Kimberly Moriarty
Diabetes Case study # 2
Note: In addition to our assigned readings, you need to reference the most current ADA
Standards of Care, available on the internet as a resource or as a PDA download. Please
also be familiar with the ACP Diabetes Resource Guide.
Mrs. Edwado is a 65-year-old Hispanic female who presents for her 3- to 6-month
diabetes checkup. Her chief complaint at this visit is her report of 2 “episodes.” The first
episode was noted 2 months ago while at work in the early afternoon. The patient states
she had skipped lunch and exercised for 45 minutes on the bike at the work gym. Later
she became fatigued, shaky, and mildly confused. A fasting blood sugar of 50 mg/dL was
noted and was treated with a regular cola. The second episode occurred 6 weeks ago
when the patient awoke at 2:30 AM to use the bathroom and passed out. The patient’s
spouse called the paramedics and the tested glucose was 32 mg/dL; she was treated at
home with glucagon.
Past medical history:
Type 2 diabetes × 15 y
Hypertension × 8 y
Dyslipidemia × 5 y
Medications:
1.
2.
3.
4.
5.
6.
7.
Glipizide 10 mg qd orally in the morning (started 1999)
Metformin 1000 mg bid orally (started 2003)
Ramipril 10 mg qd 1 orally in the morning (started 2001)
Simvastatin 40 mg qhs orally (started 2004)
Aspirin 162 mg qd orally (started 2005)
Chlorthalidone 12.5 mg qd orally (started 2005)
NPH insulin 45 units qhs subcutaneously (started 2007, dose increased at last visit
from 40 units when A1C was 8.3%)
The patient consistently takes her glucose medications and “almost always” takes her
blood pressure and lipid-lowering drugs. She is very compliant with her NPH insulin, as
it is easy for her to remember whether she has taken it, and it correlates with one of the
times she checks her blood glucose.
Allergies: NKDA
Tobacco history: Negative
Alcohol history: Occasional rare EtOH use
Drug abuse history: N/A
Family history:
Father died of CHF at age 82
Mother died of stroke at age 76
Maternal grandmother died of colon cancer at age 75
Sister with DM2 and retinopathy
Social history:
Married 35 y; 3 children live out of home
Sedentary office worker
Review of systems:
Positive for 10-lb weight gain over last 6-12 mo
Denies cardiac, respiratory issues
Does note mild upset GI with meals 1 ×/wk
Physical exam:
General: WDWN, mildly obese woman otherwise within normal limits
Vitals: BP = 126/78 mm Hg, HR = 72 BPM, Respiratory rate = 14 respirations per
minute, Wt = 208 lb, BMI = 30.2 kg/m2
Eyes: PERRLA, EOMI, Fundoscopic exam WNL
Lungs: CTA
CV: RRR S1S2, No murmur.
Extremities: Fair ROM; good pulses; no edema, sensation intact by use of monofilament
exam
Rectal: Nl tone, guaiac negative
Recent dilated eye exam: WNL
Home glucometer:



Fasting AM: 76-164 mg/dL (patient admits skipping breakfast 2-3 ×/wk)
After lunch: 106-220 mg/dL
Before bed: 150-240 mg/dL (patient admits frequently overeating at dinner and
later)
1. According to the ADA, what are the diagnostic criteria for diabetes? What are the
common signs and symptoms of diabetes? (8 points)
The diagnostic criterion for diagnosing diabetes includes fasting plasma glucose
of 126 or greater or plasma glucose greater than 200 2 hours after ingestion of 75g
of oral glucose. If positive for above, the test must be repeated on a different day
to confirm the diagnosis.
In addition, the patient must also have signs of diabetes including; polyuria,
polydipsia, unexplained weight loss, and a casual fingerstick greater than 200.
2. According to the most recent ADA Standards of care, Outline the standard of
care for: (12 points)
a. Glycemic control: Check every 3-6 months. Lower A1c to below or
around 7.
b. BP: maintain blood pressure of less than 130/80. Measure at each visit.
c. Lipid management: Check annually, unless otherwise indicated. Maintain
TC less than 200, TG less than 150, HDL greater than 40, non HDL less
than 130, and LDL less than 100.
d. Use of anti-platelet agent: Start at age 40, or unless otherwise indicated.
ASA as primary prevention for those with an increased risk of CV events
or with risk factors, ASA to be used in those with CVD, can use plavix if
there is an ASA allergy, Use of ASA not supported in those under 30,
especially those under 21.
e. Eye care: need dilated eye exam at diagnosis and annually.
f. Foot care: Screen for neuropathy within five years after diagnosis and
annually, foot inspection at each visit, comprehensive foot exam with
monofilament and screen for PVD at diagnosis and annually.
3. By class, identify oral agents used for glycemic control. Briefly indicate
mechanism of action of action of each class, and list common examples of each
class. List any side effects of the class. (20 points)
Sulfonulureas: works by stimulating insulin secretion. Glipizide, glyburide. Side
effects include weight gain and hypoglycemia.
Biguanides: works at hepatic cells, decreases hepatic gluocose production, does
not stimulate insulin secretion. Metformin. Side effects include diarrhea, nausea
abdominal bloating and anorexia.
Thiazolidinediones: Works by regulating insulin responsive genes necessary for
glucose and lipid metabolism. Improves sensitivity to insulin in skeletal muscle
and adipose tissue. Actos and Avandia. Side effects include weight gain, fluid
retention, heart failure symptoms.
