Type 2 DM Case Study

This case study is to be completed independently. Use valid resources and provide
the citation for source(s) you use (class notes, online source, book). Please answer
each question thoroughly making sure you have thought through your answer and
demonstrating what youve learned in class. Do not simply regurgitate information
you find from other resources, as you will not receive any points for doing this. You
should type your answers using good writing mechanics and submit your final copy
on Blackboard by Friday, December 5th. This case is worth 50 points; each question is
marked with its point value.
Appointment #1
TW is a 43 y/o computer programmer, a husband, and father to three. He rarely goes to the
doctor but recently he has been feeling off and complains of having episodes of fatigue,
headaches, and hunger even after eating. He was also just recently given a prescription for
glasses due to a new onset of vision problems. He currently takes no medications. He denies
gaining or losing weight in the last year and claims that he eats a normal, well balanced diet.
Upon further questioning, TW reports his typical daily diet as follows: For breakfast he
typically has a muffin or other pastry from the local gas station along with 3-4 mugs of coffee
to get him through the morning. He usually goes out to lunch for fast food as he typically does
not have a lot of time. For dinner, he eats whatever his wife puts on the table. The usual he
claims to be meatloaf, pot roast, spaghetti and meatballs, BBQ or burgers. He states that he
and his wife eat out 2-3x/week for dinner.
He says that most of his workday is spent at his desk. He states that he used to bike a lot until
he injured his back 8 years ago, which has affected a lot of what he can do physically. He states
that he has not maintained a regular exercise routine since the injury. He does occasionally
take his dogs for a walk in the evenings but this does not happen regularly because he is so
exhausted after work, especially recently.
At the time of his visit, TW presents with a BP reading of 146/88 and a HR rate of 105 after
sitting for 5 minutes. He states that he just has white coat syndrome and denies having high
BP. He weighs 247 lbs and is 511. A fasting blood glucose test was done as well as a CBC.
Electrolyte, BUN, and creatinine levels were also checked. Results are listed below.
Hgb: 17 g/dL
Hct: 37%
Glucose: 327 mg/dL
Chol: 255 mg/dL
ALT: 42 U/L
K: 4.2 mEq/L
BUN: 11 mg/dL
Creatinine: .9 mg/dL
Questions:
1. TW has just been diagnosed with type 2 diabetes.
a. List 4 signs/symptoms that suggest this? (2)

Episodes of fatigue

Type 2 DM Case Study

High glucose levels

Vision problems
High blood pressure
b. Provide a sound physiological explanation as to why 2 of his symptoms exist.
(2)

High blood glucose levels: TW may have insulin in his body but is either not producing
enough and/or the insulin is not effective enough in controlling the high amounts of sugar
in the blood leading to high blood glucose levels. (http://www.diabetes.org/living-withdiabetes/treatment-and-care/blood-glucose-control/hyperglycemia.html)
Vision problems: TW may already be having complications from diabetes, specifically he
may be having retinopathy. Retinopathy occurs from high blood sugars over time
damaging the blood vessels of the light-sensitive tissue of the retina.
(http://www.mayoclinic.org/diseases-conditions/diabeticretinopathy/basics/definition/con-20023311)
c. What other signs/symptoms would help you be more certain of the
diagnosis? In other words, what other signs/symptoms typically accompany
this diagnosis but were not provided? (2)

Type 2 diabetes has a strong genetic link. So, if we were provided with a family
history of whether or not Type 2 ran in his family that would help me to be more
certain of his diagnosis. (Module 1 lecture)
If TW showed signs of increased thirst and urination that would have also helped
me to be more certain of his diagnosis because the excess sugar in the blood
causes more fluid to be pulled from tissues leading him to drink and urinate more.
(http://www.mayoclinic.org/diseases-conditions/type-2diabetes/basics/symptoms/con-20031902)

2. Determine TWs weight status.

a. Calculate his BMI. (1)

(247lbs/(71in)^2)*703=34.4
b. How does this contribute to his diabetes? Provide a physiological
explanation. (2)

TW has a BMI of 34.4 meaning that he is obese. Obesity can lead to insulin resistance
which leads to Type 2 diabetes because fat (especially visceral fat) causes the bodys
cells to be less insulin sensitive.
(http://www.bd.com/us/diabetes/page.aspx?cat=7001&id=14163)
3. What lab values are abnormal?
a. Provide a normal range for those values that are abnormal. (2)

