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A Case Study of a Patient with Type 2 Diabetes

Table of contents, overview of health history, the overview of social history, family background, main health and social challenges, history of her health interventions (effectiveness/ineffectiveness), the history of social interventions (effectiveness / ineffectiveness).

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Home Essay Examples Health Type 2 Diabetes

Diabetes Type 2: Case Study

• Category Health
• Subcategory Disease
• Topic Type 2 Diabetes

This assignment will provide and outline a patient case study. It will critically analyse the health issue of the patient, explore and take account of the culture, socioeconomic factors, discrimination, and ethnicity. Additionally, it will also outline critically the patient’s service provision and individualised policy, practice delivery care and services the patient received. It will conclude by outlining the main issues and the challenges that arises in the discussion of the case study about the health and social practice and policy. Finally, recommendations will be made to the policies, governmental guidelines and future practice that meet the needs in this case study.

• SH6053: Type 2 Diabetes
• Name: Mrs. B
• Gender: Female
• Date of Birth: 02/03/1945
• Sexual Orient: Heterosexual
• Marital Status: widow
• Nationality:
• Cultural Background: Irish
• Religion: Christian

Overview of Health History

Mrs B reports having a fairly unremarkable medical past, until her retirement age; when she needed a hip operation after a fall. She recalls her health started to struggle when she was diagnosed with type 2 diabetes and hypertension at the age of 61. She had a stroke in 2005 and it was recently identified by her GP that after the stroke she developed a slight cognitive impairment, with the GP identifying this as the reason for her memory problem. Mrs B used to be a heavy smoker before she had the stroke. She drinks occasionally and described her diet as being usually healthy with one or two heavy meals during the week.

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The Overview of Social History

Mrs B was born in the East Midland to an English mother and Irish father, she is the only surviving child of five siblings. Mrs B left school at the age of 15 and went on to work in a holiday Inn as kitchen porter. She left the job after few years to be married and raise her family. Mrs B never went back to work again. She had financial support from the government and also obtained a small amount of pension from her late husband’s place of work.

Family background

Mrs B is a 74-year-old woman, who currently lives alone in a council property in the East Midlands. She was married in the mid 1960s and she has three children. They all live locally. Her husband used to work in a manufacturing factory until he retired due to health issues and unfortunately passed away in the mid-90s. Since then she has been living alone but moved from her family house to a smaller council flat in 2000. Mrs B is a Christian and attend church locally every Sunday church locally. She relies on her son to take her to church and shopping, whenever her son is not available to take her, she would not able to attend due to her health issue.

Main Health and Social Challenges

Mrs B did not have a good start in life. she stopped going to school at the age of 15 and went on to work at an early age, start family life by getting married and having children. Her biggest challenge was when she lost her husband and moved from her family home to a smaller apartment. Mrs B’s another major challenge was when she was diagnosed with type 2 Diabetes, hypertension and stroke in the year 2005. She is now in her 70’s and since after the stroke, she was unable to manage her medication. In this issue, she risks more complications, mainly because the medication helps her in reducing hypertension (high blood pressure) also reduced the persistent of high level of blood glucose circulating due to a significantly reduce response to insulin or the lack of insulin in the body

History of Her Health Interventions (Effectiveness/Ineffectiveness)

Following her visit to the GP, her GP conducted an assessment on mental capacity to see if she could able to make her own decision regarding her health care, the GP also identified that although Mrs B had a stroke as well as cognitive problems, and notwithstanding, she still have the mental ability to make decisions concerning her treatment and care. However, it is also important to note that whenever she visits the GP, her presentation might be altered. For instance, she sometime become confused and forgetful. Which make it important for her mental capacity to be assessed once again, before obtaining her consent in other for the care and procedures to be delivered.

The History of Social Interventions (Effectiveness/infectiveness)

Mrs B believes she has the ability to make decisions by herself regarding her treatment and care. During the GP earlier assessment, she clearly stated she did not need any support, that she could manage independently without any help. While, her children told her to accept some support in the case of them not able or available to help. Although, she still felt that she could manage without any help. Mrs b also stated that she did not want ‘people’ (social services) ‘snooping and interfering’ because she does not trust them as they might probably decide to put her in a nursing home’.

Diabetes is said to be a serious and chronic disease that happened when the body does not produce sufficient insulin or when the body cannot respond effectively using the insulin it produces. While Insulin is hormone that controls blood glucose due to non-existence of insulin in the body or a notably weaken the function or the response of insulin in the blood (Diabetes UK, 2010). Also, diabetes has great impact on the health and wellbeing of individuals, families, people and society. It is as well suggested that 9.6 % of all adults affected with diabetes in UK are men while, 7.6 per cent are women (Public Health England, 2016).

