Case Study T2DM Adapted from Bruyere (2009) 100 case studies in pathophysiology PATI ENT CASE Patient’s Chief Concern “My left foot feels weak and numb. I have a hard time pointing my toes

Case Study T2DM Adapted from Bruyere (2009) 100 case studies in pathophysiology
PATI ENT CASE
Patient’s Chief Concern
“My left foot feels weak and numb. I have a hard time pointing my toes up.”
History of Present Illness
C.B. is 48-year-old Native American woman who had high blood sugar and cholesterol levels three years ago but was lost to follow up. At that time, she had participated in the state’s annualhealth screening program and noticed that her fasting blood sugar was 141, and her cholesterol was 225. However, she felt”perfectly fine at the time” and could not afford any more medications. Except for a number of “female infections,” she has felt fine until recently.
Today she presents to the Indian Hospital general practitioner with symptoms of weakness and numbness in her left foot and difficulty flexing her foot for nearly three weeks. She denies any other weakness or numbness. However, she reports that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 65 pounds since her last pregnancy 14 years ago, 15 pounds in the last 6 months alone.
Past Medical History
Gestational diabetes with fourth child 14 years ago
HTN X 10 years
Moderate-to-severe osteoarthritis involving hands and knees X 4 years
Multiple yeast infections during the past 3 years that she has self-treated with OTC anti- fungal creams and salt baths
Occasional constipation

