolic
control, and incomplete bladder emptying due to autonomic neuropathy may all
contribute to the enhanced risk of urinary tract infections in these patients.

Trichomonas (or “trich”) is a very common sexually transmitted disease (STD). It is

caused by infection with a protozoan parasite called Trichomonas vaginalis. Although
symptoms of the disease vary, most people who have the parasite cannot tell they are
infected. Trichomoniasis is the most common curable STD. Infection is more common in
women than in men. Older women are more likely than younger women to have been
infected with trichomoniasis. About 70% of infected people do not have any signs or
symptoms. When trichomoniasis does cause symptoms, they can range from mild
irritation to severe inflammation. Some people with symptoms get them within 5 to 28
days after being infected. Trichomoniasis can increase the risk of getting or spreading
other sexually transmitted infections. For example, trichomoniasis can cause genital
inflammation that makes it easier to get infected with HIV, or to pass the HIV virus on to
a sex partner.

II. PATIENT INFORMATION

 Patient JMC, a 41-years-old female, born on June 28, 1977 at Cagayan de Oro
City, was admitted on October 19, 2018 5:15 p.m. at Justiniano R. Borja General
Hospital (JRBGH) with presenting complaints of lower leg weakness.

VITAL SIGNS

Patient JMC’s examination showed an initial vital signs revealing body

temperature of 36.6 ℃, heart rate 69 of beats per minute, respiratory rate of 20 cycles
per minute, blood pressure of 120/80 mmHg.

PATIENT HISTORY

1 week prior to admission, the patient has sudden onset lower leg weakness.
After several lab test, patient is diagnosed with Hypokalemic Periodic Paralysis,
Diabetes Mellitus-II, and Urinary tract infection. The patient is advice to be admitted at
JRBGH for further observation on her condition. Patient was given with KCl and
Ceftriaxone, also the patient was taking Gliclazide, Atorvastatin and Ciprofloxacin as her
maintenance medicines for her Diabetes Mellitus-II.

CHIEF COMPLAINT

The patient was admitted with chief complaint of lower leg weakness

III. ANATOMY AND PHYSIOLOGY

 In human body, your endocrine system includes all the glands in your body that
make hormones. These chemical messengers play a key role in making sure your body
works the way it should.

If your endocrine system isn't healthy,

you might have problems developing
during puberty, getting pregnant, or
managing stress. You also might gain
weight easily, have weak bones, or lack
energy because too much sugar stays
in your blood instead of moving into
your cells where it's needed for energy.

Many different glands make up the

endocrine system. The hypothalamus,
pituitary gland, and pineal gland are
your brain. The thyroid and parathyroid glands are in your neck. The thymus is between
your lungs, the adrenals are on top of your kidneys, and the pancreas is behind your
stomach. Your ovaries (if you're a woman) or testes (if you're a man) are in your pelvic
region.

One of the organ that plays an important role in the human body is the pancreas. It plays
an essential role in converting the food we eat into fuel for the body's cells. The
pancreas has two main functions: an exocrine function that helps in digestion and
an endocrine function that regulates blood sugar. A healthy pancreas produces the
correct chemicals in the proper quantities, at the right times, to digest the foods we eat.

Electrolytes in the body

The body contains a large variety of ions, or electrolytes, which perform a variety of
functions. Some ions assist in the transmission of electrical impulses along cell
membranes in neurons and muscles.

All of the ions in plasma contribute to the osmotic balance that controls the
movement of water between cells and their environment.These six ions aid in
nerve excitability, endocrine secretion, membrane permeability, buffering body
fluids, and controlling the movement of fluids
between compartments. These ions enter the body
through the digestive tract. More than 90 percent of
the calcium and phosphate that enters the body is
incorporated into bones and teeth, with bone
serving as a mineral reserve for these ions. In the
event that calcium and phosphate are needed for
other functions, bone tissue can be broken down
to supply the blood and other tissues with these
minerals. Phosphate is a normal constituent of
nucleic acids; hence, blood levels of phosphate
will increase whenever nucleic acids are broken
down.

Excretion of ions occurs mainly through the

kidneys.

Potassium

Potassium is the major intracellular cation. It helps establish the resting

membrane potential in neurons and muscle fibers after membrane depolarization
and action potentials. In contrast to sodium, potassium has very little effect on
osmotic pressure. The low levels of potassium in blood and CSF are due to the
sodium-potassium pumps in cell membranes, which maintain the normal
potassium concentration gradients between the ICF and ECF. The
recommendation for daily intake/consumption of potassium is 4700 mg.
Potassium is excreted, both actively and passively, through the renal tubules,
especially the distal convoluted tubule and collecting ducts. Potassium
participates in the exchange with sodium in the renal tubules under the influence
of aldosterone, which also relies on basolateral sodium-potassium pumps
Urinary System

The kidneys filter metabolic wastes, excess ions, and chemicals from the blood to
form urine.The ureters are a pair of tubes that carry urine from the kidneys to the
urinary bladder. The ureters are about 10 to 12 inches long and run on the left and
right sides of the body parallel to the vertebral column. Gravity and peristalsis of
smooth muscle tissue in the walls of the ureters move urine toward the urinary
bladder. The ends of the ureters extend slightly into the urinary bladder and are
sealed at the point of entry to the bladder by the ureterovesical valves. These
valves prevent urine from flowing back towards the kidney. Urine entering the
urinary bladder from the ureters slowly fills the hollow space of the bladder and
stretches its elastic walls. The walls of the bladder allow it to stretch to hold
anywhere from 600 to 800 milliliters of urine. The urethra is the tube through which
urine passes from the bladder to the exterior of the body. The female urethra is around 2
inches long and ends inferior to the clitoris and superior to the vaginal opening. In males,
the urethra is around 8 to 10 inches long and ends at the tip of the penis. The flow of urine
through the urethra is controlled by the internal and external urethral sphincter muscles.
The internal urethral sphincter is made of smooth muscle and opens involuntarily when the
bladder reaches a certain set level of distention. The opening of the internal sphincter
results in the sensation of needing to urinate. The external urethral sphincter is made of
skeletal muscle and may be opened to allow urine to pass through the urethra or may be
held closed to delay urination.The kidney can control the excretion of potassium, sodium,
calcium, magnesium, phosphate, and chloride ions into urine. In cases where these ions
reach a higher than normal concentration, the kidneys can increase their excretion out of
the body to return them to a normal level. Conversely, the kidneys can conserve these ions
when they are present in lower than normal levels by allowing the ions to be reabsorbed
into the blood during filtration.

Multiple potential mechanisms unique to diabetes may contribute to the

increased risk of UTI in diabetic patients.38 Higher glucose concentrations in
urine may promote the growth of pathogenic bacteria.