Week 2 discussion.
jorged021491
Casestudy1.pdf
South University College of Nursing and Public Health Graduate Online
Nursing Program
Aquifer Internal Medicine
Internal Medicine 08: 55-year- old male with chronic disease management
Author/Editor:Author/Editor: Cynthia A. Burns, MD
INTRODUCTION HISTORY
You review Mr. Morales' records on the computer.You review Mr. Morales' records on the computer.
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You are working with Dr. Clay in her outpatient diabetes clinic this morning.
Your first patient, Mr. Morales, was seen by Dr. Clay once before, eight years ago, but was lost to follow-up after that time.
Based on review of the electronic medical record you are able to collect the following information prior to heading into the room to meet Mr. Morales:
Mr. Morales is a 55-year-old Hispanic male, diagnosed with Type 2 diabetes mellitus thirteen years ago after experiencing a 20-pound unintentional weight loss, blurry vision, and nocturia.
He was hospitalized six weeks ago with a non-ST elevation myocardial infarction and required three vessel coronary artery bypass grafting. During his admission, he was found to have a reduced ejection fraction of 20%.
He was referred for today's visit by the cardiologist to focus on optimizing his glycemic control and reducing his risk of the comorbidities associated with poorly controlled Type 2 diabetes mellitus.
His last hemoglobin A1c (HbA1c) was 9.5% eight years ago, and he had microalbuminuria at that time.
DIABETES CHRONIC DISEASE MANAGEMENT 1
MANAGEMENT
You review diabetes chronic disease management with Dr. Clay.You review diabetes chronic disease management with Dr. Clay.
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Before you see Mr. Morales, Dr. Clay reviews diabetes chronic disease management with you.
Diabetes Chronic Disease Management Evaluate for and optimize prevention of diabetic complicationsEvaluate for and optimize prevention of diabetic complications
Macrovascular complications:
Cardiovascular disease Cerebrovascular disease
Microvascular complications:
Retinopathy Nephropathy Neuropathy
In particular, cardiovascular disease is the No. 1 cause of mortality for people with diabetes, and one of the top causes of morbidity.
Hypoglycemia, infections, foot ulcers, and amputations are additional causes of morbidity and mortality in patients with diabetes.
The American Diabetes Association publishes annual guidelines to assist in the management of a patient with diabetes.
Remember the large role that the psychosocial aspects of a diabetesRemember the large role that the psychosocial aspects of a diabetes diagnosis play in managementdiagnosis play in management
Non-adherence with medical recommendations could be due to economic, work-related, religious, social, or linguistic barriers to care. Care must be taken to assess the psychosocial status of each person with diabetes at each clinic visit to ensure that barriers to successful diabetes care are minimized.
Question Which of the following does the American Diabetes Association recommend to minimize the risk of cardiovascular disease in patients with diabetes? Select all that apply.
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The best options are indicated below. Your selections are indicated by the shaded boxes.
A. Smoking cessation
B. Daily aspirin therapy
C. Blood pressure less than 140/90 mmHg (if it can be
achieved without increased treatment burden, a systolic target of < 130
is appropriate in younger, healthier patients)
D. If > 40 years old, regardless of other atherosclerotic
cardiovascular disease risk factors, statin therapy
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Answer Comment > The correct answers are A, B, C, D> The correct answers are A, B, C, D
ADA Recommendations to Minimize the Risk of Cardiovascular Disease in Patients with Diabetes Smoking cessationSmoking cessation, daily aspirindaily aspirin, blood pressure controlblood pressure control and lipid controllipid control are all recommended to reduce the risk of cardiovascular disease.
Please note that as of 2018, ADA recommendations were published with the older definition of hypertension (140/90). It always takes time before multiple different organizations agree on the same thresholds.
Daily low dose aspirin is recommended for primary prevention of cardiovascular disease in diabetic patients with a 10-year risk of atherosclerotic cardiovascular disease of >10%. It is also recommended for secondary prevention of all diabetic patients with a history of atherosclerotic disease.
Reduction of cardiovascular risk is achieved with a goal of optimal glycemic control, as well as control of many other health factors that raise cardiovascular risk, such as tobacco use, obesity, poorly controlled hypertension, and hypercholesterolemia.
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References Economic Costs of Diabetes in the U.S. in 2012. American Diabetes Association. Diabetes Care. April 2013; 36(4):1033-1046. http://care.diabetesjournals.org/content/36/4/1033. Accessed May 11, 2018.
PATIENT HISTORY HISTORY
Mr. Morales tells you about his heart attack.Mr. Morales tells you about his heart attack.
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You enter the exam room and introduce yourself to Mr. Morales.
"What brought you to the oRce today?" "I had a heart attack about a month ago and had to have open-heart surgery. The heart doctors told me that my heart is weak now. My cardiologist told me that I have to get my blood sugar under control so I don't have another heart attack. I am here to get down to work."
"Tell me more about that." "I didn't come back to see Dr. Clay because my job at the furniture factory wouldn't give me time off for clinic appointments, and I couldn't risk losing
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The best option is indicated below. Your selections are indicated by the shaded boxes.
my job. I wasn't checking my blood sugar before my heart attack because the testing strips are so expensive and my supervisor wouldn't let me off the line to check anyway. Since my surgery, I haven't gone back to work, and I've been checking my sugar before each meal and before bed. The hospital social worker got me two months' worth of testing strips and lancets before I went home, but I'm going to run out in a couple of weeks. I'm worried that I won't be able to check anymore."
He also tells you that while he was in the hospital, they had to use insulin through his vein to keep his blood sugar controlled, and that was very upsetting to him.
Question True or False: In a critically ill medical patients, tight blood sugar control with intravenous insulin therapy, with a goal blood sugar of 80-110 mg/dL, is associated with lower mortality than less tight blood sugar control (e.g. 140-180 mg/dL).
A. True
B. False
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Answer Comment > The correct answer is B> The correct answer is B
EUectiveness of Intravenous Insulin for Blood Glucose Control Blood sugar control in critically ill patients has been the subject of considerable investigation. Previous research suggested that tight control (80-120 mg/dL) was desirable, but more recent research shows that aggressive blood sugar control can be associated with higher mortality.
