Frequent urination

As Mr Tan has T2DM, he might have high blood glucose levels. High blood glucose levels exceeds the capacity of the kidneys causing it to be excreted through the urine. Because glucose is solute, it drags water into the urine by osmosis resulting in more urine. Because he is excreting more urine, he experiences dehydration causing him to drink more water further increasing his urine production.

Fatigue

in T2DM, insulin resistance reduces and efficacy of glucose uptake by the body, thus impairing the bodys ability to use glucose for energy, leading to fatigue. Hyperglycaemia can also cause frequent urination, causing dehydration, hence leading to fatigue.

Blurry vision

Too much glucose in the blood can lead to a blockage of the microvascular blood supply, which can lead to retinopathy (a complication of uncontrolled DM), which affects eye vision and cause blurry vision.

Frequent headache

Mr Tan has Type 2 Diabetes Mellitus which is the presence of insulin resistance. With poorly controlled blood sugar, it lead to hyperglycaemia and hypoglycaemia, which causes symptoms like headache. Dehydration due to polyuria that is caused by hyperglycaemia, can reduce the blood flow to the brain, leading to headache.

Right toe wound infection

Uncontrolled diabetes can cause damage to blood vessels, in this case the capillaries in the peripheral nerves. The walls of the capillaries that is supplying the nerves with oxygen and nutrients is damaged, affecting the peripheral nerves’ ability to send signals. This results in diabetic neuropathy, resulting in decreased sensation in toes and fingers. Uncontrolled diabetes also results in impaired function of white blood cells, hence suppressing the immune system response needed to fight infection. With this combination of suppressed immunity and neuropathy, Mr Tan would have decreased awareness of any pain or injuries on his feet, which can get infected easily due to higher risk of infection and slower to heal.

• pancreatic stimulants

• insulin-resistance-reducers

• increased excretion of glucose in urine

• inhibitors of carb digestion

Oral medications (+ improve compliance):

• metformin

• glipizide

• glicazde

• dapagliflozin

S/C medications:

• pre-meal short acting insulin

• long-acting insulin

Weight loss surgery (indicated for ++ BMI)

Diet and lifestyle changes (Pt Education):

• less added sugar, salt, fat

• increased physical activity

• stop smoking and/or alcohol consumption

Foot care (education)

• oral antibiotics to treat ongoing rt toe wound

• self-monitor for wounds

• wear fitting footwear (even at home)

• remove all potential injury hazards at home

• non-slip mats + bars

• regular wound dressing

Education

• on using insulin pen

• s/s of hypoglycemia, DKA, HHNS

• ensuring pt consumes meal within 15-30min upon administering of insulin pen

Symptoms #1 : right toe wound infection accompanied with fever of 38.2^oC and rapid HR over 100bpm and RR 21 breaths/min with history of DM over 10 years. 

Rationale : Signs and symptoms of Diabetic foot infection which is a complication from DM. 

Symptoms #2: reduced sensation and weak dorsalis pedis pulse on the right foot, with risk factors i.e. hypertension, hyperlipidemia and smoking and alcohol intake. 

Rationale : Signs and symptoms of Diabetic Neuropathy

Symptoms #3: frequent urination 

Rationale : Uncontrolled DM causing hyperglycemic caused by glucose builds up in the blood which forces the kidneys to work overtime to filter and absorb the extra glucose.

Symptoms #4: frequent headache 

Rationale : Fluctuation in blood glucose levels can lead to pressure changes in blood vessels in the brain which can lead to headache.

Symptoms #5: blurry vision 

Rationale: Retinopathy

Symptoms #6: fatigue

Rationale: Glucose is unable to be uptake by the cells for metabolism and resulting in high blood glucose level

• Frequent urination

• Fatigue

• Blurry vision

• Frequent headache

• PMHx: HTN/ HLD/ T2DM (assume there are no records and he’s not a former pat of the hosp)

• Smokes 20 sticks of cigarettes, drinks beer at least once a week

Obj data:

• BMI 25 (overweight)

• Right wound infection

Implications: He is presenting all these s&s (chief complaint) due to his poorly uncontrolled DM

Other subjective and objective data suggest reasons behind is poorly controlled diabetes.

Looking at his blood tests, his WBCs are elevated, related to his right toe wound infection. His RBCs, haemoglobin, MCV and haematocrit are reduced, indicating anemia. This can be attributed to his prolonged disease process of diabetes that led to kidney damage, reducing erythropoietin production, which is required for RBC and other blood element production.

Mr Tan's glycemic counts are also elevated

Fasting blood glucose - 16mmol/L

Postprandial (after meal) plasma glucose - 23mmol/L

Random blood glucose - 18mmol/L

HbA1C - 12%

Poorly controlled DM, leading to hyperglycemia.

Other investigations

• Wound swab and culture: To identify the specific bacteria causing the infection in his right toe, which will guide antibiotic treatment.

• Doppler Ultrasound: To assess blood flow to the lower extremities, as diabetes can cause poor circulation and PAD, which may be contributing to the wound infection and delayed healing.

• Urine dipstick: To check for the presence of glucose, ketones, and protein, which can indicate poor diabetes control or possible diabetic nephropathy.

• Urine culture: To rule out a urinary tract infection (UTI), especially if he has been experiencing frequent urination.

• Eye Screening: To assess diabetic retinopathy, which could be causing his blurry vision

• Electrocardiogram (ECG): Given his history of hypertension, hyperlipidemia, smoking, and diabetes, he is at high risk for cardiovascular disease. TRO cardiovascular complications.

• Ankle-Brachial Index (ABI): To assess for PAD in his legs, which could contribute to his wound infection.

Sub data:

• Frequent urination

• Fatigue

• Blurry vision

• Frequent headache

• Smokes 20 sticks of cigarettes, drinks beer at least once a week

Obj data:

• BMI 25 (overweight)

• Right wound infection

• PMHx: HTN/ HLD/ T2DM

• Lab test

Implications: He is presenting all these s&s (chief complaint) due to his poorly uncontrolled DM

Other subjective and objective data suggest reasons behind is poorly controlled diabetes