Robert is a 55 - year - old truck driver with Type 2 Diabetes. His blood sugars
ID: 128643 • Letter: R
Question
Robert is a 55 - year - old truck driver with Type 2 Diabetes. His blood sugars are uncontrolled as evidenced by (AEB) A1C >10 and he complains of increasing n umbness in his feet and fingers, frequent urination during the day and overnight. Robert has a history of hypertension and hyperlipidemia.
Ht 6´3” (1.90m) Wt 242 lb (11 0 kg) BMI 30, BP: 155/90 mm Hg
Medications (daily) : Lantis 80 units at HS, Metformin 100 0mg BID, simvastatin 40 mg, enalapril 10 mg,
Lipid profile
• TC: 228 mg/dL , TG: 545 mg/dL , HDL - C: 39 mg/dL , LDL - C: 136 mg/dL
SMBG shows shows:
Aggregate mean: 218 mg/dL, Standard deviation: 48 (n = 68) over last 30 days
Frequency – 2 x/day
Fasting ( 6 AM): 173 mg/dL, Standard deviation: 35 (n = 21)
Prebreakfast (9 AM): 248 mg/dL, Standard deviation: 30 (n = 6)
Prelunch: (1 PM): 193 mg/dL, Standard deviation: 47 (n = 17)
Predinner (6 PM): 195 mg/dL, Standard deviation: 33 (n = 11)
Bedtime (n = 9): 260 mg/dL, Standard deviation 34 (n = 13)
Range: 69 mg/dL to 304 mg/dL
Food and nutrition history
Due to his job, Robert is often away from home for extended periods of time and he eats at truck stop diners, where he selects hamburgers, fried eggs with bacon and deep fried foods; he eats large quantities of chips and beef jerky as snacks. He drinks diet soda and almost no water. On weekends, when Robert is at home, he enjoys drink ing beer (8 to 10 - 12 - oz cans) and making barbecues.
6. Explain the pathophysiology of these symptoms (3)
7. What labs would be elevated if you suspect Robert is dehydrated? (2)
8. What is considered to be good control for BS (blood sugar) for someone with diabetes and what is considered poor control? (4)
9. Explain how Robert’s medications help control his diabetes (3)
10. Robert’s physician wants to initiate mealtime insulin injections. What dietary guidelines will you give to Robert regarding his food choices? (2)
11. What are some common causes of hypoglycemia and what w ill you recommend to Robert if he experiences hypoglycemia? (4)
Explanation / Answer
Type 2 Diabetes Mellitus is a progressive disorder which is non insulin dependent diabetes. This type of diabetes shows symptoms like increased thirst, increased hunger , frequently urination ,sores that doesn't heal, increased blood sugars.
6) Pathophysiology:
- In this type, there is insufficient production of insulin in the beta cells of pancreas and insulin resistance where cells doesn't absorb the insulin into cells.
- Moreover the fat cells and liver cells fail to respond to insulin, even when the levels of insulin are high in the blood. , This leads to hyperinsulinemia.
- Due to lack of energy in cells because of insulin resistance, the fat cells in triglycerides are broken down as energy resource leading to hyperlipidemia. He is also consuming foods high in content of fat which can lead to further accumulation of fatty acids.
- In the normal filtration process of the kidney, it filters the blood to form urine and reabsorb all the sugars but in diabetes the sugars are so high that some of them are released in the blood which draws more water.
7) Dehydration in diabetes is due to the frequent urination which leads to loss of water and electrolytes. There are few laboratory assessments which can help in detection of levels of dehydration in a client.
- To understand the acid base difference the following tests can be done to understand electrolyte imbalance such as;
A) Serum electrolytes like Sodium, potassium, chloride and bicarbonate levels. These levels tnd to decrease during dehydration mainly sodium and potassium plays a vital role.
B) Blood Urea Nitrogen and Creatinine levels tends to increase when there is dehydration.
- Urinalysis is done to understand the amount of urine passed in 24 hours as well as the colour and concentration of the urine.
- Complete Blood Count helps to evaluate blood cells and the amount of solid or liquid portions in blood that is hematocrit, which tends to increase due to decrease in water levels in plasma.
- Urine and/or Blood osmolarity which indicates the water content in the body
- Glucose levels in blood and urine ,to know about the levels of sugar in the body and the level of bad impact on the body tissues. High blood glucose leads to frequent urination which can leads to dehydration.
8) Controlling blood sugars are very important because of its long term ill effects on the human body like Nephropathy, retinopathy. There are factors which can help in decreasing the blood sugars whereas certain other factors can further elevate the blood sugar levels.
Good Factors:
- Obesity is a critical factor which can further elevate the blood sugars and Cholesterol levels in the tissues. So, reducing some pounds of weight under guidance can help to maintain the blood sugar levels.
- Well balanced diet which is also very necessary to achieve good control over blood sugars, like small and frequent meals with medications at correct timings, without skipping meals at at time of the day, over eating.
- These factors can help the client to reach good control of blood sugars without recurrent episodes of hypoglycemia and regulating sugar levels within normal range for a diabetic patient.
Bad Controls:
- Hb A1c is the glycated hemoglobin which helps to identify how the diabetes is being controlled. For a non diabetic persons ,the normal level of hemoglobin a1c is 4% to 5.6%. A range of 5.7% to 6.4% means chances of getting diabetes is higher. Levels more than 6.5% means the person has diabetes.
if the Hb A1c levels are more than 7.5% which indicates poorly controlled diabetes.
9) The first medication which is prescribed for type 2 diabetes is Metformin.
- Metformin comes under the category of biguanides. This drug helps improving the sensitivity to insulin on tissues which results in absorption of insulin in to the cells. This also lowers the production of glucose in the liver. There are many other newer drugs which are available in market.
- Alpha glucosidase inhibitors which helps to breakdown the starch and table sugars thus lowering the blood sugar levels.
- Dopamine agonist , the action is unknown but it is believed to affect the rhythm and lowers the insulin resistance
- DPP 4 inhibitors tend to increase the production of insulin and reduces the hypoglycemic event.
- Glucagon like peptides they are also known as incretine mimetics, which helps in B cell growth thus leading to increase in insulin secretion.
- Meglitinides which help the body to release insulin for the body cells
- Sulfonylureas which helps by stimulating beta cells for secreting insulin and these drugs are the oldest drugs used for diabetes.
- Thiazolidinediones which helps in decreasing the glucose production in liver
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