Hypoglycemia (serum glucose concentration <70 mg/dL), with rates as high as 40% in some studies, is associated with tight glycemic control.
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A meta-analysis of 29 controlled trials involving more than 8,000 adult ICU patients showed no difference in in-hospital mortality between the group assigned to tight glucose control versus usual care.
The current recommended blood glucose target for mostThe current recommended blood glucose target for most hospitalized patients is 140 to 180 mg/dL.hospitalized patients is 140 to 180 mg/dL.
References Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300(8):933.
MEDICATION REVIEW HISTORY You review Mr. Morales' medications with him:
MedicationsMedications
metformin 1000 mg twice daily pioglitazone 15 mg daily glipizide 5 mg daily aspirin 81 mg daily clopidogrel 75 mg daily long-acting metoprolol 100 mg daily furosemide 80 mg twice daily lisinopril 20 mg daily amlodipine 10 mg daily ranitidine 150 mg twice daily gabapentin 300 mg twice daily potassium chloride 10 mEq twice daily atorvastatin 80 mg daily
Mr. Morales says, "The hospital doctors sent me home on an insulin shot - 40 units in my belly every night before I go to bed. I don't like giving myself the shot, so sometimes I just don't, but I take all the rest of my medicines like they told me to."
He takes out the vial of insulin, and you see that it is insulin glargine.
Question
The best option is indicated below. Your selections are indicated by the shaded boxes.
Which of the following medications should you consider discontinuing in this patient based on your knowledge of his reduced ejection fraction? Choose the single best answer.
A. Pioglitazone
B. Atorvastatin
C. Aspirin
D. Glipizide
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Answer Comment > The correct answer is A> The correct answer is A
Thiazolidinediones Pioglitazone (A),Pioglitazone (A), a member of the class of drugs known as thiazolidinediones (TZD), is not recommended for use in patients who have newly developed heart failure and in those with known NYHA Class III and IV heart failure. The same is true for rosiglitazone, another TZD that has been associated with an increased risk of cardiovascular disease.
Mechanism of action:Mechanism of action: TZDs are peroxisome proliferator-activated receptor-gamma (PPARgamma) agonists.
Effects:Effects: TZDs decrease insulin resistance, increase glucose uptake in peripheral tissue, decrease hepatic glucose production, decrease vascular inflammation, redistribute visceral adipose tissue peripherally, and preserve beta cell function. Overall, they cause the A1c to decrease by 1% to 1.5%. Hypoglycemia is not associated with this medication class. TZDs have differing effects on lipids. Pioglitazone slightly reduces LDL levels and raises HDL. Rosiglitazone can increase LDL levels.
Side effects:Side effects: The receptors that TZDs activate are ubiquitous and are
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abundant in the cells within the renal collecting tubules. Hence, TZDs increase sodium reabsorption, leading to increased water retention. Compared to placebo, all TZDs are associated with a statistically significant increase in edema and weight.
Warnings:Warnings: Care should be used with these agents in patients with liver disease. Serum transaminases greater than 2.5 times the upper limit of normal is a contraindication to initiation of these agents, and a rise to greater than three times the upper limit of normal should lead to their discontinuation. Liver tests should be measured at baseline and periodically while the patient is on this class of medication.
Contraindications:Contraindications: The FDA has added a warning to the label of pioglitazone noting an increased risk of bladder cancer after more than one year of treatment. Pioglitazone is now contraindicated in patients with a history of bladder cancer or active bladder cancer. Patients should be counseled to tell their physician if they notice blood in their urine or a red tint to their urine.
No precautions are needed when using aspirin, glipizide, or simvastatin in patients with a reduced ejection fraction.
BLOOD GLUCOSE MONITORING HISTORY
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You continue your interview with Mr. Morales and ask him:
"Have you brought your blood sugar log with you today?" He hands you his blood sugar log proudly. Over the last four weeks, you see that his morning fasting readings are ranging 130-169 mg/dL, including before-lunch readings of 151-247 mg/dL, before-supper readings of 184-211 mg/dL, and before-bed readings of 158-305 mg/dL. There are no recorded readings under 70 mg/dL (3.9 mmol/L).
"Some days you have many readings over 200 mg/dL. Is there anything diUerent going on on those days that you can think of such as eating larger meals?" "Oh, those are the days after I didn't take my insulin shot. The readings are always higher on those days."
"Have you had any low blood sugars?" "I feel like I have low blood sugar several times a week, and I eat a Snickers bar because I'm afraid of passing out and going into a coma. I feel like I'm going to die -- shaky, sweaty, jittery! I don't check when I feel this way, I just eat as fast as I can - I can tell when my sugar is low."
See the associated reference ranges in conventional and SI units.
The best option is indicated below. Your selections are indicated by the shaded boxes.
Hypoglycemia It is important at each visit to ask diabetic patients if they have experienced any hypoglycemic symptoms or events that required the assistance of another person.
Often times, when a patient is hypoglycemic, he does not write it down because he is preoccupied treating the hypoglycemia.
When to Refer Patients with Diabetes to an Endocrinologist If a patient is having recurrent or severe hypoglycemia (seizure, coma, or impairment that requires the aid of another person), an endocrinologist should be consulted. Hypoglycemia is defined as a blood glucose <70 mg/dL.
Primary care physicians' threshold for referral varies across providers. Other conditions that would warrant referral are when a patient's A1c is 8% more than twice in a 12-month period, despite intensive treatment; for initiation of a complex multiple daily injection insulin regimen; or for initiation of continuous infusion insulin pump therapy.
Question Can patients accurately detect hypoglycemia by symptoms alone?
A. Yes
B. No
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Answer Comment > The correct answer is B> The correct answer is B
Self-Monitoring Glucose: Indications & EUectiveness
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Self-Monitoring Glucose: Indications & EUectiveness Effectiveness of Self-Monitoring Blood GlucoseEffectiveness of Self-Monitoring Blood Glucose
Patients should be advised to check their blood sugar if they feel "low" because it is well recognized that people are not able topeople are not able to accurately detect hypoglycemia (blood glucose of < 70 mg/dL)accurately detect hypoglycemia (blood glucose of < 70 mg/dL) by symptoms aloneby symptoms alone. Eating high carbohydrate food to treat perceived hypoglycemia rather than actual hypoglycemia leads to worsened overall glycemic control.
