Question

Patient with Newly Diagnosed Diabetes Mellitus (DM)

Natalie Smith is a 42-year-old female patient who presented to the emergency department at 9pm with vomiting and abdominal pain. She states that she had a 2-week history of excessive urination and thirst, accompanied by blurred vision and a 10-pound weight loss despite excessive eating. The patient indicated that she started treatment for newly diagnosed hypertension about 3 months ago.

PAST MEDICAL HISTORY:                                              CURRENT MEDICATIONS:

- Hypertension                                                                 - hydrochlorothiazide [Hydrodiuril]

- Depression                                                                     - fluoxetine [Prozac]

LAB VALUES AND VITAL SIGNS: The following table includes the patient’s lab values and vital signs upon admission:

- Smoker

Value 141 3.5 98 352 Blood Sodium (Na) Potassium (K) Chloride (CI) Calcium (Ca) Glucose Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Blood Urea Nitrogen (BUN) Creatinine Hemoglobin A1C Albumin Beta hydroxybutyrate Anion Gap Normal Range 135-145 mmol/L 3.5-5.1 mmol/L 95-105 mmol/L 2-2.6 mmol/L 65-110 mg/dL 5-30 U/L 5-10 U/L 8-21 mg/dL 0.8-1.3 mg/dL. 4.6% 35-50 g/L <1.5 mmol/L 8-16 mEq/L 1.2 11% ABG Value pH Normal Range 7.35-7.45 75-100 mm Hg 35-45 mm Hg 22-26 mmol/L 96-100% 7.25 | 95 34 15 | 97% CO2 HCO3 SaO2 Urinalysis Value Ketones 96 Vitals Normal Range Small < 20 mg/dL Moderate 30-40 mg/dL Large > 80 mg/dL Normal Range 60-100 beats/min 120/80 mm Hg 12-20 breaths/min | 97.8-99 F Value 92 124/82 | 32 979 HR RR Temp

DIAGNOSIS AND TREATMENT:

The patient was diagnosed with DM and an acute complication of DM based on her symptoms and lab values upon admission. The patient was successfully treated for her acute complication of DM, and subsequently discharged 3 days later. Upon discharge the patient was prescribed the following outpatient drug regimen:

• insulin Aspart before breakfast, lunch and dinner
• insulin glargine [Lantus] at bedtime

The patient was instructed to conduct self-monitoring blood glucose checks 4 times a day. She was scheduled to be seen in the outpatient clinic 1 week after hospital discharge.

1. What type of DM does this patient have? What alluded you to this answer (signs/symptoms)?   1 point
2. Did this patient’s DM develop within the last 30 days? What alluded you to this answer? 1 point
3. What chronic complications of DM does this patient have? Provide the basic pathophysiology behind the development of at least 1 of the patient’s chronic complications due to DM.   2 points
4. What acute complication of DM does this patient have? Provide the basic pathophysiology behind the development of at least 3 signs/symptoms of the patient’s acute complication due to DM.   2 points
5. How would you treat the patient’s acute complication of DM? Provide rationale for each treatment choice?   2 points
6. What acid-base imbalance does this patient have (include respiratory or metabolic, and alkalosis or acidosis)? What is the most likely cause of this acid-base imbalance?   2 points
7. What vital sign(s) is significantly abnormal? What is a potential cause of the abnormal vital sign(s)?    1 point
8. Which lab values are potentially concerning related to the patient’s current medical state? Why are these lab values concerning? What dosing considerations are pertinent to the patient’s abnormal lab values? 2 points
9. What is basal insulin? What is bolus insulin? When are they used? What is sliding scale insulin and what type(s) of insulin are used? When are they used/given? 2 points.
10. Provide rationale for the purpose of prescribing each insulin for the management of this patient’s DM? 2 points.
11. Identify 4 pharmacokinetic effects specific to the patient’s outpatient drug regimen.   2 points
12. Identify 3 potential adverse effects specific to the patient’s outpatient drug regimen. Describe the physiologic mechanism associated with each adverse effect.   2 points
13. Indicate 2 drug-drug interactions with the patient’s current drug history, and outpatient drug regimen? What is the potential outcome from these interactions? Are these positive and/or negative drug-drug interactions?   2 points
14. What, if any, changes would you make to the patient’s drug regimen? Provide rationale for your answer.   1 point
15. Identify at least 5 pertinent points of patient education you would provide that are specific to the outpatient drug regimen? Provide rationale for why each is important.   2 points (Note: avoid general statements, such as “take medication as prescribed”)
16. Identify at least 2 pertinent points of patient education to help the patient manage DM? Provide rationale for why each is important.   2 points (Note: this is not specific to the patient’s prescribed drug regimen)
17. The provider orders for the patient to have a follow-up visit 3 months after discharge. Identify at least 2 methods of evaluating if the patient’s outpatient prescribed drug regimen is effective in managing her DM. 1 point
18. At the 3-month follow-up visit the patient states that she has gained 11 pounds [from her baseline pre-hospitalization weight] since starting the new drug regimen to manage her DM. What rationale will you provide to the patient as a potential cause of her weight gain? 1 point

Answer 1

Patient has type 2 diabetes as patient has classic signs of polyphagia, polyuria and polydipsia

no patient must have dm quite a long time as patient has developed chronic complications related to dm like blurred vision

patient has blurred vision as high blood sugar for long time has negative effect on retina as micro aneurysms form in retinal arteries that can burst easily .and can cause macular edema. Also it leads to swelling of eye lens.

patient has developed diabetic ketoacidosis as evidenced from sign symptoms and arterial blood gas analysis.die to lack of insulin in DM and corresponding elevation of glucagon, there is more production of glucose by glycolysis and gluconeogenesis. Also there is release of fatty acids from adipose tissue in liver which are again converted to ketone bodies by beta oxidation . These ketone bodies turn blood ph acidic and as a compensatory mechanism, patient hyperventilates. Cerebral edema may result of dka.