Diabetes Mellitus (DM) Assessment Answers

DIABETES MELLITUS
Introduction
Diabetes mellitus (DM) is defined as a complex and chronic metabolic disorder which is characterized by hyperglycemia (Baig, 2015). DM is mainly caused due to defects in the secretion of insulin by pancreatic beta cells or impaired action of insulin, or both (Baig, 2015). Diabetes is a global health problem and nearly 415 million people are suffering from this illness (Fan, 2017). The chronic condition of diabetes mellitus leads to increased prevalence of mortality, morbidity, emotional and economic burden on the society (Fan, 2017). In this assessment, there is a description of various diagnoses that can be used to measure the hyperglycemic condition of patients along with the rationale and reliability of these diagnostic tests. There is a brief discussion about the sign and symptoms of diabetes mellitus. Also, the sign and symptoms that have been present by Milton in the case study have been explained with the help of physiological mechanism. There is an examination of type of diabetes encountered by Milton along with its rationale. This has been followed by the difference between type 1 diabetes mellitus and type 2 diabetes mellitus on the basis of pathophysiology, genetics, onset, age and other factors. Last, the various specific investigations which can differentiate between type 1 and type 2 diabetes mellitus are also discussed in brief.
Diagnosis of diabetes mellitus
The diagnosis of DM is very important for the management of this chronic illness and the tests which can be done for the diagnosis of DM includes fasting plasma glucose test (FPG), oral glucose tolerance test (OGTT) and glycated hemoglobin test (HbA1c). It has been reported that the fasting plasma glucose test (FPG) has been conducted for measuring the blood glucose level of a patient after fasting or for not eating anything at least for 8 hours (Pooja amp Mittal, 2014). According to the instructions of WHO and ADA, the normal range for FPG test is nearly 6.1-7.8 mmol/L (American Diabetes Association, 2018). As recommended by Australian standards the normal limit for FPG is 6.1 mmol/L (Diabetes Australia, 2015). On the other hand WHO recommended limit for FPG is 5.5mmol/L (American Diabetes Association, 2018). The FPG diagnostic test has been used to measure the blood glucose level because this test is highly sensitive with sensitivity 45.4 to 53.7 and specificity up to 100 (Aekplakorn et al., 2015). This test helps in measuring blood glucose level conveniently at a single point of time with reliable results and cost-effective in nature (Aekplakorn et al., 2015).
The OGTT has been carried out to measure the instances of DM. This test is carried out to diagnose that body is encountering problems in metabolizing the carbohydrates taken by the patient (Diabetes.Co.UK, 2019). The specified normal limits for OGTT is 11.1 mmol/L after 1 hour of taking approximately 75g of glucose and 7.8 mmol/l after 2 hours (Medline Plus, 2019). According to the specified limits in Australia for OGTT, the normal range is lt7.8 mmol/L after 2 hours (Phillips, 2016). The rationale for using this test is that it is highly sensitive with sensitivity 81.1 to 93.0 (Aekplakorn et al., 2015). This is a fast method of diagnosis of glucose tolerance impairments as it can be completed with 2 hours of glucose intake (Rydn, Viveca, Schnell amp Jaakko, 2016). Also, the specificity of the test is very high and accounts for up to 100 (Aekplakorn et al., 2015).
HbA1c has been used to measure the hemoglobin bound glucose moieties over a period of time nearly 3 months (MedlinePlus, 2018). During the processing of glucose in the body it gets attached to the hemoglobin and in case of higher glucose concentrations, the level of HbA1c increased. This test has been carried out within 3 months because this is the average life of RBCs (MedlinePlus, 2018). The normal specified limits for HbA1c are less than 6.5 mmol/l (Owora, 2018). This test helps in analyzing the overall picture of diabetes mellitus and helps in analyzing the patients who are at high risk. The sensitivity of HbA1c test is 44 with a specificity of 79 (Owora, 2018).
