Reference no: EM133593634

Case Study 1 : Norma James: Introduction

•Norma James is 65 years old and was diagnosed with T2D•several years ago following a 1-month history of weight loss•(4.5 kg), polyuria, polydipsia, and polyphagia. In addition, she has a history of hypertension and atrial fibrillation.

1. Among the three primary concepts involved in DM, which ones are potentially affecting Ms. James's blood glucose level?

2. Considering Ms. James's age, explain possible factors that may contribute to the progression of DM. What comorbidities does Ms. James have?

3. What happens to DM-related complications during the duration of DM in older adult patients?

•Ms. James has T2D that is treated with an oral glucose-lowering medication. She is taught how to test her blood glucose level using a portable glucose monitor. Additionally, she attends Classes on nutrition and on integrating exercise into her daily schedule.

4. What is the insulin mechanism of action in T2D?

5. What treatment will help to control Ms. James's hyperglycemia?

6. Is Ms. James's pancreas still producing insulin?

•Ms. James has bilateral peripheral neuropathy that affects her lower extremities. Although it had initially caused severe pain, the neuropathy has now progressed to numbness in both lower extremities. Ms. James notices a skin ulcer on her right ankle that has been present for several weeks; she begins to place "wound butter" on the ulcer, on the recommendation of a cashier at a convenience store. The ulcer becomes infected, requiring dressing changes by a visiting nurse and a 10-day course of antibiotics. The ulcer does heal; however, Ms. James's nurse practitioner outlines a plan of care on DM management, emphasizing good foot care practices.

7. Explain the type of neuropathy Ms. James is experiencing.

8. What contributed to the worsening symptom of Ms. James's right ankle ulcer?

9. What were the signs and symptoms of diabetic neuropathy Ms. James experienced?

10. Apart from the medical treatment administered, what factor is important to prevent the progression of diabetic neuropathy?

Case Study 2: Rosa Garcia: Introduction

•Rosa Garcia is 36 years old, overweight, and pregnant with her third child. Her history shows that her two previous children weighed more than 9 pounds at birth and that both newborns had hypoglycemia during the initial 24 hours of life. Ms. Garcia has no history of any type of DM. Her fasting blood glucose at 24 weeks gestation is 99 mg/dL.

1. What are major concerns that you should consider for Ms. Garcia?

2. Is Ms. Garcia at risk for developing type 2 diabetes mellitus if her hyperglycemia is prolonged and is left untreated?

3. What is the child Ms. Garcia is expecting likely to develop once born?

•Ms. Garcia is diagnosed with GDM and begins treatment with insulin•injections. She is taught how to use a portable glucose monitor and•is provided a strict schedule of glucose testing before and after•meals. Additionally, she attends classes on nutrition and on incorporating physical activity into her lifestyle.

4. What are risk factors associated with Ms. Garcia's GDM?

5. Discuss complications associated with hyperglycemia during pregnancy.

6. What management needs to be considered to prevent GDM complications in both the mother and the fetus?

•Ms. Garcia maintains normal blood glucose levels throughout her pregnancy through the use of insulin and nutrition therapy. •

In addition, she has worked with an exercise physiologist to guide her on individualized and appropriate exercise during pregnancy. Ms. Garcia delivers a normal weight infant with no complications such as hypoglycemia.

7. What factors may have contributed to the normal symptoms of the newborn?

Case study 3: Beatrice Diaz: Introduction

•Beatrice Diaz is a 55-year-old Hispanic woman who has been in her usual state of health until 6 years ago, when she developed Exophthalmos (forward displacement or "bulging" of the eyeball). She reports to her ophthalmologist for her annual examination, and he refers her to an endocrinologist. When her history is taken, she reports that she has lost 20 pounds over the past 3 months in spite of an increased appetite. She has noted an increase in her neck size, as she is no longer able to button the top button on her shirts. The endocrinologist notes that the skin on Ms. Diaz's shins bilaterally is thickened with an orange peel appearance. She is hyperreflexia and has a fine tremor of both hands. She has thinning hair and temporal balding and reports that she has developed palpitations along with feelings of nervousness and anxiety. She attributes her feelings of anxiety to increased pressures and demands at work over the previous year. In addition, she reports heat intolerance that has developed over the past 3 months.

1. What are two abnormal physical symptoms that Ms. Diaz is experiencing?

2. What are two abnormal physical signs that were found during the physical examination?

•Suspecting thyroid dysfunction, the endocrinologist orders thyroid function tests. Results of the tests include undetectable TSH and elevated T3 and T4. On the basis of clinical and laboratory findings, the endocrinologist diagnoses Ms. Diaz with Graves' disease and orders propylthiouracil (PTU), a medication to decrease the synthesis of thyroid hormone. The plan is to reevaluate her status in approximately 6 weeks and decide on radioactive iodine131 ablation therapy or thyroidectomy to permanently treat her Graves' disease.

