Type 2 Diabetes

Mellitus and
Metabolic Syndrome
Case Study
ND3
 Mrs. R is a 48 y.o , Female who is a Native American living on a
reservation. She has lived there with her family all her life, is a housewife and has
three children. Her husband works in a nearby factory. All of Mrs. R’s children
have finished high school but one still lives at home and is unemployed. The
income for Mrs. R’s family is meager and they depend on home-grown vegetables
and wild game to supplement their food supply. Government commodities
contribute a small amount.
Mrs. R has a pronounced family history of Type 2 diabetes mellitus.
Several family members have had severe complications because of poor control of
blood glucose. Mrs. R is well aware of the problems in her family’s past, but this
has not stopped her from eating whatever she wants. She is 5’6” and weighs 210
lbs with a medium frame with a waist of 42”. She is not very active but does work
in her vegetable garden a lot. Occasionally she goes for long walks on her
reservation in the evenings. She has graduate in high school and reads and writes
adequately. On several occasions she has been treated for UTIs and has frequent
colds.
She does not have a history of any major illness. During the past month,
Mrs. R noticed some significant changes in the way she feels. She becomes
fatigued easily and has to go to the bathroom more frequently, even during the
night. She is hungry all the time and is eating more but she has lost 10 pounds in
the last six weeks and her vision has become blurred. Mrs. R went to the doctor
because she developed another bladder infection. She can always tell when she has
a bladder infection by the pain in her lower abdomen and the frequency of her
urination. She decided to go to the doctor for the infection and while there,
explained the other problems she was having. Her BP was 150/88. The physician
CBC

Reference Units
Test Result Conventional SI
Hgb 14 g/dl 12-16 g/dl 120-160/ L

Hct 42% 36-48%

6 6 12
RBC 3.8x10 /µ 3.6-5.0 x10 /L 3.6-5.0 x10 /L

MCV 80 µm³ 82-98µm³ 82-98fL

WBC 10.7 10³/µl 4.5-10.5 x 10³/cells/mm³ 9

4.5-10.5 x 10/L

%Lymph 26% 25-40% of total WBC 1500-4000

MCH 27 ph/cell 26-34 pg/cell 0.40-.53 fmol/cell

MCHC 33 g/dl 32-36 g/dl 320-360 g/L

Basic Metabolic Package

Reference Units
Test Result
Conventional SI

Glu 353 mg/dl 70-110 mg/dl 3.8-6.1 mmol/L

BUN 28 mg/dl 6-20 mg dl 2.1-7.1 mmol/L

Cr 1.1 mg/dl 0.6-1.1 mg/dl 53-97 µmol/L

Ca 9.1 mg/dl 8.8-10.0 mg/dl 2.20-2.60 mmol/L

Ser alb 3.7 g/dl 3.5-4.8 g/dl 39-50 g/dl

Na 148 mEq/L 136-145 mEq/L 136-145mmol/L

K 4.8 mEq/L 3.5-5.2 mEq/L 3.5-5.2 mmol/L

Cl 104 mEq/L 96-106 mEq/L 96-106 mmol/L

Mg 2.0 mEq/L 1.8-2.6 mEq/L 136-145 mmol/L

P 3.1 mg/dl 2.7-4.5 mg/dl 4.7-6.0 kPa

Lipid Profile

Reference Units
Test Result
Conventional SI

Chol 300 mg/dl 140-199 mg/dl 3.63-5.15 mmol/L

TG 350 mg/dl <-150 mg dl <1.70 mmol/L

HDL 30 mEq/L 40-85 mEq/L 1.0-2.2 mmol/L

LDL ____? mg/dL <130 mg/dl <3.4 mmol/L

Question:

1.Determine Mrs. R’s IBW and percent of IBW.

IBW= 58.45 kg
% of IBW = 163.3% severe obesity
 2. Calculate Mrs. R’s BMI and interpret the
results.

BMI = 34 obese
 3. Calculate Mrs. R’s LDL.
• LDL Cholesterol = Total Cholesterol - HDL - (TG / 5)
Solution:
240mg/dl: 300mg/dl= 80mg/dl: x
240mg/dl: x = 300mg ( 80mg/dl )
x = 24, 000 mg/dl
240mg/dl
HDL = 100 mg/dl
To check:
Total cholesterol= LDL + HDL + Triglyceride
= 100 mg/dl + 130 mg/dl + 70 mg/dl
= 300 mg/dl
So,
LDL Cholesterol = Total Cholesterol - HDL - (TG / 5)
= 300mg/dl – 100 mg/dl – 70 mg/dl
LDL cholesterol = 130 mg/dl
4. What is A1c and how is it used with diabetes?