Type 2 DM Case Study

Hct: 40.7%-50.3%
(http://www.nlm.nih.gov/medlineplus/ency/article/003646.htm)
Fasting Blood Glucose- less than 100 mg/dL
(http://www.webmd.com/diabetes/how-sugar-affects-diabetes)
Cholesterol: below 200 mg/dL (http://www.mayoclinic.org/diseasesconditions/high-blood-cholesterol/in-depth/cholesterol-levels/art-20048245)
ALT: 10-40 u/L (http://www.webmd.com/digestive-disorders/alanineaminotransferase-alt?page=2)
b. Do these abnormal lab values relate to his diabetes? If yes, how? (3)

Hct does relate to his diabetes because it is testing to see if he is anemic. Anemia
can be caused by diabetes because one of the complications of diabetes is kidney
damage and the hormone that regulates red blood cell production (EPO) is
produced by the kidneys. So if the kidneys are damaged this can lead to reduction
in red blood cell production, which explains why TWs hct level is low.
(http://diabeteshealth.com/read/2012/02/16/7449/diabetes-and-anemia-/)
Fasting blood glucose is related to his diabetes because in type 2 diabetes blood
glucose levels are elevated due to the inability of the body to produce enough
insulin or produce effective insulin to bind the glucose circulating in the blood.
TWs blood glucose is elevated due to his inability to bind glucose. (Module 1)
TWs elevated cholesterol level is related to his diabetes. Diabetes often leads to
diabetes dyslipidemia which is where good cholesterol (HDL) levels are
reduced and bad cholesterol (LDL) and triglyceride levels are increased.
Diabetic dyslipidemia increases risk for heart attack and stroke.
(http://www.heart.org/HEARTORG/Conditions/Diabetes/WhyDiabetesMatters/C
holesterol-Abnormalities-Diabetes_UCM_313868_Article.jsp)
TWs alt level being slightly elevated is due to his diabetes. Individuals with
diabetes usually have abnormal alt results because mild chronic elevations of
transaminases often reveal underlying insulin resistance.
(http://clinical.diabetesjournals.org/content/23/3/115.full)

4. Name 3 aspects of TWs lifestyle do you think contribute to his DM? (2)
a. Based on the information you have, what reasonable modifications would
you suggest he make? Please be specific. For example, dont just say eat
better. Instead, provide a diet/meal plan indicating what kind of food and
how much he should eat. (2)

Sedentary Lifestyle: TW should aim to exercise at least 5 times a week for 30

minutes each. He should not strain himself due to his back injuries. He did
mention walking his dogs in the evening, so him and his wife taking the dogs for
a walk every night for 30 minutes would be a good option for TW.
Fast food for lunch: TW should try packing a lunch rather than eating at fast food
restaurants. For example, he could pack a salad, cup of fruit, and a lean meat
sandwich on whole wheat bread. He could also pack a healthy, low carb soup
such as chicken noodle. TW should stick to eating more fruits and vegetables for
lunch and keeping his carb range within 60-75 grams at lunch.

Type 2 DM Case Study

Gas Station for Breakfast: TW should reduce his stops at local gas stations for
breakfast pastries in the morning and either eat before he leaves the house or pack
a breakfast to eat once his reaches work. Some sample food items he could eat for
breakfast are: a cup of fresh or frozen fruit, a single serving of quick oats, one
English muffin, one ounce of unsalted nuts, eggs or egg substitutes (no more than
3 eggs in one week), and/or cup of cottage cheese. He should keep his breakfast
carb intake between 60 and 75 grams.
b. Explain how these modifications can affect blood glucose levels. In other
words, how does doing x help lower his blood glucose levels? Your
explanation needs to be sufficient enough so that it is obvious that you
understand these concepts based on what weve learned in class. (3)

Changing from a sedentary lifestyle to an active lifestyle would help lower his
blood glucose levels by helping TW to lose weight. Fat (especially visceral) leads
to insulin resistance so if he loses visceral fat he may be able to obtain some
insulin sensitivity back that he lost. (Module 3)
Packing a lunch rather than eating fast food for lunch would help lower TWs
blood glucose levels because he would decrease the amount of carbs he is eating
at a meal and the insulin would be able to act more effectively.
Not eating breakfast at the local gas station would help lower TWs blood glucose
levels because he would decrease the amount of carbs he is eating at a meal and
the insulin would be able to act more effectively.

