Posted: May 24th, 2022
Diabetes Mellitus Type II
Diabetes is described as a condition that results from a chronic problem of hyperglycaemia that is brought about by insulin inaction in the body system. Diabetes type II is a condition that fronts the case for a range of diabetic problems characterised by some pathophysiological symptoms, including increased insulin resistance and impaired insulin secretion. The problems observed in the cell function and the deteriorating pancreatic conditions develop over a period of time. The root and development of diabetes type II is linked to the abnormal secretion of insulin, its action and endogenous output of glucose (EGO Type II diabetes affects over 6.4% of the world’s population. This percentage represents over 285 million people the world over. It is expected that the number will increase to 7.7% (439 million) by the year 2030. The epidemic of Diabetes mellitus II (T2DM) as perceived by medical experts is an epidemic that is closely linked to obesity. It has been established that over 85% of patients with diabetes are obese or overweight. Further, it has been established that a lot of the treatments used for lowering glucose cause weight management complications. They lead to even more weight gain. The rise in the prevalence of diabetes and the accompanying comorbidities, plus the complications, exert a significant burden on the society and the available primary care facilities. Diabetes mellitus calls for controlling one’s diet and a restricted calories intake. Patients are advised to cut down their consumption of fat and simple carbohydrates as they increase the consumption of fibre and complex forms of carbohydrates. There is also the need to engage in regular aerobics. It is an effective way of treating diabetes mellitus II as it reduces resistance to insulin and burns extra glucose. It is also observed that such regular exercise may lower blood lipids and help deal with stress effects. These two elements are important in forestalling complications and treating diabetes (Quillen & Kuritzky, 2015). Studies show that diabetes type II has a genetic link that relates to problems with the secretion of insulin and resistance. Some of the problems have been noted to be environmental. The latter set includes obesity, lack of exercise, overeating, stress and aging, which are evident in Tompkins’ case. It is a condition that is brought about by a combination of genetic and environmental factors to a varying extent. Insulin resistance and impaired secretion contribute equally to the development of physiological conditions. Impaired insulin secretion is a condition that is manifested in decreased glucose responsiveness and is observed just before the onset of diabetes proper. The occurrence of impaired glucose tolerance, also referred to as IGT, is triggered by reduced glucose responsiveness in insulin secretion in the early stages and the accompanying decrease in insulin secretion after eating. A decrease in the secretion of insulin after meals leads to post-prandial hyperglycaemia. There is an excessive response observed in victims, such as Mr. Tompkins’ diabetic condition. Such people show reduced insulin secretion in the early phase. Indeed, this phenomenon is an important feature in the development of diabetes cases. It is an essential element in the pathophysiological changes that diabetes victims experience. The impaired insulin secretion problem is noted as a progressive response. The impairment is characterized by the toxicity of glucose and lipotoxicity. If left untreated, the conditions are known to cause pancreatic secretion reduction (Kohei, 2010).
Diabetes type II is clearly evident in Mr. Tompkins’s case. It manifests four main metabolic anomalies, i.e. insulin secretory dysfunction, impaired insulin action, obesity and a high rate of endogenous glucose output (Weyer, Bogardus, Mott & Pratley, 1999).
