Introduction
Diabetes is a condition that affects a large number of people in the world today. It is a blood glucose disorder that cuts across all age groups irrespective of gender or race. However, there are underlying factors such as heredity that make some races be at a higher risk than others. Due to the complexity associated with diabetes, it is common to find diabetics suffering a whole load of other conditions that are closely linked to diabetes. The patient’s medical history helps determine whether there is any relationship between the current ailment and diabetes. In this paper, the possible diagnoses based on the symptoms and medical history of a diabetic patient will be discussed. Also, some medications that can be administered will be suggested.
Signs and Symptoms
Betty is a 46-year-old female who has had diabetes for the last 6 years. Three days ago, she developed frequent painful passage of urine with burning pain in the lower abdomen. She passes a small amount of cloudy urine each time. Yesterday, she had a mild fever (37.8 °C) and was sweating a bit. She also complains about a lack of energy, poor effort tolerance, fatigue, dizziness, inability to concentrate, poor memory and depressed mood. In the last six months, her menstrual pattern is getting rather irregular with heavier bleeding. She noticed her heart running faster than usual and occasionally gets a strange feeling that her heart is ‘jumping’ in the chest. She also noticed occasional tingling and numbness in her fingers, but she thinks that this may be due to her work as a professional cleaner. She has been under a lot of stress in the past year, working overtime and trying to juggle her work and family. She opens her bowels every third day and passes hard stools sometimes associated with pain in the lower belly. In the last few weeks, she has been getting sharp griping pains in the upper abdomen accompanied by heartburn and nausea, especially after large meals and when she eats in a hurry. She threw up three times so far. There was no blood in vomited material. Often, after meals, she feels bloated and gets heaviness in the upper abdomen. Intermittently, she gets headaches lasting for several hours, sometimes the whole day. The pain is constant, dull and boring, sometimes, throbbing but generally, she is able to continue with daily activities. These headaches are not linked to any nausea or vomiting. She complains of sleeping difficulties (sleeplessness) that she links to the stress of working overtime and taking care of her three teenage children.
Examination results
On examination, you noticed that patient’s skin is pale and dry, blood pressure is 115/60mm Hg and pulse is 85. She brought two blood pathology reports (4 months between them): total cholesterol 6.5 and 6.8 mmol/L, Hct 34% and 33%, RCC 3.5 and 3.3 x 1012/L, Hb 103 and 100 g/L, WCC 8 and 10 x 109/L.
Diagnoses
Patients with diabetes have an increased risk of contracting urinary tract infections. These infections are caused by bacteria that grow and multiply within the human urinary tract. The infection can affect the upper parts of the urine system or the lower parts. In diabetics, the urine contains an elevated glucose level which provides an excellent environment for bacteria to survive and reproduce (National Kidney Foundation, n. d). The lower urinary tract Infections affect the bladder and urethra and they are characterised by painful passage of urine, cloudy and smelly urine, and frequent urge to urinate, pain in the lower abdomen, backache and blood-stained urine. The upper UTI affects the kidneys and the ureters and the symptoms include fever, diarrhea, backache, vomiting, flank pain and persistent shivering (Sanderson, 1998). Betty is complaining of painful and frequent urination, cloudy urine and burning pain in the lower abdomen. This combination of symptoms can be linked to lower urinary tract infections. She also suffered a mild fever and sweating. These are symptoms of upper urinary tract infection (Huland & Busch 1984).
She also complains about a lack of energy, poor effort tolerance, fatigue, dizziness, inability to concentrate, poor memory and depressed mood. These symptoms together with others such as chest pain, impaired memory, skin sensitivity, dry mouth and eyes, stiffness in the morning twitching and pain in the muscles, tingling and numbness in fingers and feet and premenstrual syndrome are signs of a condition known as fibromyalgia. Fibromyalgia syndrome is a condition that causes pain in the muscles, extreme fatigue and tiredness. This disorder is closely linked to diabetes and is mostly characterised by widespread fatigue, pain in the muscles and tissue and lack of energy. This extreme tiredness causes poor concentration. The causes of fibromyalgia syndrome are not known and the disorder has a higher preference among women than men (Yeats & Tipper, 2010).
The tingling and numbness in her fingers may be related to a nervous malfunction. This is caused by damage to the nerves which is very common in people who have had diabetes for a number of years. Diabetic neuropathy is nerve damage caused by diabetes. Betty can be diagnosed with this condition. Diabetic neuropathy is caused by damage to the blood capillaries that feed the nerves. The blood vessels are hurt by the excess blood glucose over time (National Diabetic Information Clearinghouse, n. d). Keeping blood sugar levels in check delays nerve damage and prevents further damage if the nerves are already damaged. The tingling and numbness may also be a sign of fibromyalgia. Some tests can be done to ascertain the cause; nerve conduction studies and electromyography can be carried out to find out how the nerves in your hands and feet are conducting. This test shows how well the nerves and muscles work together. A tuning fork can also be touched to the affected parts to see if the patient can feel it moving. A complete foot exam that covers the skin, bones and muscles should be done once a year. The exam also covers blood flow and sensitivity of the feet (American Diabetes Association, n.d).
