Diabetes Mellitus, Type 2 Case Stud Patient’s Chief Complaint “My left foot feel
ID: 174079 • Letter: D
Question
Diabetes Mellitus, Type 2 Case Stud
Patient’s Chief Complaint
“My left foot feels weak and number, I have a hard time pointing my toes up.”
History of Present Illness
C.B. is a significantly overweight, 48 y/o female from the Winnebago Indian tribe who had high blood glucose and cholesterol levels three years ago but did not follow up with a clinical diagnostic workup. She had participated in the state’s annual health screening program and noticed that her fasting blood sugar was 141 and her cholesterol was 225. However, she felt “perfectly fine at the time” and could not afford any more medications. Except for a number of “female infections”, she has felt fine until recently.
Today, she presents to a general practitioner complaining that her left foot has been weak and numb for nearly 3 weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. However, she reports that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to stay hydrated. She has gained a total of 65 pounds since her last pregnancy 14 years ago, 15 pounds in the last 6 months alone.
Past Medical History
Seasonal allergic rhinitis (since her early 20s)
Breast biopsy positive for fibroadenoma at age 30
Gestational diabetes with fourth child 14 years ago
Morning sickness with all 4 pregnancies
HTN x 10 years
Moderate-to-severe osteoarthritis involving hands and knees x 4 years
Multiple yeast infections during the past 3 years that she has self-treated with OTC anti-fungal creams and salt baths
Occasional constipation
Past Surgical History
C-section 14 years ago
OB-GYN History
Menarche at age 12
Menopause, natural, at age 46; despite problematic hot flashes, she has chosen not to initiate HRT
First child at 17, last child at 34, G4P4A0, all babies healthy, 4th child weight 10 lb. 4 oz. at birth
Last pap smear 4 years ago
Family History
Type 2 DM in younger sister and maternal grandmother; both were diagnosed in their mid-40s. Maternal grandmother died from kidney failure while waiting for a kidney transplant; sister is taking “pills and shots”
Father had emphysema
Two older siblings alive and apparently well
All four children are healthy
Social History
Married 29 years with 4 children; husband is a migrant farm worker
Family of 5 lives in a 2-bedroom trailer
Patient works full-time as a seamstress in a small, family-owned business
Smokes 2 ppd (since age 14) and drinks 2 beers most evenings
Has “never used illegal drugs of any kind”
Rarely exercises and admits to trying various fad diets for weight loss but with little success; has given up trying to lose weight and now eats a diet rich in fats and refined sugars
Review of Systems
General
Admits to recent onset of fatigue
HEENT
Has awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing; denies vertigo, head trauma, ear pain, ringing sensation in ears, difficulty swallowing, and pain with swallowing
Cardiovascular
Denies chest pain, palpitations, and difficulty breathing while lying down. Denies leg cramps or swelling in the ankles and feet; has never experienced weakness, tingling, or numbness in arms or legs prior to this episode
Lungs
Denies cough, SOB, wheezing
GI
Denies n/v, abdominal bloating or pain, diarrhea, or food intolerance; does experience occasional constipation
GU
Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in urine, and urinary incontinence
OB-GYN
Menses stopped 2 years ago; denies sexual dysfunction, vaginal discharge, pain, itching
Neuro
No history of seizures, denies recent headaches
Derm
No history of chronic rash or excessive sweating
Endo
Denies a history of goiter and has not experienced heat or cold intolerance
Allergies
Sulfa drugs-confusion
Medications
Lisinopril 20 mg PO QD
Acetaminophen 500 mg with hydrocodone bitartrate 5mg 1 tablet PO Q HS and Q 4h PRN
Naproxen 500mg PO BID
Omeprazole 20 mg PO QD
Docusate sodium 100 mg PO TID
Loratadine 10 mg PO QD PRN
Patient Case Question 1: Explain why this patient is taking each of the medications listed above
Physical Examination and Laboratory Tests
General
Significantly overweight Native American woman who appears slightly nervous
The patient is alert, oriented, and uses appropriate words
She does not appear to be acutely distressed and looks her stated age
Vital Signs
Patient Case Question 2: Which clinical signs from table 54.1 should arouse the most concern? Calculate and interpret the patient’s BMI
