Pathophysiology and Clinical Findings of the Disease – Diabetes

Pathophysiology and Clinical Findings of the Disease – Diabetes

Based on the review of the history, physical and lab findings, what is the most likely diabetes diagnosis for this patient?

The most probable diagnosis for J.T. is Type 2 diabetes. He is a 48-year-old male with a history of hypertension, hyperlipidemia, and obesity. These are commonly associated with Type 2 diabetes. His family history reveals that his brother has Type 2 diabetes, which further suggests a genetic susceptibility. J.T. presents with common symptoms of Type 2 diabetes. These are fatigue, weight loss, extreme thirst, and increased appetite (Vijan, 2019). The physical exam findings, such as the dry oral mucous membranes and fruity breath odor, are consistent with diabetic ketoacidosis (DKA). This is a complication more commonly associated with Type 1 diabetes. However, the presence of obesity, normal blood pressure, and the patient’s age and history support a diagnosis of Type 2 diabetes rather than Type 1. The laboratory results show a raised fasting glucose level, an abnormal oral glucose tolerance test (OGTT), and an elevated A1C. All these findings point towards impaired glucose control. When put together, the clinical picture suggests a diagnosis of Type 2 diabetes.

Explain the pathophysiology associated with the chosen diabetes diagnosis.

In Type 2 diabetes, the body’s cells become resistant to the effects of insulin. Insulin regulates blood glucose levels by enabling the uptake of glucose into cells. In Type 2 diabetes, the insulin receptors on target cells become less sensitive to insulin (Lima et al., 2022). This leads to reduced glucose uptake. This insulin resistance mainly occurs in muscle, liver, and adipose tissue cells, leading to increased blood glucose levels.

Pancreatic beta cells, which produce and release insulin, have dysfunction in Type 2 diabetes. Initially, the beta cells compensate for insulin resistance by producing more insulin to sustain normal blood glucose levels. As time goes on, the beta cells become overwhelmed. They fail to secrete adequate amounts of insulin, leading to relative insulin deficiency. This impaired insulin secretion further contributes to elevated blood glucose levels.

Different factors contribute to the development of insulin resistance and impaired insulin secretion. A sedentary lifestyle, obesity, genetic predisposition, and unhealthy diets play substantial roles (Lima et al., 2022). Excess adipose tissue, particularly visceral fat, releases pro-inflammatory substances that contribute to insulin resistance. Additionally, chronic inflammation and oxidative stress further impair insulin signaling pathways. As insulin resistance progresses and secretion declines, the balance between glucose production and utilization is disturbed. The liver continues to produce glucose through glycogenolysis and gluconeogenesis. The kidneys may also reduce glucose reabsorption leading to glycosuria. Chronic hyperglycemia has harmful effects on various organs and tissues. It can damage blood vessels, nerves, and organs. This can lead to cardiovascular disease, neuropathy, nephropathy, and retinopathy.

Identify at least three subjective findings from the case that support the chosen diagnosis.

Several subjective findings from the case support the diagnosis of Type 2 diabetes. First, J.T. complains of fatigue, weight loss, extreme thirst, and increased appetite. These symptoms are commonly associated with Type 2 diabetes due to the underlying metabolic abnormalities. Extreme thirst and increased appetite are features of hyperglycemia and insulin resistance. Additionally, J.T. mentions insomnia caused by frequent nocturnal urination. J.T. has a personal history of obesity, hypertension, and hyperlipidemia. He also has a family history of Type 2 diabetes, as his brother has this condition. These subjective findings support the likelihood of a diagnosis of Type 2 diabetes.

Identify at least three objective findings from the case that support the chosen diagnosis.

J.T.’s fasting glucose level of 132 mg/dL exceeds the reference range. Additionally, glucose is present during urinalysis. The A1C level of 7.2% reflects inadequate long-term blood glucose control. The patient’s weight of 240 lbs and BMI of 36.5 indicate obesity, a substantial risk factor for Type 2 diabetes. These objective findings collectively support the diagnosis of Type 2 diabetes.

Management of the Disease

Utilizes the required Clinical Practice Guideline (CPG) to support the chosen treatment recommendations.

The American Diabetes Association’s Standards of Medical Care in Diabetes provide evidence-based recommendations for the management of diabetes. These guidelines cover diagnosis, lifestyle changes, glucose monitoring, pharmacological treatments, and complications. They emphasize individualized care, patient education, and decision-making between healthcare professionals and patients. The guidelines also promote a comprehensive approach to diabetes management. It addresses not only glycemic control but also blood pressure, cholesterol, and other risk factors. Updates are made regularly to ensure the latest evidence-based practices are accessible to healthcare providers.

