South University College of Nursing and Public Health Graduate Online Nursing Program

South University College of Nursing and Public Health Graduate Online

Nursing Program

Aquifer Internal Medicine

Internal Medicine 08: 55-year- old male with chronic disease management

Author/Editor:Author/Editor: Cynthia A. Burns, MD

INTRODUCTION HISTORY

You review Mr. Morales’ records on the computer.You review Mr. Morales’ records on the computer.

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You are working with Dr. Clay in her outpatient diabetes clinic this morning.

Your first patient, Mr. Morales, was seen by Dr. Clay once before, eight years ago, but was lost to follow-up after that time.

Based on review of the electronic medical record you are able to collect the following information prior to heading into the room to meet Mr. Morales:

Mr. Morales is a 55-year-old Hispanic male, diagnosed with Type 2 diabetes mellitus thirteen years ago after experiencing a 20-pound unintentional weight loss, blurry vision, and nocturia.

He was hospitalized six weeks ago with a non-ST elevation myocardial infarction and required three vessel coronary artery bypass grafting. During his admission, he was found to have a reduced ejection fraction of 20%.

He was referred for today’s visit by the cardiologist to focus on optimizing his glycemic control and reducing his risk of the comorbidities associated with poorly controlled Type 2 diabetes mellitus.

His last hemoglobin A1c (HbA1c) was 9.5% eight years ago, and he had microalbuminuria at that time.

DIABETES CHRONIC DISEASE MANAGEMENT 1

MANAGEMENT

You review diabetes chronic disease management with Dr. Clay.You review diabetes chronic disease management with Dr. Clay.

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Before you see Mr. Morales, Dr. Clay reviews diabetes chronic disease management with you.

Diabetes Chronic Disease Management Evaluate for and optimize prevention of diabetic complicationsEvaluate for and optimize prevention of diabetic complications

Macrovascular complications:

Cardiovascular disease Cerebrovascular disease

Microvascular complications:

Retinopathy Nephropathy Neuropathy

In particular, cardiovascular disease is the No. 1 cause of mortality for people with diabetes, and one of the top causes of morbidity.

Hypoglycemia, infections, foot ulcers, and amputations are additional causes of morbidity and mortality in patients with diabetes.

The American Diabetes Association publishes annual guidelines to assist in the management of a patient with diabetes.

Remember the large role that the psychosocial aspects of a diabetesRemember the large role that the psychosocial aspects of a diabetes diagnosis play in managementdiagnosis play in management

Non-adherence with medical recommendations could be due to economic, work-related, religious, social, or linguistic barriers to care. Care must be taken to assess the psychosocial status of each person with diabetes at each clinic visit to ensure that barriers to successful diabetes care are minimized.

Question Which of the following does the American Diabetes Association recommend to minimize the risk of cardiovascular disease in patients with diabetes? Select all that apply.

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The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Smoking cessation

B. Daily aspirin therapy

C. Blood pressure less than 140/90 mmHg (if it can be

achieved without increased treatment burden, a systolic target of < 130

is appropriate in younger, healthier patients)

D. If > 40 years old, regardless of other atherosclerotic

cardiovascular disease risk factors, statin therapy

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Answer Comment > The correct answers are A, B, C, D> The correct answers are A, B, C, D

ADA Recommendations to Minimize the Risk of Cardiovascular Disease in Patients with Diabetes Smoking cessationSmoking cessation, daily aspirindaily aspirin, blood pressure controlblood pressure control and lipid controllipid control are all recommended to reduce the risk of cardiovascular disease.

Please note that as of 2018, ADA recommendations were published with the older definition of hypertension (140/90). It always takes time before multiple different organizations agree on the same thresholds.

Daily low dose aspirin is recommended for primary prevention of cardiovascular disease in diabetic patients with a 10-year risk of atherosclerotic cardiovascular disease of >10%. It is also recommended for secondary prevention of all diabetic patients with a history of atherosclerotic disease.