5. Name and describe two different classes of drugs that might be used to treat TW. (2)
a. What is the mechanism of each drug? In other words, how does it work?
What receptor and organ does it act on and what is the response? (3)

Biguanide (Metformin): This drug suppresses hepatic glucose production by

activating AMP-kinase in the liver leading to decreased glucose production. AMP
kinase is a liver enzyme that plays an important role in insulin signaling and
glucose and fat metabolism, activation of AMP is necessary to activate
Metformins inhibitory effect. (Module 8)
GLP-1 receptor antagonists: This drug activates GLP-1 R (GLP-1 receptors are
present in the pancreas and gastrointestinal tract) in response to this activation
insulin increases and glucagon decreases, gastric emptying decreases which leads
to satiety. All of these reactions lead to a lowered blood glucose due to increase
insulin to pick up blood glucose and less carbs being ingested due to increased
satiety. (Module 8)
b. What would you tell a patient who is taking these medications about the
complications, side effects, and other things to expect? (1)

Metformin side effects/complications/other things to expect: nausea, vomiting,

upset stomach, diarrhea, weakness, and/or a metallic taste in mouth, lactic
acidosis, b-12 deficiency, contraindication
GLP-1 receptor antagonists side effects/complications/other things to expect:
fullness, nausea, diarrhea, and very rarely necrotizing pancreatitis

Appointment #2

Type 2 DM Case Study

TW returns to the physicians office 3 weeks later with complaints of similar symptoms as
before as well as a new onset of increase thirstiness and says that he just recently realized that
he gets up to pee much more frequently than his wife throughout the night. His blood glucose
levels are still high (286 mg/dL) even though he reports that he has not eaten anything all day
and claims he has been taking his medicine somewhat regularly. He also complains that he still
suffers from frequent headache and new onset of diarrhea.. He admits that he has not changed
his diet or activity levels much at all and that he doesnt really believe that will help him
anyway.
Questions:
1. Why is TW experiencing increase thirstiness? What is the medical term to label this
symptom? How is this related to nocturia? (3)

TW is experiencing thirstiness because as he urinates more to rid his body of the extra
glucose he is becoming dehydrated from the excess fluid loss.
(http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetessymptoms/art-20044248 ) The medical term for this symptom is polydipsia and it is
related to nocturia because nocturia is when someone wakes to urinate one or more times
a night and when someone is experiencing polydipsia they are excessively drinking fluids
causing excessive urination. (http://www.racgp.org.au/afp/2012/june/nocturia-a-guideto-assessment-and-management/)
2. Given this information, what do you think the next step should be and why? Should
his medication be adjusted to help better control his blood glucose levels? Defend
your answer. If you dont think his medication should be adjusted, then provide
another solution. (4)

I do not think his medication should be changed. TW should meet with a Registered
Dietitian to create a diet and exercise plan. His symptoms are going to continue to get
worse if he does not exercise and eat right because medicine can only help so much. If he
starts eating a better diet he can lower his blood glucose levels and if he exercises he can
lose weight increasing his insulin sensitivity. Also, exercise and a better diet could help
his medications work more efficiently.
3. What other health issues would you manage? Hint: use lab values and your answer
to #3 above. Would managing this help control his diabetes? Explain. (3)

I would also manage his cholesterol and Hct levels. His Hct levels were 37% so I would
want to raise these by adding foods high in iron, which would help with his diabetes
because it can prevent anemia, which can be a secondary complication from diabetes due
to kidney damage (diabetic nephropathy).
(http://diabeteshealth.com/read/2012/02/16/7449/diabetes-and-anemia-/) The second
health issue I would manage would be his high cholesterol. This can be done through
exercise and diet. This would help control his diabetes because this would prevent
diabetic dyslipidemia from occurring, which is a secondary complication where LDL and
triglyceride levels are raised and HDL levels are reduced. Diabetic dyslipidemia can lead

Type 2 DM Case Study

to heart attack and/or stroke.

