Question

Scenario

Y.L., a 34-year-old Southern Asian woman, comes to the clinic with chronic fatigue, increased thirst, constant hunger, and frequent urination. She denies any pain, burning, or low-back pain on urination. She tells you she has a vaginal yeast infection that she has treated many times with over-the-counter medication. She works full time as a clerk in a loan company and states she has difficulty reading numbers and reports, resulting in her making frequent mistakes. She says, “By the time I get home and make supper for my family, then put my child to bed, I am too tired to exercise.” She reports her feet hurt; they often “burn or feel like there are pins in them.” She has a history of gestational diabetes and reports following a traditional eating pattern, which is high in carbohydrates.

In reviewing Y.L.’s chart, you note she last saw the provider 6 years ago after the delivery of her last child. She has gained considerable weight; her current weight is 173 pounds (78.5 kg). Today her BP is 152/97 mm Hg, and a random plasma glucose level is 291 mg/dL (16.2 mmol/L). The provider suspects she has developed type 2 diabetes mellitus (DM) and orders the laboratory studies shown in the chart.

Chart View

Laboratory Test Results

Fasting glucose

184 mg/dL (10.2 mmol/L)

Hemoglobin A1c (A1C)

8.8%

Total cholesterol

256 mg/dL (6.6 mmol/L)

Triglycer1ides

346 mg/dL (3.91 mmol/L)

Low-density lipoprotein (LDL)

155 mg/dL (4.01 mmol/L)

High-density lipoprotein (HDL)

32 mg/dL (0.83 mmol/L)

Urinalysis (UA)

+ glucose, − ketones

1. Interpret Y.L.’s laboratory results.

2. Identify 3 methods used to diagnose DM.

3. Describe the major pathophysiologic difference between type 1 and type 2 DM.

4. Name 6 risk factors for type 2 DM. Underline those that Y.L. has.

CASE STUDY PROGRESS

Y.L. is diagnosed with type 2 DM. The provider starts her on metformin (Glucophage) 500 mg, glipizide (Glucotrol) 5 mg, orally each day at breakfast and atorvastatin 20 mg orally at bedtime. She is referred to the dietitian for instructions on starting a 1200-calorie diet using an exchange system to facilitate weight loss and lower blood glucose, cholesterol, and triglyceride levels. You are to provide teaching about pharmacotherapy and exercise.

5. How can you incorporate Y.L.’s cultural preferences as you develop her teaching plan?

6. What is the reason for starting Y.L. on metformin and glipizide?

7. Outline the teaching you need to provide to Y.L. about oral hypoglycemic therapy.

8. What do you teach Y.L. to do if she becomes ill with the flu or viral illness?

9. You determine she understands your teaching about treating hypoglycemia if she states, “If my blood sugar is low, I should first have:

an apple with milk.”

peanut butter sandwich.”

fruit juice or regular soda.”

crackers with cheese slices.”

10. What benefits should Y.L. receive from exercising?

11. What do you need to teach Y.L. about exercise?

12. Besides the dietitian, what interprofessional and community referrals may be appropriate for Y.L.?

CASE STUDY PROGRESS

Y.L. comments, “I’ve heard many people with diabetes lose their toes or even their feet.” You take this opportunity to teach her about neuropathy and foot care.

13. Which symptoms that Y.L. reported today led you to believe she has some form of neuropathy?

14. What other findings in Y.L.’s history increased her risk for developing neuropathy?

15. What would you teach Y.L. about neuropathy?

16. Because Y.L. has symptoms of neuropathy, placing her at risk for foot complications, you realize you need to instruct her on proper foot care. Outline what you will include when teaching her about proper diabetic foot care.

17. What monitoring will Y.L. need for nephropathy and retinopathy?

CASE STUDY OUTCOME

Y.L. returns to the clinic 6 weeks later. Her BP is 130/78 mm Hg and fasting glucose level is 153 mg/dL (8.5 mmol/L). She says she has not had any episodes of tingling in her toes or blurred vision lately. She did meet with the diabetic educator. She is making changes to her eating, has started walking, and is happy to have lost 6 pounds (2.7 kg).