Past Surgical History
C-section 14 years ago
OB-GYN History
Menarche at age 12
Menopause, natural,at age 46
First child at age 17, last child at age 34, G4P4A0, all babies were healthy, 4th child weighed 10 lbs 61??2oz atbirth
Last Pap smear 4 years ago
Family History
Type 2 DM present in younger sister and maternal grandmother; both were diagnosed in their late 40s; maternal grandmother died from kidney failure while waiting for a kidney transplant; sister is taking “pills and shots”
Father had emphysema
Two older siblings are alive and apparently well
All four children are healthy
Social History
Married 29 years with 4 children
Family of 5 lives in a 2-bedroom trailer
Patient works full-time as a seamstress in a small, family-owned business
Smokes 2 ppd (since age 14) and drinks 2 beers most evenings
Has “never used illegal drugs of any kind”
Rarely exercises and admits to trying various fad diets for weight loss but with little success; has given up trying to lose weight and now eats a diet rich in fats and refined sugars
Patient Case Question 1. List a minimum of five risk factors that predispose this patient to type 2 diabetes mellitus.
Review of Systems
General: Admits to recent onset of fatigue
HEENT: Has awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing; denies vertigo, head trauma, ear pain, ringing sensations in the ears, difficulty swallowing, and pain with swallowing
Cardiac: Denies chest pain, palpitations, and difficulty breathing while lying down
Lungs: Denies cough, shortness of breath, and wheezing.GI: Denies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits to occasional episodes of constipation
GU: Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in the urine, or urinary incontinence
Ext: Denies leg cramps or swelling in the ankles and feet; has never experienced weakness, tingling, or numbnessin arms or legs prior to this episode
OB-GYN: Menses stopped 2 years ago; is not sexually activebut denies sexualdysfunction; also denies any vaginal discharge, pain, or itching
Neuro: Has never had a seizure and denies recent headaches
Derm: No history of chronic rash or excessive sweating
End: Denies a history of goiter and has not experienced heat or cold intolerance
Patient CaseQuestion 2. Clinical symptoms are subjective manifestations of a disease that can only be reported by the patient. List a minimum of seven symptoms that support a diagnosis of type 2 diabetes in this patient.
Allergies: Sulfa drugs (confusion)
Medications
Lisinopril 20 mg po QD
Acetaminophen 500 mg with hydrocodone bitartrate 5 mg 1 tablet po Q HS and Q 4h PRN
Naproxen 500 mg po BID (for mild-to-moderate osteoarthritis X 31??2 years)
Omeprazole 20 mg po QD
Docusate sodium 100 mg po TID
Loratadine 10 mg po QD PRN
Physical Examination and Laboratory Tests
General
Significantly overweight Native American woman who appears slightly nervous
The patient is alert, oriented, and uses appropriate words
She does not appear to be acutely distressed and looks her stated age
Vital Signs
BP 165/100, P 88, R 15, T 98
Height 5’3″/Weight 203
Patient Case Question 3 Which two clinical signs should arouse the most concern?
Skin
Dry and cool with tenting/poor skin turgor
Significant xerosis on both feet with cracking
Erythematous scaling rash in the axilla bilaterally
No petechiae, ecchymoses, moles, or tumors upon careful inspection
Normal capillary refill throughout
Head, Eyes, Ears, Nose, and Throat
PERRLA
EOMI
Pink conjunctiva
R & L funduscopic exams showed mild arteriolar narrowing but without hemorrhages, exudates, or papilledema
Non-icteric sclera
TMs intact
Nares and oropharynx clear without exudates, erythema, or lesions
Mucous membranes dry
Neck and Lymph Nodes
Supple
No thyromegaly, adenopathy, JVD, or nodules
(+) bruit auscultated over right carotid artery
Chest and Lungs
No chest deformity; chest expansion symmetric
Clear to auscultation and percussion throughout
Heart
Regular rate and rhythm with no murmurs, gallops, or rubs
Apical impulse normal at 5th ICS at mid-clavicular line
Normal S1 and S2
No S3, S4
Abdomen
Soft, NT with prominent central obesity
(+) BS in all four quadrants
(-) organomegaly, distension, or masses
Faint abdominal bruit auscultated
Patient Case Question 4. What is the significance of the two bruits auscultated in the neck and abdomen?
Breasts
No masses, discoloration, discharge, or dimpling of skin or nipples
Genitalia/Rectum
No vaginal discharge, erythema, and lesions
No hemorrhoids
Good anal sphincter tone
Stool is guaiac-negative
Musculoskeletal and Extremities
Normal ROM in upper extremities
Reduced ROM in knees
No edema or clubbing
Peripheral pulses diminished to 1+ in both feet
Feet are cold to touch and dry with cracking, but no ulceration observed
Strength 5/5 throughout except 2/5 in left foot
Patient Case Question 5. What is the significance of this patient’s cold feet and diminished peripheral pulses in the lower extremities?
Neurologic
Alert and oriented X 3
Cranial nerves II-XII intact (including good visual acuity)
Sensory response to light touch, proprioception, and vibration subnormal in both feet with abnormalities greater in the left foot
DTRs 2+ throughout
Gait normal except for left foot weakness
Patient CaseQuestion 6. Clinical signs are objective manifestations of a diseasethat can be identified by someone other than the patient (ie., you, the practitioner, can see, hear, or feel them). List a minimum of six clinical/objective signs from the case study above that support a diagnosis of type 2 diabetes in this patient.
Laboratory Blood Test Results (After Overnight Fast)
Laboratory Blood Test Results
Na 139 meq/L Ca 9.8 mg/dL T. cholesterol 246 mg/dL
K 4.0 meq/L PO4 3.3 mg/dL HDL 28 mg/dL
Cl 102 meq/L Mg 1.9 mg/dL LDL 168 mg/dL
HCO3
22 meq/L AST 19 IU/L Trig 458 mg/dL
BUN 14 mg/dL ALT 13 IU/L
HbA1c
8.2%
Cr 0.9 mg/dL Alk phos 43 IU/L Insulin 290 ?U/mL
Glu 168 mg/dL T. bilirubin 1.0 mg/dL
Urinalysis
Appearance
Pale yellow
and
clear
Bilirubin Neg
Microalbuminuria
Negative
pH 5.8 Ketones Neg
Glucose
Positive
SG 1.008 Protein Neg Microsc Microscopy Negative for microbes, red cells, and white cells
Patient Case Question 7. Which single urinalysis test result is more suggestive of type 2 than type 1 diabetes? Please explain.
Patient Case Question 8. Which three blood test results strongly support a diagnosis of diabetes. Please explain.

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