Running head: TYPICAL PATIENT CASE STUDY NEW ONSET DIABETES 1

Typical Patient Case Study New Onset Diabetes Mellitus

Anne Gonzalez

University of Arizona

Typical Patient Case Study New Onset Diabetes Mellitus

This is the case study of a 54-year-old Mexican American woman (T.T.) who is following

up with her primary doctor after a chief complaint of a non healing wound to her right lower leg.

In the initial appointment T.T. was asked about her eating habits, frequency of urinating, and how

much fluid she is drinking in a day. T.T. reported that she has been eating more than usual and

related the increase hunger to stress. On a daily basis T.T. will try to drink a gallon of water to

help keep her body healthy and flush out toxins. When frequent urination and thirst occurred the

symptoms were easily dismissed as a direct result from either drinking too much water or not

drinking enough water. She was given an order for laboratory testing and asked to follow up in

one week.
 The American College of Endocrinology (ACE) (2015), has developed a risk factor guide

that depicts indications for diabetes testing for individuals over 45 years old, sedentary life style,

certain ethnicities, and hypertension (Handelsman et al., 2016). There are many risk factors that

can trigger prediabetes and can ultimately progress to diabetes if action is not taken upon by

patient and physician (Handelsman et al., 2016). Early screening for diabetes mellitus (DM) is

best evidence based practice for all healthcare providers to perform to help halt the pandemic of

diabetes (Cefalu, 2016). As of 2014, in the United States are 21 million individuals that are

diagnosed as diabetic (Centers for Disease Control and Prevention [CDC], 2014). There is also

an estimated amount of undocumented/undiagnosed citizens with diabetes ranging at 8.1 million

(CDC, 2014).

Chief Complaint

T.T. had hit her leg on a gurney at work and noted a bruise formed. The ecchymotic area

lingered for two weeks and then became a redden mark. The redden skin became hot and started

to open up and became a wound. She treated the wound at home with over the counter triple

antibiotic ointment. The wound would not heal but did not progress to grow or appear infected.

T.T. reported having a funny tingling feeling in her feet after working all day and her legs feel

restless at night. She has noticed a lack of hair growth to her legs and toes but thought it was

related to stages of menopause. Having a nursing background T.T. became concerned that she

might have vascular issues with her legs. A monofilament test, Ipswich Touch Test and an ankle

brachial index was completed in the office. These simple assessments can identify vascular flow

abnormalities and peripheral neuropathy (Miller et al., 2014). Vital signs: blood pressure 159/88,

heart rate 65, respirations 22, oxygen saturation 98% on room air, and afebrile at 97.6.

Past Medical History

TYPICAL PATIENT CASE STUDY NEW ONSET DIABETES 3

Reviewing the chart for T.T. she has a significant past medical history for hypertension,

dyslipidemia (not currently being treated), mild depression, and insomnia. Her current body mass

index (BMI) is 20.9, weight is 100 pounds, and height is four feet and eleven inches. She has had

three live births and gained an incredible amount of weight with each pregnancy. The last

pregnancy was at age 38 and gained a total of eighty pounds. Pre pregnancy weight was achieved

a year after birth. The hypertension is under control with the medication therapy of Norvasc 5

milligrams (mg) daily. Family history is strong in coronary artery disease and degenerative

cognitive diseases.

Social History

T.T. is currently working as a registered nurse, requiring her to endure shift work and on

call hours. She is unable to exercise routinely related to work hours, family obligations, and a

demanding doctoral program. Eating habits consist of foods high in fat and carbohydrates that is

related to her cultural background. She does consume a large amount of processed food and red

meats. T.T. does drink a vast amount of water however she does also indulge in a two litter of

cola every evening. She does drink wine daily consisting of a glass or two with her nightly meal.

There is a positive history of smoking a pack a day for 5 years and she has since then cut down

to having one cigarette only once a week. According to the risk factors listed from the ACE and

T.T.s history/lifestyle she is at risk for becoming a diabetic. Over the age of 45 increases the

patients risk of developing DM (Cefalu, 2016). Her average hour of sleep is 5 hours and

interrupted, increasing the risk factors for DM related to sleep denervation (Zhang et al., 2016).