Answer 1

ANSWERS:-

1) Interpret Y.L.'s laboratory results -

Laboratory Tests	Y.L.'s result	Normal values	Interpretation
Fasting glucose	184mg/dL (10.2mmol/L)	Normal- Less than 100mg/dL( 5.6mmol/L) Prediabetic - 100 -125mh/dL Diadetic - Above 126mg/dL	Increased from normal ,Diabetes Mellitus
Hemoglobin A1c	8.8%	Below 6.0%( normal) 6.0 to 6.4%( prediabetic) Above 6.5%( Diabetic )	Y.L.'s Hemoglobin A1c is more than 6.5%, indicating diabetes
Total cholesterol	256mg/dL(6.6mmol/L)	Desirable- below 200mg/dL(5.2mmol/L) Borderline -200-239mg/dL(5.2- 6.2mmol/L) High-above 240mg/dL(above 6.2mmol/L)	Y.L's Total cholesterol is 256mg/dL ,which is high
Triglycerides	346mg/dL(3.91mmol/L)	Normal- less than 150mg/dl(1.5mmol/L) Borderline-150- 199mg/dl(1.8- 2.2mmol/L) High-above 200mg/dL(above 2.3mmol/L)	High
Low-density lipoprotein(LDL)	155mg/dL(4.01mmol/L)	Normal-below 100mg/dL(2.6 mmol/L) Borderline-100-129mg/dL(2.6-3.3mmol/L) High-above 130mg/dL(3.4mmol/L)	High
High-density lipoprotein( HDL)	32mg/dL( 0.83mmol/L)	Best- abve 60mg/dL( 1.5mmol/L) Better- 40-59mg/dL(1-1.5mmol/L) Poor- below 40mg/dl(men)50mg/dl(women)	Poor level
Urinalysis	glucose present,ketones present	normally glucose and ketone bodies are not present	Diabetes mellitus

2) Identify 3 methods used to diagnose DM -

a) History collection- Y.L.has history of gestational diabetes

* Dietary habits - eats traditional high carbohydrate diet.

* Less physical activities and exercise

b) Clinical manifestations- increased thirst( polydipsia), constant hunger( polyphagia), frequent urination( polyuria),frequent vaginal infection.

c) Laboratory investigations-

* Blood sugar levels - Fasting glucose

* Hemoglobin 1Ac( glucose bound hemoglobin)

* Urinalysis- for presence of glucose in urine.

3) Major pathophysiologic difference between type 1 and type 2 DM -

Type 1

Type2

* Also known as insulin dependent (IDDM) * Due to failure of pancreatic beta cells to produce insulin, * Can be due to genetic factors( people with certain HLA(human leukocyte antigen) type,immunological factors( antibodies are produced against normal tissues,which destructs normal tissues) and environmental factors (viral infections,toxins etc)or combination of these resulting destruction of beta cells. * Insulin is not produced so depend on insulin injection. * cause diabetic ketoacidosis ,because body uses fat for energy. * Diagnosed in early age like childhood

*Known as non-insulin dependent (NIDDM) * Due to impaired insulin secretion or tissue resistance to insulin ( decreased sensitivity of the tissues to insulin) ,so tissues may not be able to utilize the available insulin to use the glucose . * Insulin is available but less in amount ,not adequate for glucose metabolism. * usually diagnosed in adults. * treated commonly with oral hypoglycaemic agents.

4) Name 6 risk factors for type 2 DM . Underline those that Y.L.has -

* Family history of diabetes  

* Gestational diabetes( diabetes during pregnancy)

* Obesity

* Age - above 45years

*Race/ ethnicity- ( example_ African Americans, Native Americans etc)

* Medical conditions like hypertension,high cholesterol levels

* sedentary work or less physical activity

* Nutritinal patterns - high carbohydrate and fat foods.

RISK FACTORS FOR Y.L. are

* Obesity

* Medical conditions like hypertension,high cholesterol levels

* sedentary work or less physical activity

* Nutritinal patterns - high carbohydrate and fat foods.

* Gestational diabetes( diabetes during pregnancy)