This action might not be possible to undo. Are you sure you want to continue?
gov/diabetescoalition/DrJohnson/No39%2520Tired %2520Patient%2520Case%2520Study,%2520Dr.%2520Johnson,%2520Feb. %252020,%25202009.pdf+case+study+diabetic+patient&hl=en&gl=pk&pid=bl&srcid=ADGEESgc Qtx8EkEk9mnc_YDicbFZeebdz9Q7-TYUPG2g8VLSzN7mtKh5TF6q9mb9ecD2ZvsGFen7arqwTE01fXJ9Jb1JwJQ9xDltKunMkuxQ7DuHcCRav9gM8I5bvR5FjmOpJSU1Lp&sig=AHIEtbRj9goXulk MhF7ANyhYGdz8cUfE_g ase Study: Treating Hypertension in Patients With Diabetes
1. Evan M. Benjamin, MD, FACP Next Section Presentation L.N. is a 49-year-old white woman with a history of type 2 diabetes, obesity, hypertension, and migraine headaches. The patient was diagnosed with type 2 diabetes 9 years ago when she presented with mild polyuria and polydipsia. L.N. is 5′4″ and has always been on the large side, with her weight fluctuating between 165 and 185 lb. Initial treatment for her diabetes consisted of an oral sulfonylurea with the rapid addition of metformin. Her diabetes has been under fair control with a most recent hemoglobin A1c of 7.4%. Hypertension was diagnosed 5 years ago when blood pressure (BP) measured in the office was noted to be consistently elevated in the range of 160/90 mmHg on three occasions. L.N. was initially treated with lisinopril, starting at 10 mg daily and increasing to 20 mg daily, yet her BP control has fluctuated. One year ago, microalbuminuria was detected on an annual urine screen, with 1,943 mg/dl of microalbumin identified on a spot urine sample. L.N. comes into the office today for her usual follow-up visit for diabetes. Physical examination reveals an obese woman with a BP of 154/86 mmHg and a pulse of 78 bpm. Previous SectionNext Section Questions 1. What are the effects of controlling BP in people with diabetes? 2. What is the target BP for patients with diabetes and hypertension? 3. Which antihypertensive agents are recommended for patients with diabetes? Previous SectionNext Section Commentary
and peripheral vascular events. To reduce the mortality and morbidity from CVD among patients with diabetes. Recently. the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack . The United Kingdom Prospective Diabetes Study (UKPDS). stroke.5 years. found that patients with tight BP control (< 150/< 85 mmHg) versus less tight control (< 180/< 105 mmHg) had lower rates of myocardial infarction (MI). there is evidence that may help guide the selection of an antihypertensive regimen.Diabetes mellitus is a major risk factor for cardiovascular disease (CVD). compared with only one-fourth of people without diabetes in similar populations. numerous agents (three or more) are needed to achieve specific target levels of BP. Many classes of drugs have been used in numerous trials to treat patients with hypertension. The American Diabetes Association has recommended a target BP goal of < 130/80 mmHg. which followed patients with diabetes for an average of 8. Other epidemiological studies have shown that BPs > 120/70 mmHg are associated with increased cardiovascular morbidity and mortality in people with diabetes. with or without hydrochlorothiazide against placebo and found a significant reduction in acute MI. a 15% reduction for death related to diabetes. Studies that have compared antihypertensive treatment in patients with diabetes versus placebo have shown reduced cardiovascular events. patients who achieved a diastolic BP of < 80 mmHg benefited the most in terms of reduction of cardiovascular events. whereas recent trials have shown a renal protective benefit from both ACE inhibitors and ARBs. While lowering BP by any means will help to reduce cardiovascular morbidity. In addition. aggressive treatment of glycemic control as well as other cardiovascular risk factors must be initiated. recommending specific agents becomes a not-so-simple task. including hypertension. as has been implicated in the past for dihydropyridine calcium-channel blockers alone. In the HOT trial. Keeping in mind that numerous agents are often required to achieve the target level of BP control. and sudden cardiac death in the intervention group compared to placebo. and a sedentary lifestyle. Studies have shown that there is no lower threshold value for BP and that the risk of morbidity and mortality will continue to decrease well into the normal range. In the UKPDS. trials using dihydropyridine calcium-channel blockers in combination with ACE inhibitors and βblockers do not appear to show any increased morbidity or mortality in CVD. dyslipidemia. are particularly prevalent among patients with diabetes. However. Often. Use of almost any drug therapy to reduce hypertension in patients with diabetes has been shown to be effective in decreasing cardiovascular risk. These risk factors. congestive heart failure. and individual patient conditions and preferences also must come into play. The Hypertension Optimal Treatment (HOT) trial has shown that patients assigned to lower BP targets have improved outcomes. Approximately twothirds of people with diabetes die from complications of CVD. each 10-mmHg decrease in mean systolic BP was associated with a 12% reduction in risk for any complication related to diabetes. and an 11% reduction for MI. The UKPDS showed no significant differences in outcomes for treatment for hypertension using an ACE inhibitor or a βblocker. both ACE inhibitors and angiotensin II receptor blockers (ARBs) have been shown to slow the development and progression of diabetic nephropathy. ACE inhibitors were found to have a favorable effect in reducing cardiovascular morbidity and mortality. All classes of drugs have been shown to be superior to placebo in terms of reducing morbidity and mortality. ACE inhibitors and β-blockers seem to be better than dihydropyridine calcium-channel blockers to reduce MI and heart failure. In the Heart Outcomes Prevention Evaluation (HOPE) trial. Patients with diabetes are prone to a number of cardiovascular risk factors beyond hyperglycemia. Nearly half of middle-aged people with diabetes have evidence of coronary artery disease (CAD). Another trial followed patients for 2 years and compared calcium-channel blockers and angiotensin-converting enzyme (ACE) inhibitors. The literature continues to evolve.
