Case Study: Mrs. Ksanthia is a 56 year old obese woman with Diabetes Mellitus Ty
ID: 15153 • Letter: C
Question
Case Study:Mrs. Ksanthia is a 56 year old obese woman with Diabetes Mellitus Type 2 “DMT2 or DM2” who is admitted for treatment of an infected, painless, DM related foot ulcer. There is a 20x10 cm area of cellulitis surrounding the ulcer, which has some purulent drainage and contains significant fibrinous matter (the wound bed is grey and mucus looking, not red with “grains”).
The pt is started on IV antibiotics. Surgeons have requested that she be NPO (nothing by mouth) after midnight for surgical debridement in the morning. Mrs. Xanthia’s current wt is 100kg, and her recent blood sugar levels were in the mid 200s (normal 70-120). A recent glycosylated hemoglobin (HbA1C test) was 10.9% (normal less than 7%). Her home regimen includes glipizide 10 mg BID and metformin 1000mg BID. Blood glucose in the ED is 289 mg/dl.
1. What does the hemoglobin A1C test indicate? Is hers high or low?
2. Why are people with DM more likely to get a foot injury without noticing than people without DM?
3. Why are people with DM more likely to get an infection that won’t heal?
4. Why do people with uncontrolled DM often end up on dialysis?
5. What are three behavioral choices people can make to avoid getting, or control, DM-2?
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Explanation / Answer
The red blood cells that circulate in the body live for about three months before they die. When sugar sticks to these cells, it gives us an idea of how much sugar has been around for the preceding three months. In most labs, the normal range is 4-5.9 %. In poorly controlled diabetes, its 8.0% or above, and in well controlled patients it's less than 7.0%. The benefits of measuring A1c is that is gives a more reasonable view of what's happening over the course of time (3 months), and the value does not bounce as much as finger stick blood sugar measurements, hence its high. Diabetic ulcers are the most common foot injuries leading to lower extremity amputation. Family physicians have a pivotal role in the prevention or early diagnosis of diabetic foot complications. Management of the diabetic foot requires a thorough knowledge of the major risk factors for amputation, frequent routine evaluation and meticulous preventive maintenance. The most common risk factors for ulcer formation include diabetic neuropathy, structural foot deformity and peripheral arterial occlusive disease. A careful physical examination, buttressed by monofilament testing for neuropathy and noninvasive testing for arterial insufficiency, can identify patients at risk for foot ulcers and appropriately classify patients who already have ulcers or other diabetic foot complications. Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation. Adherence to a systematic regimen of diagnosis and classification can improve communication between family physicians and diabetes subspecialists and facilitate appropriate treatment of complications.