Diabetes affect more than 1.4 million people in the UK (Diabetes UK, 2010) diabetes has two types, type 1 and type 2, both having one thing in common by persistent of high level of blood glucose circulating; due to a significantly reduce response to insulin or the lack of insulin in the body or to both factor combination. Type 1 diabetes is when the glucose in the body is too high and cannot produce enough hormone called insulin. Insulin administration is required daily to regulate the glucose amount in the blood, because the body immune has destroyed the insulin. Type 2 diabetes on the other hand, is when the insulin in the pancreas (Beta cells) makes in the body that cannot work properly, and the amount of insulin produce in the cell is reduced in the body by the level of insulin resistance inside the body. In most case insulin resistance is connected with being overweight and lifestyle factors where patient’s metabolic reaction toward insulin stop reacting.

Mrs B has type 2 diabetes, she identified herself as a Christian living in a small community of older people and her children lives close by, she had a quite a number of social supports from friends in her church and her children. Being around her children and church member seem to keep her occupied. In terms of ethnicity, diabetes type 2 is more common among Black people, South Asians, of African-Caribbean origin and African (Diabetes UK, 2014). In addition, the South Asians people living in UK are 6 times more likely to develop the disease than the white population. And African-Caribbean and African population in UK are three times more likely to have the disease than white people (Public Health England, 2018). On the other hand, (Diabetes UK, 2014) also stated that Obesity is 80-85% another risk factor of developing type 2 diabetes.

According to Diabetes UK, (2017) noted, it was estimated that there are nearly 1 million people living with diabetes in UK, that are undiagnosed having type 2 diabetes. Furthermore, globally the prevalence of diabetes in adults is between the age of 20 and 79 and it was also estimated that globally in 2012, the disease affected 382 million people. In the UK, the number of growing elderly population mostly affected are aged 65 and current the figures of (Office for National Statistics, 2010) suggested that over the last 25 years 15 per cent increased in 1984 to 2009 as well as, 16 per cent rise of 1.7 million people. While Diabetes UK (2010) stated that the national trend was reflected on evidence of people over the age of 65 on local level in East Midlands where Mrs B lives suffer diabetes.

Type 2 diabetes has one of the greatest links with obesity. Although, nearly two in every three individuals in UK are obese or overweight with 65.7% of men and 61.9% of women. Also, in 2006, about one in four kids in England that were measured in reception year are obese or overweight. While, in year six the rate is almost one in three. Furthermore, in UK, high levels of men meet the recommended levels of physical activity than women (Diabetes UK, 2010); however, moderate 30 minutes physical intensive activity a day for five day a week was recommended for everyone by the department of health. Additionally, deprivation is strongly linked with greater levels of obesity, physical inactivity, unhealthy diet and lower level of blood pressure control. However, each of these factors are for the people already diagnosed with the risk of developing serious complications of the health issues; such as type 2 diabetes (Diabetes UK ,2010). While at any given age, most individual in the UK are two times more likely than the average to have diabetes. Also, women who live in a home with low income are four times likely to be diagnosed with diabetes; than the individual’s who lives in the homes with highest income, (Diabetes UK. 2010) In Mrs B” s case, as noted above, she is been living alone in a council house with the effect of financial limitation to buy healthy food and to attend healthcare appointments.

On the other hand, in terms of socioeconomic factors, Mrs B inability to further her education and where she lives, might have influenced her health condition, while education is a vital means for improving one’s health and well-being, as with people with more education are probable more likely to learn about healthy behaviours. However, patients who had education might be more likely to understand their health needs, follow guidelines, able to communicate effectively with health care providers also able to advocate with their family and others. While, on the other hand, fewer resources and lower income means that individual with fewer education are more likely to live in communities that lack good health resources. Although, these communities are usually economically disregarded and might face more risk of poor health issues, due to, availability fewer means to supermarkets or further causes of healthy food and overflow of fast food outlets and restaurants promoting unhealthy foods. Additionally, socioeconomic factors like educational accomplishment, income and occupation is one of the major factors that influence health.

According to Salway et al., (2007) individuals on low-income might find it difficult to keep a stable healthy diet and the key cause of ill health is linked with economic factors, while poverty sometime results in disadvantaged and lack of nutrition. Furthermore, poverty might also lead to discrimination (both present and past) in addition to failure in national policy and corruption which is directly associated with shorter life expectancy and ill health, (Scambler G, 2019). Furthermore, (Scambler G), stated that having poor health is mostly linked with poverty and low income. However, it can be argued that such condition might affect the living condition of the individual such as housing, food as well as medical care. Although, with more effective approach in mind, promoting of health is intended at targeting groups who are at high risk on developing health issue such as type 2 diabetes. (Salway et al., 2007). Referring this to Mrs B case, moving from her family home to a smaller apartment and being lonely might also have contributed to her health issues.