Case Study Symptoms
Increasing Dyspnea on Minimal Exertion (DOE)
Mr. Tompkins manifests an increased Dypnea on minimal exertion. This is a condition that is described as abnormal breathing that is elicited by a person, according to their fitness status. It is caused by a wide range of factors. It has multiple etiologies. It has also been established that pulmonary organ and cardiac organ systems are the most common causes of Dyspnea etiology
Dyspnea can easily be managed by the family physician. The diagnosis constitutes four basic categories, i.e. pulmonary, cardiac, non-pulmonary or mixed cardiac and non-pulmonary or non-cardiac. Dyspnea cases are caused by pulmonary or cardiac diseases and can easily be pointed out using a careful examination of the patient’s history, along with a physical exam. Mr. Tompkins falls in this category, which further shows that Tompkins comes from a family with a diabetic history. There should be a screening spirometry, and electrocardiographs should be conducted so as to get to the bottom of his condition. These will provide crucial information. Gas exchange and normal respiration physiology is a complex process; dyspnea is more complex. The wider diagnosis of Dyspnea as mentioned earlier constitutes four stages. The cardiac causes could be left, right or congestive heart from both ventricles, with the result being systolic dysfunctions, coronary disease of the artery, myocardial infarction that may be recent or remote, dysfunction of the valves, caerdiomyopathy, diastolic dysfunction, septal hypertrophy (asymmetric), ventricular hypertrophy that causes diastolic dysfunctioning, arrhythmias and pericarditis. Pulmonary triggers include restrictive and obstructive processes. Asthma and chronic obstructive pulmonary disease (COPD) are the most obstructive triggers. Obesity and chest wall or spine deformities, interstitial fibrosis pneumoconiosis, collagen and vascular disease and granulomatous disease ailment constitute common restrictive causes of dyspnea. Mixed pulmonary and cardiac disorders are common triggers of dyspnea. These causes include: pulmonary emboli and trauma as Tompkins case shows, cor pulmonale, pulmonary hypertension and deconditioning.
Dyspnea condition may also manifest as a somatic signal of psychiatric problems, including anxiety disorder and consequent hyperventilation. Checking the history, to determine if it is well captured, is a great way to pick important clues. If the history does not exist or provide much information, then the option is a proper diagnosis in most cases. The differential diagnosis can be narrowed down by a range of factors, including the number of pillows a patient needs during sleep, chest pain complaints, how smooth the sleep sessions are, exertion during the day or at night and tolerance to exercise, among others. Other important factors include: the history of tobacco usage, allergies from the environment, occupation lifestyle, congestive heart failure, coronary artery disease, valvular complications and asthma condition (Morgan & Hodge, 1998).
Tompkins family shows a history of diabetes. There is even an incident of death as a result of diabetes type II. Comprehensive family history to check lung problems, pulmonary infections, diabetes and bronchitis, among others, should be checked. Dyspnea can, usually, be easily diagnosed, if a careful study of the history and physical exam points out common pulmonary or cardiac etiologies. There is need to conduct specific diagnosis in order to confirm the condition or even assist in the therapeutic management. Peripheral edema is a common cause of confusion for many clinicians. It is a common finding in the investigation of a host of diseases. There is need, therefore, to conduct a systematic and rational checking of the patient with edema to ensure a cost effective diagnosis of the problem and the consequent treatment.
The Case of Swelling in His Legs
This paper rechecks the pathophysiological causes of the formation of edema as a means for understanding the complexities of edema formation in specific disease conditions, including the resultant implication for its treatment (Morgan & Hodge, 1998).
The Case of His Lower Legs Being Red, Warm to the Touch, and Mildly Painful
Mr. Tompkins shows that his legs and feet are swollen. These are typical of peripheral edema. They are a result of the accumulation of fluids in the tissues of the said parts. It is not ordinarily painful. Swelling is clearly seen in the lower parts of one’s body, owing to gravity. Although the swelling is a common occurrence among older people, and may not necessarily signal a serious problem, it is always safer to do a medical check up to establish the cause of the swelling. Sometimes, it may be indicative of a more serious underlying health complication. For Mr. Tompkins, overweight issues and usage of certain medicines for controlling blood pressure are the more likely causes of the swelling. Leg tissue inflammation, which may in turn be a result of injury or some ailment, may even be caused by rheumatoid arthritis or an inflammatory disorder. Mr. Tompkins feels some pain as is the case in such conditions. The lower parts of his legs are warm to the touch and feel remotely painful (Mandal, 2016).
1. Blood sugar tests show that Mr. Tompkins’ blood sugar is abnormally high at 190 in the morning, and 290 before dinner. The blood sugar test is an easy exam that uses blood samples obtained from a vein puncture using a finger stick. Diabetes is the condition that results from excessive blood sugar in one’s body. Such a scenario leads to a myriad of complications that can lead to death, if not carefully treated and/or managed. Some of the common complications that emanate from high blood sugar include: blindness; also known as restinopathy, or even the failure of the kidney; it leads to dependence on dialysis (nephropathy) to stay alive and even leads to the need for leg amputation. For Mr. Tompkins, regular exercise and eating a healthy diet can help keep the blood sugar lower, controlling diabetes. Studies have shown that, if patients with the potential of developing diabetes did a 20-minute walk, four to five times each week, their blood sugar levels would significantly reduce. Adopting a healthy diet routine for all meals is also a great way to control diabetes. Checking for low blood sugar is just as important. Some sugar level tests need adequate preparation. For instance, fasting tests need the patient to refrain from eating, for around 8 to 12 hours before the test is administered. There is no need for preparation, in case of the non-fasting blood sugar tests. 66 patients with ranging fasting levels of glucose were tested. It was noted that acute insulin response was evident in the patients that had fasting glucose levels of less than 115mg/dl. However, it was notably absent in the patients that recorded a higher figure.
His blood sugars on the finger sticks are high — at 190 fasting in the morning and 290 before evening meals.
Glucose disappearance rate of over 1.06% was noted when the acute response was at zero.
Everyone with fasting levels of glucose above 115mg/dl had disappearance rates, showing over 1.06%. The studies suggest:
1. Epidemiological data shows 115mg/dl as the higher limit for normal fasting glucose levels and 1.0% per minute as the lower limit for normal glucose disappearance levels and,
2. Evidence of the essence of the acute insulin response in determining the rate of insulin disappearance. Insulin secretion and resistance are widely known physiopathological signs of the diabetic condition that can be measured using different methods. It is easier to access FPG in routine health checkups (Mandal, 2016).
Mr. Tompkins has added weigh by 10 pounds since one month ago. Checking the state of hormones, deficiencies in vitamins and the existence of prescription medicines can signal his cause of gaining weight. The incidence of increased weight is due to Dietary choices
Genes: some individuals are predisposed genetically to experience weight gain. It is noted, however, that regular exercise and proper diet can still help maintain the desired weight levels.
Physical exercise, including regular exercise has a great impact on weight control matters and general health. Weight gain is associated with a myriad of other health complications.
Sufficient sleep. There is a relationship between the amount of sleep people get and their weight. There is a general trend that aligns to the fact that the lesser the number of hours of sleep one gets, the more they are likely to gain weight (Mandal, 2016).
The Pathophysiological Root Signs and Relationship with Diabetes Type II
The risk factors shown in this case for type II diabetes include:
History of the Family: there is a hereditary factor for type II diabetes. If a close family member has suffered from the condition, there is a greater chance that there will be more cases of the condition within that family.
Ethnicity and Race: Some races and ethnic groups tend to be more vulnerable to diabetes type II.
Age: there is a greater chance to develop the condition as one grows older. The risk factors tend to rise at the age of 45 years. The risk increases exponentially after 65.
Polycystic ovary Syndrome (PCOS) increases the risk of contracting type II diabetes. The condition is closely linked to insulin resistance. It has been observed that PCOS is a result of insulin resistance. The condition manifests by formation of cysts in the ovaries. Indeed, the existence of the condition in the body is an indicator of insulin resistance. This also means that there is a risk of developing type II diabetes (Leontis & Hess, n.d).
