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

1. Clinical comilications are

Numbness or reduced ability to feel pain or temperature change

A tingling or burning sensation

Sharp pains or cramps

Increased sensitivity to touch

Muscle weakness

Loss of reflexes, especially in the ankle

Loss of balance and coordination

Serious foot problems, such as ulcers, infections, deformities, and bone and joint

2. in case of diabetes in myocardial infarction, this is called stressed hype glycaemia,in which we have undiagnosed diabetes and patienthave impaired glucose tolerance,

it is treated by insulin

primary prevention are

1.strict glycaemic control

2.aggressive control of hypertension

IMMEDIATE MEASURE IN ACUTE MYOCARDIAL INFARCTION

a. asprin

b. ACE inhibitor

c. beta blocker

d i.v. insulin

3.The Friedewald equation is the equation typically used to calculate LDL-C concentration when a lipid panel is performed. The equation is:

LDL cholesterol (mg/dL) = total cholesterol – HDL cholesterol – (triglycerides/5)

266-29-(285/5)

=266-86

180mg/dl

4.the  microvascular and macrovascular complications, including

retinopathy, nephropathy, neuropathy (microvascular)

ischemic heart disease, peripheral vascular disease, and cerebrovascular disease (macrovascular),

resulting in organ and tissue damage in approximately one third to one half of people with diabetes. Because of the progressive nature of the disease,