(http://www.heart.org/HEARTORG/Conditions/Diabetes/WhyDiabetesMatters/Cholester
ol-Abnormalities-Diabetes_UCM_313868_Article.jsp)
4. Do you think TWs family history plays a role in his diabetes? In other words, is type
2 diabetes hereditary? If yes, then how so? (2)

Type 2 diabetes is a hereditary disease so I would say that there is a strong chance that his
family history plays a role in his diabetes. Most likely his mother, father, or another
relative have also been diagnosed with Type 2 diabetes. There have been genes that
researchers have found to be associated with Type 2 and these genes play an even larger
role in developing Type 2 than the environment. (Module 2)
5 Years Post Original Diagnosis
TW now presents with more medical issues, including a higher BP reading(162/92). He has
not lost any weight and has not demonstrated an effort to do so as his lifestyle has not
changed. His wife is with him and expresses her concern about her husbands health. His blood
glucose levels, as tested with an A1C test, have not been controlled (A1C: 9%). Results from an
eye exam 3 months ago indicated that his vision is getting worse. It is now 200/20 as opposed
to 15 years ago when he was 40/20. Even more concerning, is a stage 1 ulcer on the plantar
surface of his right foot. He reports that he has seen his primary physician in regards to this
but it appears to not be healing well since then (2 months ago). He denies any mechanism of
injury and suggests that it was probably just from walking around in the yard barefoot over
summer. He also admits that he still suffers from nocturia, headaches, and fatigue. Objective
findings indicate that he has decreased sensation in both feet, however strength is normal.
Questions:
1. What further complications could you expect to occur if he continues to not properly
manage his diabetes? Provide 3 complications and the biological basis for each. (3)

Amputation- If his ulcer continues to worsen and not heal, the infection could
continue to spread throughout his foot and if it becomes bad enough that it could
spread to the rest of the body through the blood they will have to perform an
amputation. The ulcer is most likely continuing to get worse due to his neuropathy
in his feet.
Peripheral Artery Disease- The constant high blood sugar in TWs arteries could
lead to a build up of plaque in his legs and peripheral portions of his body. This
will lead to a decreased blood flow to these important extremities, which may also
lead to neuropathy. (http://www.mayoclinic.org/diseases-conditions/peripheralartery-disease/basics/definition/con-20028731)
Loss of eye sight- The constant high blood sugar could also lead to retinopathy
possibly resulting in loss of eyesight. If proliferative retinopathy occurs this
results in new, thin blood vessels forming in the eye that usually leak blood and
eventually result in loss of sight. (http://www.mayoclinic.org/diseasesconditions/diabetic-retinopathy/basics/definition/con-20023311)

Type 2 DM Case Study

2. What education could you provide to TW about foot care? (1)

I would tell TW to start checking his feet every day, wear clean socks and shoes, never
go barefoot, drying his feet thoroughly after showers, and have a physician check his feet
at every appointment. (http://www.diabetes.org/living-with-diabetes/complications/footcomplications/foot-care.html)
a. Why is it important? (1) This is important because good foot care can
prevent ulcers, infections, and amputations.
b. If his blood glucose levels were in better control, would regular foot checks
be as important? Why or why not? (1) Yes, foot checks are important

regardless of blood glucose levels. All diabetics are at a higher risk for
complications with their feet due to poor blood flow and are therefore
unable to fight infection as efficiently.
3. Find 3 statistics/facts about type 2DM from a reputable source to help get through
to TW to empower him to better manage his DM. Remember to cite the source! (3)

50 percent of people with Type 2 diabetes die of cardiovascular disease, primarily

heart disease and stroke.
Diabetes is the leading cause of newly diagnosed adult (20-74 years old)
blindness in the United States.
Diabetes was the primary cause of kidney failure in 44 percent of all new cases in
2011.

http://www.healthline.com/health/type-2-diabetes/statistics#3
4. If necessary, what would be a more aggressive approach to treat TWs diabetes? In
other words, in addition to Metformin, what other medications could be prescribed?
(2)

TW may need to start taking injections of insulin every day to help lower his blood
glucose levels since he is not willing to make lifestyle changes. TW may also need to
take another oral agent such as an insulin secretagogue (a sulfonyurea) to help stimulate
beta cell production of insulin. (http://dtc.ucsf.edu/types-of-diabetes/type2/treatment-oftype-2-diabetes/medications-and-therapies/type-2-non-insulin-therapies/insulin-releasingpills-secretagogues/)
5. Write an additional question for this case study. It can be for either the initial
visit or the follow-up appointment sections. This should be a question that is
not in the given list of questions. Be careful to ask a truly different question,
not simply a rewording of a given question. (1 pt bonus)
Follow-up appointment: Do you think there are any psychosocial factors making TW
unwilling to change his lifestyle and improve his blood glucose levels? If so, what
factors?