CASE NO: 1 DATE: 05/07/10 CASE STUDY ON DIABETES MELLITUS Name: Mrs.

M IPNO: 697956 Age: 60Yrs DOA: 05/07/10 Gender: Female DOD: 08/07/10 Department: Endocrinology Consultant: Dr. Krishna sheshadri

CHIEF COMPLAINTS: Complaints of headache, neck pain and giddiness for past 5 years.

HISTORY OF PRESENT ILLNESS: Patient was apparently normal 5 years back after which she developed head ache, giddiness and neck pain. This is aggravated for past 2 months associated with blurred disturbance.

PAST MEDICAL HISTORY: K/C/O DM for 3 months N/K/C/O of HTN/Jaundice/Bronchial asthma

PERSONAL HISTORY AND HABITS: Sleep, appetite Normal

FAMILY HISTORY: NIL.

PHYSICAL EXAMINATION: Temperature (oF) : Afebrile Pulse rate ( /min) : 86 Respiratory Rate (/min) : 18 Blood Pressure (mm of Hg) : 128/80

SYSTEMS EXAMINATION: CVS : S1+S2+ RS : NVBS+ CNS: NFND GU &GI (ABDOMEN): Soft, BS+

LAB INVESTIGATIONS:

ANALYTE TEST I ) HEMATOLOGY & COAGULATION 1) CBC Hb 11.9 PCV 35.3 WBC DC 7920 50 40 2 0.2 5 217 181 220 13 1.0 134 3.8 100 25 0.3 0.1 55 34 185 6.6 3.6 Yellow 5.5 Nil 23 1.030 +++

REFERENCE

UNITS

F - 11-15 F - 37-46 4000-11000 P40-70 L20-40 E1-6 B<1 M2-10 80-140 70-110 80-140 7-18 0.6-1.4 134-144 3.5-5.0 98-106 21-28 0.3-1.2 0.1-0.3 30-65 15-37 50-136 6.4-8.2 3.5-5.2

g/dl % Cells/cumm

II) Blood Sugar RBS FBS PPBS III ) Renal BUN (urea) Creatinine (Cr) Sodium (Na+) Potassium (K+) Chloride (Cl-) Bicarbonate (HCO3-) VI) Liver Total Bilirubin Direct Bilirubin SGPT (ALT) SGOT (AST) Alkaline phosphate Total protein Albumin VI ) Urine Colour pH Blood Pus cells Sp.Gravity Sugar DIAGNOSIS: Uncontrolled diabetes mellitus DRUG CHART: S.No 1 2 3 4 DRUGS T. Metformin T. Glynase (Glipizide) T.B complex T. Rantac (Ranitidine)

mg/dl

mg/dl

mmol/L

mg/dl

U/L g/dl

DOSE 500 mg 5 mg 1 tab 150 mg

ROA PO PO PO PO

FREQ BD BD OD BD

DURATION 05/07/10 08/07/10 05/07/10 08/07/10 05/07/10 08/07/10 05/07/10 08/07/10

SUBJECTIVE: Patient came with the complaints of head ache, neck pain and giddiness.

OBJECTIVE: PCV is decreased RBS, FBS, PPBS, alkaline phosphate were increased

ASSESSMENT: Uncontrolled diabetes mellitus

PLANNING: Plan for the patient is S.No DRUGS 1 2 3 4 T. Metformin T. Glynase (Glipizide) T.B complex T. Rantac (Ranitidine) DOSE 500 mg 5 mg 1 tab 150 mg ROA PO PO PO PO FREQ BD BD OD BD DURATION 05/07/10 08/07/10 05/07/10 08/07/10 05/07/10 08/07/10 05/07/10 08/07/10

CRITICAL ANALYSIS OF PRESCRIPTION: Drug Of Choice: Metformin and glipizide can be used as a drug of choice for the management of diabetes Dose: Metformin: maximum daily dose is 3 gm Glipizide: maximum daily dose is 15 mg Frequency: Frequency was appropriate in this prescription Duration: Duration of therapy is appropriate Guidelines: American diabetic association evidence based recommendation ICMR guidelines for the management of type 2 diabetes

Contraindication: There is no contraindication for this patient Drug Laboratory Interaction: Liver function has to be monitored Drug Disease Interaction: There is no drug disease interaction Drug - Drug Interaction: There is no major drug drug interaction DISCUSSION: Definition: Type 2 diabetes is a chronic (lifelong) disease marked by high levels of sugar (glucose) in the blood.

