Diabetes Mellitus Type II Presentation

Description: • Chief complaint: uncontrolled thirst • HPI: JP is a 58 years old male evaluated at our primary care office with complains of uncontrolled thirst, excessive urination during day and night, morbid hungry and weight loss of 10 pounds during the last 2 months. • Past medical history: Obesity (BMI 31) and High blood pressure untreated • Family history: Mother Diabetes Mellitus Type II • Social History: current smoker, no alcohol or drug use. Patient does not practice exercise and uses to eat fast food frequently. Supported by a detailed physical exam and laboratory tests ordered we were able to diagnose

Type 2 Diabetes Mellitus (E11.65) Epidemiology: Diabetes, also known as Diabetes Mellitus (DM), is a disorder characterized by the high glucose level and can be manifested in various types, which have different pathophysiology. Diabetes mellitus is characterized by the high rates of prevalence at the global level, in the United States and in the state of Florida as well as has severe health complications. Standl et al. (2019) argue that 8.8% of global adult population suffers from various types of diabetes. In terms of numbers, 425 million of people worldwide are diagnosed with diabetes. Standl et al. 2019 exposed that people from 40 to 59 are at increased risk of development of diabetes. In terms of conditions of life and socio-economic status, seventy-seven percent of global population that is diagnosed with DM lives in the low and middle-income countries. According to the CDC (2020), 34 million people in the US have diabetes (p.4).

This number accounts for more than 10% of the population of the country. In addition, more than 7 million of citizens did not report about diabetes. Lastly, black non-Hispanic older adults comprise the group that is at high risk of development of diabetes. Approximately 90-95% have type 2 diabetes. Type 2 diabetes most often develops in people over age 45, but more and more children, teens, and young adults are also developing it. Etiology: The etiology of diabetes type 2 is result of complex interactions between environmental and genetic factors. The paths to β-cell demise and dysfunction are less well defined in type 2 diabetes compare with Diabetes Type 1, but deficient β-cell insulin secretion, frequently in the setting of insulin resistance, appears to be the common denominator. Type 2 diabetes is associated with insulin secretory defects related to inflammation and metabolic stress among other contributors, including genetic factors. There is a strong inheritable genetic connection in type 2 DM, having relatives (especially first degree) with type 2 DM increases the risks of developing type 2 DM substantially. Several studies have demonstrated the involvement of multiple genes in pancreatic beta-cell failure and insulin resistance. Studies of twins have shown that genetics play a very strong role in the development of type 2 diabetes.

A number of lifestyle factors are known to be important to the development of type 2 DM. These are physical inactivity, sedentary lifestyle, cigarette smoking and generous consumption of alcohol. Obesity has been found to contribute to approximately 55% of cases of type 2 DM. The increased rate of childhood obesity between the 1960s and 2000s is believed to have led to the increase in type 2 DM in children and adolescents. Type 2 DM is characterized by insulin insensitivity as a result of insulin resistance, declining insulin production, and eventual pancreatic beta-cell failure. This leads to a decrease in glucose transport into the liver, muscle cells, and fat cells. There is an increase in the breakdown of fat with hyperglycemia. High blood sugar is damaging to the body and can cause other serious health problems, such as heart disease, vision loss, and kidney disease. Risk Factors: Systematic reviews and meta-analyses of observational studies have indicated numerous risk factors for T2DM. According to the American Diabetes Association main risk factors are: • Age greater than 45 years • Overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans)

• First-degree relative with diabetes • High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) • History of cardiovascular disease • Hypertension (≥140/90 mmHg or on therapy for hypertension) • HDL cholesterol level 250 mg/dL (2.82 mmol/L) • Women with polycystic ovary syndrome • Physical inactivity • Women who were diagnosed with Gestational Diabetes Mellitus • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) History Type 2 Diabetes symptoms often develop over several years and can go on for a long time without being noticed. Type 2 diabetes frequently appears in adulthood. The Classic symptoms are polyuria, polydipsia, polyphagia, and weight loss. Other symptoms that may suggest hyperglycemia include blurred vision, lower extremity paresthesia, or yeast infections. However, many patients with type 2 diabetes are asymptomatic, and their disease remains undiagnosed for many years. Comorbidities/Related conditions According to the CDC (2020), diabetes was the sevenths major cause of death in 2017 in the US (p. 12). Thus, diabetes can result in the severe health complications, which significantly reduce the quality of life and health outcomes. Diabetes complications are divided into microvascular (due to damage to small blood vessels) and macrovascular (due to damage to larger blood vessels).