Clinical studies have shown that self-monitoring of blood glucose (SMBG) may improve glycemic control, although for some patients self-monitoring increases depression and anxiety. It is important to evaluate patients' abilities to use SMBG techniques to ensure they are using accurate data to evaluate their response to therapy and their degree of success in reaching blood-glucose targets. After receiving education, patients can use SMBG data to adjust their activity level, food intake and choice, as well as drug therapy to achieve optimal glycemic control.
When to Self-Monitor Blood GlucoseWhen to Self-Monitor Blood Glucose
In patients on less frequent insulin injections, SMBG may be useful in achieving glycemic goals.
Patients on an insulin pump and those using multiple daily insulin injections should self-monitor blood glucose at the following times:
before each meal at bedtime when they have symptoms of hyper- or hypoglycemia after treating hypoglycemia to ensure return of euglycemia before exercise before critical activities, such as driving
Blood Glucose Goals
HealthyHealthy *Medically*Medically **Very**Very MedicallyMedically
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AdultsAdults ComplexComplex AdultsAdults
ComplexComplex AdultsAdults
fasting andfasting and beforebefore mealsmeals
80-130 mg/dL (3.9- 7.2 mmol/L)
90-150 mg/dL
100-180 md/dL
one to twoone to two hours afterhours after a meala meal
< 180 mg/dL (10.0 mmol/L)
before bedbefore bed 100-130 mg/dL (5.6- 7.2 mmol/L)
100-180 mg/dL
110-200 mg/dL
*Medically complex adults have multiple co-existing chronic illnesses, two or more ADL impairments, or mild to moderate cognitive impairment.
**Very medically complex adults or adults in poor health have long term care or end-stage chronic illnesses, moderate to severe cognitive impairment, or two or more ADL dependencies.
See the associated reference ranges in conventional and SI units.
DIET HISTORY HISTORY You ask Mr. Morales about diet and physical activity.
"Can you tell me what you typically eat in a day?" "I usually eat breakfast and lunch at McDonald's or Denny's. For breakfast, I usually have a bacon egg and cheese biscuit with hash browns and black coffee. For lunch, I have a sandwich, fries, and soda. If I'm really hungry, I get the "value" size of the fries and soda."
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The best options are indicated below. Your selections are indicated by the shaded boxes.
"What drinks and snacks do you typically eat during the day?" "I drink Coke with lunch, whole milk with supper, and usually have a big bowl of fudge ripple ice cream before I go to bed. If I'm hungry in the afternoon, I'll grab a pack of cookies from a vending machine."
"And what do you have for dinner?" "My wife and I eat supper at home. We share the cooking. Usually, we have fried or stewed meat with gravy, rice, or pasta along with rolls. Sometimes we have vegetables cooked with side meat."
"Are you able to do any exercise during the week?" "Except for moving around at work, I didn't get much exercise before. Since my heart surgery, I feel short of breath just walking to the mailbox at the end of the driveway!"
"Do you have any chest pain or sweating?" "Not really."
SCREENING FOR COMPLICATIONS HISTORY You now decide to focus your history on screening for complications of diabetes:
"Are you having any trouble with your vision?"
"How about numbness or tingling in your hands or feet?"
Question Which of the following are types of neuropathies a patient with diabetes might develop? Select all that apply.
A. Distal symmetric polyneuropathy
B. Postural hypotension
C. Gastroparesis
D. Erectile dysfunction
E. Resting tachycardia
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Answer Comment > The correct answers are A, B, C, D, E> The correct answers are A, B, C, D, E
Diabetic Neuropathies It is estimated that 50% of patients with diabetes will eventually struggle with one or more neuropathies related to their diabetes.
Axonal loss and atrophy are responsible for the majority of clinical symptoms and loss of function in patients with neuropathy. There can also be evidence of demyelination and remyelination, with the actual number of large nerve fibers being reduced, while small nerve fibers increase.
Distal polyneuropathyDistal polyneuropathy
Distal polyneuropathy is the most common type of diabetic neuropathy. It is the progressive loss of sensation in the classic stocking/glove distribution. Diabetic foot ulcer incidence is greatly increased in patients with distal polyneuropathy.
Autonomic neuropathyAutonomic neuropathy
Autonomic neuropathy can take many forms and affect one or many organs. Specific types include:
cardiovascular (orthostatic hypotension, resting sinus tachycardia, postprandial hypotension)
gastrointestinal (gastroparesis, chronic constipation, esophageal motility disorders)
genitourinary (sexual dysfunction, neurogenic bladder)
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abnormal pupillary responses and disorders of hidrosis
OBESITY MANAGEMENT MANAGEMENT You leave the room so that Mr. Morales can disrobe for your exam. Dr. Clay asks what you have learned so far.
You present the history to Dr. Clay and tell her that you are particularly concerned about Mr. Morales' diet. You and Dr. Clay look at the triage sheet and see that Mr. Morales' height is 176.5 cm (69.5 inches) and his weight is 123 kg (272 lbs). You calculate his BMI: it is 39.6 kg/m .2
Body Weight Management in Patients with Diabetes
ClassificationClassification BMI in kg/mBMI in kg/m22
Normal 19-24
Overweight 25-29
Obese 30-39
Morbidly obese 40+
Maintenance of a healthy body weight is essential in the management of patients with diabetes. However, for some patients, attainment of an ideal body weight is too large a goal, especially if they are morbidly obese. Studies have shown that a modest weight loss of approximately 5-10%modest weight loss of approximately 5-10% of the current weight can lead to significant improvement in glycemic control, blood pressure control, and lipid parameters.
Question
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The best options are indicated below. Your selections are indicated by the shaded boxes.
Which of the following are appropriate approaches to addressing Mr. Morales' obesity and diet? Select all that apply.
A. Referral to a registered nutritionist for medical nutrition
therapy.
