Assignment Instructions
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 | Negative | | | | | | | Glucose | Positive | | | | | | | Ketones | 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
https://professional.diabetes.org/standards-of-care/practice-guidelines-resources
Sample Answer
Pathophysiology & Clinical Findings of the Disease
- Based on the review of the history, physical and lab findings what is the most likely diabetes diagnosis for this patient?
There are two types of diabetes, namely Type 1 diabetes and Type 2 diabetes. According to the presented symptoms, the patient has Type 2 Diabetes. The factors that have made the patient be diagnosed with Type 2 Diabetes included his age, which is 48 years. According to Kyrou et al. (2020), patients who are over 45 years old are vulnerable to Type 2 diabetes. The other factor supporting that the patient has Type 2 diabetes is obesity. According to Klein et al. (2022), obesity plays a significant role in Type 2 diabetes. Additionally, the physical examination indicated a fruity breath odor, a symptom that is associated with type 2 diabetes, thus concluding that the diagnosis of the patient is Type 2 diabetes.
- Explain the pathophysiology associated with the chosen diabetes diagnosis.
Type 2 Diabetes is a common metabolic disorder that is caused by defective insulin secretion produced by pancreatic β-cells and the failure of insulin-sensitive tissues to respond to insulin. The combination of the two parameters promotes an abnormal glucose level in the blood, thus enhancing Type 2 diabetes among the vulnerable groups. According to the Centers for Disease Control and Prevention (n.d.), approximately 90-95% of the population has Type 2 diabetes. Typically, beta cells have the role of secreting insulin to respond to increased blood glucose levels. In the event of beta cells failing to secrete the required number of insulins to regulate glucose in the blood, metabolic stress occurs. The glucose in the blood becomes too high to be sustained, thus increasing the chances of Type 2 diabetes.
On the other hand, insulin resistance defines a situation in which fatty tissues have a lower response to insulin stimulation. In the event of insulin resistance, hypertension, endothelin dysfunction, and reduced glucose absorption, among other effects, is prone to occur, thus promoting the onset of Type 2 diabetes among individuals with the subject deficiencies. Additional parameters that combine with the mentioned parameter to increase Type 2 Diabetes among patients include age, obesity, and family genetic history with Type 2 diabetes, among other parameters (Golembiewski et al., 2024).
- Identify at least three subjective findings from the case which support the chosen diagnosis.
Subjective information originates from people's opinions. From the provided case, the personal information includes fatigue, weight loss, and extreme thirst. The relationship between fatigue and Type 2 diabetes is that the body cells fail to utilize glucose to generate energy because of insulin resistance, thus making the victim of the illness experience fatigue (Chauhan et al., 2024). Additionally, weight loss is among the subjective findings presented by the patient, indicating the effect of insulin resistance on energy production. In the event of insulin resistance, the body is forced to break down fats and muscles for energy, thus promoting type 2 diabetes. In extreme thirst, the increased urination among patients with the subject illness causes frequent urination that eventually leads to dehydration, which contributes to the sensation of hunger. Therefore, the three factors indicate the subjective findings that suggest that the patient is suffering from Type 2 diabetes.
- Identify at least three objective findings from the case which support the chosen diagnosis
Objective findings come after medical evaluations. After a medical assessment, a fasting glucose level of 132mg/dL, AIC levels of 7.2%, and the positive glucose in urinalysis support that the diagnosis of the patient is Type 2 diabetes. Typically, the fasting glucose level has surpassed the normal range of 60 -120 mg/dL. The AIC level is also high, indicating that the patient has type 2 diabetes. The positive glucose in urinalysis suggests hyperglycemia, a condition that prevents the body cells from taking up the glucose from the bloodstream for energy.
Management of the Disease
\Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.*
- Utilizes the required Clinical Practice Guideline (CPG) to support the chosen treatment recommendations.
Upon identification of the illness, treatment recommendations must be made immediately to curb the effects of the disease on the patient. The treatment options must adhere to the Clinical Practice Guidelines and evidence-based guidelines to achieve the intended results. According to ADA's current clinical practice, a change of lifestyle and the use of medication can serve as the best treatment recommendations for the diagnosed patient (American Diabetic Association, 2024). Change of lifestyle and medical interventions are the treatment recommendations for the identified illness in the patient. Dietary changes, physical activity, and a strong watch for weight management are lifestyle changes that should be recommended to the patient to manage the identified Type 2 diabetes (American Diabetic Association, 2024). Typically, weight loss will enhance insulin sensitivity while controlling glycemic in the body.
The recommendation for dietary changes will enable the patient to be selective on food intake to avoid consumption of meals that have a higher chance of increasing his Type 2 diabetes. Other than the changes in the patient's lifestyle, the patient should have medical recommendations to manage his condition (American Diabetic Association, 2024). The medical recommendation to the patient will aid in the management of glucose levels in the patient's body. Typically, the medication recommendation, which can be taken orally or through injections, has the power to improve insulin secretion and regulate glucose production, among other functions that protect the patient from the harmful effects of Type 2 diabetes.
- Identify two (2) "Evidence A" recommended medication classes for the treatment of this condition and provide an example (drug name) for each.
