Week 2 Discussion

Week 2 Discussion

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Week 2 Discussion

Internal Medicine 08: 55-year-old male with chronic disease management
You are working with Dr. Clay in her outpatient diabetes clinic this morning.

Your first patient, Mr. Morales, was seen by Dr. Clay once before, eight years ago, but was lost to follow-up after that time.

Based on review of the electronic medical record you are able to collect the following information prior to heading into the room to meet Mr. Morales:

Mr. Morales is a 55-year-old male, diagnosed with Type 2 diabetes mellitus thirteen years ago after experiencing a 20-pound unintentional weight loss, blurry vision, and nocturia.

He was hospitalized six weeks ago with a non-ST elevation myocardial infarction and required three vessel coronary artery bypass grafting. During his admission, he was found to have a reduced ejection fraction of 20%.

He was referred for today’s visit by the cardiologist to focus on optimizing his glycemic control and reducing his risk of the comorbidities associated with poorly controlled Type 2 diabetes mellitus.

His last hemoglobin A1c (HbA1c) was 9.5% eight years ago, and he had microalbuminuria at that time.

Before you see Mr. Morales, Dr. Clay reviews diabetes chronic disease management with you.

TEACHING POINT

Diabetes Chronic Disease Management

Evaluate for and optimize prevention of diabetic complications

Macrovascular complications:

· Cardiovascular disease

· Cerebrovascular disease

Microvascular complications: Week 2 Discussion

· Retinopathy

· Nephropathy

· Neuropathy

In particular, cardiovascular disease is the No. 1 cause of mortality for people with diabetes, and one of the top causes of morbidity.

Hypoglycemia, infections, foot ulcers, and amputations are additional causes of morbidity and mortality in patients with diabetes.

The American Diabetes Association publishes annual guidelines to assist in the management of a patient with diabetes.

Remember the large role that the psychosocial aspects of a diabetes diagnosis play in management

Non-adherence with medical recommendations could be due to economic, work-related, religious, social, or linguistic barriers to care. Care must be taken to assess the psychosocial status of each person with diabetes at each clinic visit to ensure that barriers to successful diabetes care are minimized.

You enter the exam room and introduce yourself to Mr. Morales.

“What brought you to the office today?”
“I had a heart attack about a month ago and had to have open-heart surgery. The heart doctors told me that my heart is weak now. My cardiologist told me that I have to get my blood sugar under control so I don’t have another heart attack. I am here to get down to work.”

“Tell me more about that.”
“I didn’t come back to see Dr. Clay because my job at the furniture factory wouldn’t give me time off for clinic appointments, and I couldn’t risk losing my job. I wasn’t checking my blood sugar before my heart attack because the testing strips are so expensive and my supervisor wouldn’t let me off the line to check anyway. Since my surgery, I haven’t gone back to work, and I’ve been checking my sugar before each meal and before bed. The hospital social worker got me two months’ worth of testing strips and lancets before I went home, but I’m going to run out in a couple of weeks. I’m worried that I won’t be able to check anymore.”

He also tells you that while he was in the hospital, they had to use insulin through his vein to keep his blood sugar controlled, and that was very upsetting to him.

You review Mr. Morales’ medications with him:

Medications

· metformin 1000 mg twice daily

· pioglitazone 15 mg daily

· glipizide 5 mg daily

· aspirin 81 mg dailyWeek 2 Discussion

· clopidogrel 75 mg daily

· long-acting metoprolol 100 mg daily

· furosemide 80 mg twice daily

· lisinopril 20 mg daily

· amlodipine 10 mg daily

· ranitidine 150 mg twice daily

· gabapentin 300 mg twice daily

· potassium chloride 10 mEq twice daily

· atorvastatin 80 mg daily

Mr. Morales says, “The hospital doctors sent me home on an insulin shot – 40 units in my belly every night before I go to bed. I don’t like giving myself the shot, so sometimes I just don’t, but I take all the rest of my medicines like they told me to.”

He takes out the vial of insulin, and you see that it is insulin glargine.Week 2 Discussion

You continue your interview with Mr. Morales and ask him:

“Have you brought your blood sugar log with you today?”
He hands you his blood sugar log proudly. Over the last four weeks, you see that his morning fasting readings are ranging 130-169 mg/dL, including before-lunch readings of 151-247 mg/dL, before-supper readings of 184-211 mg/dL, and before-bed readings of 158-305 mg/dL. There are no recorded readings under 70 mg/dL (3.9 mmol/L).

“Some days you have many readings over 200 mg/dL. Is there anything different going on on those days that you can think of such as eating larger meals?”
“Oh, those are the days after I didn’t take my insulin shot. The readings are always higher on those days.”

“Have you had any low blood sugars?”
“I feel like I have low blood sugar several times a week, and I eat a Snickers bar because I’m afraid of passing out and going into a coma. I feel like I’m going to die — shaky, sweaty, jittery! I don’t check when I feel this way, I just eat as fast as I can – I can tell when my sugar is low.”

See the associated reference ranges in conventional and SI units.

TEACHING POINTWeek 2 Discussion

Hypoglycemia
It is important at each visit to ask diabetic patients if they have experienced any hypoglycemic symptoms or events that required the assistance of another person.

Often times, when a patient is hypoglycemic, he does not write it down because he is preoccupied treating the hypoglycemia.

TEACHING POINT

When to Refer Patients with Diabetes to an Endocrinologist
If a patient is having recurrent or severe hypoglycemia (seizure, coma, or impairment that requires the aid of another person), an endocrinologist should be consulted. Hypoglycemia is defined as a blood glucose <70 mg/dL.

Primary care physicians’ threshold for referral varies across providers. Other conditions that would warrant referral are when a patient’s A1c is 8% more than twice in a 12-month period, despite intensive treatment; for initiation of a complex multiple daily injection insulin regimen; or for initiation of continuous infusion insulin pump therapy.

You ask Mr. Morales about diet and physical activity.

“Can you tell me what you typically eat in a day?”
“I usually eat breakfast and lunch at McDonald’s or Denny’s. For breakfast, I usually have a bacon egg and cheese biscuit with hash browns and black coffee. For lunch, I have a sandwich, fries, and soda. If I’m really hungry, I get the “value” size of the fries and soda.”

“What drinks and snacks do you typically eat during the day?”
“I drink Coke with lunch, whole milk with supper, and usually have a big bowl of fudge ripple ice cream before I go to bed. If I’m hungry in the afternoon, I’ll grab a pack of cookies from a vending machine.”

“And what do you have for dinner?”
“My wife and I eat supper at home. We share the cooking. Usually, we have fried or stewed meat with gravy, rice, or pasta along with rolls. Sometimes we have vegetables cooked with side meat.”

“Are you able to do any exercise during the week?”
“Except for moving around at work, I didn’t get much exercise before. Since my heart surgery, I feel short of breath just walking to the mailbox at the end of the driveway!”Week 2 Discussion

“Do you have any chest pain or sweating?”

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