B. Office-based, brief dietary counseling.
C. Referral to an accredited diabetes care center for diabetes
management self education.
D. Patient materials about diet and exercise.
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Answer Comment > The correct answers are A, B, C, D> The correct answers are A, B, C, D
Mulitdisciplinary Approach to Diabetes Care The care of the patient with diabetes is a team endeavor. Through a multidisciplinary approach, patients can be offered the very best chance of optimizing their blood glucose control and reducing their risks of morbidity and mortality.
Refer to a registered nutritionist for medical nutrition therapy regarding daily food choices and portion sizes.
Refer to an accredited diabetes care center for diabetes management self-education, both in group and one-on-one settings. Numerous studies have shown that diabetes management self- education is effective in improving patients' self-care behaviors, lowering their A1c, improving their knowledge of diabetes and enhancing their quality of life.
Office-based counseling of basic ADA recommendations for diet and exercise can be reviewed with the patient. For example, patients can be taught how to monitor his carbohydrate intake through carbohydrate counting, food exchanges, or self-reflection. Thirty minutes of moderately intense exercise, more days than not, may be a good recommendation for many patients. Less than 10% of daily
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calories should be from fat. Patient education materials are a useful adjunct to office-based
counseling, and can be found at the ADA website section on diet/exercise.
BLOOD PRESSURE MANAGEMENT MANAGEMENT
You recheck Mr. Morales' blood pressure manually.You recheck Mr. Morales' blood pressure manually.
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You look at the rest of Mr. Morales' vital signs:
Vital signs:Vital signs:
Temperature:Temperature: 36.3 C (97.9 F) Pulse:Pulse: 74 beats/minute Respiratory rate:Respiratory rate: 12 breaths/minute Blood pressure:Blood pressure: 152/86 mmHg today (148/92 mmHg at the cardiologist's office
two weeks ago) Fingerstick blood glucose:Fingerstick blood glucose: 158 mg/dL (8.8 mmol/L)
You retake his blood pressure manually and read 150/90 mmHg.
See the associated reference ranges in conventional and SI units.
The best option is indicated below. Your selections are indicated by the shaded boxes.
Question Is this patient's blood pressure at goal?
A. Yes
B. No
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Answer Comment > The correct answer is B> The correct answer is B
Blood Pressure Goal for Patients with Diabetes There is ample, well-validated evidence that blood pressure control is one way of lowering a diabetic patient's cardiovascular risk. According to the ADA, the optimal blood pressure goal in patients with diabetes is less than 140/90 mmHg. Younger, healthier patients who can be treated without increasing the treatment burden may have a lower systolic target, such as less than 130. It is important to remember that an individual patient's blood pressure goal may be higher or lower based on his/her response to therapy and personal characteristics. Note: Other organizations recommend different blood pressure goals for patients with diabetes, such as the ACC/AHA, which recommends treatment in people with diabetes who have blood pressure greater than or equal to 130/80 mmHg, with a goal blood pressure of less than 130/80 mmHg.
The ACC/AHA guidelines on hypertension published in late 2017 suggested lower numbers for a definition of HTN; now anything over 130/80 is considered hypertension per ACC/AHA. Other organizations - like ADA - have not yet updated their guidelines to reflect this change.
Pharmaceutical managementPharmaceutical management
Most diabetic patients require multiple agents to reach and maintain their individual blood pressure goal. ACE inhibitor and ARB therapy
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are first-line treatment options because they also delay the onset and decrease the progression of diabetic nephropathy. Diuretics and calcium channel blockers can be used to attain blood pressure goals.
Reasons for uncontrolled blood pressureReasons for uncontrolled blood pressure
There are multiple reasons why a patient may have uncontrolled blood pressure. Blood pressure may be uncontrolled in patients needing increased dosages of their medications or additional agents. It may be elevated secondary to medications (e.g. NSAIDs) or alcohol. Or patients may not be taking their medications regularly, may not have taken their medications on the day of the office visit, or may have run out of their medication prior to the visit.
Before adding another medication or increasing the dose of existing medication, it is critical that nonadherence be explored first as a possible cause of uncontrolled hypertension.
When asked about his adherence to his current regimen, Mr. Morales says he took all of his medications this morning and did not miss any doses of his medications in the past week.
PHYSICAL EXAM 1 PHYSICAL EXAM
You examine Mr. Morales' eyes.You examine Mr. Morales' eyes.
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You proceed with Mr. Morales' exam, paying special attention to the fundoscopic exam.
Physical ExamPhysical Exam
GeneralGeneral: Obese, older male in no apparent distress.
HEENTHEENT: Normocephalic, atraumatic. Oropharynx clear and moist. Dentition and dental hygeine good. Pupils equal and reactive to light and accommodation. Extraocular movements intact. No icterus.
Fundoscopic examFundoscopic exam: Several microaneurysms bilaterally and hard exudates on the left.
NeckNeck: Supple and thick. No increased JVD. No carotid bruits. Carotid pulses 2+ bilaterally with normal upstroke. No thyromegaly or masses.
LungsLungs: Clear to auscultation bilaterally. No wheeze, rales, or rhonchi.
CardiacCardiac: PMI diffuse and laterally displaced. Regular rate and rhythm. Normal S1, S2, no S3, no S4, no murmurs.
AbdomenAbdomen: Soft, nontender, nondistended, no hepatosplenomegaly.
The best options are indicated below. Your selections are indicated by the shaded boxes.
Question Which of the following are recommendations for the prevention and decreased progression of diabetic retinopathy? Select all that apply.
A. Optimal blood pressure control
B. Optimal glucose control
C. Smoking cessation
D. Optimal LDL control
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Answer Comment > The correct answers are A, B, C> The correct answers are A, B, C
Diabetic Retinopathy Diabetic retinopathy, a microvascular diabetic complication, is the leading cause of preventable blindness in the developed world.
PreventionPrevention
Two large prospective trials (DCCT with Type 1 diabetics and UKPDS with Type 2 diabetics) revealed that intensive glucose management resulted in prevention or delayed onset and progression of diabetic retinopathy.
Co-existing hypertension, nephropathy, and tobacco abuse also contribute to retinopathy onset and progression.