Laboratory Results

Labs that were ordered included, a hemoglobin A1C (Hgb A1c), fasting glucose, basic

metabolic panel (BMP), liver function test (LFT), complete blood count (CBC), glomerular
TYPICAL PATIENT CASE STUDY NEW ONSET DIABETES 4

filtration rate (GFR), fasting lipid profile, and a thyroid stimulating hormone (TSH) (Cefalu,

2016). A urine sample will be collected for an analysis and an albumin to creatinine ratio (Cefalu,

2016). These diagnostic tests will help guide the physician to identify if diabetes is indeed the

root cause of the unhealing wound (Handelsman et al., 2016).

During the follow up appointment the abnormal labs reviewed were the Hbg A1c 7.4%

and fasting glucose 167mg/dL, two positive tests indicating diabetes (Inzucchi, 2012). Non-

diabetic patient will have a Hgb A1c less than 5.7% ("Diagnosis and classification," 2013).

Fasting glucose in the diabetic patient will be greater than 126 mg/dL (Inzucchi, 2012). The lipid

profile results showed low-density lipids (LDL) 152mg/dL, high-density lipids (HDL) 24mg/dL,

cholesterol 332mg/dL, and triglycerides 160mg/dL. The high results of the lipid panel will

require the physician to implement an intervention to decrease the patients risk of developing

vascular disease (Inzucchi, 2012). All other labs drawn were found to be within the normal

range.

Comprehensive Assessment Guidelines

1. General Survey: Patient will be assess from head to toe by the nurse and physician
when suspecting DM. Skin will be assessed for abnormalities and wounds will be documented.
Distorted skin color can be present from disease process (Miller et al., 2014). Height, weight and
BMI will be measured. Bodys distribution of fat content will be noted. Dental hygiene and
personal maintenance is a good indicator if the patient will participate in self-care treatments
(Cefalu, 2016). Evaluating for cigarette smell, yellow fingers and odor from the mouth
(OConnor et al., 2016). This initial assessment will indicate current lifestyle and challenges that
can be foreseen (OConnor et al., 2016).
2. Neurological: The patient with new onset of diabetes will need to have a neurological
exam to assess for level of consciousness. Patients that are experiencing hypoglycemia will
present with confusion and unable to follow commands upon request (Beckman, Paneni,
Cosentino, & Creager, 2013). Visual assessment will be completed checking for abnormalities in
the ocular field that can be related to retinopathy (Vieira-Potter, Karamichos, & Lee, 2016).
Questions to be asked about ocular care: Do you have an eye doctor that you see routinely?
When was the last time you saw your eye doctor? Have you ever been told you have any eye
diseases such as retinopathy? Do you have any problems seeing now? Asking these questions
will assist the clinician in determining if a referral to an ophthalmologist is required (Vieira-
TYPICAL PATIENT CASE STUDY NEW ONSET DIABETES 5