Sign and symptoms
From the case study, it has been revealed that Miltons wound was not showing any sign of healing, he needs to empty his bladder frequently and suffering from mild hypertension. The various signs and symptoms of diabetes include unexplained weight loss, irritability, dry mouth, itching, decreased vision, erectile dysfunction, repeated infections, fatigue, pain in feet, dark patches, reactive hypoglycemia, polydipsia, Polyphagia, poor wound healing and hypertension (Ramachandran, 2014). According to Fathollahi, Daneshgari and Hanna-Mitchell (2014), polyuria is most prevalent and first symptom of diabetes mellitus in which the patient is required to get up and empty his/her bladder frequently. The physiological mechanism behind polyuria is osmosis diuresis. In diabetes, the plasma glucose concentrations increases which result in higher filtration of glucose and results in higher reabsorption of this glucose in proximal tubules (Poudel, 2013). This mechanism is known as glucose reabsorption mechanism which is characterized by higher saturation of sodium-glucose cotransport carrier and leads to glycosuria (Poudel, 2013). Because of glucose trapped in lumen and its osmotic effects, the flow of water increased and leads to osmosis diuresis and results in the condition of polyuria (Poudel, 2013).
It has been reported that poor wound healing is another symptom of diabetes (Okonkwo amp DiPietro, 2017). The physiology behind this symptom includes thickening of basement membrane of arterioles and capillaries in diabetic patients which results in prolonged wound healing process (Okonkwo amp DiPietro, 2017). The hyperglycemic condition of the patient leads to impaired wound healing by advanced glycated end-product formation which leads to the formation of TNF- and IL-1 which are inflammatory molecules and inhibits the process of synthesis of collagen (Tsourdi, Barthel, Rietzsch, Reichel amp Bornstein, 2013). One other mechanism behind poor wound healing is high glucose concentrations and alteration in the cellular morphology (Tsourdi et al., 2013). It has been stated that increase glucose concentration results in impaired cell morphology, proliferation and keratinocytes differentiation (Tsourdi et al., 2013).
According to De Boer et al. (2017), hypertension is common among patients who have the complication of diabetes. In diabetic patients, the level of insulin secretion decreased which plays a major role in the translocation of Na/K-ATPase to the cell membrane from cytoplasm for opening the Na/H channels and these channels are responsible for the passive transport of hydrogen ions out of cells and sodium ions inside the cell (Ohishi, 2018). This results in the increase of calcium ion level in cells and leads to decrease in pH (Ohishi, 2018). When the deficiency of insulin occurs in the body of diabetic people, the activity of Na/K-ATPase decreases which in turn increases the transport of potassium ions out of cells and sodium and hydrogen inside the cells (Ohishi, 2018). This event results in the increase of sodium ion density in the cells and results in high concentration of potassium in serum (Ohishi, 2018). It has been stated that high serum concentrations of potassium ions lead to the complication of hypertension (Xi et al., 2015). Also, the increase in insulin resistance among diabetic people leads to hyperinsulinemia which leads to increased reabsorption of sodium from renal tubules and results in hypertension (Ohishi, 2018).
Differentiation of types of diabetes
Milton has been diagnosed with diabetes. The case study revealed that Milton is a 68-year-old man who is suffering from mild hypertension. He must be suffering from type 2 diabetes mellitus. It has been reported that the older adults of above than 60 years old are more vulnerable to the progression of type 2 diabetes mellitus and nearly 15 of older adults have been suffering from this complication (Chentli, Azzoug amp Mahgoun, 2015). The main reason behind the high incidence rate of type 2 diabetes mellitus among adults is combined effect of various co-morbidities and increased dysfunctioning of pancreatic islet along with insulin resistance (Yakarylmaz amp ztrk, 2017). It has been reported that glucose intolerance increased by the progression of age which makes the elderly population at high risk of type 2 diabetes mellitus (Yakarylmaz amp ztrk, 2017). With the advancement of age, insulin resistance increases among the people which results in postprandial hyperglycemia become highly prevalent among them (Yakarylmaz amp ztrk, 2017). In addition to it, with increasing age, the concentration of vitamin D decreases in the body which the main factor that inhibits the deposition of fat in the body (Chentli, Azzoug amp Mahgoun, 2015). The lack of vitamin D leads to obesity and make older adults more vulnerable to type 2 diabetes mellitus (Chentli, Azzoug amp Mahgoun, 2015).
