Monday , October 23 2017
Home / Resources / Clinical Gems / Managing Clinical Problems in Diabetes, Case Study #7: Mrs. RS

Managing Clinical Problems in Diabetes, Case Study #7: Mrs. RS

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

DCMS30_CG_Image

Mrs. RS was referred to an endocrinologist by her GP:

“Mrs. RS is a 60-year-old woman with type 2 diabetes. She has a strong family history of hypercholestaemia, hypertension and cardiac disease. She smokes 10-12 cigarettes per day and had CAGS (coronary artery bypass grafts) 2 years ago. Her HbA1c is 9.6% and she is obese. She has xanthomata on her hands and lipaemia retinalis….

Current medications:
  • Metformin 2 g BD
  • Glimepiride 4mg daily
  • Gemfibrosil
  • Aspirin
  • Atorvastatin 80 mg daily
  • Amlodipine
  • Valsartan
The dietitian told her to try harder with her diet and do more exercise and the diabetes educator told her to stop smoking. Most things seem to be reasonably controlled, but she is complaining of aching joints. Please assess and advise.”
 
Podiatrist

Mrs. RS’ feet need to be assessed to rule out peripheral neuropathy and arterial disease before Mrs. RS starts walking, which like other weight bearing exercises is not recommended if these conditions are present. Alternatives include non-weight bearing exercise such as using an exercise bike, swimming, or upper body exercises. I would suggest she consults an exercise physiologist or physiotherapist experienced in managing chronic diseases who could advise about a safe exercise program. 

A podiatrist could advise about appropriate footwear and pain management if the aching joints include her feet. Obese people often suffer from foot pain, commonly through injury to the plantar fascia (arch). The podiatrist could recommend stretches. Modify her footwear, for example by providing inner soles, or local strapping of the feet.

 
Diabetes educator

The last statement on the referral: ‘Most things seem to be reasonably controlled . . .‘ is belied by Mrs. RS’ obesity, HbA1c, complication status, and probably lipid levels, which were not provided, but are likely to be high given the lipaemia retinalis and xanthoma. I would refer her to an endocrinologist for a thorough review, especially her lipid medications and OHA regimen. Statins may be contraindicated, depending on her lipid profile. She may have some renal impairment given her cardiovascular status. Considering her HbA1c and lipaemia she probably needs insulin. Glimepiride contributes to weight gain. Metformin might be contraindicated due to her cardiac status. In the first instance she might benefit from a short admission and an intravenous insulin infusion to reduce her lipid levels. She is at risk of acute pancreatitis as well as a cardiovascular event. 

A thorough pain assessment is indicated. Statins are known to cause myalgia and contribute to aching joints and this is a possible cause of her problem. Alternatively, her weight may contribute to her joint pain. People often stop taking statins because of aching joints. The possibility that Mrs. RS is having a silent MI should be investigated (ECG, troponins, cardiac enzymes) depending on the location of the pain and its onset and duration. Some of the weight gain could also be due to oedema as a result of her cardiac status. 

Given Mrs. RS’ lipid status, it would be important to tactfully establish whether she is taking her medicines. Bone density studies might be indicated given her obesity, age, and smoking habit, to determine whether she has an osteoporotic fracture. 

Mrs. RS has probably been repeatedly ‘nagged’ about her health status. A different approach is needed, for example discussing her life and health goals. Exercise may be difficult given her obesity and cardiac status. Cardiac rehabilitation or Tai Chi might be beneficial. An appropriate diet is essential but creative ways of providing dietary advice need to be devised and should consider her living arrangements, ability to shop and cook, financial status and nutritional status.

She is probably malnourished despite her obesity. 

She needs to stop smoking. She may be able to reduce or stop smoking if she was referred to a quit program. However, stopping smoking might contribute to weight gain and could be one reason she has not stopped. Psychological counseling might be beneficial if she agrees.

 
Endocrinologist

This woman should stop smoking. In addition she has lipaemia retinalis, which suggests very severe hyperlipidemia, possibly type 3. She needs apolipoprotein E and lipoprotein electrophoresis to evaluate whether she has severe hypertriglyceridemia. If so, statin therapy would be contraindicated and fenofibrate plus fish oil and possibly even nicotinic acid therapy may be needed. 

 
References:

Dunning T (2003) Care of People with Diabetes. Blackwell Publishing, Oxford.

Dunning T, Manias E (2005) Medication knowledge and self-management by people with type 2 diabetes. Australian Journal of Advanced Nursing 11: 172–181.

Durso S (2006) Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. Journal of the American Medical Association 295: 1935–1940.

Goldney R, Phillips P, and Fisher L (2004) Diabetes, depression and quality of life. Diabetes Care 27: 1066–1070.

National Heart Foundation (2001) Lipid Management Guidelines. National Heart Foundation, Melbourne.

Nissen SE, Wolski K (2007) Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. New England Journal of Medicine 356(24): 2457–2471.

The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about each case depend on the specific clinical issue; and (3) stimulate thought and discussion. 

The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.

Next Week: Another Case Discussion

For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetesalt

Copyright © 2008 by Blackwell Publishing Ltd, UK

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath