Mini Case Studies # 5 And # 6 Case Study Examples
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MINI CASE STUDY #5: HAROLD’S HEARTACHE:
The factors putting Harold at risk for heart disease are:
Sedentary lifestyle/Physical inactivity
Stress, obesity, smoking, hypertension, dyslipidemia and physical inactivity are modifiable risk while family history is non-modifiable.
Harold’s risk of developing heart disease can be calculated using Framingham point score. It came out to be ≥30%. The scoring is given below:
Age: 3 points for 46 years
Total cholesterol: 6 points for 260 mg/dL total cholesterol at age 46 years
Smoker: 5 points for smoking at age 46 years
HDL: 2 points for 35mg/dL HDL
Systolic Blood Pressure (SBP): 1 point for untreated SBP of 143mmHg
Total points: 17 points.
According to the Framingham point scoring system (NIH, 2001), Harold’s 10 year risk for developing heart disease is greater than or equal to 30%.
The National Cholesterol Education Program (NCEP) ATP III guidelines (2001) recommend LDL goal of less than 100 mg/dL in patients with greater than 20% 10 year heart disease risk. It also recommends therapeutic intervention for lipid lowering if the LDL levels are more than 130 mg/dL. Lifestyle modification to lower the cholesterol levels is warranted if the LDL level falls between 100 to 130 md/dL.
Based on the above mentioned guidelines, Harold’s lipid profile is completely deranged that puts him at a risk of developing an atherosclerotic event leading to vascular occlusion and ischemia. In such a case, both, pharmacologic and lifestyle intervention should be administered.
According to Papadakis and McPhee (2015), patients with uncontrolled hypertension, multiple coronary disease risk factors, positive family history and obesity should reduce salt intake in their diets. Decreased sodium intake causes losing of water molecules from the kidney tubules leading to decreased volume. Lesser volume causes heart to contract normally rather than forceful contraction in case of more volume. The authors also recommended the use of Dietary Approaches to Stop Hypertension (DASH) diet which is rich in fruits, low-fat dairy products, and vegetables. It also should have reduced saturated fat and total fat content.
Harold should be counseled regarding the grave outcomes of uncontrolled hypertension, hyperlipidemia and physical inactivity. His family history is positive for cardiovascular disease and his 10 year risk is greater than 30% which fundamentally means that more than 30 men out of every 100 with the same demographics and attributes will develop a cardiac event within 10 years.
He should therefore be educated about ways to tackle such a situation. A balanced diet with decreased fat and salt intake should be encouraged with incorporation of mild to moderate physical activity. Smoking should be stopped and pharmacologic intervention should be administered to address hypertension and hyperlipidemia.
MINI CASE STUDY #6: DONNA’S DIABETES
Donna’s diabetes is uncontrolled at the time of presentation regardless of good glycemic control in the past. She has a high fasting blood glucose levels and an increased glycosylated hemoglobin levels. Both these values are indicative of diabetes mellitus. According to Papadakis and McPhee (2015), fasting blood glucose should be less than 100 mg/dL while glycosylated hemoglobin (HbA1c) should be less than 5.7%. a diagnosis of diabetes mellitus can be made if the fasting blood glucose is more than 126 mg/dL and the HbA1c level is more than 6.5%.
The estimated average glucose (eAG) can be calculated by using this formula 28.7 X A1C – 46.7 = eAG. (American Diabetes Association)
Based on the above mentioned formulae, Donna’s average glucose level is 192 mg/dL.
According to Bozkaya, Ozgu and Karaca (2010), patients with good to moderate blood glucose control are not entirely managing their blood glucose levels successfully as their eAG levels will depict. Also, they concluded that fasting blood glucose levels and eAG levels depend upon the glycemic control of the patient. Therefore, Donna’s blood fasting blood glucose is different than her eAG mainly because she failed to have a good glycemic control.
The medications used to treat hyperglycemia falls into several categories. According to Papadakis and McPhee (2015), there is a wide range of oral medications used in treating diabetes which delay the use of injectable insulin for the treatment. These medicines are generally safe with fewer undesired effects compared to injectable insulin but their efficacy is proven. The most commonly prescribed anti-diabetic medicine is a sulfonylurea which is an insulin secretagogue. It is either given alone or added with meglitinide analogs like repaglinide or a biguanide such as metformin. Insulin sensitizers can also be used which are thiazolidinediones like pioglitazone or rosiglitazone. Newer drugs like Dipeptidyl-peptidase 4 (DPP-4) inhibitors are used nowadays alone or in combination with metformin. Injectable insulin is sought if all the above medicines fail to control the hyperglycemia as well as lifestyle and dietary modifications.
According to Papadakis and McPhee (2015), type 2 diabetes occurs due to insulin resistance developed secondarily due to various factors. The authors concluded that obesity is the most common etiologic factor in the pathogenesis of type-2 diabetes. The lipodystrophy takes time to manifest in the body and there is hyperplasia in the pancreatic islet cells in initial phases of the disease. This hyperplastic change cause hyperinsulinism leading to fasting hypoglycemia followed by insulin resistance and overriding of pancreatic islet cells. The genetic predisposition in type 2 diabetes is also postulated but environmental insult is needed for genes to express themselves.
Type 1 diabetes, on the other hand, is an autoimmune process that leads to the destruction of pancreatic islet cells. In some cases, the destruction is idiopathic as well. There is absolute deficiency of insulin due to islet cell destruction.
In type 1 diabetes, the only treatment option available is administration of exogenous injectable insulin due to absolute absence of endogenous insulin. While, in type 2 diabetes, oral hypoglycemic drugs are available that can either increase the amount of insulin secreted or increase the sensitivity of insulin in the peripheral tissues.
The American Diabetes Association (ADA) recommends 45 to 65% of total daily calories be derived from carbohydrates, 25 to 35% from fat and 10 to 35% from proteins. It also recommends that fat calories should constitute of less than 7% of saturated fat. Diabetic patients should rely more on the calories from monounsaturated fat like olive or canola oil so that their triglyceride levels decrease and HDL levels are increased. Donna is obese and diabetic both, so Papadakis and McPhee (2015) recommends weight reduction with help of caloric restriction. The authors also emphasized on the cholesterol intake to be limited to 300 mg daily. Cellulose and pectin are called as dietary fiber and should be incorporated in routine diet to halt or slow down glucose absorption from the intestinal mucosa. The ADA recommends consumption of oatmeal, beans, cereals and bran as a daily dietary component in diabetic individuals.
Donna has a special tooth for sweet baked edibles. It is very harmful for her diabetes and cholesterol levels. She should refrain from taking sweet and avoid dairy products to help her regulate the cholesterol levels. If her glycemic control is not adequate, it can manifest as various complications in the multiple organs of the body. She should try to lose her weight and incorporate daily exercise.
Bozkaya, G., Ozgu, E., & Karaca, B. (2010). The Association Between Estimated Average Glucose Levels And Fasting Plasma Glucose Levels. Clinics, 65(11), 1077-1080.
National Cholesterol Education Program: ATP III Guidelines At-A-Glance Quick Desk Reference. (2001, May). Retrieved March 23, 2015, from https://www.nhlbi.nih.gov/files/docs/guidelines/atglance.pdf
Papadakis, M., & McPhee, S. (2015). Systemic Hypertension. In Current Medical Diagnosis & Treatment 2015 (54th ed., p. 439). New York: McGraw-Hill Education/Medical.
What Can I Eat? (n.d.). The American Diabetes Association. Retrieved March 23, 2015, from http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/