Diabetes

1. Answer the Case Study questions; there is no need to copy Case into your paper. Use APA format. Limit paper to 7 pages or less excluding title page and references. Use 2 current articles and Primary care A collaborative practice 4 ed By Buttaro, Trybulski, Bailey & Sandberg-Cook and current gui diabetic guidelines.
A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 2007, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118?127 mg/dl, which were described to him as indicative of ?borderline diabetes.? He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (?at least 10 lb.?), but no further action was taken.
Because of a change in A.B.?s insurance, he presents to you today as a new patient with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta) 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon. A.B. also takes atorvastatin (Lipitor) 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule.
A.B. does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. ?What would knowing the numbers do for me?? he asks. ?We already know the sugars are high.? A.B. states that he has ?never been sick a day in my life.? He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar.
During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2?3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG). A.B.?s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has ?a slice or two? of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago.
The medical documents that A.B. brings to this appointment indicate that his hemoglobin A1c (A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was ?up a little,? he was not aware of the need to keep his blood pressure ?130/80 mmHg for both cardiovascular and renal health.
A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.
A physical examination reveals the following:
? Weight: 178 lb; height: 5’2"; body mass index (BMI): 32.6 kg/m2
? Fasting capillary glucose: 166 mg/dl
? Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg
? Pulse: 88 bpm; respirations 20 per minute
? Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriovenous nicking, no retinopathy
? Thyroid: nonpalpable
? Lungs: clear to auscultation
? Heart: Rate and rhythm regular, no murmurs or gallops
? Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally
? Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle
Results of laboratory tests (drawn 5 days before the office visit) are as follows:
? Glucose (fasting): 178 mg/dl (normal range: 65?109 mg/dl)
? Creatinine: 1.0 mg/dl (normal range: 0.5?1.4 mg/dl)
? Blood urea nitrogen: 18 mg/dl (normal range: 7?30 mg/dl)
? Sodium: 141 mg/dl (normal range: 135?146 mg/dl)
? Potassium: 4.3 mg/dl (normal range: 3.5?5.3 mg/dl)
? Lipid panel
? Total cholesterol: 162 mg/dl (normal: <200 mg/dl)
? HDL cholesterol: 43 mg/dl (normal: ?40 mg/dl)
? LDL cholesterol (calculated): 84mg/dl (normal: <100 mg/dl)
? Triglycerides: 177 mg/dl (normal :<150 mg/dl)
? Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)
? AST: 14 IU/l (normal: 0?40 IU/l)
? ALT: 19 IU/l (normal: 5?40 IU/l)
? Alkaline phosphotase: 56 IU/l (normal: 35?125 IU/l)
? A1C: 8.1% (normal: 4?6%)
? Urine microalbumin: 45 mg (normal: <30mg)
Case Study Questions
1. Based on A.B.?s medical history, records, physical exam and lab results, what do you assess as his diagnoses? In other words, what is your problem list for this patient? List at least 7 items, and include self-care management or lifestyle deficits? (25 points)
2. Succinctly (limit to one page or less) describe the pathophysiologic differences between Type I and Type II diabetes. (10 points)
3. Which pharmacotherapy intervention would you recommend for A.B.?s diabetes diagnosis? Remember he stopped taking the Diabeta so he currently is not on any medication. List at least one example of a specific medication, dosing and mechanism of action. Include your rationale for choosing this medication over other options. (20 points)
4. Diet and exercise are priority factors in A.B.?s management. (15 points).
a. What is the connection between these two lifestyle modifications and type II diabetes?
b. Explain your diet and exercise management therapy for A.B., including specific recommendations.
5. What other interventions would you consider as part of A.B.?s management plan? (10 points)
6. Based on your initial plan of therapy, when do you want A.B. to return to see you for re-evaluation and what outcomes will you re-assess at this second visit? (15 points)

 
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