Causes: Diabetes is caused by a problem in the way your body makes or uses insulin. Insulin is needed to move blood sugar (glucose) into cells, where it is stored and later used for energy. When you have type 2 diabetes, the body does not respond correctly to insulin. This is called insulin resistance. Insulin resistance means that fat, liver, and muscle cells do not respond normally to insulin. As a result blood sugar does not get into cells to be stored for energy. When sugar cannot enter cells, abnormally high levels of sugar build up in the blood. This is called hyperglycaemia. High levels of blood sugar often trigger the pancreas to produce more and more insulin, but it is not enough to keep up with the body's demand. People who are overweight are more likely to have insulin resistance, because fat interferes with the body's ability to use insulin. Type 2 diabetes usually occurs gradually. Most people with the disease are overweight at the time of diagnosis. However, type 2 diabetes can also develop in those who are thin, especially the elderly. Family history and genetics play a large role in type 2 diabetes. Low activity level, poor diet, and excess body weight (especially around the waist) significantly increase your risk for type 2 diabetes. Other risk factors include:

Age greater than 45 years, HDL cholesterol of less than 35 mg/dL or triglyceride level of greater than 250 mg/dL, High blood pressure, History of gestational diabetesPolycystic ovarian

syndromePreviously identified impaired glucose tolerance by your doctor, Race/ethnicity (African Americans, Hispanic Americans, and Native Americans all have high rates of diabetes) Signs and symptoms: Often, people with type 2 diabetes have no symptoms at all. If you do have symptoms, they may include:

Blurred visionErectile dysfunctionFatigue, Frequent or slow-healing infections, Increased appetite, Increased thirst, Increased urination

Diagnosis: Type 2 diabetes is diagnosed with the following blood tests:

Fasting blood glucose level -- diabetes is diagnosed if higher than 126 mg/dL on two occasions. Haemoglobin A1c test -- this test has been used in the past to help patients monitor how well they are controlling their blood glucose levels. In 2010, the American Diabetes Association recommended that the test be used as another option for diagnosing diabetes and identifying pre-diabetes. Levels indicate:
o o o

Normal: Less than 5.7% Pre-diabetes: Between 5.7% - 6.4% Diabetes: 6.5% or higher

Oral glucose tolerance test -- diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours.

Random (non-fasting) blood glucose level -- diabetes is suspected if higher than 200 mg/dL and accompanied by the classic symptoms of increased thirst, urination, and fatigue (this test must be confirmed with a fasting blood glucose test).

Treatment: The immediate goal of treatment is to lower high blood glucose levels. The long-term goals of treatment are to prevent diabetes-related complications. The primary treatment for type 2 diabetes is exercise and diet. Medications To Treat Diabetes If diet and exercise do not help maintain normal or near-normal blood glucose levels, your doctor may prescribe medication. Since these drugs help lower your blood sugar levels in different ways, your doctor may have you take more than one. These drugs may also be given along with insulin, if needed. Some of the most common types of medication are listed below. They are taken by mouth or injection.

Alpha-glucosidase inhibitors (such as acarbose) decrease the absorption of carbohydrates from the digestive tract to lower after-meal glucose levels.

Biguanides (Metformin) tell the liver to produce less glucose and help muscle and fat cells and the liver absorb more glucose from the bloodstream. This lowers blood sugar levels.

Injectible medications (including exenatide, mitiglinide, pramlintide, sitagliptin, and saxagliptin) can lower blood sugar.

Meglitinides (including repaglinide and nateglinide) trigger the pancreas to make more insulin in response to the level of glucose in the blood.

Sulfonylureas (like glimepiride, glyburide, and tolazamide) trigger the pancreas to make more insulin. They are taken by mouth.

Thiazolidinediones (such as rosiglitazone and pioglitazone) help muscle and fat cells and the liver absorb more blood sugar when insulin is present. Rosiglitazone may increase the risk of heart problems.

PATIENT COUNSELING: 1) REGARDING DISEASE CONDITION: Type 2 diabetes is a chronic (lifelong) disease marked by high levels of sugar (glucose) in the blood.

2) REGARDING MEDICATION PROFILE: T. Metformin: It is an anti-diabetic drug. It acts by increasing peripheral anaerobic glycolysis, interfere with absorption of carbohydrate in gut, and suppress hepatic gluconeogenesis. It may cause nausea, vomiting, flatulence, anorexia, lactic acidosis, tolerance. T. Glynase (Glipizide): It is an anti-diabetic drug. It decreases blood glucose by stimulating insulin release

from pancreas and by increasing tissue sensitivity to insulin. It should be taken twice a day before food. It may cause nausea, vomiting, skin rash, headache, itching, thrombocytopenia, drowsiness, allergic reactions, and hypoglycemia. T.B complex: It is a Multivitamin tablet. It is used to increase the vitamin level. Take one tablet in the morning. T. Rantac (Ranitidine): It is an anti-ulcer drug given to prevent gastric distress. It should be taken twice daily after food. It may cause Dizziness, confusion, constipation, skin rash, headache, leucopenia and thrombocytopenia.

3) REGARDING LIFE STYLE MODIFICATION: Adhere to drug regimen Avoid taking foods rich in sugar contents, high fat meals, fruits which increase sugar levels such as mango, banana, jack fruit. Take care of your foot by cleaning it regularly, wearing appropriate slippers, etc. Do regular exercise, which helps to reduce glucose levels. Learn to monitor glucose level by self.