Case Study Metabolism PDF

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CASE STUDY: METABOLISM & GLUCOSE REGULATION Review the following case study and answer the questions. You can type directly into this document and submit in the drop box.

Y.L., a 34-year-old 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 states, “By the time I get home and make dinner 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 with her one pregnancy, and reports a tradition eating pattern which is high in carbohydrates. You review Y.L.’s chart and note she last saw the provider 6 years ago prior to the delivery of her child. She has gained considerable weight; her current weight is 173 pounds (78.5kg). Today her BP is 152/97 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 lab studies.

Chart View: Laboratory test results Fasting glucose

184 mg/dL (10.2 mmol/L)

Hemoglobin A1C

8.8%

Total cholesterol

256 mg/dL (6.6 mmol/L)

Triglycerides

346 mg/dL (3.91 mmol/L)

Low density lipoprotein

155 mg/dL (4.01 mmol/L)

High density lipoprotein

32 mg/dL (0.83 mmol/L)

Urinalysis (UA)

+ glucose, - ketones

1. Interpret Y.L.’s lab results.

The fasting glucose level of 184 mg/dL is high. The normal level would be greater than or equal to 126 mg/dL. High glucose levels are suggestive of diabetes and the body’s inability to maintain normal levels. As well the A1C of 8.8% is very high. An A1C over 6.5% is considered diabetic. The total cholesterol of 256 mg/dL is high, with anything over 200 mg/dL being the marker. Triglycerides greater than or equal to 250 mg/dL indicate that the patient’s level of 346 mg/dL is high. The LDL level of 155 mg/dL is higher than the optimal level, which should be 100 mg/dL or below. The HDL level of 32 mg/dL is too low, with the optimal level being over 40 mg/dL. The cholesterol, triglycerides, LDL, and HDL levels all indicate cardiovascular disease. The urinalysis which is positive for glucose is only alarming if the amount of glucose is above 0.8 mmol/L. The urinalysis being negative for ketones means the patient is not in diabetic ketoacidosis.

2. Identify 3 methods used to diagnose DM. The three basic methods used to diagnose diabetes mellitus are: fasting plasma glucose (after fasting at least 8 hours, glucose will be greater than or equal to 126), random plasma glucose (level will be greater than or equal to 200), and glucose level 2 hours after receiving glucose (level will be greater than or equal to 200).

3. Describe the major pathophysiologic difference between type 1 & type 2 DM. Type 1 diabetics can not control whether they have diabetes or not. They have a genetic predisposition to have type 1. The body destroys pancreatic beta cells which results in a decrease or stop of insulin production. As well there is an increase in glucose production by the liver. Type 2 diabetics usually have a slow progression to insulin resistance and problems with insulin secretion. Type 2 diabetics may be able to control their diabetes with diet and exercise first.

4. Name 6 risk factors for type 2 DM and identify which ones Y.L. has. 6 risk factors for type 2 diabetes would include the following: Ethnicity, Y.L is of Asian decent and that is a risk factor. History, Y.L had gestational diabetes in the past, which makes her at a higher risk for type 2 diabetes. Hypertension, Y.L has a blood pressure above normal at 152/97. Random glucose, Y.L has a random glucose of 291. High cholesterol and triglycerides, Y.L has both. Weight and diet, Y.L is overweight and has a carbohydrate heavy diet.

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 a 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? Since Y.L is of Asian decent and has an admittedly carbohydrate heavy diet, it would be wise to incorporate the foods she normally eats into her diet and provide substitutions or appropriate portions to them. This will help with her adherence to dietary changes.

6. What is the reason for starting Y.L. on metformin and glipizide? Metformin is usually the first line of treatment for a type 2 diabetic. Metformin decreases glucose production in the liver, while glipizide enhances insulin secretion.

7. Outline the teaching you need to provide to Y.L. about oral hypoglycemic therapy. Metformin does not carry a risk of hypoglycemia, but glipizide does. A patient taking glipizide should avoid alcohol consumption because it may contribute to low glucose levels. The patient must also be sure to consume enough calories and watch the amount of exercise they get to decrease chances of hypoglycemia. If the patient becomes hypoglycemic, they should know to drink fruit juice, or consume honey or table sugar.

8. What do you teach Y.L. to do if she becomes ill with the flu or viral illness? The flu or viral illness can worsen diabetes. It can also contribute to secondary problems because the flu and viral illness’ lower the immune system. When the immune system is compromised it is harder for the body to fight infection and maintain glucose levels. People with the flu or viral illness also don’t feel like eating, which is vital for diabetics.

9. You determine she understands your teaching about treating hypoglycemia if she states, “if my blood sugar is low, I should first have”: a. An apple with milk b. Peanut butter sandwich c. Fruit juice or regular soda

d. Crackers with cheese slices The answer would be c, fruit juice or regular soda. 10. What benefits should Y.L. receive from exercising? Exercise will benefit Y.L by lowering blood sugar and reducing cardiovascular risk factors. Exercise will lower blood sugar by increasing glucose uptake by muscles and increasing insulin use. It also increases circulation and muscle tone.

11. What do you need to teach Y.L. about exercise? Y.L needs to be careful that she does not over exercise or cause hypoglycemia. She should have an extra snack on hand prior to exercise and keep juice nearby in the case her blood sugar drops too low. She needs to wear proper footwear and look at her feet post workout. Y.L should also workout during periods of the day where her sugar is the highest.

12. Besides the dietitian, what interprofessional and community referrals may be appropriate for Y.L.? A diabetic support group would be helpful, as well as physical therapist to help with exercises, and social work to ensure resources.

Case Study Progress Y.L. comments, “I have 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 had some form of neuropathy? Y.L reports that her feet hurt, that they burn, and feel like there are pins in them. These are signs of neuropathy.

14. What other findings in Y.L.’s history increased her risk for developing neuropathy? Other findings in Y. L’s history that increase her risk of neuropathy are her weight and her inability to exercise due to fatigue. Prolonged high glucose levels increase the risk of neuropathy; thus, it is important for her to regulate her glucose.

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

Eating small meals low in fat and exercising will decrease Y. L’s risk. It is important she wears well fitting and supportive shoes and maintains foot health. It will also help if Y.L lowers her weight and the stress on her feet. It is vital Y.L controls her blood glucose also.

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. Proper diabetic foot care includes proper cleaning, drying, and lubricating of the feet, while not allowing moisture between the toes. Wearing well-fitting closed toed shoes, possibly with orthotics to relieve pressure points. Trimming toenails straight across and filing sharp edges. Reducing risk factors such as smoking and avoiding over the counter foot remedies. It is important that Y.L inspect her feet daily and well and keep them elevated when sitting.

17. What monitoring will Y.L. need for nephropathy and retinopathy? It is most important that her blood glucose levels are monitored closely to reduce the risk of neuropathy and retinopathy. This will include sugar checks and diet and exercise monitoring to maintain normal levels.

Case Study Outcome Y. L. returns to the clinic 6 weeks later. Her BP is 130/78 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)....