Potter et al., 2016). Prolonged hyperglycemia will damage the cornea, triggering cataract
formation and requiring surgical intervention (Handelsman et al., 2016). Retinopathy is another
disease process that will need to be assessed by another healthcare professional to prevent visual
loss (Vieira-Potter et al., 2016). Patient will often have peripheral neuropathy that is presented as
numbness or tingling sensation to lower legs starting in the feet and moving upward (Miller et
al., 2014). Other areas of the body are affected by neuropathy such as the hands, bladder and ears
(Cefalu, 2016). Peripheral neuropathy is common in diabetic patients and can be assessed easily
in minutes (Miller et al., 2014). Peripheral neuropathy can be described as the metabolic effect
on the swan cells of the nerve, an ischemic effect to the neurons (Beckman et al., 2013). It is a
disease that is related to microvascular complications of DM from hyperglycemia (Cefalu, 2016).
Loss of protective sensation (LOPS) can lead to falls and ulcers on the feet and a simple
assessment can be utilized to test for LOPS (Miller et al., 2014). A monofilament test is a thin
plastic wire that is used to touch on six points of the patients foot to assess for sensation (Miller
et al., 2014). The great toe and on the ball of the foot slightly below each digit is touched by the
filament (Miller et al., 2014). Another great assessment tool is the Ipswich Touch Test that is
based on touch and if the participant can feel the testers hand on certain toes (Miller et al., 2014).
A vibration test can also be used to assess for diabetic peripheral neuropathy using a tuning fork
at 128 Hz and ankle reflexes (Handelsman et al., 2016). Questions that should be asked during a
neuropathy assessment: Are you experiencing any burning or tingling sensation in your feet or
legs? Are there other parts of your body that have the same sensation? Is there a pain in your legs
when walking or at rest?
3. Cardiac and Vascular The nurse will listen to heart tones to S1 and S2 for
abnormalities, murmurs and gallop. Carotid arteries will be auscultated for bruit and visualized
for distention. The patient will be asked about chest pain and shortness of breath. Coronary artery
disease (CAD) is commonly found in diabetic patients (Paneni, Beckman, Creager, & Cosentino,
2013). The trifecta of hyperglycemia, hypertension (HTN) and dyslipidemia increase the
patients risk of developing CAD (Cefalu, 2016). Blood pressure should be assessed, reported,
and treated as indicated by the Standard of Care Guidelines from the American Diabetic
Association (Cefalu, 2016). A lipid profile should be ordered by the physician and assessed for
dyslipidemia (Beckman et al., 2013). Abnormal results should be intervened to halt the
progression to other disease processes. The patient will be assessed for heart failure by diagnostic
testing of a brain natriuitic peptide and physical assessment (Paneni et al., 2013). It is recorded
that 50% of type 2 diabetic patients will develop heart failure (Cefalu, 2016). The nurse will
obtain a set of vitals during each examination to assess for HTN and the effectiveness of
treatment. The ideal systolic pressure is less than 140 mmHg and diastolic less than 80 mmHg
(Handelsman et al., 2016). The examiner will assess for warmth and coolness to bilateral lower
extremities, edema, capillary refill, and pulses on the doraslis pedis and posterior tibial pulse
points (Cefalu, 2016). These assessments are used to help check for arterial flow to the lower
extremities. The lack of arterial blood flow will slow the process of wound healing and
ultimately causing the leg to become ischemic resulting in limb amputation (Li et al., 2015). The
examiner will perform an ankle brachial index (ABI) to help determine the strength of blood
flow to the extremities (Li et al., 2015). The legs should also be assessed for hair growth, patches
of hairless spots is an indicator of poor vasculature in the limbs (Miller et al., 2014). Questions
the examiner will ask when assessing the vascular system: How long have you had high blood
pressure? Have you been told you have poor circulation to your legs? Have you ever had
TYPICAL PATIENT CASE STUDY NEW ONSET DIABETES 6

