Dm-cbl
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CBL- ENDOCRINE SYSTEM Dr. Mehzabin Ahmed
CASE HISTORY
AM is a 45 year old male who works as an accountant at the local supermarket. He has been attending the Diabetes Clinic for regular follow up since the past 5 years. He takes 40 units of Insulin (Humulin 70/30) every morning about half an hour before breakfast. He checks his sugar “ almost everyday”. He usually can remember to check it once a day( fasting) and sometimes remember to check it before dinner. He produces a sugar chart that shows that his fasting blood sugars are usually between 140- 180 and his pre- dinner readings are around 200. On examination doctors explains to him that he is moderately overweight (height= 5’4”; weight=1651bs; body mass index [BMI]= 27.5kg per m2) and he has stage 1 hypertension (BP= 145/95mmHg). His ECG is normal.
But he has borderline lipid levels: Total cholesterol =220mg per dL; Low density lipoprotein [LDL] =115mg per dL; High density lipoprotein[HDL] = 50 mg per dL; Triglycerides = 210mg per dL.
The doctor next examines his feet and notes that pulses are 2+ in both feet. No edema is present. No lesions are noted on the dorsum, plantar surface, or between the toes. There is good vibratory sensation over the great toe and 5th toe on the left foot, but vibratory sensation is markedly decreased on the right. Sensation to monofilament testing in stocking distribution of the foot is absent. When the doctors asks him whether he has stopped smoking he admits that he still smoke about two packs of cigarettes each day. The doctor tells him that he must stop smoking, take good care of his feet and go for brisk walks for half an hour each day and report to him with a sugar chart after a month. He also refer him to an Ophthalmologist for a funduscopic examination and a Dietician to help him plan his meals. He
What type of Diabetes is AM suffering from? What are the other types of diabetes mellitus?
Type 1 Diabetes: Absolute Insulin deficiency Auto immune Idiopathic
Type 2 Diabetes: Relative Insulin deficiency Secretary defect Insulin resistance
Other specific types: Genetic defects of beta cell function Genetic defects in insulin action
Diseases of the exocrine pancreas Endocrinopathies Drug or chemical induced Infections Uncommon forms of immune mediated diabetes Other genetic syndromes sometimes associated with diabetes
Gestational Diabetes
Why does AM have to take insulin each day?
He has poor control of the hyperglycemia as a result of insulin resistance.
If patient has a poor blood glucose control despite lifestyle changes and using oral medicines, Insulin may be prescribed.
Insulin must be injected under the skin using a syringe and cannot be taken by mouth.
What is normal fasting and post-prandial blood sugar level?
Normal PPBS-
fasting- <110mg/dl
<140mg/dl
Why was AM asked to get tested for Glycosylated Hemoglobin?
Glycosylated hemoglobin (HbA1c) is a weighted threemonth average of what the blood glucose has been.
This test measures how much glucose has been sticking to the red blood cells.
It also indicates how much glucose has been sticking to other cells.
A high HbA1c is an indicator of risk for long-term complications.
Currently, the ADA recommends an HbA1c of less than 7% to protect oneself from complications.
This test should be done every three months.
What are the complications that AM can develop if he does not control his blood sugar levels?
Emergency complications include diabetic coma.
Long-term complications include: diabetic retinopathy (eye disease) diabetic nephropathy (kidney disease) diabetic neuropathy (nerve damage) peripheral vascular disease (damage to blood vessels) high cholesterol, high blood pressure, atherosclerosis, and coronary artery disease
What are risk factors in AM that can be modified to decrease the changes of developing these complications?
Modifiable risk factors
Smoking
Obesity
Hypertension
Sensory loss over feet
What is the significance of sensory loss over AM’s feet?
Due to the sensory loss the patient fails to detect minor trauma (unfelt trauma). With a diabetic foot, a wound as small as a blister from wearing a shoe that's too tight can cause a lot of damage. Diabetes decreases the blood flow, so the injuries are slow to heal. When the wound is not healing, it's at risk for infection. As a diabetic, the infections spread quickly.
Site:Foot Exam (http://www.diabetes.usyd.edu.au/foot/Fexam1.html)
Commonly reported symptoms include:
Burning, feeling like the feet are on fire
Freezing, like the feet are on ice, although they feel warm to touch
Stabbing, like sharp knives
Lancinating, like electric shocks
What advice would you give AM about foot care?
