52-Year-Old Female Patient With Type II Diabetes Case Study

Introduction

A 52-year-old woman with significant family history of type 2 diabetes came to the office for follow up after discharge from the hospital. She was admitted for 5 days with complications of hyperglycemia. She has no complains except for an ingrown toes nail that bothers her and slight tingling sensation on both feet that is not new and is per the patient is “better with Neurontin”. On examination, she is alert and communicating clearly, funduscopi exam is normal and abdomen is obese. Toenails unkempt and overgrown, skin is warm dry and intact. Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally. Temperature-96.4, Blood Pressure-130/92, Resp- 20, Heartrate-84, weight- 225lbs. height: 5′2″ and BMI- 41.1. Pertinent Lab values indicate a recent fasting blood glucose values of 200 mg/dl, Hemoglobin A1c (A1C) of 8.1%, and slight protein in urine. Patient is on Lipitor 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides) and Amlodipine 10mg daily for blood pressure. According to the patient, she has been attempting to lose weight by exercising but has actually gained 5 lbs within the past one month. She loves to eat bread and pasta and finds pastries irresistible. She has been smoking for the past 30 years and currently smokes 1 pack of cigarettes a day.

The differential diagnoses and the patient findings that leads to the diagnosis

Diabetes type two is the primary differential diagnosis because the patient presented with: A family history of diabetes, complications of hyperglycemia, blood pressure of 130/92, ingrown toenails, tingling sensation on the feet, fasting blood glucose of 200mg/dl, basal metabolic index of 41.1, pulse rate of 84 and proteinuria. Secondly, Nephrotic syndrome is the second differential diagnosis because the patient presented with hypercholesterolemia, slight protein in urine, high blood pressure of 130/92, hemoglobin levels of 8.1%, obese abdomen and weight gain. Finally, rheumatoid arthritis is the third differential diagnosis because the patient presented with ingrown toenails, tingling sensation on the feet, and warm intact skin.

Pathophysiologic and physical findings that support the differential diagnoses

Diabetes type two is a disease that a person inherits genetically, the diabetic person has low or lacks insulin and as a result, the person has to depend on external sources of insulin (Barry & Eastman, 2010). Insulin is a hypoglycemic hormone and it helps in reducing the amount of glucose in blood. When a diabetic person takes a lot of starch and carbohydrates, the body converts it into simple sugars like glucose and since this person does not have insulin, the blood sugars remain high leading to a condition known as hyperglycemia (Barry & Eastman, 2010). On the other hand, excessive exercise and too much insulin intake results into hypoglycemia, a condition in which the blood sugar levels are low because insulin increases the movement of glucose from the blood to the tissues. Therefore, such a person presents with low fasting blood glucose of 200mg/dl. Additionally, the use of insulin to control diabetes causes an increase in weight resulting in a high basal metabolic index. This is because the body converts the sugars that have moved to the body cells into fats. As the diabetes progresses, it affects other body systems leading to microangiopathy, autonomic neuropathy and damage of blood vessels (Rorsman, 2009). Microangiopathy is the damage to the tiny blood vessels resulting to nephropathy that presents with proteinuria, neuropathy that presents with tingling sensation and diabetic foot that present with ingrown toenail. On the other hand, autoimmune neuropathy is the damage to the nerves that supply the internal body organs leading to problems with the pulse rate. Finally, the damage to the inner part of blood vessels aggravates macroangiopathy leading to an increase in blood pressure (Weinger, 2010).

Nephrotic syndrome involves destructions of the kidneys resulting into increase in the permeability of the walls of glomerular capillary leading to proteinuria, edema and hypercholesterolemia (Selley, 2008). Proteinuria leads to too much loss of protein that can cause anemia. On the other hand, edema is accumulation of fluids in the tissues resulting from a drop of plasma albumin with subsequent drop in oncotic pressure that causes fluids to move from intravascular space to interstitial space (Rorsman, 2009). This results into weight gain. Additionally, the decrease of intravascular amount activates renin- angiotensin -aldosterone system that leads to hypertension. Besides, fluids can accumulate in the peritoneal cavity causing ascites that presents as obese abdomen (Sheeetz & Kings, 2010).

Rheumatoid Arthritis is a disorder of the joint that involves the inflammation of one or two joints (Salmon & Phill, 2010). When it affects the toes, it results into ingrown nails that are painful. Additionally, the toe swells and there is uncomfortable sensation of warmth of the skin. Finally, arthritis affects the bone marrow that aids in red blood cells formation leading to low hemoglobin levels (Salmon & Phill, 2010).

