Introduction
According to the World Health Organization in 2000, around 171 million people suffered from diabetes worldwide. Diabetes is a major disease found in every other person, resulting from an imbalance of blood sugar and insulin levels in the body.
Diabetes is the third leading cause of death in the United States after cancer, and every second person seems to be diabetic. Diabetes mellitus is a disease caused by high blood sugar levels, which result in defective releases of insulin in the body (Mathur, R. 2008). Initially this disease was associated with “sweet urine” and excessive loss of muscles (Mathur, R. 2008).
In Diabetic patients, the glucose levels in the blood are increased, a condition known as ‘hyperglycemia’, and glucose is excreted in the urine. Insulin is the hormone that controls the levels of glucose in the blood, and when the pancreas releases it, immediately the high levels are controlled, like after a meal. The pancreas is an organ present in our bodies. If insulin is not being produced sufficiently, or is not functioning properly, diabetes occurs. Although diabetes can be controlled, it is a chronic disease, lasting till the end of life (Mathur, R. 2008).
R.R. was diagnosed with mild case of diabetes 4-5 years ago. Over the years he developed some more severe kind of symptoms that were indicative of this disease. Certain risk factors and pathphysiology of the disease is discussed over here.
Physical Assessment
Age: 62-years
Sex: Male
Height: 1.75m
Weight: 77.1 kilograms
BP: 180/105mmHg
Signs:
Bilateral Engorged Jugular veins
Inspiratory moist rales
Dorsalis pedis
Posterior Tibial Pulses
Erythematous right foot
2nd, 5th and lateral aspects of big toe has areas of right gangrene
Sensation: Absent in right foot
Plasma glucose: 237 mg/dl
Total serum cholesterol: 266 mg/dl [Normal: <200mg/dl] High density lipoprotein (HDL) cholesterol: 29 mg/dl (Normal :>35 mg/dl)
Triglycerides: 285 (Normal: <200 mg/dl),
HbA1c 8.9% (normal <6.2%)
Smoke: Yes
Among most important risk factors associated with diabetes are obesity, high blood pressure, high blood cholesterol, old age.
The problems which he goes through are described as follows:
Gangrene
R.R. initially visited a doctor due to gangrene of the foot, and shortness of breath. Dry foot gangrene has become a part of diabetes and is a big medical problem these days. Foot gangrene is usually caused by an improper circulation of the blood – if there is insufficient oxygen-rich and nutrient-dense supply of blood due to arterial (femoral, popliteal or tibial) hindrance. The patient had a femoral- popliteal bypass too, which means that his blood supply was insufficient to keep tissues of his leg alive.
In the initial stages, a dull, aching pain is aroused, and there is immense pain in the affected area. The color of the skin slowly changes to dark purplish- blue, and later on, black. The doctors diagnosed the patient with diabetes then, and ever since he has been having skin-related and breathing problems. Diabetes causes skin infections, and wounds take longer to heal in diabetics (Smoking and Diabetes, 10th Jan, 2008).
Smoking
The patient had been a heavy smoker since the age of twenty, and this had led to myocardial infarction in him, along with the dyspnea and diabetes mellitus (Fenton, 2007). The devastating use of tobacco had injured his inner body, leading to shortness of breath. And being a diabetic, it worsened the situation. However, he quit smoking two years ago. The health issues related with smoking are well-known by everyone. There is a specific threat to the lives of diabetic patients who smoke.
The complications that may arise in smokers, who are also diabetics, may be, nephropathy, and smoking reduces retinal blood flow and affects the hypoxic environment of the diabetic retina. Prevention of tobacco use should be encouraged for all patients with diabetes. Smoking doubles the risk of diabetes in normal healthy individuals (BMJ, 2008).
Smoking and diabetes are greatly associated with one another. If smoking can cause diabetes, then it can lead a diabetic patient to a worse condition as well. Numerous studies have been conducted to associate smoking and glucose imbalance. It shows that smoking may be separately linked with glucose intolerance, abnormality in fasting glucose, and Type II diabetes ( Smoking and Diabetes, 10th Jan, 2008). The reason smoking causes diabetes is that it leads to resistance of insulin and insufficient insulin secretions. Thus, there is a 50% increase in the likelihood of increase in risk of diabetes in smoking people (Smoking and Diabetes, 10th Jan, 2008). Smoking makes the risks of diabetes twofold.