Betty suffers bloating, fullness, heartburn and nausea. These can be linked to a condition known as gastroparesis. This condition causes a sluggish movement of food down from the stomach to the small intestines; in some cases, the movement ceases altogether. It is also known as delayed gastric emptying. The movement of food down the digestive tract is aided by the contraction of the muscles in the digestive system. These contractions are controlled by the vagus nerve. Damage to this nerve interferes with the normal muscle movement resulting in delayed or stoppage of the food movement. In diabetics, high blood sugar causes damage to this nerve and hence causes gastroparesis. This condition is characterised by bloating, vomiting undigested food, nausea, acid reflux, loss of appetite and stomach pain. Large meals serve to aggravate the symptoms (National Digestive Diseases Information Clearinghouse, n.d). Betty has had nausea, has vomited, she has stomach pains, bloating and heartburn which gets worse after consuming a large meal. Therefore, it would be in order to conclude that Betty has gastroparesis.
She is complaining of sleeplessness. She may be right when she links it to her stressful lifestyle. Considering that she is diabetic, insomnia syndrome, the sleep disorder that she is suffering from, will only serve to aggravate diabetes. Lack of enough sleep or sleeping in excess destabilises the blood sugar. Diabetes may not be a root cause of insomnia but it may be a lead cause of stress which translates to insomnia. On the other hand, stress may also cause diabetes. When the body is under stress, it releases hormones that trigger energy release to the cells in readiness for a fight or flight. Glucose is released into the bloodstream and converted to energy by insulin. In diabetics, glucose conversion s impaired and hence it remains in the blood elevating the blood sugar. At 46, Betty is premenopausal and she may begin having signs of menopause. Such may include sweating, sleep disorders, irregular menstrual pattern and heavier bleeding and headaches, (Lopez, Huerta & Malacara, 1999).
These are caused by hormonal swings and get worse due to her medical condition. Other neurological causes of the headache may be ruled out by the fact that it is not associated with nausea or vomiting. Diabetes may lead to dehydration. This comes as a result of too much sugar in the bloodstream. Dehydration is a major cause of headache as well. The pale and dry skin is also an indicator of dehydration. However, from the pathological reports provided, Hct is slightly lower than normal. Low Hct rules out the possibility of dehydration. RCC is on the lower side and Hb as well. This is an indication that our patient has anemia. This is the condition that causes the skin to be pale and dry and also plays a part in causing intermittent headaches. WCC is normal and also blood pressure and pulse rate. However, the total cholesterol is high. This puts the patient at risk of heart attack, hypertension or stroke. Betty opens her bowels on the third day meaning that the frequency is less than three times in a week. This is further associated with hard stools and pain in the belly. These are symptoms of constipation. Constipation is a common disorder in diabetic patients. It is associated with dehydration caused by high blood sugar.
Treatment and Management
From the diagnoses, it is clear that most of Betty’s complaints are related to her diabetic condition, lifestyle and menopause. This, therefore, means that the first step in treatment is containing the blood sugar in the desired range; Then a lifestyle change or adoption of a coping mechanism for things that cannot be changed. For instance, she has to take care of her children and therefore counseling on how to cope with stress may be helpful. On the other hand, menopausal symptoms are naturally occurring and, in many cases, the menopausal hormones interfere with the activity of insulin (Dorman et al, 2001) This may complicate the process of managing diabetes even further; however, with some additional effort like regular blood sugar checks and recording to come up with a clear pattern will come in handy. When the pattern of glucose fluctuation is determined, it will be easier to prescribe the insulin dosage and advise accordingly. Still, on menopausal issues, more severe symptoms like unbearable headaches need medical intervention. Depression associated with hormonal changes can be dealt with; this is done by counseling and may be some medical procedures like hormone replacement therapy, (Freedman, 2005). Constipation is controlled by increasing fluid intake and food that is easily digested.
We have noticed that the patient has gastroparesis. A change in feeding habits may ease the endurance effort required to contain the condition which is normally chronic. Eating small amounts of food at a time, reducing the fibre and fat intake can be of great help, (American Diabetes Association, n.d). In addition, there are medical remedies that are used to treat the condition;
Metoclopramide (Reglan) is a drug that initiates muscle contractions in the digestive tract. These contractions aid food movement down to the small intestines. This medication should be taken before meals about 20 to 30 minutes prior to feeding and before retiring to bed. It has the effect of reducing nausea and inhibiting vomiting. It comes with some side effects, such as fatigue, sleepiness, and depression. It has been approved by the FDA but they have issued a warning regarding the use of this medication. This is due to reports that it causes tardive dyskinesia which is an irreversible neurologic side effect that affects movement.
