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

# 1.) Y.L laboratory results -

Fasting glucose - 184mg/dl that means hyperglycemia ( normal fasting glucose is less than 100 mg/dl) and more than 126 mg/dl means she is diabetic.

Haemoglobin (A1c) - 8.8 % ( Hb a1c is a simple blood test that measures your average blood sugar levels over the past 3 months, normal level is less than 5.7 %)

Total Cholesterol - 256 mg/dl ( 125-200 mg/dl is normal)

Total triglycerides - 346 mg/dl (150 mg/dl is normal )

Low density lipoprotein - 155 mg /dl ( less than 100 mg/dl is normal )

High density lipoprotein - 32 mg/dl ( more than 50mg/dl is normal)

Urinalysis - glucose (+) , ketones (-) that means glycosuria positive. It typically occurs due to high blood sugar levels or kidney damage. Glycosuria is a common symptom of both type 1 diabetes and type 2 diabetes. ( glucose is present in urine )

Patient Y.L have -

- A1C is 8.8% which is higher than normal level. Normal level is less than 5.7% . A1C indicates average blood sugar level for the past two to three months.

- Hyperglycaemia - It means increase in glucose level in blood than normal. (Normal fasting level is less than 100mg/dl)

- Hypercholesterolemia - It means increase in total cholesterol level in blood than normal level. Normal total cholesterol level is 125-200 mg/dl. Increase in cholesterol level can increase risk of heart disease. Cholesterol leads to deposit in blood vessels and lead to artherosclerosis.

- Hyperlipidaemia - It means increase in lipids level in blood than normal. Normal lipids level is 150 mg/dl. It can increase the risk of coronary artery and heart diseases.

- Glycosuria - It means presence of glucose in urine than normal. Normal level is 0 to 0.8 mmol/L. Diabetes is the most common cause of glycosuria.

* Ketonuria is commonly in diabetes type 1 and uncommonly in type 2. This patient is negative for ketonuria.

# Acc to symptoms and lab reports, the patient may be or is DIABETIC.

# 2.) METHODS TO DIAGNOSE DIABETES MELLITUS -

1) Fasting blood sugar test - A blood sample is taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL is normal. A fasting blood sugar level from 100 to 125 mg/dL is considered prediabetes and values more than 126 mg/dl considered as diabetic.

2) Random blood sugar test - A blood sample is taken at a random time, regardless of when last meal was taken, a random blood sugar level of 200 mg/dL or higher is considered as diabetic.

3) Oral glucose tolerance test -

For this test, patient fasts overnight, and the fasting blood sugar level is measured. Then patient drink a sugary liquid, and blood sugar levels are tested periodically for the next two hours.

A blood sugar level less than 140 mg/dL is normal. A reading of more than 200 mg/dL after two hours indicates diabetes. A reading between 140 and 199 mg/dL indicates prediabetes.

4) A1C (Glycated haemoglobin) test - This blood test indicates average blood sugar level for the past two to three months. It measures the percentage of blood sugar attached to hemoglobin. The higher blood sugar levels, the more hemoglobin with sugar have attached. An A1C level of 6.5 % or higher on two separate tests indicates diabetes. An A1C between 5.7 and 6.4 % indicates prediabetes. Below 5.7 % is considered normal.

# 3.) Difference btw diabetes type 1 and diabetes type 2.

The patients with diabetes type 1 does not produce insulin. The immune system attacks the pancreatic beta cells so that they can no longer produce insulin. It is often hereditary and there is no way to prevent diabetes type 1. A person with type 1 diabetes will need to use supplemental insulin from the time they receive the diagnosis and for the rest of their life.

where as,

The patients with diabetes type 2 does not respond to insulin. The pancreas produce insulin but the body’s cells start to resist the effects of insulin and unable to use it effectively. In time, body stop producing enough insulin, so the body no longer use glucose effectively. Lifestyle factors appear to play a role in its development.

# 4.) Risk factors for type 2 diabetes mellitus -

- Overweight.

- Age 45 or older.

- Family history of diabetes.

- Have a low level of HDL ( high density lipoprotein).

- History of gestational diabetes.

- History of heart disease.

- Not enough physically active.

- PCOD i.e poly cystic ovarian disease.

* Gestational diabetes, low level of HDL, less physically active, hypertension and could be overweight ( height not given ) are the risk factors present in patient Y.L.