CASE 2 FARM 2- Anos, Arriesgado, Chua, Lauglaug

FINDINGS

Patient Information:

● Name: L.H.
● Age: 45 years old
● Sex: Female
● Ethnicity: Mexican American

Objective Findings:

● Height 5 feet 5; weight, 165 pounds; BMI, 27.5 kg/m2

● Routine Urinalysis
o Glocosuria
● FPG (Fasting plasma Glucose) test: (normal-<100 mg/dl)
o 150mg/dL (1st occasion)
o 167 mg/dL (2nd occasion)
● A1C (blood sugar level over past 2-3 months (normal-4%-6%)
o 8.2%
● Lab (Fasting laboratory assessment):

o glucose of 147 mg/dL (less than 100 mg/dL (5.6 mmol/L)

o triglycerides of 400 mg/dL (normal, Below 150 milligrams per deciliter (mg/dL) for
adults;
o A1C of 8.3% (normal, 4%–6%)

o complete blood count, electrolytes, LFTs, and renal function tests

● Diagnosis: Type 2 diabetes

Subjective Findings:

● Overweight with Central obesity

● She was referred to the diabetes clinic by her gynecologist
● More thirsty than usual
● does complain of lethargy and takes afternoon naps when she can
● She has given birth to four children (birth weights, 7, 8.5, 10, and 11 pounds) and was
told during her last pregnancy that she had “borderline diabetes.”
● Works as a loan officer in bank and spends her weekends “catching up on her sleep”
and reading
● Does smoke one pack of cigarettes per day for 20 years
 ● Drinks occasional glass of wine
● Drinks at least two regular sodas daily
● Has “large” glass of orange juice every moring
● Physical activity
o Routine walking (to her car)
● Well controlled hypertension
● recurrent monilial infections
● Meds:
o lisinopril 20 mg/day (hypertension)
o fluconazole

o Metformin 500 mg BID with food

▪ Changed to 500 mg every morning and 1,000 mg every evening after 1

week

● Family history
o sister, aunt, and grandmother with type 2 diabetes; all have “weight problems”

ASSESSMENT

● BMI falls under the overweight range

● Overweight central obesity of the patient contributed to the diagnosis of the patient
● Hispanic american people are more at risk for developing type 2 diabetes
● Genetics might have played a factor to the acquisition of type 2 diabetes
● Lethargy is a common and prevalent symptom for patients having diabetes
● Excessive feeling of thirsty ( polydipsia) supports the patient's diagnosis
● Drinking of wine (not in moderation) and sodas contributed to the acquisition of type 2
diabetes
● The patient’s smoking habit may have contributed to acquisition of type 2 diabetes
● The patient’s lack of physical activeness might have contributed to acquiring type 2
diabetes
● The patient possibly had an undiagnosed gestational diabetes that resulted to very large
babies (10 and 11 pounds) which further developed into type 2 diabetes

● Glocosuria in urine indicates more sugar, or glucose, in a person's urine than there
should be.
● High blood sugar might have contributed to the Recurrent monilial infection of the patient
● FPG- elevated for both occasions (normal between 70 mg/dL (3.9 mmol/L) and 100
mg/dL (5.6 mmol/L).
● A1C level is elevated supporting the diagnosis of the patient having diabetes
● Fasting lab assessment result:
 Parameters Result Normal Result Interpretation

glucose 147 mg/dL less than 100 HIGH

mg/dL (5.6 mmol/L)

triglycerides 400 mg/dL Less than 150 HIGH

milligrams per
deciliter (mg/dL),
or less than 1.7
millimoles per liter
(mmol/L)

A1C 8.3% <5.7% HIGH

● complete blood count, electrolytes, LFTs, and renal function tests

○ all normal

● Meds:
○ Lisinopril - fluconazole – no interaction
○ Lisinopril - Metformin– Metformin may increase the effects of Metformin on
lowering blood sugar but an increased risk for hypoglycemia is present
○ Metformin-fluconazole– no interaction

RESOLUTION

● For maintained control hypertension, continue lisinopril

○ 20 mg once a day
● Continue fluconazole for recurrent monilial infection
● Continue taking metformin for type 2 diabetes
○ 500 mg BID with food
○ increase dosage to 500 mg every morning and 1,000 mg every evening after 1
week.
● To recommend taking lisinopril at lunch time preferably and metformin during breakfast
and dinner
● To recommend vitamin b-12 supplements if there is a suspected presence of associated
B12 deficiency anaemia or suspected neuropathy.
○ Monitoring of vitamin B-12 should be done through blood test
● Maintaining an SBP of <140 mmHg and DBP <90 mmHg is suggested in patients with
diabetes.
● Discontinue the intake of alcohol, orange juice, and soda as this increases the risk of
worsening/increasing blood sugar
○ Recommend water instead as this is the gold standard
● Recommend low daily sugar intake, low caloric intake, balanced diet, start exercising,
and lose weight (change in diet) as central obesity of the patient contributes to the
insulin resistance
 ● Recommend SMBG (self-monitoring blood glucose)/ CGM to monitor glucose since the
patient is taking lisinopril & metformin which could increase the risk for hypoglycemia
● Recommend smoking termination
○ Varenicline could be the drug of choice as this is first choice of treatment
■ 0.5 mg orally once daily on days 1 to 3
■ increased to 0.5 mg twice daily on days 4 through 7. It should start one
week before the target quit date.
■ Continuing Weeks: 1 mg twice daily after day 8 for 11 weeks.
■ Additional Therapy: Treatment duration can be up to 6 months and even
longer in certain patients. Further trials are needed to determine efficacy
and outcomes in those using varenicline beyond 12 months
○ Behavioural Counselling for smoking cessation
● Recommend consulting dieticians to manage blood sugar, blood pressure, and
cholesterol.
○ DASH diet can be done if the patient does not prefer guidance of dieticians

MONITORING

● Monitor blood sugar level

○ through finger-prick test, or by using an electronic blood sugar monitor called a
flash glucose monitor or continuous glucose monitoring (CGM), HbA1C test
● Monitor medication side effects
● Monitor lipid profile to estimate risk of development of other complications
● Monitor patient adherence to medications
● Monitor the patient weight during the course therapy
● Monitor blood pressure level
● Monitor GI condition after taking metformin with food
● Monitor Vitamin B-12 serum level
● Monitor the patient’s weight after therapy
● Monitor LFT (liver function test)

Reference:

https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/testing#:~:text=You%20
can%20do%20blood%20sugar,how%20much%20medication%20to%20take.