R.R. is a 62 year-old man who was initially seen because of gangrene of the foot and shortness of breath.

He had been told that he had a mild case of diabetes 4-5 years ago. He has seen physicians

intermittently, and is unaware of what his glucose regulation has been. He denies polydipsia or polyuria.

About 6 months ago, he injured his right foot, and it has failed to heal. One year ago, he was admitted to

a coronary care unit for shortness of breath. A myocardial infarction was said to have been ruled out. He

stopped smoking 15 years ago. Current medications were 5 mg glyburide twice a day.

Physical examination showed weight of 170 pounds, height 5'9", and blood pressure
180/105 mmHg.

The right foot was erythematous, and several toes had areas of dry gangrene (2nd toe, lateral aspects of

big toe, 5th toe), no tenderness and no pus. Sensation in the right foot was diminished.

The patient was educated, taught self-monitoring of blood glucose, instructed in diet, given treatment

for his congestive heart failure, which controlled his dyspnea, and had his glyburide increased to 10 mg

in the morning and 5 mg at night. Two years ago, he had a femoral-popliteal bypass and removal of two

toes. Repeat blood studies showed only a modest improvement in glycemic control (plasma glucose

levels 180-210 mg/dl). Fasting triglycerides were 240 mg/dl, HDL cholesterol was 33 mg/dl, and total

cholesterol was 286 mg/dl.

Questions:
1. What are the chronic complications of diabetes in this case? 

The chronic complications of this diabetes in this case are:

 Gangrene with supporting data, that about “6 months ago”, he injured his right foot, and it
has failed to heal. Aside from his age (62y.o) It is generally accepted that blood viscosity is
increased in diabetic patients that will lead to buildup of fats, cholesterol and other
substances in and on your artery walls (atherosclerosis), which can restrict blood flow into
his peripheral pulses then with a history of femoral popliteal bypass the rate of having
restriction in blood supply to tissues increases that causes the death of body tissues
(gangrene) due to lack of blood flow.

 Congestive heart failure is also a chronic complication of diabetic patient in this case. Aside
from his age (62y.o) the viscosity of blood increases in diabetic patient that can cause
plaque buildup in his coronary artery of his heart that can lead to coronary ischemia that
damages the ability of the myocardium to pump and either decreases the ability of the heart
to fill or pump blood.
 Hypertension is also a chronic complication of diabetic patient in this case. With supporting
data of, elevated blood pressure 180/105 mmHg low level of HDL cholesterol 33 mg/dl, and
elevated total cholesterol 286 mg/dl. Factors that increases high blood pressure.
 Peripheral neuropathy is also a chronic complication of a diabetic patient in this case. With
supporting data of diminished sensation in the right foot. Nerve damage caused by
chronically high blood sugar and diabetes.
 Injuries heal slowly, or may not heal at all is also a chronic complication of diabetic patient in
this case. With supporting data of; about 6 months ago, he injured his right foot, and it has
failed to heal and has a history of removal of two toes two years ago. High glucose levels
plasma glucose levels (180-210 mg/dl) can stiffen the blood vessels, making it harder for
blood to flow. This means that nutrients and oxygen can't reach cells, which makes it harder
to repair wounds. In the long term, lack of oxygen can cause cells to die, eventually leading
to possible necrosis and amputation.
 Weight gain is also a chronic complication of diabetic patient in this case. With supporting
data of; weight of 170 pounds, height 5’9 with total Body Mass Index of 25.10 that defines
overweight and use of medication Glyburide that causes the pancreas to produce more
insulin and increases glucose uptake, glycogen synthesis and lipid synthesis reasons of
gaining weight.
 2 Why was a serious complication such as gangrene preceded by minimal symptoms of
diabetes?  
 Type 2 Diabetes develops over time and warning signs don't necessarily make you
feel unwell and the problem is, its onset is more often a slower process, and therefore,
its victims are not aware that they are in danger of being affected by this insidious
disease. Type 2 Diabetes is a silent killer that is why gangrene and other complications
like cardiovascular diseases and insufficiency in blood flow to legs of the patient is
preceded by minimal symptoms of diabetes.

3. What are the management objectives from what you know about the clinical conditions of this

patient?

 Main glycemic objectives with appropriate pharmacological management (oral agents, insulin, or
combination of both) in type II diabetes include HbA1c < 7% for lean and younger patients (less than 65
years of age), with action suggested (pharmacological dose increments or additional therapy) if HbA1c >
8%. 
 In obese patients, or patients with advanced cardiovascular disease or renal disease, or disease that shortens
life expectancy, glycemic goals are lessened. 
 The risk-benefit ratio of more intensive treatment, especially with insulin, is not yet known. 
 In a patient such as this, a suggested goal of HbA1c may be 8 to 8.5%. 
 This patient has combined dyslipidemia, which makes him a potential candidate for a fibrate type of drug
(Gemfibrozil), to reduce triglycerides and increase HDL. 
 Should his total cholesterol remain over 200 mg/dl or LDL over 100 mg/dl, another hypolipidemic agent
designed to lower LDL cholesterol, such as HMG co-reductase inhibitors, (Simvastatin, Pravastatin,
Levastatin, etc.) or a bile sequestrant (Cholestyramine) is also indicated.