Mr. Powell is a 42-year-old gentleman with a history of hypertension and substance use disorder who was remanded to your jail this morning on a probation violation. He was living in a sober house in the community for the past 6 months, but returned intoxicated yesterday. He complains of fatigue, frequent urination, excessive thirst, and blurred vision. He also reports gradual weight gain and tingling and numbness in his extremities, which made performing chores in the sober house difficult. He reports that his problems really started about 2 years ago, and he has been in and out of jail, but really has not been fully checked out for these symptoms. His urination frequency is increasing and the volume of urine each time is lessening. He reports seeing ants around the toilet bowl every morning for about 2 weeks. He drinks a lot of water (about half gallon daily), but there has been no improvement. He is concerned because his brother and parents had diabetes.
Review of systems
A ROS is positive for the symptoms related in the HPI: polyuria, polydipsia, paresthesia, blurred vision, fatigue, and weight gain. The patient reports dry skin, cuts, and bruises that are slow to heal, poor dentition, and abdominal bloating. The ROS is negative for fever, chills, headaches, diarrhea, or vomiting. He denies blood in the urine, dysuria, or urge incontinence and has no known history of sexually transmitted diseases. He has no chest pain, stomachache, backache, extremity pain, or edema.
Relevant History
Mr. Powell reports a medical history of hypertension (diagnosed 5 years prior but currently not taking any medication). He also has a history of substance use disorder involving alcohol. He has had counseling from a behavioral health specialist at the sober house. He has no history of surgery or hospitalization. Both parents died in their early 60s from complications of diabetes. An older brother was diagnosed with type 2 diabetes at age 42 and prostate cancer at age 50. Since graduating from high school, Mr. Powell has worked as a long-haul truck driver. He had planned to return to this line of work after completing his court probation, although this may change because of this return to incarceration. He is divorced and has two adult sons; both are in good health. His diet consisted of fast food and he had little time to exercise as a trucker. He smokes half a pack per day.
Allergies: No known drug allergies; no known food allergies.
Physical Examination Vitals: T 37°C (98.6°F), P 80, R 14, BP 150/88, WT 109 kg (240.3 lbs), HT 175 cm (68.9 in.), waist circumference 42 in., BMI 35.6.
Physical Examination
General: Well-developed and nourished middle-aged man in no acute distress.
Psychiatric: Mildly anxious, animated affect, engages easy in conversation.
Skin, Hair, and Nails: Skin dry with discoloration in body folds, no rashes, or bleeding tendency. Hair intact. Nails yellow and brittle.
Head: Normocephalic.
Eyes: Vision reduced bilaterally (OS 30/20; OD 40/20); pupils equal, round and reactive to light. Intraretinal hemorrhages, exudates, and cotton wool spots in both eyes.
ENT/Mouth: Tympanic membrane pearly, grey with no fluid. Oral mucosa moist; dentition poor with multiple caries noted.
Neck: Supple with no adenopathy or thyroid enlargement.
Chest: No deformities noted.
Lungs: Clear to auscultation bilaterally.
Heart: S1 S2, RRR, without murmur, gallop, or rubs.
Peripheral Vascular: reduced dorsalis pedis and posterior tibial pulses palpated (2/4).
Abdomen: Soft, non-tender to palpation, with no masses. Active bowel sounds in all four quadrants. No hepatomegaly appreciated. Obese.
Genital/Rectal: No penile or testicular abnormalities noted. Prostate within normal limits. Lymphatics: No cervical, axillary or inguinal lymphadenopathy.
Musculoskeletal: No deformities, tenderness, or edema. Full range of motion in all joints. Neurologic: A&O×4; cranial nerves II to XII grossly intact. Reflexes present in all extremities. Mild defects on monofilament sensation soles of both feet.
Point-of-care laboratory testing revealed a random blood glucose of 340 mg/dL and urine with 3+ glucose and no ketones. An EKG was obtained to document baseline cardiac function and indicated normal sinus rhythm with mild left ventricular hypertrophy.
Diabetes insipidus is associated with frequent urination and excessive thirst, but the occurrence of high blood glucose of 340 mg/dL rules this out.
Overactive bladder is a consideration, as polyuria is a common presentation. These patients also have a sudden urge to urinate and may experience incontinence, but Mr. Powell denied any of these symptoms.
Diabetes mellitus (DM) is high on the differential. Patients with DM generally present with frequent urination, excessive thirst, fatigue, blurry vision, cuts/bruises slow to heal, weight change, and extremity tingling. They also have increased plasma glucose levels as well as abnormal glucose in urine. Mr. Powell has all these symptoms. He also has significant risk factors for DM, such as obesity, family history of diabetes, sedentary lifestyle, and middle age.