L. and β-blockers have all been documented to be effective pharmacological treatment. with nocturnal exacerbations every week or sometimes every 2 weeks for many years. diabetes. Previous SectionNext Section Clinical Pearls 1. Adding a β-blocker to the ACE inhibitor will certainly help lower her BP and is associated with good evidence to reduce cardiovascular morbidity. ACE inhibitors and ARBs are agents best suited to retard progression of nephropathy. 7. a thiazide-type diuretic. He complains of episodic wheezing and chest tightening several days a month. it may be necessary to maximize the dose of the ACE inhibitor and to add a second and perhaps even a third agent. He has difficulty arising and performing at . 2.N. ARBs. more aggressive treatment to control L. Combinations of drugs are often necessary to achieve target levels of BP control.Trial (ALLHAT) in high-risk hypertensive patients. 5. it may be necessary to individualize her treatment. is a 19-year-old Caucasian male who presents for a routine office visit to his family physician. The β-blocker may also help to reduce the burden caused by her migraine headaches. Pharmacological therapy needs to be individualized to fit patients' needs. Information obtained from recent trials and emerging new pharmacological agents now make it easier to achieve BP control targets.N. Diuretics have been shown to have synergistic effects with ACE inhibitors. and hypertension. Dr. has migraine headaches as well as diabetic nephropathy. 4. Her BP control can be improved. was superior to an ACE inhibitor. lisinopril. 6. A target BP goal of < 130/80 mmHg is recommended. 3. diuretics. demonstrated that chlorthalidone. including those with diabetes. ACE inhibitors.'s hypertension will be necessary. Because L. and one could be added. Because of the presence of microalbuminuria. is a typical patient with obesity. To achieve the target BP goal of < 130/80 mmHg.N. Hypertension is a risk factor for cardiovascular complications of diabetes. case Dan N. the combination of ARBs and ACE inhibitors could also be considered to help reduce BP as well as retard the progression of diabetic nephropathy. Overall. Clinical trials demonstrate that drug therapy versus placebo will reduce cardiovascular events when treating patients with hypertension and diabetes. Nicolette Boca. in preventing one or more forms of CVD.
presents to the ER with tachypnea. Peak flows done before and after the treatment were 125/250 and ausculation revealed loud expiratory wheezing and better airflow. The following discussion will cover the etiology. diagnosis. RR was 24 at this time and HR 108. list the 3 primary pathologic reactions during as asthmatic episode. we will learn the role of the distal airways in asthma and examine the therapeutic options that are available for patients like Dan. Ausculation revealed decreased breath sounds with inspiratory and expiratory wheezing and pt was coughing up small amounts of white sputum.0 cc normal saline in a small volume nebulizer for 10 minutes. Dan’s lung function tests seem to yield confounding results. and possibly avoiding disease progression.work on the days following such episodes. case A 37 y/o black female with a history of asthma. SaO2 was 93% on room air. Peak flows before and after showed improvements of 230/360 and on ausculation there was clearing of breath sounds and much improved airflow. An aerosol treatment was ordered and given with 0. An arterial blood gas (ABG) was ordered with the following results: pH 7. and treatment of asthma. This case is an example of what many people with asthma experience. Symptoms resolved and patient was given prescription for inhaled steroids to be used with current home meds. Dan was never diagnosed with asthma or significant allergies. avoiding any potential exacerbations of symptoms that interfere with his daily life. In this case. Let’s take a look at Dan’s history and a little more detail about his case and see how we might develop an appropriate treatment plan for him. but he has been using a short-acting ß2-agonist for intermittent wheezing since he was 13 years old. but he has had difficulty breathing during exercise. and acute shortness of breath with audible wheezing. 3. explain how a proper forced expiratory test is to be performed.5. PaO2 75. Instruction was given for use of inhaled steroids and the patient was sent home. He does not recall any instances when he has experienced symptom exacerbations or wheezing due to cold weather. with particular emphasis on managing the patient’s symptoms.5 cc albuterol with 3. Learning Objectives After completing the sections below. She contacts Dr. RR 40 with signs of accessory muscle use. 2. Gary Rachelefsky. an asthma and allergy specialist. to discuss his case and the available therapeutic options. PaCO2 27. you should be able to: 1. A physical exam revealed the following: HR 110. Complete the following sections and take the quiz to check your understanding. signs and symptoms. pathogenesis. Patient has taken her prescribed medications of Cromolyn Sodium and Ventolin at home with no relief of symptoms prior to coming to the ER. No significant irritants have been identified. his physician has diagnosed him with mild persistent asthma based on his symptoms and his frequent use of his ß2-agonist. however. 20 minutes later a second treatment was given with the above meds. . list different ways asthma is diagnosed. We will apply treatment guidelines in the clinical setting.
11. normal electrolytes. A 24-h urine collection reveals a urinary albumin excretion rate of 250 mg/day. There is no clinical evidence of congestive heart failure or peripheral vascular disease. recognize chest x-ray changes seen with asthma. serum creatinine of 1. Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD) in Western countries. and normal thyroid-stimulating hormone levels. recognize the signs and symptoms of asthma. He is asymptomatic. References Presentation R. including the American Diabetes Association.C. Should his blood pressure be treated? 3. Questions 1. despite improvements in dialysis and renal transplantation. recognize the commonly used bronchodilation agents. and a regular pulse of 84 beats/min. Overt albuminuria or macroalbuminuria is defined as a UAER >300 mg/day. The life expectancy of patients with diabetic ESRD is <50% at 3 years. He has a history of heavy alcohol use but quit drinking alcohol 2 years ago. Does this patient have renal disease? 2. random serum glucose of 169 mg/dl. What treatment strategy should be used? Commentary Diabetic nephropathy is a clinical syndrome characterized by albuminuria. accounting for ~35% of all new ESRD cases in the United States. Laboratory evaluation reveals trace protein on urinalysis. Many organizations. 10. hypertension. the term "microalbuminuria" was coined to refer to a UAER of 30–299 mg/day. is a 57-year-old man with type 2 diabetes first diagnosed 2 years ago. He presents now for routine followup and is noted to have a blood pressure of 168/100 mmHg. 12.2 mg/dl. Other medical problems include obesity and hypothyroidism. describe some of the equipment necessary for an exercise test. 6. As a result. discuss which values are most often used when testing for asthma. blood pressure of 160/100 mmHg. list the side effects related to the different asthma medications. 9. and progressive renal insufficiency. recommend . Physical exam reveals a height of 5 feet. differentiate the two types of asthma. A normal urinary albumin excretion rate (UAER) ranges from 0 to 30 mg/day. Many studies have shown that a UAER >30 mg/day is abnormal and can be used to predict the development of overt albuminuria or diabetic nephropathy and both microvascular and macrovascular disease. discuss why and how a bronchoprovocation test is done. 7. 8 inches. 5. blood urea nitrogen of 14 mg/dl. recommend the appropriate drug therapy of an asthmatic patient for chronic treatment or for an acute attack. weight of 243 lb. 8. There is no retinopathy or thyromegaly.4. Early detection and treatment of albuminuria is essential in diabetes.
