Scenario
Y.L., a 34-year-old Asian woman, comes to the clinic with complaints of chronic fatigue, increased thirst, constant hunger, and frequent urination. She denies any pain, burning, or low-back pain on urination.
She tells you she has a vaginal yeast infection that she has treated numerous times with over-the-counter medication. She works full time as a clerk in a loan company and states she has difficulty reading numbers and reports, resulting in her making frequent mistakes. She says, “By the time I get home and make supper for my family, then put my child to bed, I am too tired to exercise.” She reports her feet hurt; they often “burn or feel like there are pins in them.” She has a history of gestational diabetes and reports that, after her delivery, she went back to her traditional eating pattern, which is high in carbohydrates.
In reviewing Y.L.’s chart, you notice she has not been seen since the delivery of her child 6 years ago. She has gained considerable weight; her current weight is 173 pounds. Today, her BP is 152/97 mm Hg, and a random plasma glucose is 291 mg/dL. The primary care provider suspects that Y.L. has developed type 2 diabetes mellitus (DM) and orders the following laboratory studies:
Chart View
Laboratory Test Results
Fasting glucose 184 mg/dL
HbA1C 8.8%
Total cholesterol 256 mg/dL
Triglycerides 346 mg/dL
LDL 155 mg/dL
HDL 32 mg/dL
UA +glucose, − ketones
1.Interpret Y.L.’s laboratory results.
2.Identify the three methods used to diagnose DM.
3.Identify three functions of insulin.
4.Describe the major pathophysiologic difference between type 1 and type 2 DM.
5.What are the risk factors for type 2 DM? Place a star or asterisk next to those that Y.L. exhibits.
Y.L. is diagnosed with type 2 DM. The PCP starts her on metformin (Glucophage) 500 mg and glipizide (Glucotrol) 5 mg orally each day at breakfast and atorvastatin (Lipitor) 20 mg orally at bedtime. She is referred to the dietitian for instructions on starting a 1200-calorie diet using an exchange system to facilitate weight loss and lower blood glucose, cholesterol, and triglyceride levels. You are to provide education regarding pharmacotherapy and exercise
6.What is the rationale for starting Y.L. on metformin (Glucophage) and glipizide (Glucotrol)?
7.What teaching do you need to provide to Y.L. regarding oral hypoglycemic therapy?
8.What potential benefits could Y.L. receive from encouragement to exercise?
Y.L. comments, “I’ve heard many people with diabetes can lose their toes or even their feet.” You take this opportunity to teach her about neuropathy and foot care.
- Which of the symptoms that Y.L. reported today led you to believe she has some form of neuropathy?
10.What findings in Y.L.’s history place her at increased risk for the development of other forms of neuropathy?
11.How would you educate Y.L. about neuropathy?
12.Because Y.L. already has symptoms of neuropathy, placing her at risk for foot complications, you realize you need to instruct her on proper foot care. Outline what you will include when teaching her about proper diabetic foot care.
13.What are some changes that Y.L. can make to reduce the risk or slow the progression of both macrovascular and microvascular disease?
14.Given all of the information in the foregoing scenario, what DM-related complications do you believe Y.L. is most at risk for, and why?
15.What monitoring will be needed for Y.L. in regards to nephropathy and retinopathy?
Sample Solution