In relation to service provision for Mrs B, as noted above, Mrs B clearly stated that she did not require any assistance and believes she could cope without any help. Also, during her GP earlier assessment, she clearly stated that she did not need any support, that she could manage independently. Meanwhile, her children told her to accept some support in the case of them not able or available to help. Though, she still felt that she could manage without any help. She also stated that she did not want ‘people’ (social services) ‘snooping and interfering’ because she does not trust them as they might probably decide to put her in a nursing home’. Although, evidence clearly shown that after she had been diagnosed with type 2 diabetes, she was unable to manage taking her medication and also relies on her children to take her to church and shopping, whenever her son is not available to take her, she would not attend.

She is also unable to go out to do shopping or have social activities on a daily basis. With these, no proper evidence of socialising, eating healthy meal and her poor compliance of medication was mention in her case which might suggest; that she might require some care as well as social support. The Mental Capacity Act (MCA) (2005) stated, that there is a well-defined reference mentioned on decision-making process of individuals and on how individuals make ‘unwise decisions. In considering the circumstance surrounding Mrs B case, it seems she is making unwise-decision by not accepting help, although with her GP assessed Mrs B seems to have the ability and capacity of making her own choice based on her own informed value and belief.

While Mrs B declined to be assessed by social service on the view of receiving support care at home, potentially there would be many other support venues, that might be available and may also be a beneficial in improving her health condition and quality of life. With regard to the issue of compliance with her medication, there could be other possible ways to prompt her taking her medication, such as to explore some medication resources like medication alarms that remind individual to take their medication which can be purchase in the chemist or suggest to family to ring her. Additionally, by not taking her medication could put her in further risk of health complications, as mainly because the medication helps her in reducing hypertension (high blood pressure) also reduced the persistent of high level of blood glucose circulating due to a significantly reduce response to insulin or the lack of insulin in the body (Department of Health, 2001).

While it is important for her to continue maintaining her social life link as being elderly, Mrs B meet her religious need by attending church service where she socialises church other member before being taken home. According to (Valtorta, 2012) noted, social isolation is one factor that contribute to other health issue such as loneliness and depression, tackling these problems would consequently has the effect to reduced health inequalities along with improving individual quality of life. However, Mrs B could not able to walk to shop sometime or attend church due to her feeling physically unwell, although, the only way to addressed the issue of loneliness and depression is to see if there is any other way to help and improve her social life through voluntary drivers in the church or any other scheme the council have in their area like ‘ring and ride’ car that she could take when her children are not able to take her. However, in Mrs B case, it might be good ideal to get her shopping delivered by voluntary agencies such as Age UK and many others that may also assist her or offer her support like ordering reading meals food from some large supermarket and company that are specifically arranged to deliver food to elderly.

According to (Singh, 2009) confirmed, that Age UK, also offer different kind of service such as ensuring that Mrs B needs, and entitlement are met by helping her in reviewing her benefits and offer her befriender that might also help her to reduce further risk of social isolated mainly when her children are away.

As previously identified in the case study confidentiality plays a significantly part in the relationship between patient and doctor and the responsibility of confidence arises when individual discloses information to another person in situations that is expect for the information will be held in confidence (Department of Health 2003). However, patient relationship is built successfully, this sequentially encourage the patient to release useful information about their health without hesitation. While not trusting might prompts an impersonal and self-justification attitude to medication by the patient and clinician, which could lead to the deterioration of the quality of profession life and patient care (Guttman, 2017).

Although, during Mrs B visit to GP for assessment, one can assume that the GP conduct medical assessment, like taking her blood and doing her blood pressure; the GP could have asked her prior on carrying out both procedure which she approved on both cases NCM, (2015). However, obtaining consent is a process and important part of health care practitioners’ duties by ensuring that a consent is obtained from the patient before any care procedure can be carried out, also regards and respect must be given to individual who decline treatment. According to (NCM, 2015) stated, that code of professional practice clearly outlines guidance with regard on how to obtain consent and when fail, could be seen as the act of a breach of conduct. One of the issues identified in Mrs B case study, is the issue of code of conduct which highlight individuals that lack capacity and the issues of consent. Furthermore, the (Mental Act, 2005) is intended to protect individual who can’t make decisions for themselves or lack the mental capacity to do so. However, this could be due to a mental health condition, a severe learning difficulty, a brain injury, a stroke or unconsciousness due to an anaesthetic or sudden accident (NHS Choices, 2018). The purpose of the act is to ensure individuals are able to make as many choices for themselves as they can and as a measure of protection for individuals who may not be able to make decisions for themselves due to the reasons listed above.