People with diabetes are prone to foot problems because of complications caused by damage to blood vessels and nerves and decreased ability to fight infection.
Blood flow to the feet may become compromised and damage to the nerves may cause an injury to the foot to go unnoticed until infection develops.
Death of skin and other tissue can occur. If left untreated, amputation of the affected foot may ultimately be necessary
To prevent injury to the feet, diabetics should adopt a daily routine of checking and caring for the feet as follows:
Check your feet every day, and report sores or changes and signs of infection.
Wash feet every day with lukewarm water and mild soap, and dry them thoroughly.
Soften dry skin with lotion or petroleum jelly.
Protect feet with comfortable, well-fitting shoes.
Exercise daily to promote good circulation.
See a podiatrist for foot problems, or to have corns or calluses removed.
Remove shoes and socks during a visit to the health care provider to remind them to examine your feet.
Discontinue smoking because it worsens blood flow to the feet.
Why did the doctors advice AM to undergo funduscopy?
Retinal changes in diabetic retinopathy
Role of a dietician in management of diabetes mellitus
Meal planning includes choosing healthy foods, eating the right amount of food, and eating meals at the right time. The health care provider educates the patient on how much fat, protein, and carbohydrates is required for the patient.
Your specific meal plans need to be tailored to your food habits and preferences.
In type 2 diabetes, weight management and a well-balanced diet are important. Some people with type 2 diabetes can stop medications after intentional weight loss, although the diabetes is still present.
Consultation with a registered dietitian is an invaluable planning tool.
Lack of Insulin Decreased Anabolism Catabolism Growth hormone &
Increased secretion of Glucagon, Cortisol
Catecholamines
Increased
Glycogenolysis↑ Gluconeogenesis ↑ →
Fatigue
←
Hyperglycemia
Lipolysis ↑
Valvitis
←
Glycosuria
Hyperketonaemia ↓
Polyurea Polydypsia
← Osmotic diuresis
Wasting
→ Loss of weight
↓
Hypertension
↓
Hypothermia
Polyphagia
Acidosis
Tachycardia ← Salt & water Vasodilation Hypertension ← Depletion Hyperventilation
Diabetic
→
Ketoacidosis →
↑ Peripheral
CASE HISTORY
AM is a 45 year old male who works as an accountant at the local supermarket. He has been attending the Diabetes Clinic for regular follow up since the past 5 years. He takes 40 units of Insulin (Humulin 70/30) every morning about half an hour before breakfast. He checks his sugar “ almost everyday”. He usually can remember to check it once a day( fasting) and sometimes remember to check it before dinner. He produces a sugar chart that shows that his fasting blood sugars are usually between 140- 180 and his pre- dinner readings are around 200. On examination doctors explains to him that he is moderately overweight (height= 5’4”; weight=1651bs; body mass index [BMI]= 27.5kg per m2) and he has stage 1 hypertension (BP= 145/95mmHg). His ECG is normal.
But he has borderline lipid levels: Total cholesterol =220mg per dL; Low density lipoprotein [LDL] =115mg per dL; High density lipoprotein[HDL] = 50 mg per dL; Triglycerides = 210mg per dL.
The doctor next examines his feet and notes that pulses are 2+ in both feet. No edema is present. No lesions are noted on the dorsum, plantar surface, or between the toes. There is good vibratory sensation over the great toe and 5th toe on the left foot, but vibratory sensation is markedly decreased on the right. Sensation to monofilament testing in stocking distribution of the foot is absent. When the doctors asks him whether he has stopped smoking he admits that he still smoke about two packs of cigarettes each day. The doctor tells him that he must stop smoking, take good care of his feet and go for brisk walks for half an hour each day and report to him with a sugar chart after a month. He also refer him to an Ophthalmologist for a funduscopic examination and a Dietician to help him plan his meals. He
What type of Diabetes is AM suffering from? What are the other types of diabetes mellitus?
Type 1 Diabetes: Absolute Insulin deficiency Auto immune Idiopathic
Type 2 Diabetes: Relative Insulin deficiency Secretary defect Insulin resistance
Other specific types: Genetic defects of beta cell function Genetic defects in insulin action
Diseases of the exocrine pancreas Endocrinopathies Drug or chemical induced Infections Uncommon forms of immune mediated diabetes Other genetic syndromes sometimes associated with diabetes
Gestational Diabetes
Why does AM have to take insulin each day?
