Diabetes: Case Presentation, Diagnosis, And Management

Objectives

Introduction and topic overview

?Diabetes is a life-long and chronic metabolic disorder that is one of the major cause of death and disability worldwide.

?It is the major cause of cardiovascular disease, kidney failure and lower limp amputation.

?About 1.6 millions of death occurred due to diabetes in 2015 (World Health Organization, 2017).

?According to the 2017 Diabetes Statistics report, about 9.4% of the US population are living with diagnosis (cdc.gov, 2017). 

Overview of objectives

?To clearly understand the complications related to diabetes by case presentation

?To evaluate patient’s subjective and objective data related to diabetes

?To discuss about differential and eventual diagnosis of the disease

?To provide details about ways to manage and treat patients with diabetes related complications

History of present illness:

?A 45 years old patient was admitted to the hospital after recurrent skin infection and delay in healing of wounds after getting any cuts or bruises.

?The patients has also made complaints of excessive fatigue, excessive hunger and increase urination at night since the past one month

?The patient has been facing challenges in going to work due to excessive fatigue

Social history:

?The patient is a truck driver who has to load and unload heavy materials and he often gets injured during unloading packages

?The nature of his job requires him to sit for long hours thus indicating sedentary lifestyle of the client

?He lives with his wife and has a five year old son

?He is a regular smoker and consumes about 5 cans of beer every week

?His diet is very irregular due to his job of truck driver

Medical history:

?Although patient experienced excessive fatigue, excessive hunger (polyphagia) and increased urination (polyuria), however he has no history of health service visit in the past six months

?For treating his wound, patients has been taking over the counter antiseptic and not take any special medical treatment for delayed wound healing

?For his other symptoms like polyuria and fatigue, he has not taken any medical help to determine the reason for such symptoms.

Family history:

?His maternal side of family had a history of diabetes and hypertension related problem

?His mother was also a diabetic patient

?No diabetes related problem has been found in any other family member

Objective data:

. Body mass Index and Waist to Hip Ratio:

?Blood pressure: 140/85 mm Hg

History of present illness:

?Pulse rate: 71/min

?Body mass index: 25.9

?Waist-to-hip ratio: 0.8

. Symptoms of high blood sugar:

?The patient reported about feeling excessive fatigue since the past three months

?Symptoms of polyphagia was also found in patient indicating the major symptom of diabetes

?Patient also complained about frequent tendency to urinate

?Delay in wound healing was also found as the patient expressed that whenever he gets bruises it takes time for it to heal.

. Fasting plasma glucose level:

?As the patient symptoms indicated signs of hyperglycemia, fasting plasma glucose test was done in patient.

?The normal plasma glucose level is between 70-100 mg/dL and for patients to be diagnosed with diabetes, the value of fasting plasma glucose level should be greater than or equal to 126 mg/dL

?The fasting plasma glucose level found in patient was 150 mg/dL

Differential diagnosis: 

?Differential diagnosis is the assessment process of differentiating one disease from others having similar sign and symptoms.

?The main purpose of differential diagnosis is to determine the specific disease that is the reason for suffering in patient

?The advantage of differential diagnosis in the diagnostic process it helps to identify specific disease condition in patient and direct proper clinical steps and treatment option to manage the condition. 

Diagnostics:

?The main difference between differential diagnosis and diagnostic is that differential diagnosis is done from a general perspective whereas diagnostic is done from extremely specific perspective.

?Differential diagnosis is the first step in diagnosis process and diagnostics is the process that starts after certain disease is confirmed in patient.

?Several modern diagnostic tools supports health care professionals to come to a conclusion for confirming or ruling out suspected disease in patient

Risk factors:

?Family history of diabetes is one risk factor for patients and increases the chances of developing diabetes in patient.

?Lifestyle factors related risk for patient includes sedentary lifestyle, alcohol consumption and poor diet.

?Obesity or being overweight is also a significant factor increasing the risk of  type 2 diabetes

? Other biological risk of diabetes includes impaired glucose tolerance, insulin resistance and gestational diabetes in patient. Treatment plan:

?The objective and subjective data gives an indication of type 2 diabetes in patient

?Considering  the range of complication in patient, pharmacological intervention is an immediate priority for patient

?Patient education also needs to be included in care plan because the patient is a newly diagnosed diabetes patient and he may be unaware about ways to cope with the disease and maintain healthy lifestyle.

