CASE STUDY – Diabetes for LA 5.2

CASE STUDY – Diabetes for LA 5.2 Diabetes mellitus is a disease characterized by the inability of properly maintain normal blood glucose levels. Choose the form of diabetes mellitus; Type 1, Type 2, or Gestational diabetes, that best completes each statement. Associated with obesity, low activity, and poor diet = _____________________ (Type 2 Diabetes, Gestational Diabetes, Type 1 diabetes) Caused by an autoimmune disease that targets beta cells = _________________ (Type 2 Diabetes, Gestational Diabetes, Type 1 diabetes) Associated with pregnancy = _______________ (Type 2 Diabetes, Gestational Diabetes, Type 1 diabetes) 2. Type 1 and Type 2 diabetes account for the vast majority of all cases. Although both forms of diabetes result in the inability to properly regulate blood glucose levels, there are important differences between the two forms. Compare and contrast Type 1 and Type 2 Diabetes Mellitus. (Select all the correct statements) a) Individuals with Type 2 diabetes are typically treated with insulin; Individuals with Type 1 diabetes are treated with medications such as Metformin and Glipizide. b) Type 1 results from autoimmune destruction of beta cells, Type 2 is caused by a combination of factors including insulin resistance. c) After a meal blood, tests would reveal that individuals with Type 1 have high blood glucose and high insulin levels; Individuals with Type 2 would have high blood glucose and low insulin. d) Untreated Type 1 diabetics have hypoglycemia and untreated Type 2 diabetics have hyperglycemia. e) Individuals with Type 1 diabetes have low circulating insulin; Individuals with Type 2 diabetes have insulin insensitivity 3. Patient Y.T is an African American woman, 62 years of age, who was diagnosed with type 2 diabetes 16 years ago. Her history includes hypertension, which is currently well controlled on medication, body weight 30 lbs above ideal, clinical signs of early renal failure, cardiovascular disease, and early-stage retinopathy. She reports that, “My blood sugar never has been too good, and I don’t think it ever will be. Lately it’s gotten worse.” In your assessment, you note that Patient Y’s blood glucose has ranged from 43-383 mg/dL over the previous few months. You perform a fasting blood glucose test, and the results show that the patient has blood glucose value of 164 mg/dL (normal 80-100 mg/dL). What is the best explanation for why Y.T.’s blood glucose levels are high? a) Type 2 Diabetics destroy their insulin producing beta-cells. b) Type 2 diabetics do not make the correct form of insulin. c) Type 2 Diabetics are insulin resistant. Their insulin receptors do not respond to insulin well. d) Type 2 diabetics eat too much sugar and have a mutant form of insulin that does not work. 4. Referred by his family physician to the diabetes specialty clinic, Y.T. presents with recent weight gain, suboptimal diabetes control, and foot pain. When asked about her recent weight gain, Y.T. says, “I’m always hungry. Can’t seem to eat enough, so sometimes I just keep eating.” She says that she has been trying to keep up doing her daily walk, but because of the heat she doesn’t get out much. “I just don’t have the energy to go for a walk these days, and besides, it’s too hot out there,” she stated. Why would diabetes mellitus patients with poor self-care (properly taking medications, for example) experience polyphasic and fatigue? a) Patients experience hyperglycemia, but because of insulin resistance, glucose is not taken into the body’s cells. Therefore, cells may lack the energy stores and ATP they need to function optimally. This could cause fatigue and a demand for energy, which could stimulate hunger. b) Patients experience hypoglycemia. The cells are not getting enough glucose and therefore lack the energy stores and ATP needed to optimally fuel activities. Thus, they feel fatigue and the demand for energy stimulates hunger. c) Patients experience hyperglycemia. But without insulin activity, excess glucose is taken into the body’s cells leading to depletion of glucose in the blood. Low blood glucose then causes fatigue and hunger. d) Diabetes patients eat poorly and, as a result will commonly experience fatigue and hunger. 5. Part of your teaching plan is to help Y.T. understand the importance of physical activity for controlling her blood glucose levels. All of the following accurately describe how increased physical activity helps control blood glucose EXCEPT… a) Increased physical activity will increase muscle size and this will increase the number and volume of cells that uptake glucose. b) Increased physical activity will help deplete muscle glycogen storage causing muscle cells to uptake more glucose for storage. c) Increased physical activity leads to a decrease in production of insulin. d) Increased physical activity is linked to a decrease in adiposity and an decrease in insulin resistance factors. 