NR507 Week 6 Case Study

NR507 Week 6 Case Study

Pathophysiology & Clinical Findings of the Disease

1. Based on the review of the history, physical and lab findings what is the most likely diabetes diagnosis for this patient?

According to the history provided, physical exam findings, and laboratory results, the patient has type 2 diabetes mellitus (T2DM). T2DM is associated with increasing age and affects adults in 90% of the cases, and the patient having the onset of symptoms at the age of 48 years is more likely to have it (ElSayed et al., 2022a). His medical history is also positive for obesity and type 2 diabetes mellitus in his brother. T2DM is associated with a high genetic predisposition, and by having a positive family history of T2DM, he is likely also to have the same condition. According to ElSayed et al. (2022a), the risk of developing T2DM increases with an increase in body mass index. This is evidenced by the patient’s BMI of 36.5 significant for obesity and risk for T2DM. Upon her laboratory evaluation, he has a fasting blood sugar of 132mg/dl which is above the reference range (60-120md/dl), high hemoglobin AIC of 7.2%, urinalysis positive for glucose in the urine, and oral glucose tolerance test (OGTT) of 220mg/dl. These figures indicate hyperglycemia, which is the metabolic pathology in type 2 DM. The patient’s age, genetic predisposition, obesity, and laboratory indicators of hyperglycemia justify the diagnosis of type 2 diabetes mellitus.

2. Explain the pathophysiology associated with the chosen diabetes diagnosis.

Diabetes mellitus (DM) is a state of chronic hyperglycemia caused by defective insulin secretion (absolute deficiency), its action (relative deficiency), or both leading to various metabolic impairments (Sapra & Bhandari, 2023). It has two major clinical types, Type 1 and Type 2 diabetes mellitus (the patient’s diagnosis). Type 2 DM is a heterogenous condition in which there are fluctuating levels of insulin resistance and Ꞗ-cell dysfunction resulting in hyperglycemia, with obesity being a common finding (ElSayed et al., 2022a). According to ElSayed et al. (2022a), the primary pathology in T2DM is resistance to the insulin receptor; therefore, the insulin hormone lacks the capacity to lower the high glucose levels. In type 2 diabetes, the insulin concentration in circulation is typically elevated, but due to obesity, the sensitivity to insulin in peripheral tissues is markedly reduced, causing a relative deficiency of insulin. Because of Ꞗ-cell dysfunction, the cells are also unable to synthesize additional insulin that can overcome the resistance caused by obesity. This results in impaired glucose control hence hyperglycemia (Sapra & Bhandari, 2023). Due to hyperglycemia, patients experience classical osmotic symptoms such as polyuria and polydipsia because of the diuretic effect of marked glucosuria (Tzamaloukas et al., 2019). Patients also begin to develop weight loss because of dehydration and loss of calories in urine due to glucosuria.

3. Identify at least three subjective findings from the case which support the chosen diagnosis.

• Increasing appetite, frequency of urination, thirst, weight loss, and fatigue
• Medical history of obesity
• Positive family history of type 2 diabetes in his brother
• Age of 48 years old

According to Sapra & Bhandari (2023), T2DM has a strong genetic predisposition, with individuals having siblings with T2DM having a 50% lifetime risk of developing it. It is also associated with advancing age hence maturity-onset diabetes. Lifestyle factors and obesity are strong risk factors, and the patients present with the classical osmotic features associated with hyperglycemia.

4. Identify at least three objective findings from the case which support the chosen diagnosis.

• A body mass index of 36.5 implies obesity.
• Evidence of dehydration due to dry oral mucous membranes and lips
• A deep breathing quality with a fruity odor of the breath
• Fasting blood glucose level of 132mg/dl
• Haemoglobin A1C of 7.2%
• Glucosuria is a hallmark feature of T2DM.
• Oral glucose tolerance test (OGTT) of 220mg/dl

Management of the Disease

*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.

1. Identify two (2) “Evidence A” recommended medication classes for the treatment of this condition and provide an example (drug name) for each.