Social history:

?Follow-up of patient will also be important to determine recovery rate, effect of intervention and adherence to medication and care plan in patient

Prescription:

?Metformin drug was prescribed to patient for controlling high blood sugar level

?Glyburide was prescribed to patient to prevent complications in wound healing

?Both Metformin and Glyburide are oral hypoglycemic agents that controls glucose level and adverse effects in patient

?The advantage of oral hypoglycemic agent in treatment of diabetes is that they are better alternative to insulin. They are cheaper compared to insulin and easy to administer too.

Patient education:

?One of the main reason for late diagnosis of diabetes is lack of awareness about diabetes and its risk factor in patient

?Patient education is necessary to promote healthy lifestyle in patient, modify health related behavior and make patient aware about factors that can lead to complications

?Education related to dietary habits, level of physical activity and factors leading to complications will given to patient for proper management of disease

Follow-up:

?During follow-up with patient after treatment, the following things need to be assessed in patient:

?Improvement in symptoms after initiating pharmacotherapy

?Any possible complications or side-effects after taking the medication

?Changes in status of wound healing

?Adherence to lifestyle modification education and medications provided

Research article information:

?The article by Ghazanfari, (2010) is the final research article that confirms that fasting plasma glucose testing is an accurate tool for ruling out diabetes or early diagnosis of the disease.

?The sensitivity, specificity and predictive values of HbA1c and fasting glucose test (FGT) was determined in the study by testing a random sample of population in Kerman city

?The results of the study revealed that patient FGT is a more reliable test to distinguish diabetic patients from non-diabetic patient compared to HbA1c.

?The significance of the study is that it compared the effectiveness of FGT by comparing it with HbA1c test which is also the common test for diagnosing diabetes

?The reason for superiority of FGT compared to HbA1c test was also explained

Conclusion

?Diabetes is a lifestyle disease where analysis of patient history and family history is necessary to predict the risk of developing the disease

?Diabetes is associated with many common symptoms as well as complicated symptoms because of ignorance of the condition and delay in seeking care

?While working out diagnosis, fasting plasma glucose test is a realizable and cost effective screening method to confirm or rule out diabetes

Medical history:

Discussion question:

?Is there a possibility to make HbA1c test more cost-effective to enhance its use in screening method for diabetes?

?What can be the reason for racial and ethnic difference in prevalence of diabetes?

References

Al-Goblan, A. S., Al-Alfi, M. A., & Khan, M. Z. (2014). Mechanism linking diabetes mellitus and obesity. Diabetes, metabolic syndrome and obesity: targets and therapy, 7, 587.

Anderson, K., & Hamm, R. L. (2012). Factors that impair wound healing. Journal of the American College of Clinical Wound Specialists, 4(4), 84-91.

Behforouz, H. L., Drain, P. K., & Rhatigan, J. J. (2014). Rethinking the social history. New England Journal of Medicine, 371(14), 1277-1279.

Bener, A., Darwish, S., Al-Hamaq, A. O., Yousafzai, M. T., & Nasralla, E. A. (2014). The potential impact of family history of metabolic syndrome and risk of type 2 diabetes mellitus: In a highly endogamous population. Indian journal of endocrinology and metabolism, 18(2), 202.

Brunetti, L., & Kalabalik, J. (2012). Management of type-2 diabetes mellitus in adults: focus on individualizing non-insulin therapies. Pharmacy and Therapeutics, 37(12), 687.

cdc.gov (2017). National Diabetes Statistics Report, www.cdc.gov. Retrieved 4 February 2018, from 

Channanath, A. M., Farran, B., Behbehani, K., & Thanaraj, T. A. (2015). Association between body mass index and onset of hypertension in men and women with and without diabetes: a cross-sectional study using national health data from the State of Kuwait in the Arabian Peninsula. BMJ open, 5(6), e007043.

Chung, J. K. O., Xue, H., Pang, E. W. H., & Tam, D. C. C. (2017). Accuracy of fasting plasma glucose and hemoglobin A1c testing for the early detection of diabetes: A pilot study. Frontiers in Laboratory Medicine, 1(2), 76-81.