Skin
Dry and cool with tenting/poor skin turgor
Significant xerosis on both feet with cracking
Erythematous scaling rash in the axilla bilaterally
No petichiae, ecchymosis, moles, or tumors upon careful inspection
Normal capillary refill throughout
HEENT
PERRLA
EOMI
Pink conjunctiva
R and L funduscopic exams showed mild arteriolar narrowing but without hemorrhages, exudates, or papilledema
Non-icteric sclera
TMs intact
Nares and oropharynx clear without exudates, erythema, lesions
Mucous membranes dry
Neck and Lymph Nodes
Supple
No thyromegaly, adenopathy, JVD, or nodules
Bruit auscultated over right carotid artery
Chest and Lungs
No chest deformity; chest expansion symmetric
Clear to auscultation and percussion throughout
Heart
Regular rate and rhythm with no murmurs, gallops, or rubs
Apical impulse normal at 5ht ICS at mid-clavicular line
Normal S1 and S2, no S3 or S4
Abdomen
Soft, NT with prominent central obesity
(+) BS in all four quadrants
(-) organomegaly, distension, or masses
Faint abdominal bruit auscultated
Breasts
No masses, discoloration, discharge, or dimpling of skin or nipples
Genitalia/Rectum
(-) vaginal discharge, erythema, lesions
(-) hemorrhoids
Good anal sphincter tone
Musculoskeletal and Extremities
Normal ROM in upper extremities
Reduced ROM in knees
(-) edema and clubbing
Peripheral pulses diminished to 1+ in both feet
Feet are cold to touch and dry with cracking, but no ulceration observed
Strength 5/5 throughout except 2/5 in left foot
Patient Case Question 3: What is the significance of this patient’s cold feet and diminished peripheral pulses in the lower extremity? What is the significance of xerosis and cracking of the feet in this patient?
Neurologic
AOx3
Cranial nerves II-XII intact (including good visual acuity)
Sensory response to light touch, proprioception, and vibration subnormal in both feet, with abnormalities great in the left foot
DTRs 2+ throughout
Gait normal except for left foot weakness
Patient Case Question 4: Clinical signs are objective manifestations that can be identified by someone other than the patient. List a minimum of five signs from the information above that support a diagnosis of type 2 diabetes in this patient
Laboratory Blood Test Results (After Overnight Fast)
Urinalysis
Electrocardiogram
Findings consistent with early left ventricular hypertrophy
Patient Case Question 5: List a minimum of five risk factors that predispose this patient to type 2 diabetes.
Patient Case Question 6: Clinical symptoms are subjective manifestations of a disease that can only be reported by the patient. List a minimum of seven symptoms that support that diagnosis of type 2 diabetes.
Patient Case Question 7: Which single urinalysis test result is more suggestive of type 2 diabetes than type 1 diabetes? Which three blood chemistry test results strongly support a diagnosis of diabetes?
Patient Case Question 8: Why do stress and infection promote hyperglycemia in patients with diabetes?
Patient Case Question 9: Why should medications other than metformin be considered in the management of diabetes in this patient?
Patient Case Question 10: Describe the pathophysiologic process that leads to nerve damage and damage to microcirculation in patients with diabetes
Explanation / Answer
Question 5. Risk factors for predispose this patient to type 2 diabetes.
Weight: The more fatty tissue have the high resistant your cells develop to insulin.
Inactivity: The fewer active you are the more your risk. Bodily activity benefits you regulate your weight, usages glucose as energy and makes your cells highly sensitive to insulin.
Family history: Your risk greater if a parent/sibling has type 2 diabetes.
Race: Though it is unclear why, people of sure races — including Hispanics, American Indians, Asian-Americans blacks and— are at higher risk.
Age. Your risk greater as you become older. This may be since you incline to exercise less, fail muscle mass and addition weight as you age. But type 2 diabetes is also greater dramatically among children, adolescents and younger adults.
Question 6.
Microalbumin test for single urinalysis test result is more suggestive of type 2 diabetes than type 1 diabetes.
Three blood chemistry test results strongly support a diagnosis of diabetes
Glucose test, Hemoglobin A1c and Glucose Tolerance Test
The seven common symptoms are:
Tiredness.
Weight loss.
Being thirsty a lot of the time.
Passing large volumes of urine.
Blurred vision
Frequent infections
Extreme hunger