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Patient Case Studies
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UK/DIA/00005f Date of preparation: November 2011
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Learning objectives (Case Study 1)
• Understanding the management of a patient with
newly diagnosed type 2 diabetes
• Understanding the diagnostic approach in
diabetes
• Appreciation of the management of other
metabolic parameters in diabetes
UK/DIA/00005f Date of preparation: November 2011
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Case Study 1
A 51 year old traffic police officer presents
to clinic accompanied by his wife.
• He is complaining of lethargy and malaise for the past 3 months.
• On further questioning, he has been feeling increasingly tired for
approximately 4 years but he ascribed this to the stress of his
job.
• His weight has increased by 20 kg over this period although his
appetite remains unchanged.
• His wife reports that he frequently consumes lots of sugary
snacks when on road duty although he denies this.
UK/DIA/00005f Date of preparation: November 2011
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Case Study 1 (cont)
• Recently he has been complaining of polydipsia and
polyuria associated with dysuria and has had a few
episodes of penile thrush over the last year or so.
• He has noticed a change in vision recently, describing objects as
appearing ‘blurred’ but he is reluctant to visit an Optician as he
is concerned that having to wear glasses may impact on his
driving duties. He suffers from hypertension and gout and takes
bendroflumethazide 2.5mg daily and allopurinol 100mg daily.
• His mother had type 2 diabetes (T2D) and died from a stroke
aged 64.
• He has two grown up sons who are healthy.
• He drinks 28 units of alcohol a week and smokes 20 cigarettes
per day.
UK/DIA/00005f Date of preparation: November 2011
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Case Study 1 (Examination)
On examination, his BMI is 28 kg /m2 and his blood pressure is
164/98 mmHg. Cardiovascular and respiratory examination is
unremarkable although on abdominal examination you note the
presence of central adiposity (waist circumference 116cm) and 2cm
smooth hepatomegaly, which is not associated with any signs of
chronic liver disease.
Neurological examination revealed slightly reduced sensation in
both light touch and pinprick sensation and vibration below mid tibia
bilaterally. His dorsalis pedis and posterior tibial pulses were
palpable. Fundoscopy reveals bilateral capillary microaneurysms
and ‘dot and blot’ haemorrhages. You organise some investigations
and the results are shown in the following table:
UK/DIA/00005f Date of preparation: November 2011
Case Study 1 (Results)
FBC
Normal
LFT’s
ALT 102 IU/L (5-35 IU/L), bilirubin 9µmol/L (3-17µmol/L), albumin 41 g/L (35-50 g/L, Alkaline
Phosphatase 102 IU/L (30-145 IU/L), gamma-GT 94 IU/L (11-51 IU/L)
Uric acid
190 µmol/L (110-420µmol/L)
U&Es
Normal with eGFR >90mls/min/1.73m2
TFTs
Normal
Fasting plasma glucose
14.1 mmol/L
HbA1c
8.20%
Fasting Lipid profile
Total cholesterol 6.4mmol/L (<4mmol/L), HDL 0.74mmol/L (0.9-1.9mmol/L), LDL 5.1mmol/L
(<4mmol/L), Triglycerides 5.1mmol/L (<1.69mmol/L)
Urine albumin
estimation
Urine albumin 107mg/24hr (<30mg/24hr); Albumin:Creatinine =6.1 (<2.5)
Mid-Stream Urine
Heavy growth of C.albicans.
Ultrasound Abdomen
The liver appearances are bright with a hyper-echoic echotexture. There are no focal abnormalities. The
kidneys, spleen, and aorta all appear structurally normal.
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UK/DIA/00005f Date of preparation: November 2011
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Questions
(Q1) What is the underlying diagnosis and how does this
explain his symptoms?
Based on the presence of symptoms coupled with a random plasma glucose
>11.1mmol/L, he has a diagnosis of T2DM1. Polyuria, polydipsia and blurred
vision are called ‘osmotic symptoms’; these symptoms are a consequence of the
osmotic effects of hyperglycaemia with associated fluid shifts. The
hyperglycaemia would exceed the renal threshold for renal tubular reabsorption
thus causing glycosuria. Glycosuria effectively serves as a culture medium for
microbial growth, which would explain the growth of C.albicans in his urine and
associated balanitis.
Read answer...