According to the Clinical Practice Guideline (CPG) for the standards of Medical Care in Diabetes, among the drug classes recommended for the management of T2DM include:

• Biguanides e.g., Metformin
• Sulfonylureas e.g., glimepiride, glipizide, and glibenclamide

(ElSayed et al., 2022b)

2. Describe the mechanism of action for each of the medication classes identified above.

Metformin is the only drug in the Biguanides class (ElSayed et al., 2022b). It works by reducing the hepatic production of glucose, increasing insulin-mediated glucose uptake, and enhancing the uptake and utilization of glucose in the gut (ElSayed et al., 2022b). Metformin is also effective in reducing the resistance of peripheral tissues to insulin and reduces the percentage of HbA1C by 1-2%. Due to its ability to cause sustained weight loss of about 1-2kgs, it is effective in managing obesity. It has also been effective in preventing microvascular diseases such as diabetic retinopathy, nephropathy, and neuropathy (ElSayed et al., 2022b).

Sulfonylureas are considered insulin secretagogues, and they enhance insulin production by the pancreatic Ꞗ-cells (ElSayed et al., 2022b). They act by closing the adenosine triphosphate (ATP) sensitive channels of the pancreatic Ꞗ-cells, lowering potassium efflux, and precipitating the secretion of insulin through a chain of molecular events. Sulfonylureas effectively reduce blood glucose and may help in managing the osmotic effects of hyperglycemia in T2DM (ElSayed et al., 2022b). Just like metformin, sulfonylureas cause an increase in insulin sensitivity in peripheral tissues, enhance glucose transportation, and reduce HbA1C by about 1-2%.

3. Identify two (2) “Evidence A” recommended non-pharmacological treatment options for this patient.
4. Healthy lifestyle behaviors such as physical activity.

The patient should be encouraged to reduce on a sedentary lifestyle and regularly exercise by doing up to 150 minutes of moderate-intensity exercise weekly or 75 minutes weekly of vigorous-intensity exercise. Physical activity helps in weight management. Central obesity in patients with T2DM with an associated increase in waist circumference causes an increase in insulin resistance and potentiation of cardiovascular risk.

1. Provision of self-management education about diabetes and support. The patient should be educated about T2DM, its causes, management, the importance of compliance with oral hypoglycemic agents, and associated complications that can arise from T2DM.

• Avoiding clinical inertia (ElSayed et al., 2022b).

References

ElSayed, N. A., Aleppo, G., Aroda, V. R., Bannuru, R. R., Brown, F. M., Bruemmer, D., Collins, B. S., Hilliard, M. E., Isaacs, D., Johnson, E. L., Kahan, S., Khunti, K., Leon, J., Lyons, S. K., Perry, M. L., Prahalad, P., Pratley, R. E., Seley, J. J., Stanton, R. C., & Gabbay, R. A. (2022a). 2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes—2023. Diabetes Care, 46(Supplement_1), S19–S40. https://doi.org/10.2337/dc23-s002

ElSayed, N. A., Aleppo, G., Aroda, V. R., Bannuru, R. R., Brown, F. M., Bruemmer, D., Collins, B. S., Hilliard, M. E., Isaacs, D., Johnson, E. L., Kahan, S., Khunti, K., Leon, J., Lyons, S. K., Perry, M. L., Prahalad, P., Pratley, R. E., Seley, J. J., Stanton, R. C., & Gabbay, R. A. (2022b). 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2023. Diabetes Care, 46(Supplement_1), S140–S157. https://doi.org/10.2337/dc23-s009

Sapra, A., & Bhandari, P. (2023, May 29). Diabetes Mellitus. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551501/

Tzamaloukas, A. H., Khitan, Z. J., Glew, R. H., Roumelioti, M., Rondon‐Berrios, H., Elisaf, M. S., Raj, D. S., Owen, J., Sun, Y., Siamopoulos, K. C., Rohrscheib, M., Ing, T. S., Murata, G. H., Shapiro, J. I., & Malhotra, D. (2019). Serum Sodium Concentration and Tonicity in Hyperglycemic Crises: Major Influences and Treatment Implications. Journal of the American Heart Association, 8(19). https://doi.org/10.1161/jaha.118.011786

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References

 [Must be on a separate page and in APA format]

Preparing the Assignment

Requirements

Content Criteria

Read the case study listed below.

Refer to the rubric for grading requirements.

Utilizing the Week 6 Case Study TemplateLinks to an external site., provide your responses to the case study questions listed below.