Reduction of cardiovascular risk is achieved with a goal of optimal glycemic control, as well as control of many other health factors that raise cardiovascular risk, such as tobacco use, obesity, poorly controlled hypertension, and hypercholesterolemia.

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References Economic Costs of Diabetes in the U.S. in 2012. American Diabetes Association. Diabetes Care. April 2013; 36(4):1033-1046. http://care.diabetesjournals.org/content/36/4/1033. Accessed May 11, 2018.

PATIENT HISTORY HISTORY

Mr. Morales tells you about his heart attack.Mr. Morales tells you about his heart attack.

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You enter the exam room and introduce yourself to Mr. Morales.

“What brought you to the oRce today?” “I had a heart attack about a month ago and had to have open-heart surgery. The heart doctors told me that my heart is weak now. My cardiologist told me that I have to get my blood sugar under control so I don’t have another heart attack. I am here to get down to work.”

“Tell me more about that.” “I didn’t come back to see Dr. Clay because my job at the furniture factory wouldn’t give me time off for clinic appointments, and I couldn’t risk losing

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The best option is indicated below. Your selections are indicated by the shaded boxes.

my job. I wasn’t checking my blood sugar before my heart attack because the testing strips are so expensive and my supervisor wouldn’t let me off the line to check anyway. Since my surgery, I haven’t gone back to work, and I’ve been checking my sugar before each meal and before bed. The hospital social worker got me two months’ worth of testing strips and lancets before I went home, but I’m going to run out in a couple of weeks. I’m worried that I won’t be able to check anymore.”

He also tells you that while he was in the hospital, they had to use insulin through his vein to keep his blood sugar controlled, and that was very upsetting to him.

Question True or False: In a critically ill medical patients, tight blood sugar control with intravenous insulin therapy, with a goal blood sugar of 80-110 mg/dL, is associated with lower mortality than less tight blood sugar control (e.g. 140-180 mg/dL).

A. True

B. False

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Answer Comment > The correct answer is B> The correct answer is B

EUectiveness of Intravenous Insulin for Blood Glucose Control Blood sugar control in critically ill patients has been the subject of considerable investigation. Previous research suggested that tight control (80-120 mg/dL) was desirable, but more recent research shows that aggressive blood sugar control can be associated with higher mortality.

Hypoglycemia (serum glucose concentration <70 mg/dL), with rates as high as 40% in some studies, is associated with tight glycemic control.

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A meta-analysis of 29 controlled trials involving more than 8,000 adult ICU patients showed no difference in in-hospital mortality between the group assigned to tight glucose control versus usual care.

The current recommended blood glucose target for mostThe current recommended blood glucose target for most hospitalized patients is 140 to 180 mg/dL.hospitalized patients is 140 to 180 mg/dL.

References Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300(8):933.

MEDICATION REVIEW HISTORY You review Mr. Morales’ medications with him:

MedicationsMedications

metformin 1000 mg twice daily pioglitazone 15 mg daily glipizide 5 mg daily aspirin 81 mg daily clopidogrel 75 mg daily long-acting metoprolol 100 mg daily furosemide 80 mg twice daily lisinopril 20 mg daily amlodipine 10 mg daily ranitidine 150 mg twice daily gabapentin 300 mg twice daily potassium chloride 10 mEq twice daily atorvastatin 80 mg daily

Mr. Morales says, “The hospital doctors sent me home on an insulin shot – 40 units in my belly every night before I go to bed. I don’t like giving myself the shot, so sometimes I just don’t, but I take all the rest of my medicines like they told me to.”

He takes out the vial of insulin, and you see that it is insulin glargine.

Question

The best option is indicated below. Your selections are indicated by the shaded boxes.

Which of the following medications should you consider discontinuing in this patient based on your knowledge of his reduced ejection fraction? Choose the single best answer.