Reference 1: www.patient.co.uk, glucose tolerance tests, last accessed September 2011
UK/DIA/00005f Date of preparation: November 2011
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Questions
(Q2A) What modifiable risk factors does he have for
cardiovascular disease?
Modifiable risk factors include: smoking, obesity, hypertension, hyperuricaemia,
hyperglycaemia, a mixed hyperlipidaemia, and stress. Note hyperglycaemia,
dyslipidaemia, hyperuricaemia, and hypertension are effectively ‘modifiable’
risk factors, as with treatment, a euglycaemic improved lipid profile and
normotensive state can be achieved thus modifying the morbidity and mortality
risk to that of the background population.
Read answer...
UK/DIA/00005f Date of preparation: November 2011
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Questions
(Q2B) What non-modifiable risk factors does he have for
cardiovascular disease?
Non-modifiable risk factors include a positive family history of T2DM, and
having T2DM.
Read answer...
UK/DIA/00005f Date of preparation: November 2011
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Questions
(Q3) What treatment, if any, is indicated for:
(a) The underlying diagnosis?
1st line treatment for T2DM, in conjunction with NICE Guidelines, would include
a combination of lifestyle intervention changes from the outset and
commencing metformin if required2. Lifestyle measures should include advice
on smoking cessation and reducing alcohol consumption.
Read answer...
Reference 2: NICE Guidance CG87 May 2009
UK/DIA/00005f Date of preparation: November 2011
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(Q3) What treatment, if any, is indicated for:
(b) His weight?
One should aim for a 10% reduction in target weight3. To attain this he should
be given advice on diet and reduced caloric intake, increased exercise and
possibly referred onto an X-PERT educational programme to assist with the
management of diabetes4.
Read answer...
Reference 3: National Collaborating Centre for Chronic Conditions. Type 2 diabetes: national clinical guideline
for management in primary and secondary care (update). London: Royal College of Physicians, 2008.
Reference 4: X-PERT Educational Programme http://www.xperthealth.org.uk/, last accessed September 2011
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(Q3) What treatment, if any, is indicated for:
(c) His fasting lipid profile?
He has a typical dyslipidaemic profile of T2DM with high total cholesterol, low
HDL and a high triglyceride concentration. Dietary measures would be expected
to lower his total cholesterol by only 10%. Therefore, NICE guidelines would
advocate the use of a statin in the first instance, as he is over 40 years old with
risk factors stratifying him as intermediate-high risk for a cardiac event2.
Read answer...
Reference 2: NICE Guidance CG87 May 2009
UK/DIA/00005f Date of preparation: November 2011
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Questions
(Q3) What treatment, if any, is indicated for:
(d) His blood pressure?
NICE suggests his target blood pressure should be <140/80mmHg. If lifestyle
interventions prove unsuccessful, then antihypertensive therapy should be
employed. First line therapy should be an Angiotensin Converting Enzyme
Inhibitor (ACE-I), or an Angiotensin Receptor Blocker (ARB) if ACE-I is
contraindicated. You will note he is on a thiazide diuretic. There is evidence to
suggest that diabetic patients have a salt sensitive hypertension that is
responsive to thiazide diuretics2.
Read answer...
Reference 2: NICE Guidance CG87 May 2009
UK/DIA/00005f Date of preparation: November 2011
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Questions
(Q3) What treatment, if any, is indicated for:
(e) His LFT’s and liver ultrasound report?
Elevated levels of ALT and gamma-GT serve as sensitive biomarkers of hepatic
steatosis, when interpreted in the context of his history. This is most likely due
to, predominantly T2DM, and to a lesser but significant extent, a high alcohol
intake. The attainment of both euglycaemia and a normal lipid profile coupled
with reducing his alcohol intake would be expected to partially or even
completely reverse this process. Serial monitoring of gamma-GT and ALT may
guide this.
Read answer...
UK/DIA/00005f Date of preparation: November 2011
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Questions
(Q3) What treatment, if any, is indicated for:
(f) His urinary albumin estimation?
A urinary albumin estimation cannot be interpreted in the context of ongoing
urinary contamination. Due to the suspected presence of C.Albicans balanitis, it
should be treated with a topical anti-fungal agent. When the contamination has
resolved he would need two urinary albumin estimations three months apart in
order to be able to diagnose diabetic nephropathy.