angioplasty or stent placement in your legs? Do you have any hair on your legs or have you
noticed patches of hair missing on your legs?
4. Respiratory Lung sounds are auscultated for wheezing, crackles and diminished
sounds. Diabetic patients are at high risk for developing infections such as pneumonia related to
the body compromised stated of hyperglycemia (Casqueiro, Casqueiro, & Alves, 2012). The
examiner will ask about vaccines for the flu and pneumonia (Casqueiro et al., 2012). Viscous
blood slows the bodys response to react to an infection (Beckman et al., 2013). Questions should
be asked about the patients smoking status. Are you an active smoker? How much do you smoke
and what methods are you using to smoke? Cigarette, cigar, pipe, or vaporizer (electronic
cigarette)? The nicotine from smoking thickens the blood to become a sticky consistency slowing
down blood flow to various areas of the body (Casqueiro et al., 2012). Course blood from
glucose can cause scaring in the lung and create fibrous scaring decreasing the lungs contractility
(El-Azeem, Hamdy, Amin, & Rashad, 2013). Thus, decreasing the amount of oxygen availability
to bind with red blood cells (El-Azeem et al., 2013). The patient will be encouraged to stop
smoking and provided information about smoking cessation (El-Azeem et al., 2013).
5. Gastrointestinal: The examiner will listen to bowel sounds for hyper and hypoactive
motility. The effect of hyperglycemia can instigate gastrointestinal neuropathies presented as
stool incontinence, difficultly swallowing, constipation, and diarrhea. The abdomen will appear
distended and tender upon palpation. Diabetic patients are at high risk for developing a fatty
liver. Having a high BMI, waist circumference, and elevated lipid profile increases ones risk of
developing a fatty liver. Weight loss and tight glycemic control is recommended to treat a fatty
liver. Gastroparesis is the stomachs inability to empty contents into the intestinal system. This is
related to neuropathy of the stomach and needs to be with treated a low fat and low fiber diet.
This is diagnosed with a breath test in the office. Ask questions about bowel habits. How
frequent are you having a bowel movement? Do you have issues with constipation or diarrhea?
Do you have a sensation of feeling full?
6. Musculoskeletal: Assess for strength in handgrips and pedal flexion (Piscitelli, Neglia,
Vigilanza, & Colao, 2015). Joints should be assessed for frozen shoulder and other deformities
(Miller et al., 2014). Joint deformities in toes are hammertoes, claw toe, and bunions (Miller et
al., 2014). Ask the patient how long the joint deformities have been present. All joints should be
assessed for full rang of motion (Piscitelli et al., 2015). Patient should be asked to walk to assess
for gait disturbance. Difficulty walking from neuropathy, wounds or deformities increases the
patients risk of falling. Provide education about footwear and care. A foot exam will be
performed in the skin assessment. Screening for charcot neuroarthropathy, the mid area of the
foot will be edematous, redden and warm to touch (Miller et al., 2014). Digital sclerosis is the
development of thick waxy like thick skin over the joint of the fingers and toes (Barki, Khan,
Jilani, & Nooruddin, 2013). This disease can also affect other joints such as the elbow, knee, and
ankle. Dupuytrens disease is a contracture that occurs to the pinky and ring figure. The finger
will curl inward to the palm and can be assessed by looking at the anatomy of the fingers and
palms (Barki et al., 2013).
7. Genitourinary: Assess the frequency of urination, color, amount and odor (Sayyid &
Fleshner, 2016). Diabetic patients have a higher possibility of developing urinary tract infections
(Sayyid & Fleshner, 2016). Urine will be concentrated with glucose serving as a catalyst for
bacteria to multiple (Casqueiro et al., 2012). Hyperglycemia can cause nerve cell death and the
bladder will develop a neuropathy (Casqueiro et al., 2012). The diabetic patient will not be able
to tell the bladder if is full and will not be able to empty the bladder completely. The lack of
TYPICAL PATIENT CASE STUDY NEW ONSET DIABETES 7