Two types of diabetic retinopathyTwo types of diabetic retinopathy
1. Non-proliferative diabetic retinopathyNon-proliferative diabetic retinopathy
Involves cotton wool spots, hard exudates, microaneurysms, and retinal hemorrhages.
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Vision loss usually results from severe macular edema, a thickening of the retina with resultant edema of the macula.
2. Proliferative diabetic retinopathyProliferative diabetic retinopathy
Involves neovascularization of the retinal vessels or optic disc, retinal hemorrhage (dot-blot, flame), retinal fibrosis with traction detachment, and vitreous hemorrhage. Macular edema can occur as well.
Image of proliferative retinopathy with neovascularizationImage of proliferative retinopathy with neovascularization
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OnsetOnset
Development of diabetic retinopathy is directly related to disease duration and is generally not seen in patients who have had diabetes less than five years. The exception is Type 2 diabetic patients who were likely hyperglycemic more than five years prior to their diabetes diagnosis.
ScreeningScreening
Annual dilated eye exams by an ophthalmologist are recommended for all Type 1 diabetic patients within five years of diagnosis and
shortly after diagnosis in patients with Type 2 diabetes. Patients with progressive retinopathy are often seen quarterly or biannually.
Panretinal TreatmentPanretinal Treatment
Panretinal laser photocoagulation is the treatment of choice for proliferative diabetic retinopathy and severe cases of non-proliferative retinopathy. Screening is done aggressively due to the well- documented efficacy of laser photocoagulation in the prevention of vision loss. Ranibizumab, an anti-vascular endothelial growth factor, injected into the vitreous showed noninferiority to laser therapy and can also be used.
PHYSICAL EXAM 2 PHYSICAL EXAM
You perform a diabetic foot exam on Mr. Morales.You perform a diabetic foot exam on Mr. Morales.
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You are glad you will have the opportunity to practice the diabetic foot exam you reviewed last night.
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You proceed with Mr. Morales' exam:
Physical ExamPhysical Exam
Extremities:Extremities: Full range of motion without clubbing or cyanosis. No peripheral edema.
Diabetic foot exam:Diabetic foot exam: 1+ dorsal pedis and posterior tibialis pulses bilaterally with decreased sensation to monofilament and vibration to the mid-shin. No ulcers. + diffuse onychomycosis.
Neurologic:Neurologic: Awake, alert and oriented times four. Cranial nerves II-XII are grossly intact. Muscle strength is 5/5 throughout with normal tone and bulk. Deep tendon reflexes are trace throughout. Gait normal. No tremor.
When to Perform the Diabetic Foot Exam It is important to do a thorough foot exam in a diabetic patient on an annual basis for low-risk patients and more often in patients at high risk for foot ulcer formation.
Patients at High Risk for foot Ulcer FormationPatients at High Risk for foot Ulcer Formation
Patients with known diabetic polyneuropathy, sensory or vascular deficits, patients who smoke, and patients with a prior history of diabetic foot ulcer or amputation.
Foot Exam in Patients with Diabetes Visually inspect the feet for callus formation, ulceration, nail infections, and bony deformities.
Assess skin integrity, especially between toes and under metatarsal heads.
Palpate the dorsalis pedis and posterior tibialis pulses to screen for peripheral vascular disease and look for signs of peripheral vascular disease, such as hair loss.
Check sensation using a 128 Hz tuning fork (vibration) and a cool metal object, potentially the same tuning fork (temperature).
Check pressure sensation using a 10-g monofilament:
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Show the monofilatment to the patient and try it on their hand to show them it will not hurt.
Ask the patient to close their eyes or look at the ceiling and tell you each time they feel the monofilament touch their foot.
Randomly place the end of the monofilament on the 9 different areas of the foot (see image to the right) with enough pressure to bend the monofilament.
If the patient does not say "yes" at a particular site, continue to the next site and re-test that site at the end.
Check achilles reflexes.
Question List some of the preventive measures will you recommend to Mr. Morales regarding foot care.
The suggested answer is shown below.
Letter Count: 0/1000
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Answer Comment
Foot Care for Patients with Diabetes It is important to review and provide information about foot self-care
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with diabetic patients.
Patients should be instructed to check the dorsal and plantar surfaces of their feet everyday for cuts, sores, redness, and swelling.
If the patient is unable to view his entire foot by himself, then a caregiver should be asked to do it for him.
Feet should be washed daily and dried well. Remind patients to use their forearm to check water temperature to
prevent burns. Patients should keep the skin of their feet smooth and soft with
lotion. Toenails should be trimmed weekly or as needed. Patients should be encouraged to wear white socks, as these will
show any drainage from a previously unknown sore, and well-fitting, comfortable shoes.
Shoes and socks should be worn at all times. There is no robust evidence to warrant the recommendation that all
patients with diabetes be fitted with special shoes to prevent diabetic foot ulcers.
High-risk patients should be referred to a podiatrist for comprehensive foot care.
DIABETES LAB EVALUATION TESTING
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The best options are indicated below. Your selections are indicated by the shaded boxes.
You discuss the next steps for Mr. Morales with Dr. Clay.You discuss the next steps for Mr. Morales with Dr. Clay.
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You tell Mr. Morales that you are finished with your exam and explain that after you talk with Dr. Clay, you'll both be back. You step out and present the findings from your physical exam to Dr. Clay. The two of you start to discuss the next steps for Mr. Morales.
Question Which of the following laboratory studies are appropriate to order for Mr. Morales today? Select all that apply.
A. Hemoglobin A1c
B. Fasting lipid profile
C. Liver function profile
D. Basic metabolic profile
E. Spot urine albumin/creatinine ratio
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Answer Comment
Answer Comment > The correct answers are A, B, C, D, E> The correct answers are A, B, C, D, E
All tests listed are appropriate because Mr. Morales has not had these tests in the last year. A reasonable A1c goal for a patient such as Mr. Morales with prevalent coronary artery disease would likely be 7-8%.
Chronic Diabetes Evaluation Hemoglobin A1cHemoglobin A1c
Hemoglobin A1c should be ordered every six months in patients who are meeting their individualized treatment goals, and every three months if they are not or if therapy is changing.