Diabetics who are smokers are more at a risk of having worsened their health. They are more prone to diseases such as heart attack, stroke, blood glucose, blood pressure, high cholesterol (the level of cholesterol increases in smokers), skin infections, and kidney and nerve infections (Smoking and Diabetes, 10th Jan, 2008).
Smoking affects the damage caused to the body by diabetes, by doubling it. The bodies large arteries leading to the legs and brains are affected, and this leads to more cases of stroke and amputations.
Effects of Diabetes
The following conditions may result from diabetes. Some of them have been mentioned earlier:-
- Blindness,
- Kidney failure,
- Damage of nerves,
- Damage to other vessels, smaller in size, causing microvascular diseases,
- Atherosclerosis,
- Strokes,
- Coronary heart disease,
- Macrovascular diseases.
Since the patient had had diabetes since the last few years, it may have led to the shortness of breath he experienced a year ago, since diabetes may lead to heart diseases (Mathur, R. 2008)
Types of Diabetes
There are two types of diabetes, one is the Type I and the second is the Type II diabetes. The former is also called insulin dependent diabetes, or diabetes mellitus. In this case, the pancreas ceases to produce insulin for some reason. The patients suffering from Type I diabetes also possess abnormal antibodies. Antibodies are proteins that are found in blood, which are a component of the immune system. Thus in the case described, the patient may be suffering from a number of problems due to his weak immune system. A diabetes mellitus patient is compelled to take in insulin to keep alive (Mathur, R. 2008)
Type II diabetes is non-insulin dependent. In this situation, a patient may still produce insulin, but is insufficient for the body. Type II diabetes is said to occur more frequently in people over thirty years of age, though now it is more common in childhood, than Type I diabetes.
Symptoms of Diabetes
The symptoms of diabetes include,
- Dehydration in the body due to increase in urine frequency
- Loss of weight
- Fatigue
- Nausea
- Vomiting
- Bladder, skin and vaginal infections
- Blurred vision
- Lethargy
- Coma, in extreme cases.
The case being studied initiated with skin problem, i.e. gangrene. Diabetes may have caused it, as it does give rise to such infections. Foot ulcers are also common in diabetes patients (Bentley, J. 2007).
Pathophysiology
Insulin is responsible for the processing of all the nutrients that enter our bodies. It reduces the levels of glucose in the blood by stimulating it to convert into glycogen (Lamb, W. 2007). Insulin also slows the breakdown of fat to triglycerides, fatty acids and ketones. It additionally stops the breakdown of fat in the liver and kidneys. Since the patient was diabetic, lack of insulin could not slow the fat breakdown process, and thus he had a record of high triglycerides (Lamb, W. 2007). Triglycerides are essential for body functions, but a balance is necessary (Forogos, R. 2008).
A condition known as hyperglycemia occurs when the deficiency of insulin leads to “gluconeogenesis”. The circulation of glucose is stopped, neither is it stored. The glucose is unable to be absorbed by the kidneys, due to its large quantities, and this in turn causes glycosuria, osmotic diereses, thirst, and dehydration. The weight loss experienced by a diabetic patient is due to the increase in breakdown of fats and proteins, which is resultant in creation of ketones (Lamb, W. 2007).
This does not mean that an excess of insulin in the body is beneficial. If in too much quantity in the body, the release of glucose into the bloodstream is reduced, and this results in a condition known as “hypoglycemia”.
Other Risk Factors of Diabetes
Some of the commonly prevailing diseases or conditions resulting from diabetes are risk of colorectal cancer (Larrson, S. 2005), obesity, high blood pressure, and high cholesterol levels.
Obesity
Obesity and diabetes are major causes of deaths in the United States. Both are interlinked, weight gain causes an increase in risks of diabetes (Mokdad, A, 2001). The costs of health care for diabetics are on the rise, and are problem-causing. Studies have shown that the occurrence of weight gain and diabetes have increased yearly. The Body Mass Index of an individual is measured by the division of the weight in kilograms by the square of height in metres. Further studies have been carried out to see whether there is a constant increase in obesity and diabetes, or if there are any plans for the people to lose weight to remain healthy.
The outbreak of obesity and diabetes took place in the 1990s, and even the current records show that most adults in the USA are overweight, and 7.3% have diabetes (Mokdad, A. 2001). Some diabetics are not even diagnosed, but are affected. BMI and gain in weight are mutual risk factors for diabetes. For every one kilogram increase in weight, the risk of diabetes goes up by 4.5%.