6. Y.T. indicates that she has a good understanding of the basic principles of meal planning and that her family is generally supportive of her dietary needs. Her dietary recall, however, reveals that she makes many inappropriate food choices. She skips or delays meals in some cases and eats large amounts at other times. Her diet history also reveals excessive carbohydrate intake in the form of bread and pasta. In apparent frustration, she states, “It doesn’t seem to matter whether I eat right or not.” As part of your patient education plan, you want Y.T. to better understand how her diet might influence her ability to control her diabetes. Which of the following best explains why a diet high in carbohydrates prevents a Type 2 diabetes patient from properly controlling their blood glucose levels? (Choose all correct answers) a) A diet high in carbohydrates would cause a surge insulin production and hypoglycemia. b) A diet high in carbohydrates will cause surges in blood glucose levels that may remain high for long periods of time due to insulin resistance. c) Excess carbohydrate intake can cause beta cells to die, leading to a decrease in insulin production. d) Excess carbohydrate intake can lead to weight gain. Increased adiposity can cause greater insulin resistance. 7. Y.T. complains that she often wakes up at night to urinate. Further questioning reveals that this typically coincides with a dinner high in carbohydrates and late night snacks of ice cream with chocolate and caramel sauce. Why do untreated diabetes mellitus patients experience glucosuria, polydipsia, and dehydration? High carbohydrate intake can lead to elevated blood glucose, glucose in the urine and excess fluid loss. High carbohydrate intake can lead to lower blood glucose levels, glucose in the urine, and excess fluid loss. High carbohydrate intake can lead to lower blood glucose levels, glucose in the urine, and fluid retention High carbohydrate intake can lead to elevated blood glucose levels, glucose in the urine, and fluid retention 8. Y.T tells you that despite her recent problems, she feels confident in her ability to monitor her blood glucose and administer her medications. She demonstrates that she is able to do it. However, she is concerned about her widely fluctuating blood glucose levels. She says, “Sometimes my sugar’s too high, and I don’t know what I did to make it high. Other times, it’s low, and I get really scared that I’ll end up in a coma.” In fact, her history shows several instances when her blood glucose levels fell below 60 mg/dL. She goes on to report that if her blood sugar is less than 100 mg/dL, she will routinely treat herself with a tablespoon of sugar added to 10-12 ounces of orange juice. Hypoglycemia is a serious concern for patients with diabetes. How could a diabetic patient become hypoglycemic? (Select all correct answers) a) Eating too much food without taking insulin or medication. b) Taking Metformin and Glipizide medication without eating enough food. c) Taking glucagon without eating food. d) Taking insulin medication without eating enough food. e) Taking insulin medication, eating a small meal, and then exercising. 9. In an emergency situation, what hormone can be administered to a diabetic who is experiencing severe hypoglycemia? a) Thyroid hormone b) Glycogen c) Glucagon d) Insulin 10. It is important to teach Y.T. that she can safely prevent and manage hypoglycemia in a way that will help her achieve better overall blood glucose control. In order to gain her trust, the patient’s fear of hypoglycemia should be validated by acknowledging that it can be a serious side effect of treating diabetes. You want her to know that keeping her safe is your priority as well. As part of your patient education, you inform Y.T. about diabetic ketoacidosis (DKA), a serious complication of diabetes mellitus. You stress the importance of maintaining a proper diet and compliance with taking her medications. You teach her that diabetic ketoacidosis is caused by the following problems… (Select all correct answers) a) Cells cannot uptake glucose for energy and instead rely on fat for energy b) The generation of excess ketones from fat breakdown c) Decrease in fat synthesis d) Low insulin activity and low glucose uptake by cells of the body e) Decrease in glucose synthesis f) Increase in fat breakdown for energy g) Increase in glycogenolysis 11. In your role as diabetes educator, you teach Y.T. the importance of foot care, demonstrating her inability to feel the light touch of the monofilament. You also explain that she will need to be more vigilant in checking her