In conclusion, this assignment has discussed a case study that mainly focused on a health issue in which the patient in the case study was suffering from type 2 diabetes and the assignment also explore the intervention individualised care the patient received. However, there are many issue that can present when a patient been diagnosed with type 2 diabetes, the assessment also show that the main key issue in the case study is on how to control Mrs B diabetes, although, in other to control her diabetes, she needs to accept social service assessment for her to received home care support, maintain effective contact and family involvement and also for her to compline with her medication and furthermore, by encouraging her to accept services that is available.

Taking into account of the issue of type 2 diabetes, which have already increased over the last 25 years, it is obvious that more has to be done in safeguarding and protect the future occurrences of type 2 diabetes in UK. It will be suggested to add to the general nursing approach to individualised care by providing effective regular and appropriate home care sitting, providing effective assessment, teaching plan to help patient to maintain and control their blood sugar level.

• Department of Health. (2005). Mental Capacity Act. London: HMSO. Available at: http://www.legislation.gov.uk/ukpga/2005/09 (Accessed March 18, 2019)
• Department of Health. (2003). Confidentiality NHS code of practice. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/200146/Confidentiality_-_NHS_Code_of_Practice.pdf. Google automatically generates HTML (Accessed July 18, 2019)
• Department of Health, (2001) (high blood pressure) hypertension. Available at www.dh.gov.uk/publications (Accessed May 15, 2019).
• Diabetes UK (2014) version 3. Available at: https://www.diabetes.org.uk/resources-s3/2017-11/diabetes-key-stats-guidelines-april2014.pdf. (Accessed May 20, 2019)
• Diabetes UK (2017), Diabetes Prevalence 2017 (November 2017), Available at: https://www.diabetes.org.uk/professionals/position-statements-reports/statistics/diabetes-prevalence-2017 (Accessed March 09, 2019)
• Diabetes UK (2010), Key statistics on diabetes (March 2010) Available at: https://www.diabetes.org.uk/resources-s3/2017-11/diabetes_in_the_uk_2010.pdf. (Accessed March 20, 2019)
• Guttman,N. (2017). Ethical Issues in Health Promotion and Communication Interventions. Oxford Research Encyclopedia of Communication. Ed. Available at: https://oxfordre.com/communication/view/10.1093/acrefore/9780190228613.001.0001/acrefore-9780190228613-e-118. (Accessed March 20, 2019)
• Nursing & Midwifery Council. (2015) The code: Professional standards of practice and behaviour for nurses and midwives. London: NMC. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-old-code-2008.pdf (Accessed May 11 2019)
• ‘NHS Choices – Your health, your choices’. www.nhs.uk. 15 August 2018. (Accessed May 19, 2019)
• Public Health England (2018) Health matters: preventing Type 2 Diabetes (May 2018), Available at; www.doh.gov.uk (Accessed March 20, 2019)
• Public Health England (2016) 38 million people in England now have diabetes Available at: https://www.gov.uk/government/news/38-million-people-in-england-now-have-diabetes. (Accessed July 09, 2019)
• Scambler G (2019) Sociology, Social Class, Health Inequalities, and the Avoidance of “Classism”. Front. Sociol. 4:56. doi: 10.3389/fsoc.2019.00056 Available at: https://www.frontiersin.org/articles/10.3389/fsoc.2019.00056/full (Accessed July 20, 2019)
• Singh A, Misra N. Loneliness, depression and sociability in old age. Ind Psychiatry J. 2009;18(1):51–55. doi:10.4103/0972-6748.57861 Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016701/. (Accessed July 22, 2019)
• Salway, S., Platt, L., Chowbey, P., Harriss, K. and Bayliss, E. (2007). Long-term ill health, poverty and ethnicity. Great Britain: Joseph Rowntree Foundation by The Policy Press, pp. 41, 43. (Accessed March 20, 2019)
• Valtorta, N., & Hanratty, B. (2012). Loneliness, isolation and the health of older adults: do we need a new research agenda?. Journal of the Royal Society of Medicine, 105(12), 518–522. doi:10.1258/jrsm.2012.120128 (Accessed March 20, 2019)

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Type 2 diabetes: a case study, priscilla cunningham nursing student, queen’s university belfast, belfast, northern ireland, helen noble lecturer, health services research, school of nursing and midwifery, queen’s university belfast, belfast, northern ireland.

