PBL Sessions: Vascular Diseases 1

Page 10

Final Discussion of Case:

Typical Smith family meals:

Tasks

• Review the diagnoses for all of these family members.

• Explain the pathophysiology for their problems.

• Outline a plan to approach the long-term care of this family.

Vascular PBL - Case Summary

The case illustrates risk factors and complications for diabetes mellitus and metabolic syndrome. There are identifiable risk factors for these.

The calculated BMI for family members is as follows:

Name	Age	Height	Weight	BMI
Robert	35	6' 1" (185 cm)	262 lb (119 kg)	35
Valerie	32	5' 7" (170 cm)	191 lb (87 kg)	30
Vickie	12	5' 5" (165 cm)	90 lb (41 kg)	15
Wayne	4	3' 5" (105 cm)	46 lb (21 kg)	19
Doris	61	5' 3" (160 cm)	147 lb (67 kg)	26

Robert has diabetes mellitus, type 2. His high BMI indicates that obesity is the risk factor. Both the urinary tract infection and the foot ulcer can be complications of diabetes mellitus. Bacterial infections are more likely to occur. Neuropathy can include autonomic neuropathy, which can affect bladder emptying, predisposing to infection. Neuropathy is also suggested by the foot ulcer, because he does not feel minor traumatic events or superficial injuries that progress to more severe problems. The 1+ lower extremity pulses suggest a component of peripheral vascular disease from accelerated atherosclerosis, and this further exacerbates any minor trauma, because healing is delayed from poor circulation, and infection is more likely to complicate any wound.

Valerie does not by definition qualify for a diagnosis of diabetes mellitus, but she does meet criteria for metabolic syndrome. Regardless, she is at risk for cardiovascular diseases. Her obesity puts her at risk for a variety of diseases, including cholelithiasis. Her latest pregnancy is complicated by gestational diabetes. The risk for fetal malformation is not increased, but the growth enhancing effects of increased insulin in the fetus lead to macrosomia. Following birth, the baby becomes hypoglycemic because of elevated insulin produced by increased numbers of islets of Langerhans.

Doris meets criteria for diabetes mellitus. Her BMI is only slightly increased. She probably gets the most exercise of any of the adults in the family, because she stays home and takes care of the children and the household. Nevertheless, she develops a thrombotic event: a deep venous thrombosis of her right leg, complicated by a non-fatal pulmonary embolus. Risk factors in her case include her age and smoking. In addition, the laboratory findings suggest that the episode of chest pain a week prior to the PE was likely an ischemic event involving the heart. She also has risk factors for cardiovascular disease from atherosclerosis. Thus, she has likely lost some myocardial function from ischemia. Her ejection fraction is diminished, but not markedly so.

Vickie has a low BMI, which suggests a catabolic state or an eating disorder. The subsequent events are consistent with ketoacidosis complicating type 1 diabetes mellitus. She is started on insulin therapy. However, diabetes mellitus can be difficult to manage in children, who are not always adherent to strict medication and dietary requirements because they do not understand the implications or do not want the disease interfering with their life. Thus, she has an episode of hypoglycemia, probably because she got the insulin but did not eat what she was supposed to eat.

Wayne has a BMI that is high for his age, and this suggests that he is going to follow his father's lifestyle, putting him at risk for diabetes mellitus/metabolic syndrome even at an earlier age.

The only person in the family who absolutely needs pharmacologic therapy is Vickie, who cannot survive without regular insulin injections. Lifestyle modifications could go a long way in solving problems of remaining family members. It would be best if they all worked at adopting changes at once.