He has poor control of the hyperglycemia as a result of insulin resistance.
If patient has a poor blood glucose control despite lifestyle changes and using oral medicines, Insulin may be prescribed.
Insulin must be injected under the skin using a syringe and cannot be taken by mouth.
What is normal fasting and post-prandial blood sugar level?
Normal PPBS-
fasting- <110mg/dl
<140mg/dl
Why was AM asked to get tested for Glycosylated Hemoglobin?
Glycosylated hemoglobin (HbA1c) is a weighted threemonth average of what the blood glucose has been.
This test measures how much glucose has been sticking to the red blood cells.
It also indicates how much glucose has been sticking to other cells.
A high HbA1c is an indicator of risk for long-term complications.
Currently, the ADA recommends an HbA1c of less than 7% to protect oneself from complications.
This test should be done every three months.
What are the complications that AM can develop if he does not control his blood sugar levels?
Emergency complications include diabetic coma.
Long-term complications include: diabetic retinopathy (eye disease) diabetic nephropathy (kidney disease) diabetic neuropathy (nerve damage) peripheral vascular disease (damage to blood vessels) high cholesterol, high blood pressure, atherosclerosis, and coronary artery disease
What are risk factors in AM that can be modified to decrease the changes of developing these complications?
Modifiable risk factors
Smoking
Obesity
Hypertension
Sensory loss over feet
What is the significance of sensory loss over AM’s feet?
Due to the sensory loss the patient fails to detect minor trauma (unfelt trauma). With a diabetic foot, a wound as small as a blister from wearing a shoe that's too tight can cause a lot of damage. Diabetes decreases the blood flow, so the injuries are slow to heal. When the wound is not healing, it's at risk for infection. As a diabetic, the infections spread quickly.
Site:Foot Exam (http://www.diabetes.usyd.edu.au/foot/Fexam1.html)
Commonly reported symptoms include:
Burning, feeling like the feet are on fire
Freezing, like the feet are on ice, although they feel warm to touch
Stabbing, like sharp knives
Lancinating, like electric shocks
What advice would you give AM about foot care?
People with diabetes are prone to foot problems because of complications caused by damage to blood vessels and nerves and decreased ability to fight infection.
Blood flow to the feet may become compromised and damage to the nerves may cause an injury to the foot to go unnoticed until infection develops.
Death of skin and other tissue can occur. If left untreated, amputation of the affected foot may ultimately be necessary
To prevent injury to the feet, diabetics should adopt a daily routine of checking and caring for the feet as follows:
Check your feet every day, and report sores or changes and signs of infection.
Wash feet every day with lukewarm water and mild soap, and dry them thoroughly.
Soften dry skin with lotion or petroleum jelly.
Protect feet with comfortable, well-fitting shoes.
Exercise daily to promote good circulation.
See a podiatrist for foot problems, or to have corns or calluses removed.
Remove shoes and socks during a visit to the health care provider to remind them to examine your feet.
Discontinue smoking because it worsens blood flow to the feet.
Why did the doctors advice AM to undergo funduscopy?
Retinal changes in diabetic retinopathy
Role of a dietician in management of diabetes mellitus
Meal planning includes choosing healthy foods, eating the right amount of food, and eating meals at the right time. The health care provider educates the patient on how much fat, protein, and carbohydrates is required for the patient.
Your specific meal plans need to be tailored to your food habits and preferences.
In type 2 diabetes, weight management and a well-balanced diet are important. Some people with type 2 diabetes can stop medications after intentional weight loss, although the diabetes is still present.
Consultation with a registered dietitian is an invaluable planning tool.
Lack of Insulin Decreased Anabolism Catabolism Growth hormone &
Increased secretion of Glucagon, Cortisol
Catecholamines
Increased
Glycogenolysis↑ Gluconeogenesis ↑ →
Fatigue
←
Hyperglycemia
Lipolysis ↑
Valvitis
←
Glycosuria
Hyperketonaemia ↓
Polyurea Polydypsia
← Osmotic diuresis
Wasting
→ Loss of weight
↓
Hypertension
↓
Hypothermia
Polyphagia
Acidosis
Tachycardia ← Salt & water Vasodilation Hypertension ← Depletion Hyperventilation
Diabetic
→
Ketoacidosis →
↑ Peripheral
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