Increased prevalence of diabetes in the community has been accompanied by an increase in diabetes in hospitalised patients. About a quarter of these patients experience a hypoglycaemic episode during their admission, which is associated with increased risk of mortality and length of stay. This article examines the aetiology, pathophysiology, diagnosis and treatment of type 2 diabetes using a case study approach. The psychosocial implications for the patient are also discussed. The case study is based on a patient with diabetes who was admitted to hospital following a hypoglycaemic episode and cared for during a practice placement. The importance of early diagnosis of diabetes and the adverse effects of delayed diagnosis are discussed.

Nursing Standard . 29, 5, 37-43. doi: 10.7748/ns.29.5.37.e9142

This article has been subject to double blind peer review

Received: 20 May 2014

Accepted: 15 July 2014

Blood glucose - case study - diabetes - glucose testing - hyperglycaemia - hypoglycaemia - insulin resistance - sulfonylureas - type 2 diabetes

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07 October 2014 / Vol 29 issue 5

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Type 2 Diabetes Essay

Introduction.

Diabetes is a health condition that is developed when sugar level in the blood increases above normal levels. The two major types of diabetes are type 1 diabetes and type 2 diabetes. Type 2 diabetes is more prevalent than type 1 diabetes. This essay discusses some of the most frequently asked questions about type 2 diabetes through a sample dialogue between a patient and a doctor.

Patient: What is type 2 Diabetes and how is it developed?

Doctor: Type 2 diabetes can be described as a complication in the metabolic processes characterized by a relative shortage of insulin and high levels of glucose in the blood (Barnett, 2011). It differs from type 1 diabetes where there is a complete deficiency of insulin caused by destruction of pancreatic islet cells.

In addition, type 2 diabetes is more common in adults unlike type 1 diabetes which is prevalent amongst young people. The typical symptoms of type 2 diabetes include: recurrent urination, excessive thirst, and persistent hunger (Wilson &Mehra, 1997).

Type 2 diabetes is caused by a mixture of lifestyle and hereditary factors. Even though some factors, like nutrition and obesity, are under individual control, others like femininity, old age, and genetics are not. Sedentary lifestyle, poor nutrition and stress are the major causes of Type 2 diabetes.

Particularly, excessive consumption of sugar and fats increases the risk of infection. Genetic factors have been linked to this condition. For instance, research indicates that if one identical twin is infected, there is a 90% probability of the other twin getting infected. Nutritional condition of a mother for the period of fetal growth can as well lead to this condition. Inadequate sleep is associated with Type 2 diabetes since it affects the process of metabolism (Hawley & Zierath, 2008).

Patient: How is type 2 Diabetes transmitted?

Doctor: Type 2 diabetes cannot be transmitted from one individual to another, since it is not caused by micro-organisms that can be spread. Instead, it is a health condition where the body is unable to create sufficient insulin to maintain the blood sugar level.

Nevertheless, a child from diabetic parents is likely to develop the complication due to genetic inheritance. According to Hanas & Fox (2007), there are some genes that may result in diabetes. As in 2011, research showed that there are more than thirty-six genes that increase the risk of type 2 diabetes infection.

These genes represent 10 per cent of the entire hereditary component of the complication. For instance, a gene referred to as TCF7L2 allele, increases the probability of diabetes occurrence by 1.5 times. It is the greatest threat amongst the genetic invariants. Children from diabetic parents are, therefore, likely to get infected since genes are transferrable from parents to the offspring.

Patient: How is type 2 Diabetes treated?

Doctor: The first step in the treatment of type 2 diabetes is consumption of healthy diet. This involves avoiding excessive consumption of foods that contain sugar and fats as they are likely to increase the levels of sugar in the blood. In addition, getting involved in physical activity and losing excessive weight are also important.

These management practices are recommended because they lower insulin resistance and improve the body cells’ response to insulin. Eating healthy food and physical activity also lower the level of sugar in the blood. There are also pills and other medications that can be injected when these lifestyle changes do not regulate the blood sugar (Roper, 2006).

Type2 diabetes pills function in different ways. Some pills work by lowering insulin resistance while some raise the level of insulin in the blood or decrease the rate of food digestion. Even though the non-insulin injected medicines for this condition work in complex ways, essentially, they lower the levels of blood glucose after injection.

Insulin injection treatment basically raises the insulin level in the blood. Another treatment for type 2 diabetes is weight loss surgery that is recommended for obese people. This treatment has been proved effective since most of the patients can maintain regular levels of sugar in their blood after surgery (Codario, 2011).