A. Pioglitazone

B. Atorvastatin

C. Aspirin

D. Glipizide

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Answer Comment > The correct answer is A> The correct answer is A

Thiazolidinediones Pioglitazone (A),Pioglitazone (A), a member of the class of drugs known as thiazolidinediones (TZD), is not recommended for use in patients who have newly developed heart failure and in those with known NYHA Class III and IV heart failure. The same is true for rosiglitazone, another TZD that has been associated with an increased risk of cardiovascular disease.

Mechanism of action:Mechanism of action: TZDs are peroxisome proliferator-activated receptor-gamma (PPARgamma) agonists.

Effects:Effects: TZDs decrease insulin resistance, increase glucose uptake in peripheral tissue, decrease hepatic glucose production, decrease vascular inflammation, redistribute visceral adipose tissue peripherally, and preserve beta cell function. Overall, they cause the A1c to decrease by 1% to 1.5%. Hypoglycemia is not associated with this medication class. TZDs have differing effects on lipids. Pioglitazone slightly reduces LDL levels and raises HDL. Rosiglitazone can increase LDL levels.

Side effects:Side effects: The receptors that TZDs activate are ubiquitous and are

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abundant in the cells within the renal collecting tubules. Hence, TZDs increase sodium reabsorption, leading to increased water retention. Compared to placebo, all TZDs are associated with a statistically significant increase in edema and weight.

Warnings:Warnings: Care should be used with these agents in patients with liver disease. Serum transaminases greater than 2.5 times the upper limit of normal is a contraindication to initiation of these agents, and a rise to greater than three times the upper limit of normal should lead to their discontinuation. Liver tests should be measured at baseline and periodically while the patient is on this class of medication.

Contraindications:Contraindications: The FDA has added a warning to the label of pioglitazone noting an increased risk of bladder cancer after more than one year of treatment. Pioglitazone is now contraindicated in patients with a history of bladder cancer or active bladder cancer. Patients should be counseled to tell their physician if they notice blood in their urine or a red tint to their urine.

No precautions are needed when using aspirin, glipizide, or simvastatin in patients with a reduced ejection fraction.

BLOOD GLUCOSE MONITORING HISTORY

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You continue your interview with Mr. Morales and ask him:

“Have you brought your blood sugar log with you today?” He hands you his blood sugar log proudly. Over the last four weeks, you see that his morning fasting readings are ranging 130-169 mg/dL, including before-lunch readings of 151-247 mg/dL, before-supper readings of 184-211 mg/dL, and before-bed readings of 158-305 mg/dL. There are no recorded readings under 70 mg/dL (3.9 mmol/L).

“Some days you have many readings over 200 mg/dL. Is there anything diUerent going on on those days that you can think of such as eating larger meals?” “Oh, those are the days after I didn’t take my insulin shot. The readings are always higher on those days.”

“Have you had any low blood sugars?” “I feel like I have low blood sugar several times a week, and I eat a Snickers bar because I’m afraid of passing out and going into a coma. I feel like I’m going to die — shaky, sweaty, jittery! I don’t check when I feel this way, I just eat as fast as I can – I can tell when my sugar is low.”

See the associated reference ranges in conventional and SI units.

The best option is indicated below. Your selections are indicated by the shaded boxes.

Hypoglycemia It is important at each visit to ask diabetic patients if they have experienced any hypoglycemic symptoms or events that required the assistance of another person.

Often times, when a patient is hypoglycemic, he does not write it down because he is preoccupied treating the hypoglycemia.

When to Refer Patients with Diabetes to an Endocrinologist If a patient is having recurrent or severe hypoglycemia (seizure, coma, or impairment that requires the aid of another person), an endocrinologist should be consulted. Hypoglycemia is defined as a blood glucose <70 mg/dL.

Primary care physicians’ threshold for referral varies across providers. Other conditions that would warrant referral are when a patient’s A1c is 8% more than twice in a 12-month period, despite intensive treatment; for initiation of a complex multiple daily injection insulin regimen; or for initiation of continuous infusion insulin pump therapy.

Question Can patients accurately detect hypoglycemia by symptoms alone?