Diabetes mellitus is a set of metabolic disorders that are manifested in serious hyperglycaemia triggered by insulin inaction. This form of diabetes accounts for between 90 to 95% of people with diabetes. It is most common in adults above the age of 40 years. 80% of people with type II diabetes are also overweight as is Tompkins’ case. The increased incidence of obesity makes the diagnosis and detection of the condition more common in people of a younger age and even in children. At the onset, in the occurrence of type II diabetes, there is secretion of insulin, but somehow, it does not act normally. This situation is referred to as insulin resistance. Most of those with the diabetes mellitus condition end up with little or no insulin being released into their bloodstream. The condition of Type II diabetes arises as a consequence of the failure of the body to produce sufficient insulin or the insulin secreted failing to act as it is supposed to, because the various cells of the system do not respond to it. Glucose, which is essential to the body, is acquired from the carbohydrates in the diet. The liver is known to manufacture glucose too. In normal circumstances, when a person eats food, blood sugar rises. The rise in blood sugar triggers the release of insulin from the beta cells of the pancreas. The process triggers cells to absorb the glucose from the blood. Ordinarily, therefore, once the blood sugar has gone down, the system ceases to produce insulin until they are triggered again to repeat the cycle. For patients with diabetes Type II, the body either fails to produce sufficient insulin or does not produce insulin at all, or if it releases the insulin, it fails to act, owing to the resistance in the system as is the case of Mr. Tompkins. Resistance here refers to when the cells fail to respond to the presence of insulin, even in concentrated amounts. Fat cells break down triglycerides for the production of fatty acids to produce energy. Muscle cells are starved of energy while the cells in the liver cannot build up glycogen stores as they normally do. The result is an increased level of glucose in the bloodstream. Since glycogen stores are depleted, there is no glucose even when it is urgently released. Lack of exercise and obesity are reported to be significant causes of resistance to insulin (Mandal, 2016).
Type II diabetes is a multi-factorial ailment. It is caused by a range of factors, including lack of exercise, insulin resistance, obesity, impaired insulin secretion from the pancreas, aging, stress, genetic factors, overeating and more (Mandal, 2016). The major pathophysiological features of type II diabetes cases in Japan are insulin resistance and impaired secretion of the hormone.
There is a clear association of Tompkins’s case with the family history as far as diabetes is concerned. The occurrence of the condition among monozygotic twins rather than monozygotic singles is indicative of genetic factors at play. The pathogenesis involves genetic anomalies in hormones responsible for the regulation and breaking down of glucose. Smoking and similar lifestyle habits, such as drinking are independent contributory factors.
Obesity in general, resulting from lack of exercise, comes with a reduced level of muscle mass. It triggers resistance to insulin and is strongly linked to the fast increase in the numbers of patients from middle to older ages. Dietary changes, including an increased tendency to consume simple sugars, and lack of fibre in the diet, promotes the incidence of obesity. All these increase the chances of reduced tolerance to glucose. The sign of type II diabetes intensifies over time. It is reported that one can live and walk around with type II diabetes for many years, without knowing it. Look out for signs, such as frequent urination and frequent thirst. If you have excess sugar in your bloodstream, water is drawn from the tissues, which makes one feel thirsty (Kohei, 2010). It is not clear why insulin resistance happens or even why the pancreas stops producing insulin, but these are the primary causes of diabetes type II. Researchers have only gone as far blaming it on lifestyle habits and lack of sufficient exercise (Morgan & Hodge, 1998).
The process of glucose regulation happens as follows:
The pancreas releases insulin into the blood system
Insulin moves around to facilitate sugar to get into the cells
The amount of blood sugar is lowered in the bloodstream
Insulin reduces as the blood sugar reduces in the system (Mayo, 2016).
Diagnostic Tests for Tompkins Swing on both Ends of the Scale
In the case of Mr. Tompkins’, the evaluation of Dyspnea can be done in family doctors’ office. The primary determination is directed by the likely causes as suggested by the history and physical check-up. The common organic causes of Dyspnea are pulmonary and cardiac problems.