People with type 2 diabetes should be screened from the time of diagnosis. then annual screenings are indicated. Fosinopril (Monopril) has a dual route of elimination and therefore may have an advantage over other ACE inhibitors. Patients identified with persistent microalbuminuria should be aggressively treated both with respect to glycemic and blood pressure control. Clinical Pearls 1. Because there is also marked day-to-day variability in urinary albumin excretion. Type 1 diabetic patients should be screened 5 years after diagnosis of diabetes and after puberty. renoprotective therapy should be continued indefinitely. The treatment of choice for hypertensive diabetic patients with or without microalbuminuria remains angiotensin-converting enzyme (ACE) inhibitors. attempts need to be made toward lifestyle modifications. the renoprotective effects apply to both normotensive and hypertensive patients with microalbuminuria. 3. weight control. Newer methods. If the initial test is elevated. Therefore. 4. Recognize hypertension in diabetic patients with a blood pressure >140/90 mmHg. acute febrile illness. Once started. Screen diabetic patients for microalbuminuria. a positive test should be confirmed on a subsequent occasion before designating a patient as having persistent microalbuminuria. The goal for the management of hypertensive diabetic patients is to keep the blood pressure <130/85 mmHg. permit reliable semiquantitative determination of microalbuminuria and can be used in the office for dipstick screening of diabetic patients. following an appropriate diet. regardless of blood pressure. but all ACE inhibitors appear to be effective. In addition to aggressively managing blood pressure. Studies have also shown that the renoprotective effects of ACE inhibitors go beyond those expected from blood pressure reduction by itself.regular screening for microalbuminuria. maintaining optimal body weight. the indication for ACE inhibition can be persistent microalbuminuria. Germany). Spot urine samples may be assayed for microalbuminuria and creatinine and a ratio >30 µg/mg or mg/g is abnormal. Patients are considered to be hypertensive if their blood pressure is >140/90 mmHg. since many type 2 diabetic patients have had undiagnosed disease for some time. and exercise CASE A 44 year old moderately dehydrated man was admitted with a two day history of . Traditional urinary dipsticks are insensitive at detecting albuminuria <300 mg/day. Transient elevations in urinary albumin excretion may be associated with marked hyperglycemia. exercise. heart failure. Additionally. Discontinuing therapy will result in a recurrence of microalbuminuria. particularly when used for patients with renal insufficiency or failure. diet. Mannheim. hypertension. Only captopril (Capoten) is approved for the treatment of diabetic nephropathy. these and other potential causes of renal disease should be considered and ruled out. including blood glucose control. If the initial screening is negative. and urinary tract infection. and exercising regularly. 2. seeking counseling to stop smoking. Counsel diabetic patients on lifestyle modifications. smoking cessation. such as Micral-Test II test strips (Boehringer Mannheim. ACE inhibition is the preferred treatment of microalbuminuria and/or hypertension. ACE inhibitors have been shown to prevent or slow the progression from microalbuminuria to overt nephropathy. These include meticulous control of blood glucose.
31 pCO2 33 mmHg pO2 . Now we know that an acidosis must be present (because of the acidaemia). * The elevated urea & creatinine is noted but this has not been sufficient to elevate the anion gap so there has not been significant retention of acid anions. Cl. the acid-base diagnosis Looking at the results systematically:1.113. * There is no evidence to support the co-existence of a high AG acidosis and a normal AG acidosis. Formulation: The acid-base diagnosis is a normal anion gap metabolic acidosis with appropriate respiratory compensation.16. 5. K+ 2. Arterial Blood Gases pH 7.this pattern is found in respiratory alkalosis and in metabolic acidosis. 2.1 mmol/l Assessment Firstly.acute severe diarrhoea. 6. A lactate level would have been useful to totally exclude any lactic acidosis. Confirmation: This is no investigation which can assist here.5 x 16 + 8) which is 32 mmHg. Secondly. This is close to the actual measured value of 33mmHg. the clinical diagnosis This patient has acute diarrhoea causing a mild normal anion gap metabolic acidosis. Pattern: Both the pCO2 & HCO3 are low .30 mmol/l. HCO3.not given HCO3 16 mmol/l K+ 2.9. . The expected pCO2 (by Rule 5) is (1. The delta ratio is slightly negative and certainly not in the range which would suggest a combined acidosis. creatinine 0. Compensation: Here we ask is the respiratory compensation appropriate? The maximal amount of respiratory compensation takes 12-24 hours to occur so sufficient time has elapsed. so no primary respiratory disorder is present. This is consistent with the history as there was no evidence of a respiratory disorder. so therefore the diagnosis is metabolic acidosis 3.3. Anion gap 8. pH: A net acidaemia is present so an acidosis must be present to have caused this. 4. urea 12. Electrolyte results (in mmol/l): Na+ 134. Clues: * The normal anion gap with an elevated chloride suggests a normal anion gap acidosis. the initial clinical assessment The possibilities suggested by the history of severe diarrhoea with hypovolaemia are: * Hyperchloraemia with normal anion-gap acidosis due to the diarrhoea * Acute pre-renal renal failure with elevated urea and creatinine * Acute lactic acidosis (high anion gap acidosis) due to peripheral circulatory failure. Finally.
elevated chloride.php#cases for dehydation incxludes all drug nd their contraindictiohn . http://www. normal anion gap and the elevation of urea and creatinine.The volume loss is probably responsible for pre-renal azotaemia. acidosis usually does not occur in renal failure until GFR is less than 20 mls/min (or a creatinine level of about 0. Some pre-renal renal failure is present but there is no evidence of a high anion gap acidosis due to renal failure. As a general guideline.anaesthesiamcq. Comments Pertinent points were the acidaemia. Note that this laboratory has calculated the anion gap as (Na + K) .30-0. Hypovolaemia results in secondary hyperaldosteronism which increases sodium reabsorption but increases excretion of K+ resulting in hypokalaemia.35 mmol/l).com/AcidBaseBook/ab9_6. Similarly tissue perfusion is still adequate enough to prevent development of a lactic acidosis.(Cl + HCO3).
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.