A HbA1c goal of < 7% is generally a reasonable goal for a nonpregnant, otherwise healthy adult patient. More stringent A1c goals (< 6.5%) may be appropriate in some patients, with shorter disease duration, long life expectancy, and no significant cardiovascular disease, if it can be attained without significant hypoglycemia.
The ADA Standards of Medical Care in Diabetes state, "less stringent A1c goals (such as < 8%) may be appropriate for patients with history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, and those with longstanding diabetes in whom a stringent goal is difficult to attain." For patients who have limited resources and a poor support system, and/or are unable to prioritize self-care due to social, economic or psychological stressors, a less stringent A1c goal may also be appropriate.
Remember that HbA1c levels are unreliable in patients with hemoglobin variants, such as sickle cell disease; with end-stage kidney failure/on dialysis, and who have recently had blood transfusions or large blood loss.
Individuated Hemoglobin A1c Goals
Healthy Nonpregnant Adults, without severe recurrent hypoglycemia/hypoglycemic unawareness
< 7%
Medically Complex Adults, with history of severe
TEACHING POINTTEACHING POINT
hypoglycemia and/or longstanding diabetes < 8%
Medically Complex Adults/Adults in Poor Health, with severe recurrent hypoglycemia/hypoglycemic unawareness
< 8.5%
Fasting lipid profileFasting lipid profile
The ADA and the AHA/ACC are overall in agreement regarding lipid management in diabetic patients.
The AHA/ACC guidelines are:The AHA/ACC guidelines are:
Lifestyle modification (weight loss, increased physical activity, reduced fat intake) should be recommended for all patients with diabetes, where appropriate.
All patients with diabetes and cardiovascular disease, regardless of age, should be on a high intensity statin.
All patients aged 40 to 75 with diabetes should be on a moderate- intensity statin. If ASCVD risk is >7.5%, they should be on a high- intensity statin.
For patients aged <40 or >70 with diabetes, consider statin therapy depending on risks/benefits and patient preferences.
The ACC/AHA does not recommend lipid goals at this point. See the requiredrequired Aquifer Cholesterol Guidelines module for more
information about this.
Liver function profileLiver function profile
Indicated if the patient takes a TZD. When patients take this class of medication, liver tests should be monitored periodically.
Basic metabolic profileBasic metabolic profile
Indicated to monitor renal function if the patient takes metformin and in patients with diabetes in general.
Spot urine albumin/creatinine ratioSpot urine albumin/creatinine ratio
Indicated annually in patients with Type 2 diabetes without evidence of increased urinary albumin excretion (<30 mcg albumin/mg creatinine) and more often to assess for progression and effect of
DIAGNOSES
FINDINGS
NOTES
MENUMENU
therapy in patients with established increased urinary albumin excretion (30 mcg albumin/mg creatinine or greater). A diagnosis of increased urinary albumin excretion is made when two of three specimens collected within a 3- to 6-month period are 30 mcg/mg creatinine or greater. Remember that vigorous exercise within the last 24 hours, menstruation, illness, fever, markedly elevated blood pressure, CHF exacerbation, and acute hyperglycemia can cause false- positive results.
Urine dipstick measurements are not used to diagnose or follow increased urinary albumin excretion because of the insensitivity of the method for detecting the initial small increases in protein excretion. Protein excretion must exceed 300 mcg per day to turn the dipstick positive.
Estimated GFR based on the serum creatinine should also be used to assess for chronic kidney disease, at least annually, looking at declining GFR as another marker of kidney disease progression.
See the associated reference ranges in conventional and SI units.
CONCLUDING THE VISIT CARE DISCUSSION
" DEEP DIVEDEEP DIVE
BOOKMARKS
The best options are indicated below. Your selections are indicated by the shaded boxes.
Mr. Morales explains his frustration with quitting smoking.Mr. Morales explains his frustration with quitting smoking.
!
You and Dr. Clay return to speak with Mr. Morales. Dr. Clay spends time catching up with him, clarifying some parts of the history and performing her own physical exam.
She then asks, "How's the smoking going?"
He responds, "I know I need to stop smoking, Dr. Clay. I've cut down to less than half a pack a day, but I just can't quite seem to do it."
She encourages him, "We'll help you come up with a plan for stopping completely. We know that you can do it!"
Dr. Clay asks Mr. Morales to get redressed and go to the lab to have some blood drawn. She directs him to return to the exam room when he is finished so you can discuss the next steps for his care together.
Question Which of the following recommendations should be given to Mr. Morales today? Select all that apply.
A. Discontinue metformin.
B. Attempt smoking cessation (with help in putting a plan in
place).
C. Increase lisinopril to 40 mg daily, and return to the lab for a
potassium and creatinine measurement in one week.
D. See a dentist every other year.
E. Pneumococcal vaccination.
F. Influenza vaccination.
G. Return to clinic in six months.
SUBMITSUBMIT
Answer Comment > The correct answers are A, B, C, E, F> The correct answers are A, B, C, E, F
Smoking Cessation in the Setting of Diabetes Complete smoking cessation is the goal in all patients, and smoking cessation counseling should be part of every clinic visit. Merely asking if the patient is considering smoking cessation increases the chance that the patient will quit. Patients who have already cut down should be congratulated on accomplishing that hard task, then they should be encouraged to build on this success and quit completely.
Studies have shown that diabetic smokers suffer far more cardiovascular comorbidity than patients without diabetes who smoke and that smoking cessation leads to decreased progression of retinopathy and nephropathy.
Vaccinations for Patients with Diabetes Diabetic patients should receive a pneumococcal vaccination and should be immunized for influenza annually. They should also receive the Hepatitis B vaccine series if they are between 19 and 59 years old.
TEACHING POINTTEACHING POINT
TEACHING POINTTEACHING POINT
Dental Care for Patients with Diabetes Diabetic patients should be seen by a dentist regularly; the recommendation is twice a year.