Chest radiographs and electrocardiogram are the most effective methods for diagnosing Dyspnea. The approaches are affordable, safe and accessible. They help the clinician rule out a range of common diagnoses. For instance, the electrocardiogram shows the problems associated with rhythm and heart rate or even point to infarction, ischemia or injury. If the voltage is abnormal, there is a chance of right or left ventricular hypertrophy. However, if the voltage is in excess or pericardial effusion, obstructive illness with higher diameter of the chest is possible, if there is a reduced voltage. Chest radiographs are used to establish the presence of problems, such as osteoporosis, scoliosis, fractures and parenchymal anomalies, including hyperinflation, infiltrates, atelectasis, mass lesions, pneumothorax and pleural effusion.
A greater pericardial or chamber size can cause higher levels of cardiac silhouette. For Mr. Tompkins, a comprehensive blood count or even using finger stick haemoglobin can establish the seriousness of anaemia. Measuring the serum thyroid-stimulant hormone level can be used to assess thyroid anomalies, which rarely present with Dyspnea.
As mentioned earlier, cases of Dyspnea can be identified fairly easily by the use of physical examination and checking the history of a patient and identifying common pulmonary and cardiac etiologies. There are cases where there is need to perform specific testing to confirm the ailment, assisting with the management of the condition (Morgan & Hodge, 1998).
Some helpful second line tests include: oximetry, spirometry, pulse and the tread mill tests. They can help to confirm the initial diagnosis, if it is inconclusive or suggests an abnormality (Morgan & Hodge, 1998). They can also assist to interpret the import of abnormal lab test results. Diabetes has far reaching negative implications and, thus, requires extensive self-care. It also affects many body parts.
The Case of Gaining 10 Pounds
Diabetes patients, such as Tompkins, are usually advised to visit several physicians may times in a year, so as to check and detect possible problems that might emanate from other body organs, such as eyes, feet, legs and other diabetes-sensitive areas.
There is also the need to check the patient’s blood pressure. These tests have been proposed by the American Diabetes Association. They are useful in tracking and controlling blood sugar levels checking kidney function status, cardiovascular conditions and more. Although the physiological conditions and processes that lead to the different types of the strains of diabetes are clear, many tests do not state the type preset in a patient. Therefore, the terms used in one patient, can be used to refer to another. The common main tests for the diagnosis of diabetes are the oral glucose tolerance test and the fasting plasma glucose test. By the standards of the fasting plasma glucose tolerance test, the condition of diabetes is defined as the state in which the blood glucose is at 125mg/dl or higher. Pre-diabetes is placed at a level between 100mg/dl and 125mg/dl. If the results are on the borders, a doctor may order a fresh test since there are other causes of rising blood sugar levels. Such a physician may even order a different type of test for the same reasons. There are numerous lab tests available in health facilities nowadays. According to the American Society of Clinical pathologists, lab tests contribute up to 70% in the decision that physicians make with regard to treatment. It is therefore, critical to understand tests; why they are prescribed, what the results mean and what ailments are being tested. Such a stance assists the patient in forging cooperation with the physician, and consequently, dealing with the health conditions encountered (Morgan & Hodge, 1998).
The patient’s symptoms were analyzed using the POLDCARTS tool. See Table 1 below
Name: Case Study 3 — Diabetes Mellitus, Type II
Diabetes Mellitus, Type II
Dyspnea on Exertion
Swelling in the Legs
Legs red, warm to the touch and painful
High blood sugars on finger sticks
10 lb. wt. gain ks
P = Previous similar occurrence
Feel dyspneic with strenuous exercise
Nothing indicated in the symptoms
Pain in his legs when he walks
Not clearly stated in the diagnosis
Not stated in the symptoms
O = Onset
Type 2 diabetes is familial
As an adult
In his adult life
In his adult life
As an adult
L = Location
In an industrialized country
In an industrialized country
Living in a developed nation
D = Duration
Over a period of one month
For one week
In the last 30 days
For the last 30 days
Over a period of one month
C = Characteristics (radiation, quality, associated symptoms, setting)
Dyspnea is unpleasant or uncomfortable breathing.
