MODULE 9

CASE STUDY 3: DIABETES MELLITUS

Objectives:
1. To explain how blood glucose levels are maintained within narrow limits by insulin and glucagon.
2. To compare and contrast the etiology and pathogenesis of type 1, type 2 and gestational diabetes.
3. To describe acute and chronic complications of diabetes.
4. To compare and contrast the pharmacotherapy of the different types of diabetes.

Like the nervous system, the endocrine system is a major controller of homeostasis. Whereas a
nerve exerts instantaneous control over a single muscle fiber or gland, a hormone from the endocrine
system may affect all body cells and take as long as several days to produce an optimum response.
Hormonal balance is kept within a narrow range: Too little or too much of a hormone may produce
profound physiological changes.

Diabetes is one of the leading causes of death in the world. One in every 400 to 600 children
and adolescents has type 1 diabetes while 20.9% of all people 60 years or older has diabetes. Diabetes
can lead to serious acute and chronic complications, including heart disease, cerebrovascular accident
(CVA), blindness, kidney failure, and amputations.

Procedure:
1. Review the given case study.
a. Identify and interpret abbreviations used
b. give the meaning of the medical terms used in the case study
c. comment on the abnormal PE findings and laboratory findings
2. Differentiate Type 1 from Type 2 diabetes mellitus
3. Discuss the physiology of insulin. Include the different analogues of human insulin.
4. Answer the questions at the end of the case study.

CASE STUDY:

CC
"I'm here for my regular check up. I don’t have any problems today"

HPI
John McGuire is a 68 yo man who comes to the diabetes outpatient clinic for a follow-up visit. His blood glucose
logbook indicates that he has been monitoring his blood glucose levels twice a day (before breakfast and dinner)
with a range of 140 to 175 mg/dL. He reports adherence to an 1800-calorie meal plan ad 40 minutes of walking
on a treadmill every morning.

PMH
Type 2 DM x 5 years
HTN x 13 years
Hyperlipidemia x 1 year

FH
Maternal grandmother had DM, father had emphysema; no family history of CAD
SH
Married, retired factory worker, active in church and a social club. No current tobacco use (stopped 40 years ago),
consumes about 7 – 14 alcoholic drinks per week.

Meds
Glynase 6 mg po QD x 1 year
Glucophage 1 gram po BID x 6 months
Zestril 20 mg po QD
EC ASA 81 mg po QD

All
NKDA

ROS
Denies nocturia, polyuria, polydipsia, nausea, constipation, diarrhea, signs or symptoms of hypoglycemia,
paresthesias, and dyspnea. Reports occasional blurry vision and occasional lower leg pain.

PE
Gen
WDWN mildly obese, elderly Caucasian man in NAD

VS
BP 182/82, P 80, RR 16, T 38.6C; Wt 82.2 kg, Ht 66.5”

HEENT
PERRLA; EOMI; R & L fundus exam without retinopathy

Cor
RRR; no m/r/g

Lungs
Clear to A & P

Abd
NT/ND

Genit/Rect
Deferred

MS/Ext
Carotids, femorals, popliteals, right dorsalis pedis pulses 2+ throughout; left dorsalis pedis 1+; feet show thick
calluses on MTPs

Neuro
DTRs 2+ throughout; feet with normal sensation (5.07 monofilament) and vibration

Labs
Na 139 mEq/L Ca 9.8 mg/dL Fasting Lipid Profile
K 5.3 mEq/L Phos 3.3 mg/dL T. chol 238 mg/dL
Cl 102 mEq/L AST 19 IU/L LDL-C 168 mg/dL
CO2 22 mEq/L ALT 13 IU/L HDL-C 42 mg/dL
BUN 23 mg/dL Alk phos 43 IU/L Trig 170 mg/dL
SCr 1.2 mg/dL T.bili 1.0 mg/dL Free thyroxine index 3.4 U
Glu (random) 289 mg/dL HbA1C 8.2%

UA
(-) protein; (-) microalbuminuria

Assessment
The patient reports adherence to diet, exercise, and drug therapy as prescribed. His glycemic control has improved
somewhat (FBG and pre-dinner BG previously 170 to 200 mg/dL) with addition of Glucophage 6 months ago.
His cholesterol levels have also improved (T. chol 268 mg/dL 10 months ago) Blood pressure has remained
consistently high for the past 10 months. He has lost 1.6 kg in the last 3 months. His glycemic control, blood
pressure, and lipid profile have not improved adequately in response to a combination of nutrition therapy utilizing
the NCEP Step II diet (2 visits with a dietitian) and drug therapy implemented for the last 6 months.

QUESTIONS

problem identification
1. a. Discuss the pathophysiology of the patient's pathologic condition.
b. What findings indicate poorly controlled diabetes in this patient?

desired outcome
2. a. What are the goals of treatment for the management of type 2 diabetes for this patient?
b. What individual patient characteristics should be considered in determining the goals of treatment?

therapeutic alternatives
3. a. What non-pharmacologic interventions would you recommend for this patient?
b. What pharmacologic interventions could be considered for this patient?

optimal plan
4. a. What pharmacotherapeutic regimen would you recommend for this patient?
b. What alternative therapies might be appropriate if the initial plan fails?

assessment parameters
5. What parameters should be monitored to evaluate the efficacy and possible adverse effects associated with
the optimal regimen you selected?

patient counseling
6. What information should be given to the patient regarding diabetes mellitus and his treatment plan to increase
adherence, minimize adverse effects, and improve outcomes?

follow-up case question

7. What are the measurable objectives and long-term goals for treating hypertension and hyperlipidemia in this
patient?
8. What non-pharmacological and pharmacological interventions would you consider to reach these goals?
9. Discuss the phenomenon known as syndrome X and the role that insulin resistance is postulated to play in its
sequelae.
10. Explore the advantages and disadvantages of using combination oral agents in the management of type II
diabetes and the rationale for delaying the initiation of insulin therapy.
11. Discuss combination therapy using various oral hypoglycemic agents with insulin.
12. In your assessment of this case, does the absence of retinal changes on physical examination or finding of no
protein on urinalysis exclude the presence of retinopathy and nephropathy, respectively?
13. Conduct a comparative review of the efficacy of several insulin analogues relative to the insulin products
commercially available.
14. Discuss the role of ACE inhibitors in the prevention of the onset and/or the progression of diabetic retinopathy.

References: