CASE STUDY ANALYSIS: DIABETES
Case Study Analysis: Diabetes
Rita Gail Summerlin
Liberty University
CASE STUDY ANALYSIS: DIABETES
CC: “I’m here for my regular check-up for my diabetes. I think I have been doing well
for an old guy.”
HPI: CF is a 70 yo AA male who is visiting his family practice physician for follow-up. His
blood glucose diary shows he has been monitoring his glucose levels twice daily (before
breakfast and dinner). They range between 135–200 mg/dl.
PMH: HTN x 20 yrs., Type II DM.
FH: Mother with DM and HTN; Father with CAD, DM and HTN; 1 brother (75 YO)
who has HTN but is otherwise healthy.
SH: No tobacco (cigarettes) x 35 yrs., alcohol usually 10–14 beers per week at the golf
course
club house but does not play or exercise regularly.
Allergies: NKDA
Medication History:
Glyburide 5 mg QD
EC ASA 325 mg QD
Altace 2.5 mg QD
Physical Exam:
Gen–A & O, obese elderly African American male
VS–BP 145/84, P 80, RR 20, T 98.6, Ht. 5’7,” Wt. 102 kg
HEENT–PERRLA, EOMI, fundi benign, no retinopathy seen
Neck–no bruits, mild JVD, no thyromegaly
Lungs–Clear
CV–nl S1 and S2, no S3 or S4
Abd–non-tender, soft, no bruits
MS/Ext–nl ROM, muscle strength 5/5 in UE and LE, no peripheral edema
Neuro–all cranial nerves intact
Lab Results:
Na 141 mEq/L
K 4.0 mEq/L
Cl 106 mEq/L
CO2 22 mEq/L
BUN 20 mg/dL
Scr 1.0 mg/dL
Glu (random) 290
mg/dL HbA1c 8.6%
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CASE STUDY ANALYSIS: DIABETES
I. AP Note
A. Present the problem
CF, 70 yo AA male, presents for f/u of his DM Type II. His blood glucose log
shows that he is checking his blood glucose (BG) level twice a day (before
breakfast and supper) and the levels range between 135-200 mg/dl. No other
complaints today.
B. Risk Factors
African American
Family history: Mother - DM & HTN; Father - CAD, DM, HTN; Brother -
HTN
Age
Unhealthy diet
Comorbidities: HTN x 20 yrs.
Alcohol consumption (10-14 beers/ wk)
Sedentary lifestyle and physical inactivity
Obesity - BMI 35.2
History of tobacco use – quit 35 yrs ago
C. Assessment
1. Evaluation:
CF is a 70 y/o AA male presenting for f/u of his DM II. He checked his
BG twice a day (before breakfast and dinner) and keeping a BD log. His BG
log shows BG level range between 135-200mg/dL. His BG is 290 mg/dL today
in the office and his HbA1c is 8.6%. Both levels are high. The recommended
HbA1c <7% and postprandial plasma BG <180mg/dl. Modification of CF’s
current treatment is warranted because BG levels show poor management of
DM II. BP is 145/84 mmHg is a little higher than the recommended BP <
140/90 mmHg. Risk factors for CF are obesity, age, sedentary lifestyle, no
physical activity other than an occasional golf game, alcohol use, family
history, unhealthy diet, and uncontrolled BG levels. CF is a high risk of
developing long-term complications of DM II. The new plan of treatment will
require CF to change his lifestyle, as well as changing some of his medications.
CF was noted to have mild JVD and this could become a cardiovascular issue.
An echocardiogram, EKG, chest x-ray, and cardiac enzymes are needed to r/o
cardiac disease.
Home medications:
Glyburide 5 mg QD
EC ASA 325 mg QD
Altace 2.5 mg QD
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CASE STUDY ANALYSIS: DIABETES
2. Determine appropriateness of medications:
Glyburide - Appropriate for DM but not controlling DM
(a) Indications: non-insulin management indicated for type II DM. Need second line
treatment. Use exercise, weight loss, and healthy diet with Glyburide to improve BG
levels.
(b) Interactions: Contraindicated for patients with severe renal disease (GFR <30),
liver disease, and acute or chronic metabolic acidosis. Glyburide can cause
teratogenic effects, so pregnant and lactating women should avoid this medication.
Medications to be avoided when taking glyburide are NSAIDS, sulfonamides,
fluoroquinolones, histamine type 2 receptor antagonists, broad spectrum antibiotics,
MAOIs, and anti-coagulants. These medications can potentially cause hypoglycemia.
Beta-blockers can cause decreased effects of glyburide. Oral miconazole taken with
glyburide can cause severe hypoglycemia. Alcohol consumption when on glyburide
can cause headache, nausea, chest pain, blurred vision, confusion, and anxiety. The
elderly should be considered when prescribing glyburide because of the prolonged
hypoglycemic effects.
(c) Drug dosing: For geriatric patients, the recommended initial dose is 1.25 to 2.5 mg
(standard) orally 1.5-3mg (micronized) orally once a day with breakfast. The dose can
be increased by 2.5 mg (standard) or 1.5 mg (micronized). Per week. The increase
will be dependent on BG levels. Maximum dose is 20 mg/day (Standard) or 12
mg/day (micronized) and can be given in divided doses twice daily before breakfast
and before supper depending on the patient’s tolerance to the medication.
(d) Compliance: According to CF, he takes glyburide with breakfast every day. This
shows compliance as far as taking his medication.
(e) Outcome: CF’s BG log, random BG level in the office, and HgbA1c result show
that his DM is not well controlled. Glyburide is effective when combined with a
healthy diet, exercise, and healthy weight. Since CF’s BMI is high, alcohol is
consumed daily, and CF does not exercise, he is non-compliant. Since the elderly
should not take glyburide, a new hypoglycemic will be prescribed. Will educate
patient on modifying his lifestyle and encourage him to make changes to his lifestyle
by improving dietary intake, decreasing alcohol consumption, and increase his
physical activity. Hopefully, with these changes, CF will lose weight, which will help
control DM. Will set a goal of HbA1c to be < 7.5% by the patient’s next visit.
(f) Adverse effect: Prolonged hypoglycemia is a common side effect. Adverse side
effects include leukopenia, thrombocytopenia, hepatic failure, aplastic anemia,
hepatotoxicity, agranulocytosis, and cholestatic jaundice.
EC ASA - Appropriate for prophylaxis of Myocardial Infarction and could require a
lower dosage.
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CASE STUDY ANALYSIS: DIABETES
(a) Indication: Due to high risk for stroke r/t DM, HTN, family history, age, and
social history of smoking, EC ASA is used for prophylaxis for MI.
(b) Interactions: Contraindicated in patients with a history of bleeding of any kind,
PUD, vitamin K deficiency, increased ICP, active hepatic disease, or anti-coagulant
therapy. Taking EC ASA with anti-inflammatories, alcohol, steroids, or NSAIDS can
increase the risk of GI ulcer formation. When taken with methotrexate, thrombolytics,
Depakote, insulin, or Coumadin, the effects of these medications can be increased.
Risk for bleeding can also be caused by consuming alcohol when taking Plavix,
thrombolytics, anti-coagulants, ginger, garlic, ticlopidine, tirofiban, ginkgo, ginseng,
or fish oil.
(c) Drug dosing: For MI/stroke prophylaxis, 50-325 mg orally daily is appropriate for
adult patients. In patients with DM II, over 40 years of age, increased cardiovascular
risk, family history of CVD, and smoking as with CF, the recommended dose is 75-
162 mg orally daily.
(d) Compliance: CF also reports he takes his aspirin with breakfast every morning.
(e) Outcome: The American Diabetes Association (ADA) recommends EC ASA 81
mg orally daily for patients with DM II and at risk for cardiovascular disease. This
dose reduces the development of an MI. A lower dose of Aspirin has been shown just
as effective as a higher dose in preventing MI.
(f) Adverse effect: Hepatic failure, GI Bleed, hemolytic anemia, hepatitis, leukopenia,
thrombocytopenia, agranulocytosis, neutropenia, anaphylaxis, seizures, and laryngeal
edema are adverse effects of ASA.
Altace – Appropriate for HTN.
(a) Indication: HTN; reduces the risk for MI. prevention of diabetic nephropathy
(b) Interactions: Use with caution with geriatric patients, patients with hypovolemia,
blood dyscrasias, CHF, COPD, impaired renal and hepatic function, and renal artery
stenosis. Due to increased risk of hypotension, Altace should not be given to dialysis
patients, patients who take diuretics and other hypertensives. Do not give to patients
who have a hypersensitivity to ACE inhibitors and history of ACE-inhibitor-induced
angioedema. Patients who take potassium-sparing diuretics, prazosin, hydralazine,
vasodilators, sympathomimetics, or potassium supplements should not be given this
medication d/t increase risk of toxicity.
(c) Drug dosing: Initially for adults, use 2.5 mg orally daily. Then 2.5 – 20 mg daily
can be used or can be divided into 2 separate doses daily.
(d) Compliance: CF stated that he takes Altace with breakfast with his other
medications.
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CASE STUDY ANALYSIS: DIABETES
(e) Outcomes: CF’s BP is 145/84 mmHg. The goal is <140/90 mmHG. Current
therapy will be maintained. Will educate patient to check BP every morning before
taking Altace and keep a BP log until his next appointment.
(f) Adverse Effects: Pancreatitis, leukopenia, pancytopenia, eosinophilia, hepatic
failure, hepatitis, thrombocytopenia, angioedema, anaphylaxis, Stevens-Johnson
syndrome, and toxic epidermal necrolysis are all adverse effects of Altace.
3. Additional information needed:
Past HbA1c levels
Trend history of DM
History of previous hypoglycemic episodes
Dietary intake
Weight history
Exercise habits (past and present)
Diabetes education and self-management education history
Compliance history
Health disparities (financial issues, cultural barriers, access to
healthy food)
Past and current Fasting Lipid Profile (Total LDL, HDL &
Triglycerides)
Renal Function Tests
Liver Function Tests
Serum creatinine and GFR
Urinary albumin-to-creatinine ratio and ketones
Cardiac Panel
Chest X-ray
EKG
Psychosocial screening
Patient’s willingness and attitude towards disease.
Depression due to alcohol intake
Goals on health management
Psychiatric and behavioral history
4. Desired therapeutic outcomes:
(a) Short term goal(s) of treatment:
Decrease BG levels to 80-1320 mg/dL pre-prandial and <1860
mg/dL postprandial
Decrease HbA1c level to <7.5% in 3 months
BP control <140/90mmHg
Prevent hypoglycemic events
Reduce alcohol intake
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CASE STUDY ANALYSIS: DIABETES
Exercise regularly – begin with walking for 30 minutes a day, 3
days a week and increase up to 50 minutes a day 3 days a
week. Rest 2 days in between
Lose 5% of body weight in 3 months
Make healthy food choices per ADA recommendations
Continue checking BG twice daily
Take blood pressure at least once a day and keep a log
(b) Long term goals(s) of treatment:
HbA1c level of <7.0%
Maintain fasting BG 80-1300 mg/dL
Maintain BP level <140/90 mmHg to prevent cardiac
complications
Prevent diabetes complications (neuropathy, retinopathy, foot
ulcers)
Maintain BG 80-120 mg/dL pre-prandial and <160 mg/dL
postprandial
Weight loss of >5% of initial body weight
Reach and maintain BMI 18.5 – 25
Cease alcohol consumption
Increase life expectancy
D. Plan:
1. Recommendations:
(a) Non-pharmacological therapy:
Stop alcohol consumption
Use healthy food choices per ADA recommendations and
DASH diet; use portion control; watch carbohydrate intake;
no concentrated sweets
Physical exercise 150 minutes per week with a maximum
heart rate of 50-70% maximal heart rate 3 days a week,
skipping at least 1 day in between
Weight loss of at least 5% of initial body weight every 3
months until desired weight is obtained
Refer patient to:
Diabetic nurse educator for diabetes education
Nutritional specialist for dietary intake and
healthy food choices
Ophthalmologist for yearly eye exam
Podiatrist for foot care as needed
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CASE STUDY ANALYSIS: DIABETES
Schedule follow-up visit in 4 weeks to re-evaluate new
medications, glucose level, weight loss, and blood pressure
readings
Evaluate HbA1c levels in 3 months for improvement
Repeat lab work in 4 weeks
Provide educational materials on newly prescribed
medications, HTN, lifestyle modifications, diet and
exercise therapy, s/s of MI and CVA
Continue smoking cessation
Self-monitoring of blood glucose
(b) Pharmacologic therapy:
Short term HbA1c target will be <7.5%. If no changes occur after
plan of treatment in 3 months, then metformin will be added as a
preferred monotherapy unless contraindicated. If HbA1c goal is
not met after 3 months of using metformin, dual therapy will be
started.
1) Metformin - oral anti-hyperglycemic.
Start CF on metformin as a monotherapy to control his DM. Patients
with renal insufficiency and heart failure should not take this
medication because it is contraindicated. The patient’s renal function
should be checked prior to starting this medication. Metformin is most
effective when combined with a healthy diet and exercise.
Oral dose: 850 mg/day PO daily with breakfast initially; then may
increase by 500 mg weekly or 850mg every 2 weeks up to 2550000
mg/day. Adjust to lowest effective dose for geriatric patients.
NEW MEDICATION
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CASE STUDY ANALYSIS: DIABETES
E
or
AE
Parameter Method Goal Alter Tx
When/If
E Lower blood
glucose level Self-monitoring of BG
twice a day reported by pt
per BG log
Laboratory results:
fasting glucose, HbA1c
every 3 months; random
plasma glucose
Short term
HbA1c:
<7.5%
Long term
HbA1c:
7.0%
Pre-prandial
plasma
glucose: 90-
130 mg/dL
Postprandial
plasma
glucose: <180
mg/dL
If HbA1c not
improved in 3
months, then
increase fasting
plasma glucose
level check
AE GI upset Self-report No nausea,
vomiting,
abdominal
discomfort, or
diarrhea
Pt has persistent
diarrhea
AE Hypoglycemic
reactions
Pt. self-report
Self-monitoring of BG
levels
No
hypoglycemic
events
(weakness,
dizziness,
sweating,
anxiety,
tremors)
Continued
hypoglycemia
even when
medication is
taken with meals
AE Lactic
Acidosis
Pt self-report
Lab evaluation: Increased
serum lactate level
No s/s of
lactic
acidosis;
normal serum
lactate level
(normal range
1-1.8
mmol/L)
Pt develops s/s
of renal failure,
fatigue, malaise,
chills, myalgia,
hyperventilation,
somnolence, and
an increase
serum lactate
level
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CASE STUDY ANALYSIS: DIABETES
2. Glipizide - oral hypoglycemic medication
If HgbA1c target is not achieved after 3 months of monotherapy with
metformin, glipizide can be used in combination with metformin.
Glipizide has a lower potency and has a shorter half-life than glyburide
and is preferred for elderly patients. Glipizide is contraindicated to
patients with hepatic and renal impairment.
Oral dose: Start with 2.5 mg PO daily 30 minutes before breakfast for
elderly patients. The dose can be increased by 2.5 – 5 mg after several
days. Max dose is 40 mg/day in divided doses or 15 mg/dose.
NEW MEDICATION
E
or
AE
Parameter Method Goal Alter Tx When/If
E Lower blood
glucose level Self-monitoring of BG
twice a day reported by pt
per BG log
Laboratory results:
fasting plasma glucose;
HgbA1c every 3 months;
random plasma glucose
Short term:
HbA1c:
<7.5%
long term:
HbA1c: <7%
Pre-prandial
plasma
glucose: 90-
130 mg/dL
Postprandial
plasma
glucose: <180
mg/dL
If HgbA1c in 3
months has not
improved, then
increase fasting
plasma glucose
level check
AE Hypoglycemic
reactions
Pt self-report
Self-monitoring of BG
levels
No
hypoglycemic
events
(weakness,
dizziness,
sweating,
anxiety,
tremors)
Continued
hypoglycemia
AE GI upset Pt self-report No nausea,
vomiting,
abdominal
discomfort, or
diarrhea
Pt has persistent
diarrhea
AE Cholestatic Pt self-report of s/s of No s/s With s/s of
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CASE STUDY ANALYSIS: DIABETES
Jaundice jaundice, dark urine, light
colored stool
Physical assessment
Laboratory results: liver
panel
cholestatic
jaundice;
normal liver
enzymes
cholestatic
jaundice and
increased levels of
bilirubin
AE Blood
dyscrasias
Laboratory results: CBC Normal CBC
levels
Abnormal CBC
result:
leukopenia,
thrombocytopenia,
anemia, or
agranulocytosis
2) Atorvastatin - anti-lipidemic
DM is a significant cardiovascular risk factor. CF has DM and is at
risk for cardiovascular disease. Atorvastatin will lower CF’s lipids.
Patients over the age of 40 with DM and another risk factor for
cardiovascular disease should take a statin medication to reduce
cardiovascular complications according to the ADA.
Oral dose: 40-80 mg/day PO for high-intensity statin therapy
NEW MEDICATION
E
or
AE
Parameter Method Goal Alter Tx
When/If
E Lower
cholesterol/
LDL levels
Laboratory evaluation:
Lipid panel
LDL <100;
Trig <150;
HDL >40
If LDL level does
not improve
AE GI issues Pt self-reports No s/s of GI
upset or
discomfort
If complaint of
abdominal
cramps,
constipation,
diarrhea,
heartburn,
nausea, or
dyspepsia
continue.
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CASE STUDY ANALYSIS: DIABETES
AE Nasopharyngitis Pt reports sore throat,
fever, runny nose, cough,
and nasal obstruction
Comprehensive physical
assessment
No s/s of
cold-like
symptoms
Symptoms are
not resolved.
AE Arthralgia Pt reports joint pain No s/s of
joint pain
Symptoms are
not resolved.
AE Liver
Dysfunction
Laboratory evaluation:
Liver panel
Normal
levels AST,
ALT, LFT,
liver
enzymes
Increased lab
values – AST,
ALT, LFT
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CASE STUDY ANALYSIS: DIABETES
References
American Diabetes Association. (2020). 12. Older adults: Standards of medical care in diabetes –
2020. Diabetes Care, 43(Suppl 1), S152-S162. 10.2337/dc20-S012. 10.2337/dc20-S012.
Burchum, J. R. & Rosenthal, L.D. (2019). Lehne’s pharmacology for nursing care (10th ed.).
Elsevier.
Skidmore-Roth, L. (2019). Mosby’s 2019 nursing drug reference (32nd ed.). Elsevier.
Wells, B. G., Schwinghammer, T. L., DiPiro, J. T., & DiPiro, C. V. (2017). Pharmacotherapy
handbook (10th ed.). McGraw-Hill.
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