Metformin Contraindications Metformin is not recommended for patients with reduced ejection fraction requiring pharmacologic therapy, in particular patients with unstable or acute heart failure. It is likely safe in patients with well- compensated, stable CHF. It is prudent to stop a patient's metformin in the setting of a recent heart failure diagnosis but it may also be reasonable to restart it in the future should their symptoms stabilize.
Metformin is also contraindicated in patients with a GFR of < 30 mL/min/1.73m . In addition, it shouldn't be started in patients with a GFR of 30 to 45 mL/min/1.73m though can be continued at a reduced dose with a GFR in this range in patients started on the medication when kidney function was normal. It is also contraindicated in patients with alcohol abuse or marked liver disease. These contraindications exist due to the increased risk of lactic acidosis in these patients. Metformin should be routinely discontinued when patients are hospitalized due to the increased risk of dehydration and opportunity for IV contrast dye use, which could reduce renal function.
2
2
Increase lisinopril to 40 mg daily (C)Increase lisinopril to 40 mg daily (C): Mr. Morales' blood pressure is above goal, so increasing his ACE inhibitor will hopefully lower his blood pressure while affording renal protection and decreasing urinary albumin excretion. It is prudent to evaluate for hyperkalemia and a further increase in creatinine in one week, given that both are known side effects of ACE inhibitor therapy.
Mr. Morales' A1c is likely not at goal of 7% to 8%, and today you are discontinuing his metformin and pioglitazone. He is likely going to need additional hypoglycemic agents to lower his blood glucose, perhaps prandial insulin. Waiting six months to see him again (G) puts him at great risk of incurring additional co-morbidity from poorly controlled Type 2 diabetes. He should be seen in two to four weeks to ensure that
TEACHING POINTTEACHING POINT
TEACHING POINTTEACHING POINT
additional agents are added in a timely manner if necessary.
See the associated reference ranges in conventional and SI units.
MEDICATIONS TO TREAT DIABETES TEACHING Dr. Clay uses this as an opportunity to teach you a little bit about oral and injectable medications that are used in the management of the Type 2 diabetic patient.
Injectable Medications for Type 2 Diabetes InsulinInsulin
Different types of insulin are used to manage diabetes.
The ADA Standards of Medical Care in Diabetes state, "consider initiating insulin therapy (with or without additional agents) in patients with newly diagnosed Type 2 diabetes who are symptomatic and/or have A1c 10% or greater and/or blood glucose levels 300 mg/dL or greater."
Evidence is accumulating that earlier use of insulin in the treatment of patients with uncontrolled Type 2 diabetes results in better long-term glycemic control. In a patient with an A1c value 9% or greater, oral hypoglycemic and non-insulin injectable medications as monotherapy are unlikely to bring the patient's A1c to goal, and dual therapy is recommended.
When insulin is used, typically a basal insulin, such as glargine or detemir, is initiated first, with continuation of one or more oral medications (usually metformin, unless there is a contraindication). The regimen is then escalated every three to six months until the A1c goal is attained.
In patients on a single oral agent whose A1c is within one percentage point of goal, adding another oral agent or non-insulin injectable should be considered. A well-known meta-analysis found that for each non-insulin agent added from a different class, the A1c could be expected to decrease 0.9-1.1%.
For a comprehensive list of available insulins refer to table 8.2: Pharmacology of available glucose-lowering agents in the U.S. for the treatment of type 2
TEACHING POINTTEACHING POINT
diabetes
Glucagon-like peptide-1 receptor agonistsGlucagon-like peptide-1 receptor agonists
Mechanism of action:Mechanism of action: There are several GLP-1 receptor agonists available, commonly prescribed agents include exenatide and liraglutide. These agents increase insulin secretion in a blood glucose dependent manner. They also decrease post prandial glucagon secretion, slow gastric emptying, centrally increase satiety, and decrease appetite. *
Administration:Administration: These agents are all delivery by subcutaneous injection. There are monthly, weekly, daily and twice daily formulations. They can be used in combination with most oral medications and with basal insulin. *
Side effects:Side effects: The most common side effect is nausea, which can be significant, accompanied by emesis. *
Effects:Effects: A1c decreases of approximately 1% and statistically significant weight loss are associated with use.
Contraindications:Contraindications: There have been post marketing reports of exenatide- induced pancreatitis, so its use in patients with a history of pancreatitis should be avoided. Tumors of the C-cells have been reported.
References American Diabetes Association Standards Of Medical Care In Diabetes-2018. Diabetes Care. 2018 Jan; 41 (Supplement 1): S1-S2. http://care.diabetesjournals.org/content/41/Supplement_1. Accessed May 4, 2018.
American Diabetes Association Standards Of Medical Care In Diabetes-2016. The Journal of Applied Research and Education. January 2016, Volume 39, Supplement 1. http://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of- Care.pdf.. Accessed May 4, 2018.
CONCLUDING THE VISIT CARE DISCUSSION You and Dr. Clay return to the exam room to talk to Mr. Morales about your recommendations for his diabetic care.
Dr. Clay starts, "We'd like you to stop taking the metformin and pioglitazone because those medications are not the best or safest in patients who have heart failure like you do."
"But won't that make my blood sugars go up with two less medicines everyday? I thought we were going to get my blood sugars lower," Mr. Morales wants to know.
"You're right, Mr. Morales. Without those two medicines, your readings will likely increase, so we'd like to increase your glipizide to 10 mg daily to help. Taking glipizide with glargine insulin every day will also help. We'd like to have you call the office in a few days with your readings so we can see how it's going. We will be working closely in the coming weeks and months to keep your glucose well controlled, and we'd like you to see a diabetes educator and a nutritionist for help with your food choices and portions."
You tell him that you'd like to better control his blood pressure, and he agrees to take the increased lisinopril dose.
"The good thing, Mr. Morales, is that getting your glucose and blood pressure under control will help your kidneys function better. And stopping smoking will help too. Have you thought about whether you are ready to quit now? Would you consider setting a quit date?"
He responds, "Maybe we can talk about that when I come back the next time."
You remind him to check his blood sugar with his glucose meter when he feels "low" so that he doesn't eat when he doesn't need to. You reiterate the proper treatment of blood glucose to achieve a reading of >70 mg/dL (>3.9 mmol/L).