Multiple prescriptions can be applied in controlling the levels of blood sugar. Actually, combination treatment is a popular remedy for Type 2 diabetes. If a single therapy is not sufficient, a health care provider may prescribe two or more different kinds of pills.

For instance, individuals with type 2 diabetes have high fat levels in the blood and high blood pressure. Therefore, doctors can prescribe medicines for treatment of these conditions at the same time. The kind of medication prescribed depends on the health condition of the patient (Ganz, 2005).

Patient: What are the chances of survival?

Doctor: Diabetes is one of the major causes of deaths in the United States each year. Statistics indicates that it contributes to approximately 100,000 deaths every year. In the United States, there are over 20 million reported cases of diabetes, the majority being Type 2 diabetes. Proper remedy including change of lifestyle and medications is known to improve the health condition of a patient. If properly used together, lifestyle changes and medication can increase the chances of survival of a patient by up to 85 per cent (Rosenthal, 2009).

Barnett, H. (2011). Type 2 diabetes. Oxford: Oxford University Press.

Codario, A. (2011). Type 2 diabetes, pre-diabetes, and the metabolic syndrome. Totowa, N.J: Humana Press.

Ganz, M. (2005). Prevention of Type 2 Diabetes . Chichester: John Wiley & Sons.

Hanas, R., & Fox, C. (2007). Type 2 diabetes in adults of all ages. London: Class Health.

Hawley, A., & Zierath, R. (2008). Physical activity and type 2 diabetes: Therapeutic effects and mechanisms of action. Champaign, IL: Human Kinetics.

Roper, R. (2006). Type 2 diabetes: The adrenal gland disease : the cause of type 2 diabetes and a nutrition program that takes control! . Bloomington, IN: AuthorHouse.

Rosenthal, S. (2009). The Canadian type 2 diabetes sourcebook. Mississauga, Ont: J. Wiley & Sons Canada.

Wilson, L., & Mehra, V. (1997). Managing the patient with type II diabetes . Gaithersburg, Md: Aspen Publishers.

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Type 2 diabetes: a case study

Affiliation.

• 1 Queen's University Belfast, Belfast, Northern Ireland.
• PMID: 25270482
• DOI: 10.7748/ns.29.5.37.e9142

Increased prevalence of diabetes in the community has been accompanied by an increase in diabetes in hospitalised patients. About a quarter of these patients experience a hypoglycaemic episode during their admission, which is associated with increased risk of mortality and length of stay. This article examines the aetiology, pathophysiology, diagnosis and treatment of type 2 diabetes using a case study approach. The psychosocial implications for the patient are also discussed. The case study is based on a patient with diabetes who was admitted to hospital following a hypoglycaemic episode and cared for during a practice placement. The importance of early diagnosis of diabetes and the adverse effects of delayed diagnosis are discussed.

Keywords: Blood glucose; case study; diabetes; glucose testing; hyperglycaemia; hypoglycaemia; insulin resistance; sulfonylureas; type 2 diabetes.

Publication types

• Case Reports
• Anxiety / complications
• Depression / complications
• Diabetes Mellitus, Type 2 / diagnosis*
• Diabetes Mellitus, Type 2 / physiopathology
• Diabetes Mellitus, Type 2 / therapy
• Hypoglycemic Agents / therapeutic use
• Middle Aged
• Hypoglycemic Agents

• Diabetes & Primary Care
• Vol:23 | No:04

Interactive case study: Hypoglycaemia and type 2 diabetes

• 12 Aug 2021

Share this article + Add to reading list – Remove from reading list ↓ Download pdf

Diabetes & Primary Care ’s series of interactive case studies is aimed at GPs, practice nurses and other professionals in primary and community care who would like to broaden their understanding of type 2 diabetes.

The four mini-case studies created for this issue of the journal cover various aspects relating to hypoglycaemia and type 2 diabetes.

The format uses typical clinical scenarios as tools for learning. Information is provided in short sections, with most ending in a question to answer before moving on to the next section.

Working through the case studies will improve your knowledge and problem-solving skills in type 2 diabetes by encouraging you to make evidence-based decisions in the context of individual cases.

You are invited to respond to the questions by typing in your answers. In this way, you are actively involved in the learning process, which is hopefully a much more effective way to learn. By actively engaging with these case histories, I hope you will feel more confident and empowered to manage such presentations effectively in the future.

Active, 76-year-old Jean, who has type 2 diabetes, has experienced dizziness, confusion and speech slurring after gardening for several hours. A capillary blood glucose reading of 2.3 mmol/L was found.

How would you respond to her episode?

John, a 49-year-old HGV driver, uses metformin, gliclazide and alogliptin for his type 2 diabetes. Occasionally, he experiences mild symptoms of hypoglycaemia.

