Good morning everybody. Now, we will explain about diabetes case.

CASE
Mr.L is 65 years old. He was diagnosed wih diabetes since 5 years ago. Previously he had fasting blood glucose records indicating values of 118-127 mg / dl. He also said that he was urinating frequently, especially at night, frequent thirst and increased appetite. At the time of initial diagnosis, the doctor advised him to lose weight, but no further action was taken by the patient. Doctors also advise patients to control his blood sugar once a month. Suggestions are also made by the patient. The patient expressed his doubts whether it could help in controlling the increase in diabetes. Mr.L diet history reveals excessive carbohydrate intake in the form of bread and pasta. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG). Even though his father had type 2 diabetes, Mr.L has limited knowledge regarding diabetes self-care management and he does not understand why he has diabetes since he never eats sugar. 10 years ago, Mr.L is a smoker. The medical documents showed that Hemoglobin A1C has never been <8%. His blood pressure has been 150/70, 150/90, and 170/90 mmHg on separate occasions during the past year. Although he was told that his blood pressure was increase, he was not aware of the need to keep his blood pressure <130/80 mmHg for both cardiovascular and renal health. A physical examination reveals the following:

Weight: 83 kg; height: 160 cm; body mass index (BMI): 32.4 kg/m2 Fasting capillary glucose: 166 mg/dl Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg Pulse: 88 bpm; respirations 20 per minute Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes

Results of laboratory tests (drawn 5 days before the office visit) are as follows:

Glucose (fasting): 178 mg/dl (normal range: 65109 mg/dl)

Creatinine: 1.0 mg/dl (normal range: 0.51.4 mg/dl) Sodium: 141 mg/dl (normal range: 135146 mg/dl) Lipid panel o Total cholesterol: 162 mg/dl (normal: <200 mg/dl) o HDL cholesterol: 43 mg/dl (normal: 40 mg/dl) o LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl) o Triglycerides: 177 mg/dl (normal: <150 mg/dl)

Glycated haemoglobin (A1C): 8.1% (normal: 46%) Urine microalbumin: 45 mg (normal: <30 mg)

CASE REPORT
Based on Mr.Ls medical history, records, physical exam, and lab results, we can assassed that he has:

Uncontrolled type 2 diabetes (A1C >7%) Obesity (BMI 32.4 kg/m2) Hyperlipidemia Hypertension (by previous chart data and exam) Elevated urine microalbumin level Self-care management/lifestyle deficits o Limited exercise o High carbohydrate intake o No SMBG (Self Monitoring of Blood Glucose) program

Poor understanding of diabetes

From that case known that Mr.L has Diabetes Mellitus Type 2. Diabetes mellitus, or simply diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced.

Classification
There are three main types of Diabetes Mellitus:

1. Type 1 diabetes mellitus results from the bodys failure to produce insulin. Some people may refer to this type as insulin-dependent diabetes, juvenile diabetes, or early-onset diabetes. Patients with type 1 diabetes will need to take insulin injections for the rest of their life. They must also ensure proper blood-glucose levels by carrying out regular blood tests and following a special diet. 2. Type 2 diabetes mellitus results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. Some people may be able to control their type 2 diabetes symptoms by losing weight, following a healthy diet, doing plenty of exercise, and monitoring their blood glucose levels. However, type 2 diabetes is typically a progressive disease (it gradually gets worse) and the patient will probably end up have to take insulin. 3. The third main form, gestational diabetes occurs when pregnant women without a previous diagnosis of diabetes develop a high blood glucose level. The majority of gestational diabetes patients can control their diabetes with exercise, diet, and they need to take some kind of blood-glucose-controlling medications. Based on case, Mr.L has type 2 diabetes mellitus which is caused by unhealthy eating patterns like high carbohydrate intake or high fat and low fiber intake, obesity, limited exercise, and genetic factor which is inherited to patient from family who has a history of diabetes mellitus.

Signs and symptoms

The classic symptoms of diabetes are polyuria (frequent urination), polydipsia (increased thirst), and polyphagia (increased hunger).

Diagnosis
Diabetes mellitus can diagnosed from symptoms that complained by patient, like urinating frequently, especially at night, frequent thirst and increased appetite. Also can diagnosed by checking on: Blood pressure (>130/80mmHg) Fasting blood glucose level (>109 mg/dl) Blood glucose level two hours after meals (200 mg/dl) Blood lipid level

Glycated haemoglobin (> 6%) Urine microalbumin ( 30 mg)

Management
Mr. L presented with uncontrolled type 2 diabetes and complex set of comorbidities, all of which needed treatment. The first task that should be done by nurse is to select the most pressing health care issues and prioritize his medical care to relieve obesity, hypertension, and hyperglicaemia. Management of diabetes mellitus type 2 can begin from change lifestyle, for example diet to lose weight. Losing weight can be an important first step in reducing his blood pressure. Nurse can provide patient referral to dietitian for a medical nutritional therapy with focus on weight loss and improved diabetes control. Advise the patient to do some exercises like jogging, walking, bycycling, swimming, and aerobics. Create the schedule with patient to exercise at least 3 times a week for 30 minutes each time. Discuss the need to improved glycemic control using anti-diabetic medications. This medications designed to decrease blood glucose level when diet and exercise aren't sufficient for managing diabetes. metformin is one type of drugs administered orally to patient. The other drugs for patient with diabetes mellitus are insulin, exenatide, pramlintide, and liraglutide. They are given by injection.