You make him an appointment for a dilated eye exam and advise him to check his feet daily.
You are able to give him two more weeks of testing strips and the toll-free number to the patient assistance line for glargine insulin so that he can request samples. You ask him to see the clinic's social worker for further help with patient assistance and hand him a note for work explaining his need to be allowed off the line to check his blood sugar regularly, as well as his need to be seen in close follow up with Dr. Clay.
As he leaves, Mr. Morales says, "I'll see you in two weeks, and thank you for taking the time to really talk to me and find out how to help. I feel like I am really going to be able to take care of myself this time, and I'll have my tobacco quit date when I see you again!"
See the associated reference ranges in conventional and SI units.
LAB RESULTS AND DIABETIC NEPHROPATHY
MANAGEMENT
It is two weeks later and Mr. Morales is back in Dr. Clay's diabetes clinic.
You take a look at the electronic medical record, and the lab results from Mr. Morales' initial clinic visit reveal:
Lab Values: Conventional: SI:
Potassium 4.8 mEq/L 4.8 mmol/L
BUN 29 mg/dL 10.4 mmol/L
Creatinine 1.8 mg/dL 159 μmol/L
Hemoglobin A1c 8.3%
Total cholesterol 213 mg/dL 5.52 mmol/L
Triglycerides 385 mg/dL 4.35 mmol/L
HDL 38 mg/dL 0.98 mmol/L
LDL 117 mg/dL 3.03 mmol/L
Liver function panel: normal
Spot urine albumin to creatinine ratio: 120 mcg/mg creatinine
You realize that the spot urine albumin to creatinine ratio confirms Mr. Morales' prior history of increased urinary albumin excretion. Prior to seeing Mr. Morales, you decide to look up some information about diabetic nephropathy.
You are glad that you increased Mr. Morales' lisinopril dose during the last visit since it will hopefully slow progression of his diabetic nephropathy.
You highlight that his A1c is above goal, but you tell Dr. Clay that it may not be necessary to make adjustments to his diabetic regimen since that was done at the last visit.
See the associated reference ranges in conventional and SI units.
Diabetic Nephropathy
TEACHING POINTTEACHING POINT
Diabetic Nephropathy EpidemiologyEpidemiology
Diabetic nephropathy occurs in 20% to 40% of diabetic patients and is the most common etiology of end-stage renal disease in the U.S.
Risk factors associated with the progression of diabetic nephropathy include: obesity, increasing age, African American race, and tobacco abuse.
PathogenesisPathogenesis
Kidney insult appears to originate with glomerular hypertension and hyperfiltration. Chronic hyperglycemia leads to mesangial expansion, deposition of matrix, increased amount of VEG-F and other cytokines, local inflammation, and activation of protein kinase C.
Prevention / TreatmentPrevention / Treatment
Two large prospective trials (DCCT with type 1 diabetics and UKPDS with Type 2 diabetics) revealed that intensive glucose management resulted in prevention or delayed onset and progression of diabetic nephropathy.
Aggressive blood pressure lowering is critical for treatment of increased urinary albumin excretion. In patients with hypertension with increased urinary albumin excretion, an ACE inhibitor or ARB therapy is recommended to delay the onset and decrease progression of diabetic nephropathy.
ReferralReferral
Referral to nephrology is appropriate if the the cause of kidney disease is not certain, and or there are challenging management issues present, such as resistant hypertension or electrolyte derangement. The threshold for referral to nephrology varies across providers; however, nephrology should be consulted if Stage 4 or greater chronic kidney disease (GFR < 30 ml/min per 1.73 m ) develops since this has been found to reduce cost, improve quality of care, and keep people off dialysis longer.
2
FOLLOW-UP VISIT CARE DISCUSSION
You and Dr. Clay congratulate Mr. Morales on his weight loss before tellingYou and Dr. Clay congratulate Mr. Morales on his weight loss before telling him to return for a follow-up visit.him to return for a follow-up visit.
!
You and Dr. Clay review Mr. Morales' vitals. His weight is down two pounds and his blood pressure is 129/72 mmHg.
Mr. Morales greets you, "You are going to love these blood sugars! That ADA Web site has great information and the social worker has gotten it worked out so that I receive patient assistance for most of my medications and supplies. I've learned so much from the nutritionist and diabetes educator. I've completely changed the way I eat and I'm taking a walk around the block every evening before supper. There is one thing, though. My wife does most of the grocery shopping and she doesn't speak English very well. Are there any resources available in Spanish?"
"Certainly, Mr. Morales - I'll make sure that you have that information before you leave."
You both review Mr. Morales' blood sugar log and find that by taking his glargine insulin daily, his fasting readings have come into goal nicely and his prandial readings are within goal >75% of the time.
"Congratulations on all your hard work, Mr. Morales! These readings look wonderful and your weight and blood pressure are coming down nicely. I don't think I'll make any changes to your diabetes regimen today, but keep calling every week with your readings so that we can stay on top of your sugar control. You know, if you keep losing weight, you may be able to come off the insulin."
"Thanks, Dr. Clay. I've been working hard, and I sure would like to stop giving myself that shot, so I'm going to keep on losing. And I've decided to quit smoking next Monday."
"That's great, Mr. Morales! We'll make sure that you get some printed information, as well as some website addresses, so you can maximize your chances for success.
You review the remainder of Mr. Morales' labs, including his HbA1c, renal function, and the presence of microalbuminuria.
Dr. Clay tells Mr. Morales to return to the office in four weeks for a follow-up visit and reminds him to stop at the lab to check on his potassium and kidney function because of the higher ACE inhibitor dose.
"See you then, Dr. Clay. I'll be calling with my readings in a week or two."
Diabetes Patient Resources in Spanish The ADA website has excellent resources for Spanish-speaking patients and their families.
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TEACHING POINTTEACHING POINT
LEARNING OBJECTIVES LEARNING OBJECTIVES
QUESTION 1 SAQ
QUESTION 2 SAQ
QUESTION 3 SAQ
QUESTION 4 SAQ
QUESTION 5 SAQ Thank you for completing Internal Medicine 08: 55-year-old male with
chronic disease management.