Muscle infarction caused by atherosclerosis and diabetic
Microangiopathy leading to ischemia of the muscle resulting in an intense inflammatory
(Imran, Ardasenov Brown, Maz & Magadan, 2015)
Diabetic peripheral neuropathy (DPN), due to nerve damage
His blood sugars on his finger sticks have been high — 190 fasting in the morning and 290 before evening meal
Weight 225 lbs +10 pounds since his last visit 1 month ago, BMI 30
A = Aggravating
Being overweight since dyspnea is related to overweight
Walking for long
R = Relieving
Stopping and resting until breathing returns
Muscle activity of the lower leg
Optimal glucose control helps to prevent it. Many people will require a medication to manage their painful symptoms
Blood sugar monitoring is also important for people with type 2 diabetes
Lifestyle modification incorporating healthy, calorie-appropriate diets and increased physical activity, in addition to metformin, are central components to diabetes management and weight management
T = Temporal
It is temporal because it is insidious
It has not been established
Not clearly evident in his symptoms
It is not temporal
It has not been shown in the diagnosis
S = Severity
It is not severe
Severe because it reduced his activity
It is severe
Very severe, increasing 10 pounds in a month
This case focuses on a patient that exhibits a significant rise in dyspnea on DOE, swollen legs, reddening of the lower parts of the leg, mild pain that is approximately 4/10 on a scale of pain, and warm touch. It is also evident that the blood sugar levels on the patient’s finger sticks have been high. They have been 190 on fasting in the morning and at 290 in the evening before meal times. The patient has acquired extra weight by 10 pounds from the last visit one month back.
There is glycemic control by the patient. This observation suggests a more intensive treatment. If triple therapy is to be applied, there should be consideration for complementary action mechanisms. Oral agents generally lower the blood sugar by 1.0%. Therefore, attaining 7% may be tricky if there is no change in lifestyle in this patient’s case. There is an increased chance of drug interactions and other adverse effects. Moreover, reluctance to adhere to therapy by patients is linked to multidrug regimens. Owing to these reasons, there is need for monitoring the patient closely (Quillen & Kuritzky, 2015).
Imran, M., Ardasenov, Z., Brown, K., Maz, M., & Magadan, J. (2015). Diabetic Myonecrosis of Bilateral Thighs in Newly Diagnosed Type 2 Diabetes Mellitus.
Kohei, K. A. K. U. (2010). Pathophysiology of type 2 diabetes and its treatment policy.
Leontis, L., & Hess, A. (n.d.). Type 2 Diabetes Risk Factors. Retrieved February 24, 2016, from http://www.endocrineweb.com/conditions/type-2-diabetes/type-2-diabetes-risk-factors
JMAJ, 53(1), 41-46.
Mandal, A. (2016). Diabetes Mellitus Type 2 Pathophysiology. Retrieved February 21, 2016, from http://www.news-medical.net/health/Diabetes-Mellitus-Type-2-Pathophysiology.aspx
Mayo. (2016). Type 2 diabetes. Retrieved February 20, 2016, from http://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/dxc-20169861
Morgan, W. C., & Hodge, H. L. (1998). Diagnostic evaluation of dyspnea. American family physician, 57, 711-718.
Quillen, D., & Kuritzky, L. (2015). Case Studies of Patients with Type 2 Diabetes Mellitus: Exercises in Problem Solving. Retrieved February 24, 2016, from http://www.consultant360.com/articles/case-studies-patients-type-2-diabetes-mellitus-exercises-problem-solving
Weyer, C., Bogardus, C., Mott, D. M., & Pratley, R. E. (1999). The natural history of insulin secretory dysfunction and insulin resistance in the pathogenesis of type 2 diabetes mellitus. The Journal of clinical investigation, 104(6), 787-794.
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