Dipeptidyl Peptidase 4 inhibitors: works by increasing insulin resistance and
decreases glucagon levels in circulation. Januvia. Side effects include headache,
URI.
Meglitinides: Helps supplement glucose induced insulin output. Prandin, Starlix.
Side effects include hypoglycemia and weight gain.
Alpha Glucosidase inhibitors: Works by slowing the absorption of carbohydrates.
Also helps to reduce post prandial blood sugars. Precose, Glyset. Side effects
include diarrhea abdominal pain, gas.
Numerous combination products available.
4. Explain the differences in the different types of insulin by onset and duration of
action. (15 points)
Lispro (Humalog) Aspart (novolog) and Glulisine (Apidra) O: 5-15 min D: 3-4
hours
Regular (Humalin or Novolin) O: 30-60min D: 6-10 hours
NPH (Humilin or Novolin) O: 1-2 hours D: 10-20
Glargine (Lantus) O: 1-2 hours D: 24 hours
Detemir (Levemir) O: 1-2 hours D: 12-24 hours
PREMIXED
75/25 and 50/50 Humalog O: 0-15 min D; 15-18 hours
70/30 and 50/50 O: 30 min D: 12 hours
70/30 Novolog O: 10-20 min D: 15-18 hours
5. Identify patients requiring referral to a Diabetic Specialty group. (5 points)
A patient requiring a diabetic specialty group would be one that cannot maintain
adequate control with their primary care provider. They could be very sensitive to
insulin and/or other medications, unable to manage their condition at home, have
numerous compounding factors, and those with serious adverse effects from
previously unmanaged diabetes. As a practitioner, I feel that all those with
diabetes should be in some sort of group therapy/education regularly about the
condition. The more education to the patient the more likely they will be
successful in their treatment. I would base my referral to a specialty group when I
don’t feel like the patient nor I can effectively manage their condition successfully.
6. Discuss at least 5 major health risk factors that often accompany diabetes, provide
a brief pathophysiology explanation as to why. State the screening that you should
be performing to assess for each of complications. When would you decide to
referral your patient? (10 points)
Diabetic retinopathy: Because of elevated sugar levels, the vessels in the eye
become damaged, new vessels form, which are more prone to leak blood. This
leakage causes scarring and fibrosis. This scarring and fibrosis puts pressure on
the retina, causing loss of vision. Screening should be done within five years of
diagnosis and annually thereafter. Referral would be indicated with anyone with
macular edema or severe retinopathy, or with vision loss.
Diabetic nephropathy: Too much sugar in the blood causes damage to the kidneys
(nephrons) and leads to scarring. Eventually, the kidneys begin to leak, and
protein will be found in the urine. Screening includes a urine test annually. The
ADA also recommends annual serum Creatinine and GFR staging. Referral is
indicated when GFR is less than 60.
Peripheral vascular disease, foot ulcers: PVD and foot ulcers are again caused by
too much sugar in the blood. The sugar ends up damaging the capillaries, causing
impaired circulation. The skin is broken down and unable to heal without
adequate blood flow. Screening includes a foot exam every visit and a
comprehensive foot exam yearly. Referral would be indicated in those with s/s of
PVD (loss of foot hair, slow CRT, absence of pulses), open wounds, and non
healing wounds.
Coronary Artery disease: Diabetics usually have other risk factors (HTN,
Dyslipidemia, smoking etc) that contribute to the development of CAD. The
elevated levels of sugar in the blood can do damage to the lining of the vessels,
which weakens them, contributing to CAD. The ADA recommends a stress test
for those who have a history of PVD, a sedentary lifestyle, 35 or older, or two or
more risk factors for cardiovascular disease. Referral would be indicated on an
abnormal stress test.
Diabetic peripheral neuropathy: Again, those darn sugars floating around in the
periphery can end up in vessels, placing pressure against the nerves. This causes
pain, and eventually can result in numbness and tingling. Screening is
recommended annually in all patients with a monofilament test. Referral is
recommended if monofilament test is abnormal, or progressively worsening.
7. For Edwado above briefly document what further workup would you order if any
and why or why not? (10 points)
Hemoglobin H1c : check levels of sugar. Maintain goal of less than 7.
Lipids: to be checked annually. This would be routine if not done in the last year.
Beyond these, I see no reason to check anything, as she is just in for her routine
checkup.
8. In addition to your other work up you find that some of your test results are as
follows: A1C level: 8.0%
Hemoglobin/hematocrit: 13.5 g/39%
Urine microalbumin: < 28 mg/dL
What would your treatment plan would be, (include your follow up plan) give
brief rationale for each intervention. (20 points)
A1c level is higher than would be recommended. The level should be at or below
7. This means her levels are still high enough to cause damage. She needs tighter
control of her sugars. To start, she needs more education to make sure she
understands the importance of lifestyle changes. She needs to know to eat some
simple carbs before exercise. Her insulin dosage should be changed. I would
recommend her dosing of insulin be given before lunch, this helps to control her
overeating at dinner, and would prevent the middle of the night low blood sugar.
In effect, her dosing could also be done BID, dividing the insulin into morning
and evening doses. This may provide more consistent control. If she can only do
once a day, perhaps a switch to lantus for 24 hours control would be beneficial.
After trying one of these, I would send her to a specialist if no there was no good
control over her sugars.
Her H/H is normal. No further intervention needed. Recheck annually or if
indicated.
Her urine microalbumin is normal. Anything below 30 is normal. Repeat this
annually, and optimize blood pressure and glycemic control. Take note that it is
borderline high, maintaining control over her sugars is essential. Refer to
nephrologist if it increases.