• Glycated hemoglobin (hemoglobin A1c, HbA1c, A1C, or Hb1c)

is a form of hemoglobin that is measured primarily to identify the
average plasma glucose concentration over prolonged periods of
time. It is formed in a non-enzymatic glycation pathway by
hemoglobin's exposure to plasma glucose.
• Normal levels of glucose produce a normal amount of glycated
hemoglobin. As the average amount of plasma glucose increases,
the fraction of glycated hemoglobin increases in a predictable
way. This serves as a marker for average blood glucose levels
over the previous 8 weeks prior to the measurement as this is the
half life of red blood cells.
• In diabetes mellitus, higher amounts of glycated hemoglobin,
indicating poorer control of blood glucose levels, have been
associated with cardiovascular disease, nephropathy, and
retinopathy. Monitoring HbA1c in type 1 diabetic patients may
improve outcomes.
 5. List the symptoms of Type 2 diabetes that
are manifested in Mrs. R.
• Polyuria
• Loses weight of 10lbs in six weeks
• Hyperglycemia
• Blurry Vision
• Fatigue
• Prehypertension ( BP: 150/88)
6. Define the following terms:

• Polydipsia: The term given to excessive thirst is one of the initial

syptoms od Diabetes. It is also accompanied by temporary or
prolonged dryness of the mouth.

• Polyphagia: It refers to excessive hunger or increased appetite

• Polyuria: a condition usually defined as excessive or abnormally

large production or passage of urine (greater than 2.5[1] or 3[2] L
over 24 hours in adults). Frequent urination is sometimes included
by definition.
Government commodities:
• A product or service that is indistinguishable
from ones manufactured or provided by
competing companies and that therefore
sellsprimarily on the basis of price rather than
quality or style.
7. What incidence did the MD have that suggested that
Mrs. R was dehydrated?

• The incidence in which the MD suggested that Mrs. R

was dehydrated because of her having symptoms of
fatigued, weight loss and polyuria, a frequent
urination.This is because the increased glucose in the
blood causes the kidneys to create more urine than
usual. Losing more fluid in the urine makes a person
dehydrated, dehydration leads to great thirst.

• Weight loss without any loss of apetite, also is

common. The weight loss is due in part to dehydration.
People with new, uncontrolled type 1 diabetes can lose
a gallon of water from dehydration.
 8. What labs may be elevated due to dehydration?
Laboratory tests:

Basic Metabolic Panels (BMP)

• -Electrolytes
• -BUN (Blood Urea Nitrogen)
• Urinalysis
• CBC
• Glucose
• Urine and/or blood osmolality
 9. On what basis did the MD decide that Mrs. R
was anemic?
• The MD decided that Mrs. R was anemic
because of her extreme fatigue or being very
tired.
• Biochemical Assestment – Mrs. R has a Low
Hgb
10. After Mrs. R’s BS is corrected what
changes in other blood values would you expect?
Explain your answer.
• After Mrs. R’s blood sugar is corrected the
changes in other blood values may be free of
the risk and symptoms of diabetes, or at least
lessen it. She may also be able to be free or
stop taking her medications.
11. What is considered to be good control for BS for someone with
diabetes and what is considered poor control?
Good control of a healthy blood glucose (or blood sugar)
includes steps like following a balanced meal plan, engaging in an
active lifestyle with sufficient physical activity, and taking blood
glucose-lowering medications as you need them over the years.
You might also need other medications to control your blood
pressure and lipids (cholesterol). Drink plenty of calorie-free beverages,
especially water, every day. This is especially true when your blood
sugar levels are elevated. Because high blood sugar can cause excessive
urination, drinking plenty of water helps prevent dehydration.
Poor control for blood sugar is eating too much food which
contributes an excess than enough to the blood. Also, less physical
activities and inadequate intake of water in the body can contribute to
poor blood sugar. Too little sleep or poor sleep can disrupt your
hormones, leading to increased appetite, higher blood sugar, and a
thicker waistline.
12. Why should the physician be concerned about the
abnormal lipid profile of a person with diabetes who is out of
control like Mrs. R?

• The physician should be concern about the abnormal lipid

profile of a person with diabetes who is out of control like
Mrs. R because lipid abnormalities in type 2 diabetes are
characterized by high triglyceride concentrations, low high
density lipoprotein-cholesterol concentrations, and normal
total and low density lipoprotein-cholesterol (LDL-c)
concentrations.
• LDL particles, however, are small and dense.
Epidemiological evidence for these lipid abnormalities, and
for the associations between lipid abnormalities and the
increased risk of cardiovascular disease.
13. Mrs. R’s BP was 150/88. What is the
current recommended BP for Mrs. R?
• Since, Mrs. R is only 48 years old her Blood
Pressure range must be < 140mmHg systolic
and < 90mmHg diastolic.
14. What is metabolic syndrome and what symptoms of metabolic syndrome
does Mrs. R demonstrate?
• A. Metabolic syndrome is cluster of disorders, including obesity, insulin,
resistance, high blood pressure, an abnormal blood lipids, which together
increase risk of diabetes and cardiovascular disease. It is also known as
Insulin Resistance syndrome or Syndrome X. Excessive body induces a
number of metabolic changes lead to insulin resistance, which leads to
hyperglycemia and other abnormalities.

• The abnormally high fat content of these tissues in the muscle, liver and
abdominal region may perturb cellular responses to insulin and result to
insulin resistance. Unless, the pancreas can secrete enough glucose to
compensate, glucose uptake from the blood is reduced, contributing to
hyperglycemia.
• Obesity can also alter production of hormones and various other proteins
made in adipose cells, which influence metabolic processes and fuel use in
the body.
• B. Mrs. R’s Symptoms of having a Metabolic Syndrome:
• Obesity
• Insulin Resistance

• - High Triglycerides: 350 mg/dl