•Ms. Diaz's symptoms resolve within a month. Feeling better, she does not renew her prescription for PTU. Approximately 2 weeks later, she notes a recurrence of diaphoresis, palpitations, tremors, hyperreflexia, heat intolerance, and feelings of anxiety and nervousness. She also notes dyspnea on exertion and weakness of the muscles in her shoulders and thighs. She is admitted to the hospital for observation to evaluate for possible cardiac arrhythmias. She is placed on PTU again and begins radioactive iodine131 ablation therapy. She develops a transient thyroiditis that resolves without complications. Her thyroid function tests are monitored for 2 years, after which time she is lost to follow-up.

3. What is Graves disease?

4. What is PTU, and how does it work?

•Approximately 5 years after treatment, Ms. Diaz is brought to the emergency department by her daughter, who states that Ms. Diaz has been complaining of depression, fatigue, tiredness, and lack of energy and has recently become very lethargic. On Physical examination, Ms. Diaz has delayed deep tendon reflexes, periorbital edema, and hair loss. Her temperature is 97.2°F, and her chest x-ray reveals bilateral pneumonia. She reports a 30-pound weight gain in the past year. Suspecting thyroid dysfunction, the attending physician orders thyroid function tests, which reveal an increased TSH and decreased T3 and T4. Ms. Diaz is diagnosed with hypothyroidism and started on levothyroxine for thyroid replacement therapy. An appointment is made for follow-up.

5. Why does Ms. Diaz now have hypothyroidism?

6. Why is there an increase in TSH and a decrease in T3 and T4?

•Ms. Diaz's daughter becomes increasingly concerned about her mother's health and makes a plan to ensure that her mother will attend scheduled medical appointments and refill all prescriptions.

Ms. Diaz's symptoms resolve with levothyroxine therapy.

7. What is levothyroxine therapy?

8. Why is it important that Ms. Diaz follow all the recommendations made by her doctor?

Case Study 4: Reginald Owens: Introduction

•Reginald Owens is a 65-year-old male with a 40-year history of type 1 diabetes and hypothyroidism caused by Hashimoto thyroiditis. He recently noticed that he has increased lethargy, anorexia, weight loss, and lightheadedness on arising. He has had an increased number of hypoglycemic events and has needed to call the paramedics for hypoglycemic treatments twice over the previous month. He has been having increased difficulty carrying out activities of daily living because of his symptoms, so he makes an appointment to see his endocrinologist.

1. Name two symptoms of endocrine dysfunction from which Mr. Owens is suffering.

2. Name the life-threatening symptom Mr. Owens has experienced.

3. What are two endocrine diseases Mr. Owens suffers from?

•Mr. Owens visits the endocrinologist, who reviews his medical history and clinical signs and symptoms in detail. The endocrinologist notes increased pigmentation in light-exposed areas, pressure points, and the buccal mucosa. Mr. Owens's vital signs are pulse 100, respirations 20, blood pressure 90/50 mmHg. Orthostatic changes in blood pressure are noted when Mr. Owens moves from lying to a standing position. Laboratory values are significant for dehydration, and thyroid function is normal. Suspecting adrenal dysfunction, the endocrinologist orders an ACTH challenge test that reveals primary adrenal insufficiency. Mr. Owens is placed on prednisone and fludrocortisone for cortisol and mineralocorticoids, respectively. His symptoms resolve, and he is maintained on a stable dose of these medications. In addition, he is given instructions to contact his endocrinologist in the event of any other stressful event or acute illness.

4. Why did the endocrinologist prescribe prednisone and fludrocortisone?

5. Why was dehydration present in Mr. Owens's laboratory values?

•Mr. Owens is stabilized on his medication regimen. He develops a respiratory infection while traveling overseas and decides to wait until he returns home to seek treatment. He develops nausea, vomiting, abdominal pain, and diarrhea on the plane home and proceeds directly to the emergency department (ED) after arriving home from the airport. In the ED, he is diagnosed with pneumonia and acute adrenal insufficiency. He begins antibiotic treatment for pneumonia and is given intravenous glucose and fluids for hypoglycemia and dehydration. Because he continues to have nausea and vomiting, he is provided with intravenous forms of cortisol with mineralocorticoid activity. His symptoms begin to resolve. However, in view of his underlying type 1 diabetes, he is admitted to a hospital unit for observation.

6. What are the causes of acute adrenal insufficiency?

7. Why did this occur?

•Mr. Owens returns home after a 1-day admission to the hospital. The discharge nurse meets with Mr. Owens and his family to review the need for changes in cortisol and mineralocorticoid coverage during times of physiologic stress, such as trauma or infection. Mr. Owens feels confident that he will consult with healthcare providers in the future when under stressful circumstances.

8. What signs and symptoms of adrenal insufficiency should the nurse teach Mr. Owens and his family?

9. Why should Mr. Owens consult his healthcare provider in times•of stress?