You must use at least one scholarly reference to provide pathophysiology statements. For this class, use of the textbook for pathophysiology statements is acceptable. You may also use an appropriate evidence-based journal.

You must use the current Clinical Practice Guideline (CPG) for the Standards of Medical Care in Diabetes -Abridged for Primary Care Providers provided by the American Diabetes Association to determine the patient’s type of diabetes and answer the treatment recommendation questions. The most current guideline can be found at the following web address: https://professional.diabetes.org/content-page/practice-guidelines-resourcesLinks to an external site. At the website, locate the current year’s CPG for use.

Proper APA format (in-text citations, reference page, spelling, English language, and grammar) must be used.

Case Study Scenario

Chief Complaint

J.T. is a 48-year old male who presents to the primary care clinic with fatigue, weight loss, and extreme thirst and increased appetite.

History of Present Illness

J.T. has been in his usual state of health until three weeks ago when he began experiencing symptoms of fatigue, weight loss, and extreme thirst. He reports that he would like to begin a walking program, but he feels too fatigued to walk at any point during the day. Now he is very concerned about gaining more weight since he is eating more. He reports insomnia due to having to get up and urinate greater than 4 times per night.

Past Medical History 

Hypertension

Hyperlipidemia

Obesity

Family History

Both parents deceased

Brother: Type 2 diabetes 

Social History

Denies smoking

Denies alcohol or recreational drug use

Landscaper  

Allergies

No Known Drug Allergies 

Medications

Lisinopril 20 mg once daily by mouth

Atorvastatin 20 mg once daily by mouth

Aspirin 81 mg once daily by mouth

Multivitamin once daily by mouth

Review of Systems

Constitutional: – fever, – chills, – weight loss.

Neurological: denies dizziness or disorientation

HEENT: Denies nasal congestion, rhinorrhea or sore throat.  Chest: (-)Tachypnea. Denies cough.

Heart: Denies chest pain, chest pressure or palpitations.

Lymph: Denies lymph node swelling.

General Physical Exam  

Constitutional: Alert and oriented male in no acute distress   

Vital Signs: BP-136/80, T-98.6 F, P-78, RR-20

Wt. 240 lbs., Ht. 5’8″, BMI 36.5

HEENT 

Eyes: Pupils equal, round and reactive to light and accommodation, normal conjunctiva. 

Ears: Tympanic membranes intact. 

Nose: Bilateral nasal turbinates without redness or swelling. Nares patent. 

Mouth: Oropharynx clear. No mouth lesions. Teeth present and intact; Oral mucous membranes and lips dry. 

Neck/Lymph Nodes 

Neck supple without JVD. 

No lymphadenopathy, masses or carotid bruits. 

Lungs 

Bilateral breath sounds clear throughout lung fields. Breathing quality deep with fruity breath odor

Heart 

S1 and S2 regular rate and rhythm; – tachycardia; no rubs or murmurs. 

Integumentary System 

Skin warm, dry; Nail beds pink without clubbing.  

Labs

Test Patient’s Result Reference

Glucose (fasting)

132

60-120 mg/dL

BUN

20

7-24 mg/dL

Creatinine

0.8

0.7-1.4 mg/dL

Sodium

141

135-145 mEq/L

Sodium

141

135-145 mEq/L

Chloride

97

95-105 mEq/L

HCO3

24

22-28 mEq/L

A1C

7.2

Urinalysis

Protein

Glucose

Ketones

Negative

Positive

Negative

Oral glucose tolerance test (OGTT)

220 mg/dL

J.T. is diagnosed with diabetes. Review all information provided in the case to answer the following questions.

Case Study Questions

Pathophysiology & Clinical Findings of the Disease

Review the lab findings and decide if the diagnosis is Type 2 or Type 1 Diabetes Mellitus.

Explain the pathophysiology associated with your chosen diagnosis

Identify at least three subjective findings from the case which support the chosen diagnosis.

Identify at least three objective findings from the case which support the chosen diagnosis.

Management of the Disease

*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.

Identify two (2) “Evidence A” recommended medication classes for the treatment of this condition and provide an example (drug name) for each.

Describe the mechanism of action for each of the medication classes identified above.

Identify two (2) “Evidence A” recommended non-pharmacological treatment options for this patient.

Utilizes the required Clinical Practice Guideline (CPG) to support the chosen treatment recommendations