Epidemiology of the differential diagnoses

In the world, approximately one hundred and fifty million people suffer from diabetes and there is anticipation that the number will rise to three hundred million. A study done in Australia reported that 8% of the people between 25 years and above had type 2 diabetes (Selley, 2008). Moreover, the prevalence of diabetes type two increases with age and as a result, 20% of the people between the age of sixty years and above suffer from diabetes. Despite the fact that diabetes type 2 is uncommon in Africa, Asia and India, it makes up 90% of cases of diabetes worldwide. Moreover, the risk of cardiovascular diseases like dyslipidaemia and hypertension worsen as the diabetes progresses (Weinger, 2010). Additionally, the susceptibility to diabetes is determined genetically and people of Aborginal, Chinese and Micronesians are at increased risk (Titler, 2008). Even though there are evidences suggesting that genetics contributes to obesity and diabetes, the rise in diabetes and obesity in both the developed and the developing countries are because of a change in balance between diet and exercise.

Nephrotic syndrome can occur at any age and it is prevalent in boys than girls (Rorsman, 2009). Although it is a rare condition, it is very important because it damages the kidney leading to proteinuria, hypoalbuminemia and hyperlipidemia (Rorsman, 2009). Additionally, the occurrence of this syndrome is approximately three incidences per one hundred thousand every year. Moreover, diabetes is the common second cause of nephrotic syndrome in adults. On the other hand, the annual occurrence of nephrotic syndrome in children is approximately six cases per one hundred thousand children (Sheeetz & Kings, 2010).

The rheumatoid arthritis prevalence is almost constant in many places occurring at around 1%.However, it is high in India at a percentage of 6.8. On the contrary, a recent research reported a low prevalence in china and japan and it supported genetic inheritance as a risk of the disease. Moreover, other studies have demonstrated genetic inheritance in rheumatoid arthritis as minimal compared with autoimmune diseases (Salmon & Phill, 2010). The hormones of the female have a protective mechanism in rheumatoid arthritis; for instance, oral contraceptive use and pregnancy are associated with a reduced risk (Salmon & Phill, 2010). On the contrary, postpartum spell is a risk period for the development of the rheumatoid arthritis. Additionally, the risk of development of rheumatoid arthritis is high smokers than non-smokers.

Diagnostic testing for each differential diagnosis

There are diagnostic tests that physicians use to rule in or rule out diabetes and they include, fasting plasma glucose levels, plasma glucose and causal plasma glucose (Titler, 2008). Therefore, the following findings are suggestive of diabetes: A fasting plasma glucose level that is more than 126mg/dl, plasma blood glucose that is more than 200mg/dl and causal plasma glucose that is more than 200mg/dl (Selley, 2008). On the other hand, diagnostic tests for nephrotic syndrome are urine total protein estimation, Comprehensive metabolic panel, lipid profile, electrolyte, urea and creatinin evaluation. As a result, the following suggests nephrotic syndrome: proteinuria of more than 3.5g per 1.73m² per 24 hours, hypoalbuminaemia with albumin levels of more than 2.5g/dl, hypercholesterolemia and increase in the levels of electrolyte, urea and creatinine (Titler, 2008). Finally, diagnostic tests for rheumatoid arthritis include imaging and blood tests. X-rays of the feet in early stages demonstrate swelling of the soft tissues, articular osteopenia and lack of the joint space while in late stages it demonstrates subluxation and erosion (Salmon & Phill, 2010). Ultimately, the blood tests include testing for rheumatoid factor and in case it is absent the arthritis is referred to as seronegative because in 15% of the patients, rheumatoid factor is usually absent in early stages of the disease (Salmon & Phill, 2010). As a result, the clinicians usually use serological test because it is specific (Salmon & Phill, 2010).Finally, information about the cost of the above testing was inaccessible.

Expected standard of care for the differential diagnosis

Diabetes is an incurable disease therefore, care concentrates on keeping the levels of blood sugars close to the normal and this is via exercise, diet, medications and support (Allbright, 2009).To begin with, the diabetic person should modify his lifestyle in a number of ways. For example, he should take a diet low in carbohydrates, fats and salts while high in vitamins. Additionally, he should learn to balance exercise and diet to avoid hypoglycemia that results when a diabetic person exercises too much after taking a diet with low calories (Selley, 2008). Moreover, the diabetic person should stop smoking because it hastens the harmful effect of diabetes. On the other hand, diabetic medications are significant when diet cannot control diabetes. Finally, the diabetic person requires support like counseling so that they can find it easy to adapt to the new situation of a completely different lifestyle (Selley, 2008).