The pathophysiology behind DM includes impaired insulin secretion and insulin resistance (Skyler et al., 2017). In type 1 diabetes mellitus, the inflammation and autoimmunity lead to the destruction of insulin-producing -cells (Skyler et al., 2017). On the other hand, inflammation and metabolic stress are the reasons behind -cell dysfunctioning in type 2 diabetes mellitus (Skyler et al., 2017). It has been reported that inflammation and oxidative stress is highly prevalent among older adults and leads to metabolic syndromes and type 2 diabetes mellitus (Alicka amp Marycz, 2018). From the genetic point of view, the variation in HLA gene (human leukocyte antigen) alters the binding of HLA protein to antigenic peptides and contributes to an autoimmune disorder in type 1 diabetes mellitus (Skyler et al., 2017). Also, nearly 50 additional genes regulate the onset of type 1 diabetes mellitus among people. In type 2 diabetes mellitus more than 130 genetic variations can lead to the onset of diabetes, low insulin level and glucose levels among people (Skyler et al., 2017). It has been stated that the various in HLA gene can occur in nearly 5 of the children who have immediate family members with altered HLA gene and the onset of type 1 diabetes mellitus can be diagnosed among them by the age of 20 years old (Noble amp Valdes, 2011).
According to Xu et al. (2018), type 1 diabetes mellitus is highly prevalent in childhood and called juvenile onset whereas, type 2 diabetes mellitus is highly prevalent among the people above than 40-year-old called adult onset. It has been stated that in type 1 diabetes mellitus the secretion of insulin is completely impaired whereas in type 2 diabetes mellitus the insulin could be present in aplenty amount but still the resistance of cells can lead to hyperglycemic condition among the patients (American Diabetes Association, 2017). There is variation in the symptoms of type 1 and type 2 diabetes mellitus. The various sign and symptoms of type 1 diabetes mellitus include hunger, weight loss, thirst, fatigue, nausea, dry skin and fruity breath. On the other hand, type 2 diabetes mellitus is characterized by frequent infections poor wound healing, polyuria, numbness in hands and feet (American Diabetes Association, 2017).
The diagnosis of type 1 diabetes mellitus can be done by random glucose test whereas for the diagnosis of type 2 diabetes mellitus, HbA1C and ketoacidosis analysis needs to be done. The patients suffering from type2 diabetes mellitus highly encountered diabetic ketoacidosis so analysis of this complication is very important for these patients American Diabetes Association, 2017). It has been reported that Type 1 diabetes mellitus is an autoimmune disorder so the antibody test which needs to be done for type 1 diabetes mellitus includes GADA, IA-2, ICA, ZnT8 and IAA (National Collaborating Centre for Womens and Childrens Health UK, 2015). On the other hand, there is no evidence for the conduction of antibody test for type 2 diabetes mellitus (National Collaborating Centre for Womens and Childrens Health UK, 2015).
Conclusion
In this given assessment, various diagnostic tests which can detect the hyperglycemic condition of the patient has been discussed and it has been found that oral glucose tolerance test has the highest specificity and sensitivity and can measure the increased glucose level with 2 hours of the glucose intake. The various sign and symptoms of DM have been examined in the assessment along with the clinical presentations of Milton. It has been found that diabetes leads to osmosis dieresis because of which polyuria is encountered by the patient. DM leads to the advanced glycated end-product formation and results in poor wound healing complication among patients. In diabetic patients level of insulin secretion decreased because of which these patients encounter the complication of hypertension. The pathophysiological mechanism of both subtypes of diabetes has been discussed and it has been examined that type 1 diabetes mellitus, insulin producing -cells destroyed by inflammation and autoimmunity and in type 2 diabetes mellitus inflammation and metabolic stress are the leads to -cell dysfunctioning. In type 1 diabetes mellitus, along with HLA gene, 50 additional genes regulate the onset whereas in type 2 diabetes mellitus onset of diabetes is regulated by more than 130 genetic variations.
References
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