Diabetes and obesity can be prevented. Changes in lifestyles can help prevent the diseases, especially in those who are prone to them. Studies show that if weight is controlled, then everything automatically falls in place, like blood pressure, triglycerides, high-density lipo-protein cholesterol levels, etc. Therefore, an improvement in the diet and adequate physical activities can reduce the chances of diabetes and obesity.
High Blood Pressure
The cardiovascular system of an individual is badly affected if hypertension or high blood pressure, and diabetes exist together. If the hypertensive patient has diabetes mellitus, the risk of him getting a stroke, or experiencing any other heart-related problem, will be normal, and much expected (Grossman, E. 2000). The patient in consideration was diabetic, had high blood pressure, and the triglyceride ratio in his body was high also. Thus, all such problems are inter- linked.
If the blood pressure is lowered, there is a substantial cut down in the risk of a cardiovascular event. Renal problems are also decreased with low blood pressure.
High Cholesterol
High cholesterol takes its toll in the body over many years, and is basically caused by atherosclerosis (Effects of High Cholesterol, 2007). Atherosclerosis is the contraction of the arteries, and the high cholesterol that is caused by this condition leads to further heart illnesses, like heart attack and stroke. The best way to avoid such an instance is to reduce the amount of cholesterol in the diet, so that the cholesterol in the blood is also reduced. If the level of cholesterol in the blood is too high, the low-density lipo-proteins will tend to leave spare cholesterol in the blood. If the high-density lipo-proteins do not take all of this cholesterol, it will start accumulating in the walls of arteries, with fat and other remains. The building up of this cholesterol in arteries is termed as ‘plaque’, and the increase in plaque is called atherosclerosis.
The effects of high cholesterol leave a profound effect on the other systems of the body, and lead to heart attack, coronary heart disease, stroke, angina, and high blood pressure (Effects of High Cholesterol, 2007). It is apparent that R.R was suffering from diabetes, high blood pressure, and high cholesterol, and these were all interlinked. The cause of his femoral-popliteal bypass may also be due to the blockage of arteries in the leg, of which high cholesterol may have been the cause.
Femoral-popliteal Bypass
R.R had also gone through a femoral-popliteal bypass surgery, the newer procedure is also called percutaneous transluminal angioplasty (PTA) of the femoral artery. The femoral- popliteal bypass is the opening of the upper leg through surgery, to directly be able to view the femoral artery. The blocked portion of this artery is replaced with another blood vessel. These vessels or pieces of veins may be extracted from the legs. The blood flow is rerouted by attaching one piece of vein above and one below the blockage. One of the reasons for the need of this surgery is “gangrene”, apart from other causes, like nonhealing wounds (which is mainly caused in diabetic patients), and ischemic rest pain (Ouriel, 2001).
It can also be concluded that the myocardial infarction the patient had a year ago was partly the cause of the femoral-popliteal bypass he had two years ago, because there is a risk of such complications after the surgery (Ouriel, 2001).
Conclusion
The condition of R.R was an unhealthy one, with severe irritating diseases or malfunctioning in the body. The diabetes may have been existing and the main cause of the rest of the disorders, such as the gangrene, high blood pressure, and high cholesterol. All these disorders are inter-related and if proper medical care is not aided, result in complications
References
Bentley J, Foster A. (2007) Multidisciplinary management of the diabetic foot ulcer.Br J Community Nurs. 2007 Dec;12(12):S6, S8, S10 passim. Web.
Kinshuck, David (2008) Smoking in Diabetes. Web.
Lam, Michael (2002). Diabetes. Web.
Lamb, William (2007). Diabetes Mellitus, Type 1. Web.
Larsson, S.C., Orsini, N., Wolk, A (2005) Diabetes Mellitus and Risk of Colorectal Cancer: A Meta-Analysis. JNCI Journal of the National Cancer Institute 2005 97(22):1679-1687; Web.
Mathur, Ruchi (2008). Diabetes Mellitus. Web.
Mokdad, A Barbara A. Bowman, PhD; Earl S. Ford, MD,MPH; Frank Vinicor, MD,MPH; James S. Marks, MD,MPH; Jeffrey P. Koplan, MD,MPH (2001). The Continuing Epidemics of Obesity and Diabetes in the United States.JAMA. 2001;286:1195-1200. Web.
Schoenstadt, Arthur. (2006) Effects of High Cholesterol. Web.
Ward WK, Beard JC, Halter JB, Pfeifer MA, Porte D Jr. Pathophysiology of insulin secretion in non-insulin-dependent diabetes mellitus.Diabetes Care. 1984 Sep-Oct;7(5):491-502. Web.