Type 2 Diabetes Diagnosis and Management

Mr Roland is 55 year old patient who has been complaining of various symptoms including blurred vision, urinary frequency, thirst and generalised fatigue for the past 6 months. His medical history includes knee replacement and multiple emergency room admissions for coronary related events.

He has been referred to the pharmacist clinician for pharmacotherapy assessment and management of his multiple conditions

· Upon physical examination, he is an obese middle aged male with body mass index (BMI): 32.6 kg/m2. His blood pressure 150/95 mmHg, Pulse: 88 bpm; respirations 20 per minute.

· He is asked to give a urine sample for immediate testing. The doctor examines the sample using a dipstick. The test shows abnormal amount of glucose and protein in his urine. Mr Roland is referred for further testing.

Lab Results:

· Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)

· HbA1C: 8.1% (normal: 4–6%)

· Urine albumin : creatinine ratio (ACR)= 15 mg/mmol (reference range: Less than 3.0 mg/mmol

· Total cholesterol: 290 mg/dl (normal: <200 mg/dl)

· AST: 14 IU/l (normal: 0–40 IU/l)

· ALT: 19 IU/l (normal: 5–40 IU/l)

· Alkaline phosphatase: 56 IU/l (normal: 35–125 IU/l)

Following initial assessment at his local GP, Mr Roland has been advised that he might be suffering from type 2 diabetes.

Your report should include answers for the following questions:

1- Describe the general clinical presentation of type 2 diabetes highlighting its possible complications

2- Interpret the current clinical presentation and assess the available test results arguing the case for the current diagnosis (type 2 diabetes) and highlighting the significance of all given tests and information in the diagnosis of the metabolic syndrome. (Your answer should include evidence derived from the history, signs and symptoms as well as the test results)

3- Briefly describe the nature of the condition known as “the metabolic syndrome” and discuss its pathogenesis

4- Suggest the most common treatments available for type 2 diabetes and explain why this patient was referred to pharmacotherapy assessment Guidelines on writing your assignment:

You will need to describe the general clinical picture of type 2 diabetes (signs and symptoms). You may mention different presentations (typical/atypical), you may highlight how complications contribute to the clinical picture (late/early presentation).

Your answer should reflect that this is a multisystemic disorder that can affect multiple organs. Moving on to the 2nd part, you need to look at the available test results, history and physical examination data to deduct which given data support a diagnosis of type 2 diabetes.

You need to comment on the significance of the given data, even normal results should be mentioned. Which tests are diagnostic of diabetes? What are the pros and cons of each test?

Which test is considered the gold standard for diabetes diagnosis? Why other tests were ordered?

Remember that a correct diagnosis requires the interpretation of the tests in the context of the overall clinical picture.

Your answer should reflect the complexity of the case. So you also need to comment on which test results/ information denote the presence of the metabolic syndrome. Remember, this is not just a simple case of diabetes.

Refer to diabetes lecture for basic information about the disease, refer to module page for quiz about the metabolic syndrome. You will need to look for supporting information using online scientific journals, pubmed, google scholar, library books, etc. All resources should be cited appropriately.

Students need to give a general understanding of the condition known as “the metabolic syndrome” (general definition). You should also explain its pathogenesis (risk factors, causes, mechanisms, etc). This is a broad topic so students need to focus on key elements of the pathogenesis without going into too many details. Multifactorial nature should be evident.

Students must appreciate that this is a complex case with multiple co-morbidities. Students need to identify the nature of the syndrome and its impact on management. Outline the main treatment modalities available for diabetes.

Identify the role of patient education in management of diabetes. Assess the role of follow-up in the management of this case.

Students do not need to name drugs but should be able to identify the different types/categories of drugs used. Students should identify the role of lifestyle changes in management. Students should identify the impact of polypharmacy on the management of the case (what could possibly go wrong? how can it be avoided?