Read answer...
UK/DIA/00005f Date of preparation: November 2011
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(Q3) What treatment, if any, is indicated for:
(g) The findings of the neurological examination?
He has evidence of a sensory neuropathy with both small (spinothalamic - pain)
and large (dorsal column – light touch, vibration) neuronal fibre involvement.
He is at an increased risk of diabetic foot complications and he should be given
advice on foot care e.g. regular self-examination of feet, including regular nail
trimming and spotting any changes in temperature or swelling5. He should be
referred to a Podiatrist where any trauma can be documented. The Podiatrist
may wish to carry out a thorough foot examination, to include doppler analysis
of pedal pulses and 10g monofilament sensory testing, which should constitute
an integral part of his annual review foot examination6. If he has symptoms
suggestive of neuropathic pain, these should be investigated and managed
appropriately.
Read answer...
Reference 5: www.thepodiatrist.com, foot problems, diabetes and your feet, care of the diabetic foot,
last accessed September 2011
Reference 6: NICE CG10, type 2 diabetes, prevention and management of foot problems, January 2004
UK/DIA/00005f Date of preparation: November 2011
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(Q4) What complications of the underlying diagnosis has he
developed?
There is evidence of microvascular complications predominantly retinopathy, a
neuropathy and microalbuminuria. He does not yet meet diagnostic criteria for
nephropathy.
Read answer...
UK/DIA/00005f Date of preparation: November 2011
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(Q5) What advice would you offer regarding his reduced visual
acuity and his employment?
His visual acuity will improve with the restoration of euglycaemia. As he has
background retinopathy it must be noted that restoration of euglycaemia
should be attained gradually as rapid attainment could result in a deterioration
of retinopathy. However, this is usually a problem in patients on insulin therapy
and would be very unlikely in this case it may seem contradictory to a lay person
but this is factually correct. It isn't well appreciated that in individuals with
diabetes if you improve their control too quickly (particularly with insulin) then
their retinopathy may actually deteriorate rather than improve. As he is a
serving police officer, he may wish to consider informing his employers of his
diagnosis, so that they can discuss whether his condition will affect his day to
day duties and if so, what support can be offered to overcome this3.
Read answer...
Reference 3: National Collaborating Centre for Chronic Conditions. Type 2 diabetes: national clinical guideline for
management in primary and secondary care (update). London: Royal College of Physicians, 2008.
UK/DIA/00005f Date of preparation: November 2011
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Learning Objectives (Case Study 2)
• How to manage patients with type 2 diabetes
(T2D) and deteriorating glycaemic control on
relatively optimal oral hypoglycaemic therapies
• Consideration of the psychological changes of
insulin conversion
• Understanding issues of self glucose monitoring
UK/DIA/00005f Date of preparation: November 2011
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Case Study 2
A 54 year old teacher, with a 6 year history of
type 2 diabetes mellitus (T2DM), presents for
annual review.
• Over the last year her weight has increased by 6kg
• She is feeling more lethargic but denies any osmotic symptoms.
• She is conscious of her weight and confesses to feeling
depressed over this.
• She monitors her capillary blood glucose five times a week. The
fasting capillary blood glucose average ~9mmol/L and 2hr postprandial readings average ~14mmol/L. Her HbA1c at her last
annual review was 8.3%.
UK/DIA/00005f Date of preparation: November 2011
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Case Study 2 (cont)
• She is taking metformin 1g b.i.d., gliclazide
160mg b.i.d., lisinopril 10mg o.d., simvastatin
20mg nocte, and 75mg aspirin o.d.
• She is needle phobic and is not keen on any injectable form
of therapy.
• Her mother had T2D and died from a myocardial infarction
aged 74.
• She has two grown up sons who are healthy.
• She drinks 22 units of alcohol a week and smokes 10
cigarettes per day. She is keen to stop smoking and has
tried nicotine replacement therapy with little success.
UK/DIA/00005f Date of preparation: November 2011
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Case Study 2 (Examination)
On examination, her BMI is 29 kg / m2, resting heart rate is
118bpm, and her blood pressure is 144/95 mmHg in the
supine position and 108/70 mmHg erect. There is mild
bilateral pitting oedema to the ankles. Respiratory, abdominal
and neurological examination is unremarkable.