The care of nephrotic syndrome depends on the cause but in general, the health care professionals direct care towards alleviating the presenting signs and symptoms that are edema and high blood pressure. The patient with nephrotic syndrome require a bed rest with elevated lower limbs so as to decrease the lower limbs edema which is usually common in this patients ( Rorsman, 2009). Besides, the health care professional monitors the amount of fluid intake and output because too much intake of fluid will exacerbate the condition. On the other hand, a decreased output means that the kidneys are not functioning well (Sheeetz & Kings, 2010). Additionally, the modification of diet is imperative because a diet that is low in salt greatly helps in regulating the blood pressure. Finally, the treatment of underlying cause facilitates faster recovery (Rorsman, 2009).

Although the health care professionals usually focus on objective measurement of the rheumatoid arthritis, the impact of the disease on the quality of patient’s life is important. Therefore, efficient biologic therapies can improve the patient’s quality of life by reducing pain (Salmon & Phill, 2010). Recently, the management of rheumatoid arthritis has shifted from a slow approach where administration of treatment was slowly in response to the signs of the disease to an aggressive approach where control of inflammation is in the earliest time possible (Mari, Baldi, & Guarino, 2008). Additionally, primary care physicians are responsible for early treatment because they are the first ones to come in to contact with the patients and their actions determines the patient’s prognosis. Besides, they should refer patients to the rheumatologists if they cannot diagnose the disease because the rheumatologist can help to confirm the disease and commence on the appropriate modifying therapies (Mari, Baldi, & Guarino, 2008).

First line and second line treatment of the differential diagnoses

In amalgamation with lifestyle modifications, medications play a significant function in controlling hyperglycemia in diabetic patients. As a result, Metformin is an oral anti diabetic first line drug that diabetic patients use when lifestyle modification alone is not sufficient (Allbright, 2009). As the disease progress, metformin may fail to control the levels of glycemia and hence many diabetic patients will require additional oral drugs or insulin as the second line treatment. Examples of second line anti diabetic medication include meglitinides, sulfonylureas, and insulin. When the metformin is not effective, the presented guidelines recommend a variety of options. Nevertheless, the guidelines lack specific information regarding which drugs are second lines and which ones as first line but instead it recommends a stepwise approach in adding drugs from various sources (Allbright, 2009). Moreover, the recommendation concentrates on efficacy and safety but cost effectiveness is not considered. Since there is a large population of patients with diabetes, the sub optimal use of second line drugs is likely to have a detrimental effect on the health outcome and the cost effective use of the medication (Braunwald, 2009). Therefore, there is the need for recommendations that focus on clinical and cost effectiveness of the medication in the patients with insufficiently controlled diabetes.

The first line treatment of nephrotic syndrome depend on the cause of the disease and it can include corticosteroids like prednisolone to reduce the swelling, diuretics to reduce edema and Angiotensin II receptor blocker to reduce the protein loss in urine, blood pressure and the disease progress ( Rorsman, 2009). In case the condition worsens, the health care professional prescribes the second line treatment to avoid the development of chronic kidney disease. This treatment includes hemodialysis, peritoneal dialysis or a kidney transplant (Sheeetz & Kings, 2010).

The two lines of medication that treats rheumatoid arthritis include first line treatment that alleviates pain and acute inflammation and second line treatment that promotes the remission of the disease and prevents the progression of the destructions of the joints. First line medications are available in oral formulations and they include Non Steroidal Anti inflammatory drugs like aspirin and etodolac (Mari, Baldi, & Guarino, 2008). On the other hand, second line treatments are available in both oral and injectable formulation and they include disease-modifying antirheumatic drugs like hydroxychloroquine, and cyclophosphamide (Salmon & Phill, 2010).

Conclusion

In conclusion, diabetes is a complicated disease because it presents with symptoms that are suggestive of other diseases. Therefore, the health care professionals need to be alert while carrying out the investigations so that they do not miss out the proper diagnosis. In the above presented case, the patient has type II diabetes and not nephrotic syndrome or rheumatoid arthritis. This is because most of her presentations are suggestive of diabetes. Additionally, diabetes can progress to nephrotic syndrome and diabetic foot, which usually present like rheumatoid arthritis.

References

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Mari, A., Baldi, S., & Guarino, D. (2008). Management of Rheumatoid Arthritis: A Changing Standard of Care. The journal of Clinical Endocrinology and Metabolism , 327(76), 49-72.

Rorsman, P. (2009). Nephrotic Syndrome:Treatment Overview. The British Journal of Diabetes and Vascular Diseases , 108(28), 1183-1192.

Salmon, P., & Phill, G. (2010). Rheumatoid Arthritis and Associated Conditions. Journal of the Royal Society of Medicine , 97(25), 175-184.

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Weinger, T. (2010). State of the Science of Diabetic Management: Strategies for Nursing. America Journal Of Nursing , 35(7), 330-345.