feet for any skin lesions caused by poorly fitting footwear. You tell her that diabetics can develop foot ulcers that heal poorly. What complications of diabetes would cause her inability to feel light touch and foot ulcers that fail to heal properly? a) Peripheral neuropathy can cause loss of sensation in the extremities. b) Low blood glucose levels associated with diabetes can cause death of neurons in the feet. c) High blood glucose levels coincides with low blood oxygen saturation, which can damage neurons and skin. d) Poor circulation can cause foot ulcers to form that do not heal. 12. In your discussion with Y.T. you emphasize potential serious complications that may result from poorly treated diabetes. Which of the following are potential serious complications of diabetes mellitus? (Select all correct answers) a) In your discussion with Y.T. you emphasize potential serious complications that may result from poorly treated diabetes. b) Which of the following are potential serious complications of diabetes mellitus? Select all correct answers. c) Peripheral vascular disease that can lead to amputation. d) Strokes and brain damage e) Osteoporosis and higher incidence of broken bones f) Blindness, retinopathy, cataracts, and glaucoma g) Coronary artery disease and heart attacks h) Neuropathy leading to loss of sensation in the feet. i) Kidney damage and renal failure 13. The graph below shows blood glucose levels in three individuals after eating a bagel, which contains about 60 grams of carbohydrates (~260 calories without any add ons). Image transcription text Blood Sugar Response after Eating Bagel 375 350 Ronald 325 300 275 250 Wendy Blood Glucose Concentration in mg dl … Show more PART 1: What cells of the pancreas respond to an increase in blood glucose levels? ________________ (Beta cells, Alpha cells, Acinar cells) These cells respond to an increase in blood glucose by producing: _____________ (Glucagon, Insulin) PART 2: (MATCH THE PRIMARY TARGET ORGANS FOR INSULIN INTO THEIR APPROPRIATE TISSUE RESPONSE) Increases glucose uptake and glycogen synthesis ______________ (Liver, Adipose, Muscle) Increase glucose uptake and glycogen storage, decreases glucose synthesis _____________ (Liver, Adipose, Muscle) Stores excess glucose as fat synthesis ______________ (Liver, Adipose, Muscle) PART 3: Blood glucose levels remain stable between meals despite the fact that the body’s cells continually use glucose as an energy source. Answer the following questions on how the body maintains blood glucose at normal levels (90-100 mg/dL blood) between meals. Which cells respond to fasting? ___________ (Exocrine, Alpha, Beta) Which hormone do they produce?­­­ ________________ (Insulin, Digestive Enzymes, Glucagon) This hormone has the following actions: _____________________________ (Stimulates muscle to release glucose into blood, Stimulates liver to breakdown glycogen to glucose and synthesize glucose, Stimulates liver to store glucose as glycogen) PART 4: As shown in the graph above, Wendy and Ronald are unable to properly regulate blood glucose levels. What are two possible defects in hormone signaling that would explain their inability to maintain glucose homeostasis? Choose two possibilities from the options below: a) Insulin receptor insensitivity b) They are unable to produce insulin c) They are unable to produce glucagon d) Secreting too much glucagon e) Glucagon receptor insensitivity f) Tissues are being over-stimulated by insulin 14. When liver and muscle is resistant to insulin, what happens to glycogen storage? What happens to blood glucose levels? a) Blood glucose increase and glycogen storage increase. b) Blood glucose increase and glycogen storage decrease. c) Blood glucose decrease and glycogen storage decrease. d) Blood glucose decrease and glycogen storage increase. 15. The figures below show blood glucose and plasma insulin levels in three patients following a carbohydrate-rich meal Image transcription text Patient 1 Patient 2 Patient 3 Blood Glucose Concentration 150 400 250 400 250 400 = = = = Plasma Insulin Concentration… Show more Analyze the graphs and decide which patient is normal, has Type I diabetes, or has Type II diabetes. Patient 1: _____________________ Patient 2: _____________________ Patient 3: _____________________ 16. John has Type II diabetes and treats his condition with two medications, Metformin and Glucotrol. Metformin works by telling the liver to produce less glucose and by helping muscle, fat and liver absorb more glucose from the bloodstream. Glucotrol (glipizide) works by telling the pancreas to boost insulin production. John takes his medication before he eats each meal. John had two pieces of bread with peanut butter and jam with his diabetes medication at 7:00am. Following breakfast, John and his wife left for Minneapolis to see their son. At noon, John took his pills in preparation for lunch. However, he could not find a restaurant he or his wife liked so he decided to wait until he got to Minneapolis to eat. About an hour later, John started to get sweaty, his hands began to shake, and he felt light-headed and dizzy. Upon arriving in Minneapolis, John was still not feeling well and told this to his daughter-in-law. She scolded him for being careless and immediately gave him something, after which he began to feel much better. Below is a graph of how John’s blood sugar levels changed during his trip to Minneapolis Image transcription text 200 260 240 220 Blood glucose 200 180 160 150 high blood sugar (mg glucose / 100 ml blood) Blood Glucose Concentra… Show more Why do you think John began to feel ill on the trip to Minneapolis? He became hyperglycemic because he ate without taking his medication He became hyperglycemic because he took his medication without eating He became hypoglycemic because he ate without taking his medication What did John’s daughter-in-law give him to make him feel better? She gave him an insulin injection She gave him something with glucose in it, like orange juice She gave him his medication She gave him some pain medication John’s daughter-in-law gave him advice on how to treat this problem if it ever arose again. What did she tell John to do if he ever experienced these symptoms again? Never eat sugary foods Never eat without taking your medication Always carry a source of glucose with you and take it when you experience hypoglycemia Never take your medication after you eat 17. KT is twenty years old and has Type I diabetes. To treat her condition, KT injects herself with insulin to control her blood glucose levels. KT is a skinny girl but because she has diabetes she is afraid of gaining weight. On a recent day, KT and a friend had lunch at a local cafe. After lunch, the two sat and talked for a while. During this time KT went to the restroom to urinate twice and later complained of thirst and a bad headache. Her friend became concerned and asked her about how she manages her diabetes. KT became defensive and refused to discuss the topic. Her friend pushed KT to talk, and she finally admitted that she has a problem. Below is a graph of KT’s blood glucose levels. Image transcription text 280 260 240 220 200 Blood glucose 180 16 Blood Glucose Concentration (mg glucose / 100 ml blood) high blood sugar n… Show more 1) In response to eating, does insulin normally promote storage or metabolism (breakdown) of sugars? a) Metabolism (breakdown) b) Storage 2) Normally, what happens to the excess sugars we eat? a) They get stored as glycogen b) They get stored as glucose c) They get urinated out d) They get stored as fat 3) Based on the graph above, is KT managing her diabetes properly? __________ (Yes/ No) 4) What is KT doing to mismanage her diabetes? a) She is taking too much insulin b) She is not taking her insulin c) She is not eating enough d) She is eating too much 5) Why did KT begin to feel ill? a) She ate and drank too much b) Her high blood glucose is causing an inflammatory reaction c) Her high blood glucose was causing her to urinate frequently and become dehydrated d) She is hypoglycemic and her CNC is shutting down 6) Why is KT purposely mismanaging her Type I diabetes? a) She is taking too much insulin to make her lose weight b) She wants to be able to eat high carb meals c) She worried that taking insulin will make her store fat d) She is concerned that her medication is too expensive 7) KT is thin for her height. How does KT’s mismanagement of her diabetes lead to weight loss? a) Without insulin her body burns all of the glucose in her bloodstream b) Taking too much insulin boosts her metabolism to burn more fat and muscle c) Not eating means her body burns the fat and muscle for energy d) Without insulin no glucose is stored, and her body must burn fat and muscle for energy 18. J.Q. has Type II diabetes. He is taking two medications, Metformin and Glucotrol, to help control his blood glucose levels. Metformin works by telling the liver to produce less glucose and by helping muscle, fat and liver absorb more glucose from the bloodstream. Glucotrol (glipizide) works by telling the pancreas to boost insulin production. J.Q. takes his medications about 30 min. before each meal. J.Q. and his wife left for their European vacation at 9:00 am. At lunchtime, J.Q. looked in his carry-on for his pills, but realized he had packed them in his checked luggage. He didn’t think much of this oversight and carried on with his day. Later on the flight, he snacked on some pretzels and cookies, drank two beers, and ate dinner (pasta, a dinner roll, and chocolate