Identify two (2) “Evidence A” recommended medication classes for the treatment of this condition and provide an example (drug name) for each.

Evidence A” recommended medication classes

According to the American Diabetes Association’s Standards of Medical Care in Diabetes, two medication classes are classified as “Evidence A” for the treatment of Type 2 diabetes. These are metformin and sodium-glucose cotransporter-2 (SGLT2) inhibitors. Metformin is a biguanide medication that is considered the first-line therapy for Type 2 diabetes (Baker et al., 2021). It has shown effectiveness in improving glycemic control and its favorable safety profile. On the other hand, SGLT2 inhibitors are a relatively newer class of antidiabetic medications. An example of an SGLT2 inhibitor is empagliflozin.

Describe the mechanism of action for each of the medication classes identified above.

Metformin works through the inhibition of hepatic glucose production. It activates AMP-activated protein kinase (AMPK), which leads to decreased gluconeogenesis. Metformin also improves peripheral insulin sensitivity. Additionally, it has been shown to reduce intestinal glucose absorption and decrease appetite. These combined effects help lower blood glucose levels and improve glycemic control in patients with Type 2 diabetes.

Empagliflozin blocks the sodium-glucose cotransporter-2 in the proximal renal tubules of the kidneys. This prevents the reabsorption of glucose, leading to increased urinary glucose excretion. SGLT2 inhibitors also have an effect on body weight reduction and blood pressure. Empagliflozin provides an additional benefit of reducing the risk of cardiovascular events. This reduces mortality in patients with Type 2 diabetes and cardiovascular disease.

Identify two (2) “Evidence A” recommended non-pharmacological treatment options for this patient.

Non-pharmacological treatment options are very important in managing type 2 diabetes. According to the American Diabetes Association (ADA) guidelines, two “Evidence A” recommended interventions are medical nutrition therapy (MNT) and regular physical activity (Davies et al., 2022). MNT involves personalized meal planning and dietary counseling provided. This is done by a certified diabetes care and education specialist. It focuses on achieving and maintaining optimal blood glucose control and controlling weight. MNT promotes a well-balanced, nutrient-rich diet. It also stresses portion control, carbohydrate monitoring, and healthier food choices. Regular physical activity is also vital. It helps improve insulin sensitivity, lower blood glucose levels, manage weight, and reduce the risk of cardiovascular complications. Encouraging J.T. to engage in moderate-intensity physical activities such as brisk walking or cycling, along with resistance training, can have marked benefits for his health.

References

Baker, C., Retzik-Stahr, C., Singh, V., Plomondon, R., Anderson, V., & Rasouli, N. (2021). Should metformin remain the first-line therapy for treatment of type 2 diabetes? Therapeutic Advances in Endocrinology and Metabolism, 12, 2042018820980225. https://doi.org/10.1177/2042018820980225

Davies, M. J., Aroda, V. R., Collins, B. S., Gabbay, R. A., Green, J., Maruthur, N. M., … & Buse, J. B. (2022). Management of hyperglycemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia, 65(12), 1925-1966. https://doi.org/10.1007/s00125-022-05787-2

Lima, J. E., Moreira, N. C., & Sakamoto-Hojo, E. T. (2022). Mechanisms underlying the pathophysiology of type 2 diabetes: From risk factors to oxidative stress, metabolic dysfunction, and hyperglycemia. Mutation Research/Genetic Toxicology and Environmental Mutagenesis, 874, 503437. https://doi.org/10.1016/j.mrgentox.2021.503437

Vijan, S. (2019). Type 2 diabetes. Annals of Internal Medicine, 171(9), ITC65-ITC80. https://doi.org/10.7326/AITC201911050

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The purpose of this assignment is to apply endocrine pathophysiological concepts to explain the assessment findings of a patient with Diabetes. Students will examine all aspects of the patient’s assessment including Chief Complaint (CC), History of Present Illness (HPI), Past Medical History (PMH), Family History (FH), Social History (SH), Review of Systems (ROS), and Medications and then answer the questions that follow on the provided Comprehensive Case Study template.