A. Yes

B. No

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Answer Comment > The correct answer is B> The correct answer is B

Self-Monitoring Glucose: Indications & EUectiveness

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Self-Monitoring Glucose: Indications & EUectiveness Effectiveness of Self-Monitoring Blood GlucoseEffectiveness of Self-Monitoring Blood Glucose

Patients should be advised to check their blood sugar if they feel “low” because it is well recognized that people are not able topeople are not able to accurately detect hypoglycemia (blood glucose of < 70 mg/dL)accurately detect hypoglycemia (blood glucose of < 70 mg/dL) by symptoms aloneby symptoms alone. Eating high carbohydrate food to treat perceived hypoglycemia rather than actual hypoglycemia leads to worsened overall glycemic control.

Clinical studies have shown that self-monitoring of blood glucose (SMBG) may improve glycemic control, although for some patients self-monitoring increases depression and anxiety. It is important to evaluate patients’ abilities to use SMBG techniques to ensure they are using accurate data to evaluate their response to therapy and their degree of success in reaching blood-glucose targets. After receiving education, patients can use SMBG data to adjust their activity level, food intake and choice, as well as drug therapy to achieve optimal glycemic control.

When to Self-Monitor Blood GlucoseWhen to Self-Monitor Blood Glucose

In patients on less frequent insulin injections, SMBG may be useful in achieving glycemic goals.

Patients on an insulin pump and those using multiple daily insulin injections should self-monitor blood glucose at the following times:

before each meal at bedtime when they have symptoms of hyper- or hypoglycemia after treating hypoglycemia to ensure return of euglycemia before exercise before critical activities, such as driving

Blood Glucose Goals

HealthyHealthy *Medically*Medically **Very**Very MedicallyMedically

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AdultsAdults ComplexComplex AdultsAdults

ComplexComplex AdultsAdults

fasting andfasting and beforebefore mealsmeals

80-130 mg/dL (3.9- 7.2 mmol/L)

90-150 mg/dL

100-180 md/dL

one to twoone to two hours afterhours after a meala meal

< 180 mg/dL (10.0 mmol/L)

before bedbefore bed 100-130 mg/dL (5.6- 7.2 mmol/L)

100-180 mg/dL

110-200 mg/dL

*Medically complex adults have multiple co-existing chronic illnesses, two or more ADL impairments, or mild to moderate cognitive impairment.

**Very medically complex adults or adults in poor health have long term care or end-stage chronic illnesses, moderate to severe cognitive impairment, or two or more ADL dependencies.

See the associated reference ranges in conventional and SI units.

DIET HISTORY HISTORY You ask Mr. Morales about diet and physical activity.

“Can you tell me what you typically eat in a day?” “I usually eat breakfast and lunch at McDonald’s or Denny’s. For breakfast, I usually have a bacon egg and cheese biscuit with hash browns and black coffee. For lunch, I have a sandwich, fries, and soda. If I’m really hungry, I get the “value” size of the fries and soda.”

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The best options are indicated below. Your selections are indicated by the shaded boxes.

“What drinks and snacks do you typically eat during the day?” “I drink Coke with lunch, whole milk with supper, and usually have a big bowl of fudge ripple ice cream before I go to bed. If I’m hungry in the afternoon, I’ll grab a pack of cookies from a vending machine.”

“And what do you have for dinner?” “My wife and I eat supper at home. We share the cooking. Usually, we have fried or stewed meat with gravy, rice, or pasta along with rolls. Sometimes we have vegetables cooked with side meat.”

“Are you able to do any exercise during the week?” “Except for moving around at work, I didn’t get much exercise before. Since my heart surgery, I feel short of breath just walking to the mailbox at the end of the driveway!”

“Do you have any chest pain or sweating?” “Not really.”

SCREENING FOR COMPLICATIONS HISTORY You now decide to focus your history on screening for complications of diabetes:

“Are you having any trouble with your vision?”

“How about numbness or tingling in your hands or feet?”

Question Which of the following are types of neuropathies a patient with diabetes might develop? Select all that apply.