cake). Despite eating all day, he still felt very hungry and felt exhausted. He was also making many trips to the bathroom to urinate and felt very thirsty. Upon arriving in London and collecting his luggage, he found his medications and took his pills. In about an hour he began to feel much better. Below is a graph how J.Q.’s blood sugar levels changed during his trip to London. Image transcription text 280 260 Blood glucose 240 220 200 180 16 Blood Glucose Concentration (mg glucose / 100 ml blood) high blood sugar n… Show more 1) Why do you think J.Q. experienced hunger and fatigue? a) His body was burning more calories than he consumed b) His cells were unable to the glucose he ate and were starved of energy c) His body was storing too much glucose for him to be able to use d) His diet was full of empty calories that his body couldn’t use 2) What caused J.Q.’s frequent urination and thirst? a) His body needs lots of water to absorb all of the glucose her consumed b) His body removed the glucose through urination which causes fluid loss c) He drank too much beer 19. Which of the following are possible causes of J.Q.’s high blood glucose levels? (Choose all correct answers) a) Target cell response to insulin is lower than normal b) Insulin production is lower than normal c) Low glucose uptake by liver and muscle cells d) Glucagon production is lower than normal e) Glycogen production is higher than normal 20. G.M. has Type I diabetes. To treat his condition, he injects himself with insulin to control his blood glucose levels. G.M. must take his insulin before he eats or drinks anything with sugar. G.M. is an avid swimmer and he routinely swims 100 laps each morning. On a recent morning, he woke up late and didn’t have much time to eat before his swim. So he quickly ate a small cup of yogurt, took his insulin shot, and went for his swim. About an hour later, as he was finishing his swim he became very hungry, his hands began to shake, and he felt light-headed and dizzy. He quickly showered and headed home. Upon arriving home, G.M. was feeling even worse and told this to his friend who was in town for a visit. She scolded him for being careless and immediately gave him some orange juice and crackers to eat. After drinking the juice and eating the crackers, he began to feel much better. Below is a graph of G.M’s blood glucose. Image transcription text 280 260 Blood glucose 240 220 200 180 16 Blood Glucose Concentration (mg glucose / 100 ml blood) high blood sugar n… Show more 1) What is the major defect in Type I diabetes? a) Autoimmune destruction of alpha cells, can’t make insulin b) Autoimmune destruction of beta cells, can’t make insulin c) Receptor hypersensitivity to insulin d) Receptor insensitivity to insulin 2) Why did G.M. began to feel ill after his swim? a) He was hyperglycemic b) He was hypoglycemic 3) What led to him to be in this state? a) He did not eat enough, took too much insulin, exercise used up glucose b) He did not eat enough, not enough insulin and exercise raised blood glucose c) He ate too much, not enough insulin, exercise used up glucose d) He ate too much, took too much insulin and exercise raised blood glucose 4) Why did G.M. experience light-headedness and shaking? a) His body experiencing hyperglycemia and releasing catecholamines to lower blood glucose b) His body experiencing hypoglycemia and releasing catecholamines to raise blood glucose c) His body is fighting the high levels of insulin d) His body is fighting the high levels of glucose 5) Why would drinking juice and eating crackers help G.M. feel better? a) It caused his body to release glucagon b) It raised his blood glucose to normal c) It raised his insulin levels to normal d) It helped him not feel hungry 21. KT is 26-weeks pregnant and is given a glucose tolerance test, which measures how quickly glucose is cleared from the blood after ingesting a glucose-rich drink. The results show that her blood glucose levels rise higher than normal and remain above normal for more than three hours. Image transcription text 300 250 200 Blood glucose (mg/100 ml) 150 KT results 100 50 normal pregnant female 2 Glucose Time (hours) given Which of the following are possible causes of KT’s results? (Choose all possible answers.) a) Which of the following are possible causes of KT’s results? Choose all possible answers. b) The pancreas is not secreting enough insulin to maintain blood glucose levels within the normal range c) The pancreas is secreting excess glucagon in response to ingestion of glucose. d) Peripheral muscle is less sensitive to insulin causing a decrease in glucose uptake. e) Peripheral muscle tissue has increased glucose uptake in response to ingestion of glucose.

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