Why should medications other than glipizide or glyburide be considered for management of diabetes in this patient? List four sighs of dehydration in this patient? What is the significance of xerosis and cracking of the feet in this patient?
Extracted text: 262| PART 7- NEUROENDOCRINE DISORDERS CASE STUDY 54= DIABETES MELLITUS, TYPE 2 263 Heart Pa can • Regular rate and rhythm with no murmurs, gallops, or rubs • Apical impulse normal at 5th ICS at mid-clavicular line • Normal S, ands, • No S, S, case Laboratory Blood Test Results (After Overnight Fast) Abdomen See Patient Case Table 54.2 • Soft, NT with prominent central obesity • (+) BS in all four quadrants • (-) organomegaly, distension, or masses • Faint abdominal bruit auscultated Patient Case Table 54.2 Laboratory Blood Test Results 9.8 mg/dl. 3.3 mg/dL. 1.9 mg/dL LDL 19 IU/L Trig HbA, 43 IU/L. 139 meg/l. Ca 4.0 meq/L PO, Na T. cholesterol 246 mg/dl. K HDL 28 mg/dL. 168 mg/dL ci 102 meg L Mg 22 meq/l. AST 14 mg/dl. ALT 0.9 mg/dl. Alk phos нсо, HCO, 458 mgidl. BUN 13 IUL 8.2% Cr Ins 290 uU/ml. Glu 168 mg/dl. T. bilirubin 1.0 mg/dl. Breasts No masses, discoloration, discharge, or dimpling of skin or nipples Urinalysis Genitalia/Rectum See Patient Case Table 54.3 • (-) vaginal discharge, erythema, and lesions • (-) hemorrhoids • Good anal sphincter tone • Stool is guaiac-negative Patient Case Table 54.3 Urinalysis Appearance Pale yellow and clear Bilirubin Negative Microalbuminuria Negative Musculoskeletal and Extremities 5.8 Ketones Negative Glucose Positive Negative for microbes, red cells, and white cells SG 1.008 Protein Negative Microscopy • Normal ROM in upper extremities • Reduced ROM in knees • (-) edema or clubbing • Peripheral pulses diminished to 1+ in both feet • Feet are cold to touch and dry with cracking, but no ulceration observed • Strength 5/5 throughout except 2/5 in left foot Electrocardiogram Findings consistent with early left ventricular hypertrophy Patie Neurologic • Alert and oriented x 3 • Cranial nerves II-XII intact (including good visual acuity) • Sensory response to light touch, proprioception, and vibration subnormal in both feet with abnormalities greater in the left foot • DTRS 2+ throughout • Gait normal except for left foot weakness Palte diagnosis of dn Pport a
Extracted text: CASE STUDY 54▪ DIABETES MELLITUS, TYPE 2 259 CASE STUDY Past Surgical History 54 C-section 14 years ago DIABETES MELLITUS, TYPE 2 OB-GYN History • Menarche at age 12 • Menopause, natural, at age 46%: despite problematic hot flashes, she has chosen not to ini- tiate HRT • First child at age 17, last child at age 34, G,P,A, all babies were healthy, 4th child weighed 10 Ibs 6% oz at birth • Last Pap smear 4 years ago Family History • Type 2 DM present in younger sister and maternal grandmother; both were diagnosed in their late 40s; maternal grandmother died from kidney failure while waiting for a kidney transplant; sister is taking "pills and shots" • Father had emphysema • Two older siblings are alive and apparently well • All four children are healthy For the Disease Summary for this case study, see the CD-ROM. PATIENT CASE Patient's Chief Complaints "My left foot feels weak and numb. I have a hard time pointing my toes up." Social History • Married 29 years with 4 children; husband is a migrant farm worker • Family of 5 lives in a 2-bedroom trailer • Patient works full-time as a seamstress in a small, family-owned business • Smokes 2 ppd (since age 14) and drinks 2 beers most evenings • Has "never used illegal drugs of any kind" • Rarely exercises and admits to trying various fad diets for weight loss but with little success; has given up trying to lose weight and now eats a diet rich in fats and refined History of Present Illness C.B. is a significantly overweight, 48-year-old woman from the Winnebago Indian tribe who had high blood sugar and cholesterol levels three years ago but did not follow up with a clin- ical diagnostic work-up. She had participated in the state's annual health screening program and noticed that her fasting blood sugar was 141 and her cholesterol was 225. However, she felt "perfectly fine at the time" and could not afford any more medications. Except for a num- ber of "female infections," she has felt fine until recently. Today, sugars presents to the Indian Hospital general practitioner complaining that her left foot has been weak and numb for nearly three weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. However, she reports that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symp- toms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 65 pounds since her last pregnancy 14 years ago, 15 pounds in the last 6 months alone. Review of Systems General Admits to recent onset of fatigue HEENT Past Medical History • Seasonal allergic rhinitis (since her early 20s) • Breast biopsy positive for fibroadenoma at age 30 • Gestational diabetes with fourth child 14 years ago Morning sickness with all four pregnancies • HTN x 10 years • Moderate-to-severe osteoarthritis involving hands and knees x 4 years • Multiple yeast infections during the past 3 years that she has self-treated with OTC anti- fungal creams and salt baths • Occasional constipation Has awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing; denies vertigo, head trauma, ear pain, ringing sensations in the ears, diffi- culty swallowing, and pain with swallowing Cardiac Denies chest pain, palpitations, and difficulty breathing while lying down Lungs Denies cough, shortness of breath, and wheezing 258