A. Distal symmetric polyneuropathy

B. Postural hypotension

C. Gastroparesis

D. Erectile dysfunction

E. Resting tachycardia

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Answer Comment > The correct answers are A, B, C, D, E> The correct answers are A, B, C, D, E

Diabetic Neuropathies It is estimated that 50% of patients with diabetes will eventually struggle with one or more neuropathies related to their diabetes.

Axonal loss and atrophy are responsible for the majority of clinical symptoms and loss of function in patients with neuropathy. There can also be evidence of demyelination and remyelination, with the actual number of large nerve fibers being reduced, while small nerve fibers increase.

Distal polyneuropathyDistal polyneuropathy

Distal polyneuropathy is the most common type of diabetic neuropathy. It is the progressive loss of sensation in the classic stocking/glove distribution. Diabetic foot ulcer incidence is greatly increased in patients with distal polyneuropathy.

Autonomic neuropathyAutonomic neuropathy

Autonomic neuropathy can take many forms and affect one or many organs. Specific types include:

cardiovascular (orthostatic hypotension, resting sinus tachycardia, postprandial hypotension)

gastrointestinal (gastroparesis, chronic constipation, esophageal motility disorders)

genitourinary (sexual dysfunction, neurogenic bladder)

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abnormal pupillary responses and disorders of hidrosis

OBESITY MANAGEMENT MANAGEMENT You leave the room so that Mr. Morales can disrobe for your exam. Dr. Clay asks what you have learned so far.

You present the history to Dr. Clay and tell her that you are particularly concerned about Mr. Morales’ diet. You and Dr. Clay look at the triage sheet and see that Mr. Morales’ height is 176.5 cm (69.5 inches) and his weight is 123 kg (272 lbs). You calculate his BMI: it is 39.6 kg/m .2

Body Weight Management in Patients with Diabetes

ClassificationClassification BMI in kg/mBMI in kg/m22

Normal 19-24

Overweight 25-29

Obese 30-39

Morbidly obese 40+

Maintenance of a healthy body weight is essential in the management of patients with diabetes. However, for some patients, attainment of an ideal body weight is too large a goal, especially if they are morbidly obese. Studies have shown that a modest weight loss of approximately 5-10%modest weight loss of approximately 5-10% of the current weight can lead to significant improvement in glycemic control, blood pressure control, and lipid parameters.

Question

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Which of the following are appropriate approaches to addressing Mr. Morales’ obesity and diet? Select all that apply.

A. Referral to a registered nutritionist for medical nutrition

therapy.

B. Office-based, brief dietary counseling.

C. Referral to an accredited diabetes care center for diabetes

management self education.

D. Patient materials about diet and exercise.

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Answer Comment > The correct answers are A, B, C, D> The correct answers are A, B, C, D

Mulitdisciplinary Approach to Diabetes Care The care of the patient with diabetes is a team endeavor. Through a multidisciplinary approach, patients can be offered the very best chance of optimizing their blood glucose control and reducing their risks of morbidity and mortality.

Refer to a registered nutritionist for medical nutrition therapy regarding daily food choices and portion sizes.

Refer to an accredited diabetes care center for diabetes management self-education, both in group and one-on-one settings. Numerous studies have shown that diabetes management self- education is effective in improving patients’ self-care behaviors, lowering their A1c, improving their knowledge of diabetes and enhancing their quality of life.

Office-based counseling of basic ADA recommendations for diet and exercise can be reviewed with the patient. For example, patients can be taught how to monitor his carbohydrate intake through carbohydrate counting, food exchanges, or self-reflection. Thirty minutes of moderately intense exercise, more days than not, may be a good recommendation for many patients. Less than 10% of daily

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calories should be from fat. Patient education materials are a useful adjunct to office-based

counseling, and can be found at the ADA website section on diet/exercise.

BLOOD PRESSURE MANAGEMENT MANAGEMENT

You recheck Mr. Morales’ blood pressure manually.You recheck Mr. Morales’ blood pressure manually.