Corsino, L., Dhatariya, K., & Umpierrez, G. (2014). Management of diabetes and hyperglycemia in hospitalized patients. Available at: 

Dellasega, C., Gabbay, R., Durdock, K., & Martinez-King, N. (2010). Motivational interviewing (MI) to change type 2DM self care behaviors: A nursing intervention. Journal of diabetes nursing, 14(3), 112.

Floh, A. A., Manlhiot, C., Redington, A. N., McCrindle, B. W., Clarizia, N. A., Caldarone, C. A., & Schwartz, S. M. (2015). Insulin resistance and inflammation are a cause of hyperglycemia after pediatric cardiopulmonary bypass surgery. The Journal of thoracic and cardiovascular surgery, 150(3), 498-504.

Ghazanfari, Z., Haghdoost, A. A., Alizadeh, S. M., Atapour, J., & Zolala, F. (2010). A comparison of HbA1c and fasting blood sugar tests in general population. International journal of preventive medicine, 1(3), 187.

Gossain, V. V., & Aldasouqi, S. (2010). The challenge of undiagnosed pre-diabetes, diabetes and associated cardiovascular disease. International Journal of Diabetes Mellitus, 2(1), 43-46.

Family history:

Gray, N., Picone, G., Sloan, F., & Yashkin, A. (2015). The Relationship between BMI and Onset of Diabetes Mellitus and its Complications. Southern medical journal, 108(1), 29.

Hilding, A., Eriksson, A. K., Agardh, E. E., Grill, V., Ahlbom, A., Efendic, S., & Östenson, C. G. (2006). The impact of family history of diabetes and lifestyle factors on abnormal glucose regulation in middle-aged Swedish men and women. Diabetologia, 49(11), 2589-2598.

Hill, J., Nielsen, M., & Fox, M. H. (2013). Understanding the social factors that contribute to diabetes: a means to informing health care and social policies for the chronically ill. The Permanente Journal, 17(2), 67.

Kerner, W., & Brückel, J. (2014). Definition, classification and diagnosis of diabetes mellitus. Experimental and Clinical Endocrinology & Diabetes, 122(07), 384-386.

Khan, M. U. (2012). Lifestyle modification in the prevention of type II diabetes mellitus. Oman medical journal, 27(2), 170.

Lin, Y. W., Liu, P. S., Pook, K. A., & Wei, L. N. (2018). Glyburide and retinoic acid synergize to promote wound healing by anti-inflammation and RIP140 degradation. Scientific reports, 8(1), 834.

Lyssenko, V., & Laakso, M. (2013). Genetic screening for the risk of type 2 diabetes: worthless or valuable?. Diabetes care, 36(Supplement 2), S120-S126.

Muhrer, J. C. (2014). The importance of the history and physical in diagnosis. The Nurse Practitioner, 39(4), 30-35.

Nachum, Z., Zafran, N., Salim, R., Hissin, N., Hasanein, J., Letova, Y. G. Z., … & Yefet, E. (2017). Glyburide versus metformin and their combination for the treatment of gestational diabetes mellitus: a randomized controlled study. Diabetes Care, 40(3), 332-337.

National Academies of Sciences, Engineering, and Medicine. (2016). Improving diagnosis in health care. National Academies Press.

Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., … & Vivian, E. (2015). Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Journal of the Academy of Nutrition and Dietetics, 115(8), 1323-1334.

Raz, I. (2013). Guideline approach to therapy in patients with newly diagnosed type 2 diabetes. Diabetes Care, 36(Supplement 2), S139-S144.

Roche, M. M., & Wang, P. P. (2014). Factors associated with a diabetes diagnosis and late diabetes diagnosis for males and females. Journal of clinical & translational endocrinology, 1(3), 77-84.

Rockette-Wagner, B., Edelstein, S., Venditti, E. M., Reddy, D., Bray, G. A., Carrion-Petersen, M. L., … & Montez, M. G. (2015). The impact of lifestyle intervention on sedentary time in individuals at high risk of diabetes. Diabetologia, 58(6), 1198-1202.

Sharma, M., & Majumdar, P. K. (2009). Occupational lifestyle diseases: An emerging issue. Indian journal of occupational and environmental medicine, 13(3), 109.

Skamagas, M. (2013). Management of Diabetes and Hyperglycemia in Hospitalized Patients. In Essentials of Hospital Medicine: A Practical Guide for Clinicians (pp. 537-551).

World Health Organization.  (2017).  Diabetes.  Retrieved 4 February 2018, from .