Urinary tract infection is not high on the differential list because of the absence of dysuria, fever, chills, and lower abdominal or back pain; UTI is uncommon in men of Mr. Powell’s age. Frequent urination is a common symptom of UTI, but he does not present with any other symptoms.
Benign glycosuria is a consideration. Patients with benign glycosuria have normal or low concentrations of blood glucose and have no apparent symptoms. Mr. Powell presented with an elevated blood glucose and complained of many symptoms that make a diagnosis of benign glycosuria unlikely.
Benign prostatic hyperplasia can result in frequent urination in a male >40 years. Physical examination of the prostate was negative for prostate enlargement.
Diabetes Mellitus Type II.
Mr. Powell presented with frequent urination (polyuria), excessive thirst (polydipsia), fatigue, blurry vision, cuts/bruises slow to heal, weight changes, and tingling (paresthesia), all of which are common signs and symptoms of Type II DM. He had significant risk factors such as family history of diabetes, sedentary lifestyle, obesity, and middle age. The physical examination findings are consistent with symptoms of diabetes: intraretinal hemorrhages, exudates and cotton wool spots, dry skin, discoloration in body folds (acanthosis nigricans), and the reduced peripheral pulses. The patient satisfied the diagnostic criteria:
A1C ≥ 6.5% (48 mmol/mol). [obtained during initial evaluation and results of 8.8% received that evening]
A random plasma glucose ≥ 200 mg/dL (11.1 mmol/L) in a setting of classic symptoms of hyperglycemia.
Absence of ketones suggests a diagnosis of Type II Diabetes rather than Type I. Further testing will be done to differentiate between Type I and Type II DM.
DM is a chronic metabolic disease caused by either absolute or relative insulin deficiency or varying degrees of insulin resistance resulting in high blood glucose levels (hyperglycemia). If pancreatic beta cells do not produce enough insulin or the body does not respond to the insulin, glucose builds up in the blood instead of being used by the cells, leading to prediabetes or diabetes. Over time, high blood glucose damages nerves and blood vessels leading to complications. Diabetes is classified into the following general categories.
Type 1 DM (due to beta-cell destruction leading to insulin deficiency).
Type 2 DM (progressive loss of insulin secretion on the background of insulin resistance).
Gestational DM (diagnosed in the second or third trimester of pregnancy).
MODY—Maturity-onset diabetes of youth caused by mutations of different types: Most common forms are glucokinase and HNF alpha mutations.
LADA (type 1.5 DM)—Latent autoimmune diabetes of adults is a form of type 1 diabetes that develops during the adult years. It is sometimes misdiagnosed as type 2 diabetes given the adult onset and similarities with type 2 diabetes.
Long-term complications of diabetes are due to microvascular and macrovascular disease. The pathophysiology of diabetes-related complications involves multiple metabolic pathways.
Results
Labs drawn and results:
HbA1C to check for the average level of blood glucose of the past 3 months: 8.8%.
Fasting plasma glucose: 145 mg/dL.
Fasting lipid profile: Total lipids: 246 mg/dL; LDL: 164 mg/dL, HDL: 38 mg/dL, triglycerides: 202 mg/dL.
10-year ASCVD risk: 16.5% (intermediate; according to American College of Cardiology).
Pancreatic assays revealed a mean C-peptide level of 5.0 ng/mL, and islet cell antibody testing was negative.
CBC values all were in normal range.
CMP results were within normal limits except for glucose.
Serum creatinine: 1.06 mg/dL.
eGFR: 55 mL/min/1.73 m2.
Urinary albumin-to-creatinine ratio was 32.
TSH was 0.7 μ/L.
PSA was 2.5 ng/mL.
Mr. Powell was administered 10 units of regular insulin and was admitted to the Infirmary, where his blood sugars were monitored hourly until they were under 200 mg/dL. Hydration was encouraged. He was placed on metformin (500 mg BID) for DM, with a sliding scale AM and PM based upon blood glucose readings; lisinopril (10 mg) for HTN, a moderate dose statin (atorvastatin 40 mg daily) for hyperlipidemia, and low-dose aspirin (81 mg daily).
Mr. Powell was scheduled for daily provider evaluations in the Infirmary, and multiple patient education sessions with nursing staff to review Diabetes Mellitus and self-care. He was enrolled in the Chronic Disease program at the facility and was scheduled to be seen in two weeks.
Although Mr. Powell had family members with diabetes, patent education began with the basics. Patient education included use of a glucometer and lancets, with return demonstrations indicating competency. Mr. Powell was encouraged to quit tobacco. A heart-healthy diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish was recommended. Finally, the signs and symptoms of hyperglycemia and hypoglycemia were reviewed with Mr. Powell and the importance of notifying healthcare staff should any signs appear. Mr. Powell had ample time to have his questions answered.
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