Her annual review results are tabulated on the following slide:
UK/DIA/00005f Date of preparation: November 2011
Case Study 2 (Results)
FBC
Normal
Random plasma glucose
9.4mmol/L
HbA1c
8.1%
Total cholesterol 5.4mmol/L (<4mmol/L), HDL 0.94mmol/L (0.9-1.9mmol/L), LDL 3.1mmol/L
Fasting lipid profile
(<4mmol/L), Triglycerides 3.1mmol/L (<1.69mmol/L).
U&E’s
Normal with eGFR >90mls/min/1.73m2
TFT’s
Normal
Urine albumin estimation
Urine albumin 4mg/24hr (<30mg/24hr); Albumin:Creatinine =1.1 (<2.5)
Retinal Photography
Grade ‘R1’
Podiatry assessment
Low – intermediate risk
ECG
Sinus rhythm with left ventricular hypertrophy
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UK/DIA/00005f Date of preparation: November 2011
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Questions
(Q1) What advice would you offer to improve her overall
diabetic control?
To attain a target HbA1c of <7.5%1, her oral hypoglycaemic therapy needs to be
escalated (assuming she is compliant with treatment, which should be checked).
She is on optimal doses of first and second line therapy in the form of
metformin and gliclazide. There is little evidence to suggest that 3g of
metformin offers superior glycaemic control compared to 2g and the risks of
gastrointestinal adverse effects outweigh any benefits.
Read answer...
(continued on next slide)
Reference 1: www.patient.co.uk, glucose tolerance tests, last accessed September 2011
UK/DIA/00005f Date of preparation: November 2011
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Questions
(Q1 cont.) What advice would you offer to improve her overall
diabetic control?
Third line therapy is now indicated. A thiazolidinedione would be
contraindicated in view of the features of mild cardiac failure, thus, a DPP-IV
inhibitor would be an appropriate third choice agent. However, gliptins are
associated with modest HbA1c reductions of ~0.4 – 0.7% and it is likely that in
the future she will need either GLP-1 agonist therapy, or insulin. However, she
is needle phobic and whilst there is scope to escalate oral therapy with a third
line agent then that seems the most appropriate choice.
Read answer...
(continued on next slide)
UK/DIA/00005f Date of preparation: November 2011
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Questions
(Q1 cont.) What advice would you offer to improve her overall
diabetic control?
Similarly, she should be offered advice to assist weight loss with the aim of
achieving a 10% weight reduction2. This could also be assisted by encouraging
a reduction in alcohol consumption as there are a considerable amount of
calories in alcohol. Both exercise and weight loss would assist glycaemic
control. She should be encouraged to adhere to a calorie restricted diet of
approximately 1500 kCals/d and to also exercise. She may also benefit from a
patient education programme such as X-PERT4.
Read answer...
Reference 2: NICE Guidance CG87 May 2009
Reference 4: X-PERT Educational Programme http://www.xperthealth.org.uk/, last accessed September 2011
UK/DIA/00005f Date of preparation: November 2011
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(Q2) When would insulin be indicated?
She is not keen on injectable therapy. The increase in HbA1c over the last year
suggests that her beta-cell mass is progressively declining and/or she is
becoming more insulin resistant. Once triple therapy is initiated she would be
on appropriate insulinotropic and insulin sensitising therapy but if her HbA1c
continued to decline over the next 6 months, then insulin therapy would be
indicated.
Read answer...
She has microvascular complications (retinopathy and neuropathy) and so
improved glycaemic control is necessary to reduce the progression of such
complications potentially mandating the use of insulin.
UK/DIA/00005f Date of preparation: November 2011
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(Q3) What advice would you offer regarding capillary blood
glucose monitoring?
Her fasting capillary blood glucose levels should be <7mmol/L and her 2 hour
post prandial levels should ideally be 9-11mmol/L. 2 hour-post prandial
capillary glucose levels >11mmol/L correlate strongly with progression of
microvascular disease and confer a poorer prognosis. However there is little
evidence to indicate that self monitoring improves HbA1c, decreases body
weight or reduces hypoglycaemic events5.
Read answer...
Reference 5: www.thepodiatrist.com, foot problems, diabetes and your feet, care of the diabetic foot,
last accessed September 2011
UK/DIA/00005f Date of preparation: November 2011