sensation and absence of pain can be dangerous for the patient (Funfstuck, Nicolle, Hanefeld, &
Naber, 2012). The healthcare provider will need to teach the patient of the signs and symptoms
of a urinary tract infection (Funfstuck et al., 2012). A urine analysis will be performed to assess
for renal function and presence of bacteria (Funfstuck et al., 2012). Poorly controlled glucose
and hypertension can damage the kidneys and screenings should be done routinely to prevent
renal impairment. A urine test albumin-to-creatinine ratio and a blood draw for a GFR test can
measure the function of the kidneys and conclude if treatment is therapeutic.
8. Integumentary: The skin will need to be assessed from head to toe; wounds and
abnormalities can be present on any part of the body. A foot exam is an extremely important part
of the skin assessment (Miller et al., 2014). The nails, hair, color, temperature, and general
appearance will be assessed. Nail dystrophy can cause infection, length, color, thickness and
ingrown nails should be identified (Miller et al., 2014). Infection in the toes can be hard to treat
if blood flow is compromised and amputation will be recommended if gangrene starts (Miller et
al., 2014). Assess for a possibility of a fungal infection, ask if the patient has a history of athletes
foot or any other fungal infections (Cefalu, 2016). Checking between the toes for moisture and
hidden maceration will stop the formation of wounds and infection (Miller et al., 2014). Heels
and sides of the feet will be evaluated for fissures and calluses. Recent research has provided
healthcare providers with evidence that calluses can start the formation of diabetic foot ulcers
(Miller et al., 2014). Loss of hair should be noted from the lower legs and suspect vascular
complications. Acanthosis nigricans is common in obese diabetic patients and is presented as
darkening of the skin in folds of the underarms, groin, neck, arms and legs (American Diabetes
Association [ADA], 2014). This skin condition can be reversed with weight loss or skin
lightening creams (ADA, 2014). Another skin condition is diabetic dermopathy that is
nonischemic and occurs from poor glucose control (ADA, 2014). Dark round spots will appear
all over the skin and is considered to be scaring from hyperglycemia (ADA). Diabetic
dermopathy is the most common diagnosed skin disorder in diabetic patients (ADA). Course of
treatment is tight glycemic control.
9. Symptom Assessment: There are three classic symptoms a patient will present with:
polyphagia, polydipsia, and polyuria (Cefalu, 2016). Questions should be asked about frequency
of urination, hunger and thirst. A 24-hour diet recall should be used to develop a general idea of
eating habits (Cefalu, 2016). Dizziness and lethargy are also common symptoms of diabetes
(Handelsman et al., 2016). After eating meals high in carbohydrates how does the patient feel?
How do you feel after eating large amounts sugar? How much water are you drinking during the
day? How many times a day are you urinating? Do you ever feel like your thirst is quenched
after drinking water? What type of beverages are you drinking? Do you drink alcohol? How long
have you had increase thirst? Hunger? Urination? Do you have any numbness or tingling in your
hands or feet? Is it a burning sensation? Do you have pain in your legs when walking? Have you
noticed a change in your vision? Are there any wounds that are not healing? How long has the
wound been present? Do your feet/legs feel cold all the time? Are your legs restless while
sitting? Have you noticed and abnormal hair loss?

Holistic Assessment

Psychological
TYPICAL PATIENT CASE STUDY NEW ONSET DIABETES 8

The diagnosis of diabetes is very stressful for the patient and family. The healthcare

provider will need to assess the psychological, social, and spiritual well being of the patient.

Depression is prevalent in diabetic patients estimating 38 percent to 48 percent newly diagnosed

diabetic patients will experience a form of emotional distress (Handelsman et al., 2016). This

emotional distress is directly affecting their quality of life. Creditable assessment tools such as

the Diabetes Distress Scale (DDS) or Patient Health Questionnaire-2 (PHQ-2) should be used to

establish course of treatment (Cefalu, 2016). Assessing the physical appearance in regards to

patient hygiene, are the blood sugars in target range, and is the patient taking home medications?

These are characteristics of depression, the healthcare provider will be evaluating when looking

at the patients physical appearance (Zhang et al., 2016). Helping the patient establish a support

team with a spouse or family member will keep the patient positive and participate in self-care

(Zhang et al., 2016).

Social

Socializing is a large part of daily living and a new diagnosis of diabetes can hinder the

patients current lifestyle. Providing education about healthier eating and ordering off dinner

menus in restaurants will help keep patients active in their social life (OConnor et al., 2016).

Patient will need to maintain high quality of life in a healthy approach. Recommending support

groups and educational classes will provide social interactions with other diabetics (OConnor et

al., 2016). Evaluation will be obtained about work and financial status.

Spiritual
TYPICAL PATIENT CASE STUDY NEW ONSET DIABETES 9

Spiritual needs will be evaluated and addressed per cultural beliefs. Encouraging patients

to seek spiritual guidance with a chaplain or personal religious organization will help with

accepting and coping with this diagnosis (Ammerman, Harden, & Mitchell, 2015). Many

religious identities offer support groups for disease processes with an emphasis in spiritual care.

Studies have provided evidence that patients that participate routinely in a spiritual belief are

higher to comply with self-care and tight glycemic control (Ammerman et al., 2015). Physical

activities like yoga and tai chi help with balancing and bringing peace to mind, body, and spirit

(Ammerman et al., 2015). Participating in yoga will help gain mindfulness and start a healthy

path of physical activity.