Activity Learning Outcomes
Through this assignment, the student will demonstrate the ability to:

Examine the case scenario and analyze the exam and lab findings results to determine the patient’s type of diabetes. (CO1)
Explain the pathophysiology of the type of diabetes. (CO1)
Differentiate between subjective and objective findings which support the chosen diagnosis. (CO4)
Apply evidence-based practice guidelines to develop an appropriate treatment plan. (CO1, CO5)

Requirements

Content Criteria

Read the case study listed below.
Refer to the rubric for grading requirements.
Utilizing the Week 6 Case Study Template, which links to an external site, provide your responses to the case study questions listed below.
You must use at least one scholarly reference to provide pathophysiology statements. For this class, the use of the textbook for pathophysiology statements is acceptable. You may also use an appropriate evidence-based journal.
You must use the current Clinical Practice Guideline (CPG) for the Standards of Medical Care in Diabetes -Abridged for Primary Care Providers provided by the American Diabetes Association to determine the patient’s type of diabetes and answer the treatment recommendation questions. The most current guideline can be found at the following web address: https://professional.diabetes.org/content-page/practice-guidelines-resourcesLinks to an external site. At the website, locate the current year’s CPG for use.
Proper APA format (in-text citations, reference page, spelling, English language, and grammar) must be used.
Case Study Scenario

Chief Complaint

J.T. is a 48-year-old male who presents to the primary care clinic with fatigue, weight loss, extreme thirst, and increased appetite.

History of Present Illness

J.T. was in his usual state of health until three weeks ago, when he began experiencing symptoms of fatigue, weight loss, and extreme thirst. He reports that he would like to begin a walking program, but he feels too fatigued to walk at any point during the day. Now he is very concerned about gaining more weight since he is eating more. He reports insomnia due to having to get up and urinate greater than 4 times per night.

Past Medical History

Hypertension
Hyperlipidemia
Obesity
Family History

Both parents deceased
Brother: Type 2 diabetes
Social History

Denies smoking
Denies alcohol or recreational drug use
Landscaper
Allergies

No Known Drug Allergies
Medications

Lisinopril 20 mg once daily by mouth
Atorvastatin 20 mg once daily by mouth
Aspirin 81 mg once daily by mouth
Multivitamin once daily by mouth
Review of Systems

Constitutional: – fever, – chills, – weight loss.
Neurological: denies dizziness or disorientation
HEENT: Denies nasal congestion, rhinorrhea, or sore throat.
Chest: (-)Tachypnea. Denies cough.
Heart: Denies chest pain, chest pressure, or palpitations.
Lymph: Denies lymph node swelling.
General Physical Exam

Constitutional: Alert and oriented male in no acute distress
Vital Signs: BP-136/80, T-98.6 F, P-78, RR-20
Wt. 240 lbs., Ht. 5’8″, BMI 36.5
HEENT

Eyes: Pupils are equal, round, and reactive to light and accommodation, with normal conjunctiva.
Ears: Tympanic membranes intact.
Nose: Bilateral nasal turbinates without redness or swelling. Nares patent.
Mouth: Oropharynx clear. No mouth lesions. Teeth present and intact; Oral mucous membranes and lips dry.
Neck/Lymph Nodes

Neck supple without JVD.
No lymphadenopathy, masses, or carotid bruits.
Lungs

Bilateral breath sounds clear throughout lung fields. Breathing quality deep with fruity breath odor
Heart

S1 and S2 have regular rates and rhythms, tachycardia, and no rubs or murmurs.
Integumentary System

Skin warm and dry; Nail beds pink without clubbing.
Labs

Test Patient’s Result Reference
Glucose (fasting)

132

60-120 mg/dL

BUN

20

7-24 mg/dL

Creatinine

0.8

0.7-1.4 mg/dL

Sodium

141

135-145 mEq/L

Sodium

141

135-145 mEq/L

Chloride

97

95-105 mEq/L

HCO3

24

22-28 mEq/L

A1C

7.2

Urinalysis

Protein

Glucose

Ketones

Negative

Positive

Negative

Oral glucose tolerance test (OGTT)

220 mg/dL

J.T. is diagnosed with diabetes. Review all information provided in the case to answer the following questions.

Case Study Questions

Pathophysiology & Clinical Findings of the Disease

Review the lab findings and decide if the diagnosis is Type 2 or Type 1 Diabetes Mellitus.
Explain the pathophysiology associated with your chosen diagnosis
Identify at least three subjective findings from the case that support the chosen diagnosis.
Identify at least three objective findings from the case that support the chosen diagnosis.
Management of the Disease

*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.

Identify two (2) “Evidence A” recommended medication classes for the treatment of this condition and provide an example (drug name) for each.
Describe the mechanism of action for each of the medication classes identified above.
Identify two (2) “Evidence A” recommended non-pharmacological treatment options for this patient.
Utilizes the required Clinical Practice Guideline (CPG) to support the chosen treatment recommendations