Would you make any changes to his medication?

Chinua has had type 2 diabetes for 13 years. He has recently switched from a basal insulin to a twice-daily premixed insulin. He has heard that his risk of experiencing hypoglycaemia may be higher.

What symptoms should Chinua be looking out for?

65-year-old Candice has collapsed at her type 2 diabetes review. Her capillary glucose reading is 1.7 mmol/L.

How can you manage this episode of severe hypoglycaemia?

By working through these interactive cases, you will consider the following issues and more:

• What constitutes hypoglycaemia.
• Its causes and risk factors in type 2 diabetes.
• Practical advice on its detection and management.
• Strategies for minimising the risk.

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Clinical pearls, article information, case study: diabetic ketoacidosis in type 2 diabetes: “look under the sheets”.

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Brian J. Welch , Ivana Zib; Case Study: Diabetic Ketoacidosis in Type 2 Diabetes: “Look Under the Sheets”. Clin Diabetes 1 October 2004; 22 (4): 198–200. https://doi.org/10.2337/diaclin.22.4.198

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Diabetic ketoacidosis (DKA) is a cardinal feature of type 1 diabetes. However, there is a strong, almost dogmatic, errant perception by physicians that DKA is a complication that only occurs in patients with type 1 diabetes. This is not true. DKA does occur in type 2 diabetes; however, it rarely occurs in the absence of a precipitating event.

R.T., a 25-year-old African-American man with type 2 diabetes presented with a 5-day history of nausea and vomiting. He also reported a 2-week history of polyuria and polydipsia and a 10-lb weight loss. A review of symptoms was pertinent for a 5-day history of persistent lower back pain.

The patient was diagnosed with type 2 diabetes 5 years ago when he presented to a different hospital with symptoms of polyuria, polydipsia, and weight loss. He was given a prescription for a sulfonylurea, which he says he took until his initial prescription ran out 1 month later. He had not taken any other medication since that time.

Physical examination revealed an afebrile, obese man (BMI 40 kg/m 2 ) with prominent acanthosis nigricans, no retinopathy by direct funduscopic exam, and a normal neurological exam, including motor function and sensation. The patient had no tenderness to palpation over the lumbrosacral spine or paraspinous muscles despite his complaint of lower back pain.

The laboratory data showed an anion gap, metabolic acidosis, and hyperglycemia (pH of 7.14, anion gap of 24, bicarbonate 6 mmol/l, urinary ketones 150 mg/dl, glucose 314 mg/dl) consistent with the diagnosis of DKA. His white blood count was 20,400/μl. Urinalysis demonstrated no evidence of infection. The patient's hemoglobin A 1c (A1C) was 13.5%.

The patient was admitted and treated aggressively with intravenous fluid and an insulin-glucose infusion. A non-contrast magnetic resonance imaging(MRI) of the lumbosacral spine (L-spine) was obtained because of the patient's persistent complaint of lower back pain. The L-spine MRI results were negative for pathology. However, R.T. reported increasing discomfort and now noted weakness and numbness in his bilateral lower extremities.

Neurology was consulted, and during their assessment, the patient became incontinent and was found to have 0/5 strength in the lower extremities,severely compromised sensation, and decreased rectal tone. A contrast MRI of both the thoracic and lumbar spine was ordered, and the patient was found to have a T10-T12 epidural abscess ( Figure 1 ).

Epidural abscess precipitating DKA in a type 2 diabetic patient.

The patient's antibiotic coverage was broadly expanded, high-dose intravenous steroids were initiated, and neurosurgery was urgently consulted. Emergent evacuation of the epidural abscess with laminectomies of T10-T12 was performed without complication.

R.T.'s neurogenic bladder resolved without further intervention. After intensive inpatient rehabilitation, he had 3/5 strength in bilateral lower extremities and was still unable to ambulate.

S.D., a 39-year-old white man with type 2 diabetes and mild mental retardation, presented with a 3-week history of polyuria and polydipsia, as well as dysuria, left hip pain, and a feeling of incomplete bladder emptying. Because of the severity of his left hip discomfort, the patient required a cane to ambulate.

The patient was diagnosed with type 2 diabetes 4 years ago on the basis of an elevated fasting blood glucose level during a routine medical examination. He was started on oral hypoglycemic agents, but he discontinued them after 1 month because he was unable to pay for them.

On physical exam, S.D. was afebrile but tachycardic (heart rate 131 bpm)and hypertensive (blood pressure 192/118 mmHg). General examination revealed a wasted, severely volume-depleted man. Thrush was observed on oropharyngeal exam. Cardiopulmonary and abdominal examinations were unremarkable. The patient had point tenderness on the anterior aspect of his left hip. Rectal examination revealed a non-tender prostate.