Health Promotion Factors

There are key risk factors that are modifiable and there are other factors that are non-

modifiable. Diabetes is a totally preventable disease with healthier decision-making skills.

Modifiable risk factors that can be addressed are physical inactivity, poor dietary choices, and

unhealthy habits such as smoking and lack of adequate rest (ADA, 2015). If a support system is

not present the patient could easily stop participating in healthy lifestyle changes. Peer pressure

is another risk factor that should be evaluated (Van Name et al., 2016). There can be an

incredible amount of peer pressure to eat out for meals or have cocktails, slowing down the

progress of change (Neamah, Sebert Kuhmann, & Tabak, 2016). Readiness for change will be

assessed for in deciding if the patient is ready to start a healthy life (Neamah et al., 2016). There

are many assessment tools available for healthcare professionals to use to evaluate readiness to

learn.

It is time to make a call to action to change habits, to become healthier, and to prevent or

decrease this prognosis of diabetes. Obesity is a well-known precursor to diabetes (Neamah et

TYPICAL PATIENT CASE STUDY NEW ONSET DIABETES 10

al., 2016). Promoting programs that help overweight/obese individuals become healthier is a

primary level of prevention to help stop diabetes from starting (Neamah et al., 2016). Health

promotion classes for a diabetic patient should emphasis that decreasing BMI, changing eating

habits, and increasing physical activity can halt diabetes from worsening. Participating in

programs that hold a person nutritionally responsible and encourage physical fitness will help

with wellbeing (Ammerman et al., 2015).

Summary of Assessment

There are five key elements that are expected with the new diabetic patient, polyuria,

polyphagia, polydipsia, slow to heal wounds, and tingling/numbness in lower extremities.

Polyuria, polyphagia, and polydipsia are seen the most because of hyperglycemia (Barrett,

Boitano, Barman, & Brooks, 2012). Body cells are unable to open up and accept or transport

insulin and/or glucose (Molina, 2013). Cells will send a distress message to the brain requesting

more resources to feed cellular hunger (Lutz, Mazur, & Litch, 2015). The brain will trigger

hormones to be released to increase appetite or polyphagia (Barrett et al., 2012). Polyuria is

related to the high concentration of glucose in the urine (Lutz et al., 2015). The body is unable to

absorb the excess glucose requiring the aid of more fluid to help filter the blood (Barrett et al.,

2012). This will instigate polydipsia, the patient to feel dehydrated and having an unsatisfied

thirst for fluids (Barrett et al., 2012).

Patients will present with wounds that are slow to heal because of the thickness of the

blood from glucose. The body is not able to respond to an inflammatory response as a

nondiabetic patients body (Casqueiro et al., 2012). Macrophages are unable to move freely to

areas of trauma and infection due to hyperglycemia (Casqueiro et al., 2012). Blood vessels are
TYPICAL PATIENT CASE STUDY NEW ONSET DIABETES 11

also compromised, unable to bring large amounts of oxygenated blood to the tissues to help with

repair (Paneni et al., 2013). The vasculature of the legs or other body parts start to narrow from

the constant scratching of sticky blood (Beckman et al., 2013). Thus, creating scaring in blood

vessels. Having a high Hgb A1c will also impede the healing process (Inzucchi, 2012). Oxygen

is unable to bind with the heme, therefore decreasing the amount of oxygen available for the

body (Inzucchi, 2012).

Numbness and tingling are primary symptoms of diabetes (Cefalu, 2016). Death to swan

cells on the myelin sheath causes the nerve to become exposed and damaged from the abundance

of glucose (Handelsman et al., 2016). Nerve pain can be described as burning, tingling or numb

feeling (Handelsman et al., 2016). Patients can develop loss of sensory pressure, damaging soles

of the feet and other body surfaces (Cefalu, 2016). Hyperglycemia has a profoundly dramatic

effect on the body damaging multiple organ systems and the psyche.

My youtube video: https://youtu.be/Bt6U6p9fzsY

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