Question

Case Study # 4

Type 2 Diabetes Mellitus

Dorothy is a 45-year-old woman. She is in the office for a follow-up visit today, after having been diagnosed with Type 2 Diabetes 3 months ago.  She has been attempting to control her Type 2 DM with diet and exercise, and was started on Metformin 1,000 mg twice daily last month.  She monitors her blood sugar once a day.  She has a record of her BS values over the past week, the range is 180 – 218 (mg/dl).  

PMH

Type 2 DM x 2 months

HTN x 10 years

Dyslipidemia x 10 years

Morbid obesity x 20 years

Depression diagnosed about 12 years ago

FH

Father has history of HTN, dyslipidemia, and depression.  Mother has history of HTN and dyslipidemia.  Brother has DM and alcoholism.

SH

Dorothy has been married for 23 years. She has a total of three children; two teenage children and one child in college.  She works as a sales associate at a major department store.  She denies tobacco use. She drinks alcohol occasionally (3 glasses of wine per week).

Medications:

Metformin 1,000 mg tabs twice a day with food.

Lisinopril 40 mg tabs daily

Pravastatin 40 mg tabs daily

Sertraline 50 mg daily

Allergy:

Penicillin  - hives

Complaints today:

Headaches

Constipation

Nocturia

Fatigued

Physical exam:

BP  134/82

HR  84

RR  16

T 37

Wt 109 kg (240 lbs) (a gain of 1 kg since her last visit one month ago)

Ht 5’7”

Waist circ. 38 inches

Physical exam unremarkable. No pedal edema, pedal pulses 2+.  Foot health good, with normal sensation.

Glucose (random) 190 mg/dl

A1C 8%

Total cholesterol 244 mg/dl

LDL 141 mg/dl

HDL 58 mg/dl

Trig 225 mg/dl

TC/HDL ratio 4.2  

Patient reports that she exercised at most once a week. Her diet is irregular as she is often keeping up with work and her children’s busy schedules.  She is worried about her health, but seems unable to make the changes she needs to make in her life to promote her health. Her glycemic control has improved slightly, her A1C was 9% last month. Her glucose and cholesterol are not at goal on current medications.

What findings indicate poorly controlled Type 2 DM in this patient?

2. What are the goals of treatment for this patient? (Consider individual patient characteristics in determining the treatment goals.)

4. What pharmacotherapeutic regimen would you recommend for each of the patients' drug therapy problems? (Provide the generic name, and the dose of each drug prescribed

Answer 1

The patient random blood sugar of 190 mg/dl and an A1C report of 8% indicates that her diabetes is poorly controlled

2) The main goals for treating this patient are as following

• Controlling and maintaining sugar level ,trying an A1C level at least near to normal level
• weight management because she is overweight this can result in poor prognosis
• Maintaining a proper diet control for diabetes, hypertension and increased cholestrol level
• The patient should inculcate exercise in her daily schedule
• to give a clear knowledge onbtge disease condition and management to prevent depression
• Patient has fever so antipyretics to be administered
• Analgesic to be given to relieve her pain
• Constipation has yo be relieved
• Bathroom support can be provided has she has fatiguness and nocturia

4)The patient has to take the anti diabetic drug (Metformin 1000mg) it suppresses the gluconeogenesis and improves insulin sensitivity and glucose uptake

Lisinopril 40 mg is an antihypertendive drug ,this inhibits the ACE in RAAS and thus preventing conversion of ACE 1to ACE 2 and decreasing blood pressure

Pravastatin 40mg( lipid lowering drug) this inhibits the action of HMGcOA enzyme reducing cholesterol synthesis

Sertraline 50mg ( anti depressant ) this inhibits the SERT and preventing the neuronal activity of CNS absorption of seratonin and prevents depression.