Question

what would be a complete health history assessment of a patient with type 2 diabetes. including a Review of Systems

Answer 1

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Pathophysiology of Type 2 Diabetes

Type 2 diabetes mellitus has major problems of insulin resistance and impaired insulin secretion.

Insulin could not bind with the special receptors so insulin becomes less effective at stimulating glucose uptake and at regulating the glucose release.

There must be increased amounts of insulin to maintain glucose level at a normal or slightly elevated level.

However, there is enough insulin to prevent the breakdown of fats and production of ketones.

Uncontrolled type 2 diabetes could lead to hyperglycemic, hyperosmolar nonketotic syndrome.

The usual symptoms that the patient may feel are polyuria, polydipsia, polyphagia, fatigue, irritability, poorly healing skin wounds, vaginal infections, or blurred vision.

Clinical Assessment:

Hypoglycemia may occur suddenly in a patient considered hyperglycemic because their blood glucose levels may fall rapidly to 120 mg/dL or even less.

Serum glucose: Increased 200–1000 mg/dL or more.

Serum acetone (ketones): Strongly positive.

Fatty acids: Lipids, triglycerides, and cholesterol level elevated.

Serum osmolality: Elevated but usually less than 330 mOsm/L.

Glucagon: Elevated level is associated with conditions that produce (1) actual hypoglycemia, (2) relative lack of glucose (e.g., trauma, infection), or (3) lack of insulin. Therefore, glucagon may be elevated with severe DKA despite hyperglycemia.

Glycosylated hemoglobin (HbA_1C): Evaluates glucose control during past 8–12 wk with the previous 2 wk most heavily weighted. Useful in differentiating inadequate control versus incident-related DKA (e.g., current upper respiratory infection [URI]). A result greater than 8% represents an average blood glucose of 200 mg/dL and signals a need for changes in treatment.

Serum insulin: May be decreased/absent (type 1) or normal to high (type 2), indicating insulin insufficiency/improper utilization (endogenous/exogenous). Insulin resistance may develop secondary to formation of antibodies.

Electrolytes:

Sodium: May be normal, elevated, or decreased.

Potassium: Normal or falsely elevated (cellular shifts), then markedly decreased.

Phosphorus: Frequently decreased.

Arterial blood gases (ABGs): Usually reflects low pH and decreased HCO₃ (metabolic acidosis) with compensatory respiratory alkalosis.

CBC: Hct may be elevated (dehydration); leukocytosis suggest hemoconcentration, response to stress or infection.

BUN: May be normal or elevated (dehydration/decreased renal perfusion).

Serum amylase: May be elevated, indicating acute pancreatitis as cause of DKA.

Thyroid function tests: Increased thyroid activity can increase blood glucose and insulin needs.                                                                                                                               Urine: Positive for glucose and ketones; specific gravity and osmolality may be elevated.   Cultures and sensitivities: Possible UTI, respiratory or wound infections