The laboratory data showed an anion gap, metabolic acidosis, and hyperglycemia (pH 7.24, bicarbonate 9 mmol/l, anion gap 24, urinary ketones 150 mg/dl, and glucose 322 mg/dl) consistent with the diagnosis of DKA. Urinalysis was remarkable for large blood, 4+ bacteria, and > 400 white blood cells. S.D.'s serum white blood count was 22,200, and his erythrocyte sedimentation rate was 109 mm/hour. His A1C result was 12.6%.

The patient was admitted and treated with intravenous fluids and an insulin-glucose infusion. Cultures were obtained. S.D. was started empirically on ticarcillin/clavulanic acid because of concern for left hip osteomyelitis and complicated urinary tract infection. An MRI of the left hip was ordered to evaluate for suspected osteomyelitis. Unexpectedly, it revealed left hip myonecrosis and a large loculated prostatic abscess( Figure 2 ).

Prostatic abscess precipitating DKA in a type 2 diabetic patient.

Urology was consulted, and the patient underwent transurethral drainage of the prostatic abscess. Methicillin-sensitive Staphylococcus aureus grew from both blood and urine cultures. S.D. was treated with intravenous antibiotics per culture sensitivities. The myonecrosis was treated conservatively.

The patient recovered well. He was started on subcutaneous insulin and discharged home to complete a 2-week course of intravenous antibiotics.

What is the mechanism of DKA?

Why does DKA occur in type 2 diabetes?

DKA is a cardinal feature of type 1 diabetes, which has led to the widespread errant perception that it is a complication unique to type 1 diabetes. However, it has been repeatedly reported that DKA does occur in patients with type 2 diabetes. 1 - 5   Moreover, as the cases presented here illustrate, it can occur even in patients who were previously insulinindependent.

A recent study evaluating 138 consecutive admissions for DKA at a large academic center observed that 21.7% had type 2 diabetes. 6   Nearly 70% of the admissions involved discontinuation of medications, and almost half had an identifiable infection when an intensive search was undertaken.

A review of the mechanism of DKA is important. Ketoacidosis occurs as a function not only of severe insulin deficiency, but also of elevated glucagon levels. Insulin is an anabolic hormone. Severe insulin deficiency results in decreased glucose utilization by muscle and an unregulated increase in lipolysis. This leads to an enhanced delivery of gluconeogenetic precursors(glycerol and alanine) to the liver. Furthermore, removal of the normal suppressive effect of insulin causes glucagon elevation. 7 , 8   Glucagon is a catabolic hormone. Glucagon promotes gluconeogenesis, decreases oxidation of free fatty acids to triglycerides, and promotes hepatic ketogenesis. 9  

Importantly, the concentration of insulin required to suppress lipolysis is only one-tenth of that required to promote glucose utilization. 10   Typically, moderate insulin deficiency (as observed in patients with type 2 diabetes) is associated with sufficient insulin to block lipolysis (and therefore ketoacid formation), but not enough to promote glucose utilization. This leads to hyperglycemia without formation of the ketoacids.

When DKA occurs in patients with type 2 diabetes, the presumed mechanism of ketoacidosis is the combination of relative insulin deficiency and increased secretion of glucagon (as well as other counteregulatory hormones such as cortisol, catecholamines, and growth hormone) in response to stress from 1 ) overwhelming infection, 2 ) infarction of tissue, or 3 ) other severe illness. The elevated catecholamines further suppress insulin secretion to perpetuate a downward spiral. The increased glucagons-to-insulin ratio causes a mismatch that promotes unregulated lipolysis and proteolysis with subsequent uninterrupted formation of ketoacids.

To summarize, DKA is not a unique feature of type 1 diabetes. Though much more common in type 1 diabetes, it does occur in patients with type 2 diabetes, as illustrated by these case reports. However, it is rare for DKA to occur in type 2 diabetes in the absence of some precipitating event. When DKA occurs in an individual with type 2 diabetes, the clinician should “look under the sheets” and initiate an intensive search for the precipitating factor. Once identified, the trigger should be treated promptly and appropriately.

DKA does occur in type 2 diabetes.

DKA in type 2 diabetes rarely occurs without a trigger.

When it does, an intensive search for the precipitating factor should be undertaken.

Brian J. Welch, MD, and Ivana Zib, MD, are fellows in the Division of Endocrinology and Metabolism at the University of Texas Southwestern Medical Center in Dallas.

The authors thank Philip Raskin, MD, for his support and guidance.

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