Question

R.R. is a 62 year-old man who was initially seen because of gangrene of the foot and shortness of breath. He had been told that he had a mild case of diabetes 4-5 years ago. He has seen physicians intermittently, and is unaware of what his glucose regulation has been. He denies polydipsia or polyuria. About 6 months ago, he injured his right foot, and it has failed to heal. One year ago, he was admitted to a coronary care unit for shortness of breath. A myocardial infarction was said to have been ruled out. He stopped smoking 15 years ago. Current medications were 5 mg glyburide twice a day.

Physical examination showed weight of 170 pounds, height 5'9", and blood pressure 180/105 mmHg. He had bilateral engorged jugular veins and inspiratory moist rales. Dorsalis pedis and posterior tibial pulses were absent bilaterally. The right foot was erythematous, and several toes had areas of dry gangrene (2nd toe, lateral aspects of big toe, 5th toe), no tenderness and no pus. Sensation in the right foot was diminished. Laboratory data were plasma glucose 237 mg/dl, total serum cholesterol 266 mg/dl (desirable: <200 mg/dl), high-density lipoprotein (HDL) cholesterol 29 mg/dl (desirable: >35 mg/dl), triglycerides 285 mg/dl (desirable: <200 mg/dl), and HbA1c 8.9% (normal <6.2%).

The patient was educated, taught self-monitoring of blood glucose, instructed in diet, given treatment for his congestive heart failure, which controlled his dypsnea, and had his glyburide increased to 10 mg in the morning and 5 mg at night. Two years ago, he had a femoral-popliteal bypass and removal of two toes. Repeat blood studies showed only a modest improvement in glycemic control (plasma glucose levels 180-210 mg/dl). Fasting triglycerides were 240 mg/dl, HDL cholesterol was 33 mg/dl, and total cholesterol was 286 mg/dl.

Questions

1. What are the chronic complications of diabetes in this case?  

2. Why was a serious complication such as gangrene preceded by minimal symptoms of diabetes?  

3. Calculate the LDL cholesterol by Friedenwald's formula (total cholesterol - triglycerides divided by 5 - HDL cholesterol = LDL cholesterol).  

4. Identify the cardiovascular and microvascular risk factors in the history, physical examination, and laboratory data in this patient.  

5. What are the management objectives from what you know about the clinical conditions of this patient?  

Answer 1

Answers -1

​​​​chronic complications of diabetes 8 those of end-organ diseases from damage to the blood vessels (angiopathy) secondary to chronic hyperglycemia

In this scenario, the chronic complications occur in this patient are

Neuropathy

​​​​​​Diabeticdiabetic neuropathy is a nerve damage that occurs because of the metabolic derangements associated with diabetes mellitus.the most common type of neuropathy affecting person with diabetes is sensory neuropathy. this can leads to a loss of protective sensation in the lower extremities and coupled with other factors in this significantly increase the risk of complications that result in lower limb amputation.

A) sensory neuropathy

​​​​​​Thethe most common form of sensory neuropathy is distal symmetric neuropathy which affect the hands or feet bilaterally.

the characteristics of distal symmetric neuropathy include loss of sensation, abnormal sensations, pain and Parastheesias. Pain, which is often described as burning, cramping, crushing aur tearing is usually worse at night and may occur only at that time. Patient report feeling of walking on pillows or numb feet. at times the skin become so sensitive and even light pressure from the bed sheet cannot be tolerated. Complete or partial loss of sensitivity to touch and temperature is common. Foot injury and ulcerations can occur without the patient ever having pain. neuropathy can also cause atrophy of small muscles of the hands and feet causing deformity and limiting fine moment.

B) autonomic neuropathy

Autonomicautonomic neuropathy can affect nearly all body systems only to hypoglycemic unawareness, bow incontinence and diarrhoea, and urinary retention.

delayed gastric emptying is common of water Namak neuropathy that can produce anorexia, nausea, vomiting gastroesophageal reflux and persistent feeling of fullness.

cardio vascular abnormalities associated with autonomic neuropathy are postural hypertension, resting tachycardia, and painless myocardial infarction. a person with postural hypertension should be in struggled to change from lying or sitting position slowly.

Complications complications of feet and lower extremities

Foodfood complications are the most common cause of hospitalization in the patient with diabetes. Diabetic photo complications is multifactorial process. There is set from combination of microvascular and macrovascular diseases that take place the patient at the risk of injury on the serious infection that may leads to amputation.

sensory neuropathy is a major risk factor for lower extremity amputation is the person with diabetes.protective sensation of an prevents the patient from becoming aware that a foot injury has occurred.

If a patient has loss of protective sensation, fantasy message that must be taken to teach the patient how to prevent foot ulceration. Businesses in rural selection of proper footwear, including prescription shoes.

peripheral artery disease increases the risk of amputation by causing reduction in the blood flow to the lower extremities. when the blood flow is decreased oxygen blood white cells Andhra whitener regions are not available to the tissue therefore I want take longer to heal and risk for infection increases.

Integumentary complications of an affected in patient with diabetes.

photo complications are more common cause of hospitalization in person with diabetes. Diabetic foot complication is multifactorial process. Sensory neuropathy is a major risk factor for extremity amputation in the person with diabetes loss of protective sensation often prevents the patient from becoming aware that its foot injury has occurred. Peripheral arterial

Diseases increase the risk of amputation by causing reduction in the blood flow to the lower extremities. when blood flow is decreased oxygen, white blood cells, and vital nutrients a,not available to the tissues.

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