Betty has high cholesterol which if left untreated is fatal. It may cause heart failure, stroke and other serious conditions. High cholesterol leads to blockage of arteries leading to the above conditions. Watching a healthy lifestyle like a proper diet low in cholesterol and exercising regularly will help to bring it down. In addition, drugs are available upon prescription, these help lower cholesterol; Statins is the most effective of all drugs. It works by lowering the rate at which cholesterol is produced and increasing the rate at which the liver removes cholesterol from the blood. The results begin showing after using the medication for about 6 to 8 weeks. The results should be compared with the first results to determine the adjustments that may be required in the dosage. Possible side effects of statins include constipation, stomach upsets, abdominal pains and gas.
A rare side effect is widespread muscle breakdown which is serious. It is characterised by muscle pain and weakness and dark colored urine. In case of the onset of any of these symptoms, medication should be stopped and medical intervention sought. Statins come in different names and are available by prescription. Some of these include Lipitor, Lescol, Mevacor and Pravachol.
We have also noted that the patient has anemia. This condition can also be improved by including iron-rich foods and vitamin B in the diet. Iron supplements are also available by prescription. Ferrous sulphate is the most commonly used iron supplement. It has various side effects including nausea, stomach pain, heartburn and black stools, (Bunn 2011). Ferrous sulphate, when taken with meals, exhibit reduced side effects. In the event that the side effects are unbearable, ferrous gluconate can be taken instead but the dose will however be over a prolonged time period (Bryant & Knights, 2010).
The urinary tract infection can be treated by various microbials. In this case, let us consider putting the patient on a dose of nitrofurantoin. It goes under the following brand names: Furadantin, Macrobid, Macrodantin, and Nitro Macro.
The commonest side effects include drowsiness, nausea and vomiting, dark yellow or brown urine and loss of appetite. Adverse side effects include pulmonary reactions such as dry coughs and chest pain, elevated liver enzymes and skin rashes are also rare effects. These can be treated by immediately stopping the drug course and starting a corticosteroid dose (Vahid and Wildemore, 2006)
Drugs that have an alkalinising effect should be avoided during the drug course period. A higher pH of urine reduces the efficacy of the drug. Some anti-acids reduce the absorption rate of nitrofurantoin (Baxter, 2008).
Lyrica (pregabalin) is a drug used in the treatment of fibromyalgia and diabetic neuropathy. These two conditions are related to nerve activity. While diabetic neuropathy comes as a result of damaged nerve cells, fibromyalgia is caused by two many signals sent by the nerves causing the affected areas to react by being overly sensitive. This sensitivity makes otherwise painless sensations become painful. Lyrica works by reducing the number of nerve signals produced and thus calms down over sensitive nerves.
The side effects associated with lyrica include dizziness, sleepiness, weight gain, dry mouth, blurred vision and swelling of the hands and feet. Severe side effects include labored breathing and loss of concentration. Allergic reactions may also occur and are characterised by swelling of face, neck or mouth. In case of any of these sins, stop the medication and seek medical advice. Do not drive or operate machinery. Possible drug interactions include interaction with blood pressure and diabetes medicines that increase chances of swelling and weight gain, narcotics with lyrica increase dizziness and sleepiness.
References
American Diabetes Association. (n. d). Living with Diabetes: Gastroparesis. Web.
American Diabetes Association. (n. d). Living with Diabetes: Diabetic Neuropathy. Web.
Baxter, K. (Ed.) (2008). Stockley’s drug interactions: a source book of interactions, their mechanisms, clinical importance and management. 8th ed. London: Pharmaceutical Press.
Bryant, B., & Knights, K. (2010). Pharmacology for Health Professionals (3rd edition). Sydney: Elsevier/Mosby.
Bunn, H. (2011). Approach to the anemias. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier.
Busch, R., & Huland, H. (1984). Pyelonephritic scarring in 213 patients with upper and lower urinary tract infections: long-term follow-up. Journal of Urology; 132(11).
Dorman, J. C., Steenkiste, A. R., Foley, T. P., Strotmeyer, E. S., Burke, J. P., Kuller, L. H., & Kwoh, C. K. ( 2001). Menopause in type 1 diabetic women: is it premature? Diabetes 50(8),1857-62.
Lopez-Lopez, R., Huerta, R., & Malacara, J. M. (1999). Age at menopause in women with type 2 diabetes mellitus. Menopause. 6(2), 174-178.
National Diabetic Information Clearinghouse Diabetic Neuropathies, (n. d). The Nerve Damage of Diabetes. Web.
National Digestive Diseases Information Clearinghouse. (n. d). Gastroparesis. Web.
National Kidney Foundation. (n. d). Diabetes and Chronic Diseases. Web.
Freedman, R. (2005). Seminars in Reproductive Medicine: Pathophysiology and Treatment of Menopausal Hot Flashes; Web.
Sanderson, P. J. (1998) Laboratory methods. In: Brumfitt, W., Hamilton-Miller, J. and Bailey, R.R. (Eds.) Urinary tract infections. London: Chapman & Hall Medical.
Vahid, B., & Wildemore, B. M. M. (2006) Nitrofurantoin pulmonary toxicity: a brief review. Internet Journal of Pulmonary Medicine 6(2).
Yeats, B., & Tipper R. (2010). Women’s Health. Gender Impact Assessment (13) Victoria – Melbourne. Web.