The two medical classes that act as Evidence A prescription for type diabetes include metformin and SGLT2 inhibitors. In the control of Type 2 diabetes, metformin is prioritized as the first-line pharmacological medication that works by reducing hepatic glucose production while increasing insulin sensitivity in peripheral tissues like muscles (de Boer et al., 2022). An example of a drug in the metformin class includes Glucophage. The other Evidence A recommended medication for Type 2 diabetes is SGLT2 Inhibitors, which aid in limiting the reabsorption of glucose in the kidney to increase the excretion of urinary glucose, thus lowering the glucose level in the blood (Ishiguro, Mori & Nishimura, 2020). An example of an SGLT2 inhibitor is empagliflozin, among other drugs.
- Describe the mechanism of action for each of the medication classes identified above.
Metformin medical class for controlling type 2 diabetes works by improving glucose tolerance in the patient's body. The subject class works by reducing plasma glucose levels, which eventually enables the patient to manage the illness. Metformin drugs work directly with the liver to decrease hepatic glucose generation with the intention of reducing the level of glucose in the bloodstream (Ishiguro, Mori & Nishimura, 2020). Typically, Glucophage drugs work to lower the amount of glucose in the blood by decreasing the amount of glucose produced in the liver while increasing the sensitivity of muscle cells to insulin. According to Metformin, it has the benefit of boosting peripheral glucose uptake and utilization of the same. On the other hand, empagliflozin comes as a tablet that is taken through the mouth to help Type 2 patients remove extra sugar from their bodies through urination (Ishiguro, Mori & Nishimura, 2020). The drug enables the body to minimize the absorption of sugars, thus allowing the body to lower its blood sugar levels. Usually, empagliflozin is used together with physical exercise to control blood glucose.
- Identify two (2) "Evidence A" recommended non-pharmacological treatment options for this patient.
Other than medical prescriptions to the patient, nonpharmacological treatment options can be used to manage Type 2 diabetes. Changes in the patient's lifestyle, including dietary, weight, and engaging in physical activities, will positively enable the patient to handle the identified Type 2 diabetes (Zu et al., 2023). Dietary observation, though dining on balanced diets with fruits, vegetables, and whole grains, among other foods, will help the patient to control type 2 diabetes. Besides, setting targets for weight loss, like controlling the size of portions, will enable the patient to solve obesity issues, which will minimize the patient's risk of type 2 diabetes. Aerobic exercises like swimming will serve as the best strategy for controlling Type 2 diabetes (American Diabetes Association, 2021) Additionally, listening to health specialists through workshops and seminars is another nonpharmacological treatment option for type 2 diabetes patients. Expertise advice will enable the patient to opt for suitable strategies for overcoming type 2 diabetes.
References
American Diabetes Association. (2021). 5. Facilitating behavior change and well-being to improve health outcomes: standards of medical care in diabetes---2021. Diabetes Care, 44(Supplement_1), S53-S72. https://diabetesjournals.org/care/article/44/Supplement_1/S53/30778/5-Facilitating-Behavior-Change-and-Well-being-to?searchresult=1
American Diabetic Association (2024). Epidemiology and Prognostic Implications of Coronary Artery Calcium in Asymptomatic Individuals With Prediabetes: A Multicohort Study. https://doi.org/10.2337/dc23-1864
Centers for Disease control and Prevention. What is Diabetes https://www.cdc.gov/diabetes/basics/diabetes.html
Chauhan, S., Jhawat, V., Singh, R. P., & Yadav, A. (2024). Topical Delivery of Insulin Using Novel Organogel Formulations: An Approach for the Management of Diabetic Wound. Burns.
de Boer, I. H., Khunti, K., Sadusky, T., Tuttle, K. R., Neumiller, J. J., Rhee, C. M., \... & Bakris, G. (2022). Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care, 45(12), 3075-3090. https://doi.org/10.2337/dci22-0027
Golembiewski, E. H., Garcia Bautista, A. E., Polley, E., Umpierrez, G. E., Galindo, R. J., Brito, J. P., \... & McCoy, R. G. (2024). Outomes and Attributes Patients Value When Choosing Glucose-Lowering Medications: A Mixed-Methods Study. Clinical Diabetes, cd230042. https://doi.org/10.2337/cd23-0042
Ishiguro, M., Mori, Y., & Nishimura, R. (2020). 2222-PUB: Differences In Clinical Background between Patients with and without Increased Glucagon Secretion while on SGLT2 Inhibitors: A Comparison of Canagliflozin and Other SGLT2 Inhibitors. Diabetes, 69(Supplement_1). https://doi.org/10.2337/db20-2222-PUB
Klein, S., Gastaldelli, A., Yki-Järvinen, H., & Scherer, P. E. (2022). Why does obesity cause diabetes?. Cell metabolism, 34(1), 11-20. https://www.cell.com/cell-metabolism/pdf/S1550-4131(21)00631-8.pdf
Kyrou, I., Tsigos, C., Mavrogianni, C., Cardon, G., Van Stappen, V., Latomme, J., \... & Manios, Y. (2020). Sociodemographic and lifestyle-related risk factors for identifying vulnerable groups for type 2 diabetes: a narrative review with emphasis on data from Europe. BMC endocrine disorders, 20, 1-13. https://link.springer.com/article/10.1186/s12902-019-0463-3
Zu, C., Liu, M., Su, X., Wei, Y., Meng, Q., Liu, C., \... & Qin, X. (2023). Association of Body Weight Time in Target Range With the Risk of Kidney Outcomes in Patients With Overweight/Obesity and Type 2 Diabetes Mellitus. Diabetes Care, dc231727. https://doi.org/10.2337/dc23-1727