• Eye related complications: Glaucoma, Cataracts, Retinopathy: non-proliferative and proliferative. • Neuropathy: Peripheral neuropathy, Autonomic neuropathy, Neuropathic arthropathy (Charcot’s Joint) • Nephropathy (end stage renal disease) • Foot complications: Neuropathy, Skin changes, Calluses, Foot ulcers, Poor circulation, Amputation • Cardiovascular disease: coronary artery disease with chest pain (angina), heart attack, stroke and atherosclerosis.

• Diabetes-related skin conditions: Acanthosis nigricans, Diabetic dermopathy, Necrobiosis lipoidica diabeticorum, Allergic reactions, Diabetic blisters (bullosis diabeticorum), Eruptive xanthomatosis, Digital sclerosis, Disseminated granuloma annulare Besides assessing diabetes-related complications, clinicians and their patients need to be aware of common comorbidities that affect people with diabetes and may complicate management. Diabetes comorbidities are conditions that affect people with diabetes more often than age-matched people without diabetes. 1. Cancer: Diabetes is associated with increased risk of cancers of the liver, pancreas, endometrium, colon/rectum, breast, and bladder. 2. Cognitive Impairment/Dementia: Diabetes is associated with a significantly increased risk and rate of cognitive decline and an increased risk of dementia.

3. Nonalcoholic Fatty Liver Disease Diabetes is associated with the development of nonalcoholic fatty liver disease, including its more severe manifestations of nonalcoholic steatohepatitis, liver fibrosis, cirrhosis, and hepatocellular carcinoma. 4. Hepatitis C Infection: Infection with hepatitis C virus (HCV) is associated with a higher prevalence of type 2 diabetes, which is present in up to one-third of individuals with chronic HCV infection.

5. Pancreatitis: Diabetes is linked to diseases of the exocrine pancreas such as pancreatitis, which may disrupt the global architecture or physiology of the pancreas, often resulting in both exocrine and endocrine dysfunction. 6. Sensory Impairment: Hearing impairment, both in high-frequency and low- to midfrequency ranges, is more common in people with diabetes than in those without, perhaps due to neuropathy and/or vascular disease. 7. Low Testosterone in Men: Mean levels of testosterone are lower in men with diabetes compared with age-matched men without diabetes, but obesity is a major confounder. 8. Obstructive Sleep Apnea: The prevalence of obstructive sleep apnea in the population with type 2 diabetes may be as high as 23%, and the prevalence of any sleep-disordered breathing may be as high as 58%. 9. Periodontal Disease: Periodontal disease is more severe, and may be more prevalent, in patients with diabetes than in those without and has been associated with higher A1C levels. Physical exam • General appearance: assess height, weight, BMI-generally central obesity

• Vital signs: blood pressure measurement will disclose hypertension, which is particularly common in patients with diabetes. Respiratory rate and pattern suggest Kussmaul respiration should be consider for diabetic ketoacidosis (DKA). • Skin: acanthosis nigricans, and candida infections • Neurologic: decreased or absent light touch, temperature sensation, and proprioception, loss deep tendon reflexes • Eye exam: funduscopic examination should include a careful view of the retina.

Because the diagnosis of type 2 diabetes often is delayed, 20% of these patients have some degree of retinopathy at diagnosis. The optic disc and the macula should be visualized. If hemorrhages or exudates are seen, the patient should be referred to an ophthalmologist as soon as possible. • Foot examination: complete foot inspection, including assessment of foot structure, skin integrity, vascular status, and pedal pulses; testing for loss of sensation, vibration sensation, ankle reflexes, pinprick sensation, or vibration perception threshold. The dorsalis pedis and posterior tibialis pulses should be palpated, and their presence or absence noted to rule out Peripheral artery disease.

This is particularly important in patients who have foot infections, because poor lower-extremity blood flow can slow healing and increase the risk of amputation. Differential Diagnosis The diagnosis of diabetes is straightforward in a patient with polyuria and polydipsia • Type 1 diabetes: Onset often at age