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The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
CASE MATERIAL
DAY 1, PART 1
Maria Gonzales is brought to her pediatrician’s
office by her mother for her annual exam. Her
mother has no concerns about Maria’s health or
development. She is an 8 year old Hispanic
female currently in the third grade at a local
parochial school. She is progressing nicely with
her schoolwork and is not a behavioral problem.
Maria’s mother reports that the school nurse sent
a letter home explaining that she had passed her
vision and hearing screening tests but that she
was overweight and at risk for obesity. She is
obviously offended by this information and
explains that Maria has always been “big boned”
and that she does not agree with the school
nurse’s assessment.
PMH
Maria was born at 41 6/7 weeks gestation to
her G1P0 mother by spontaneous vaginal
delivery. She weighed 4068 gms at birth and
had APGAR scores of 7 and 9. Her mother
was not employed at the time of this
pregnancy and did not seek prenatal care
until the day of delivery. She describes the
pregnancy as uneventful.
Maria has had all of her childhood
vaccinations and no hospitalizations since
birth. She does not take any prescription
medications and other than recurrent ear
infections as a small child has been healthy.
LEARNING OBJECTIVES
DISCUSSION QUESTIONS
At the conclusion of Part 1 students should be
able to:
1) Discuss the potential barriers to acceptance
of childhood obesity by parents
1) What do you make of Maria’s mom’s reaction to the
letter from the school nurse about Maria’s weight and
risk for obesity?
2) Calculate BMI
2) What is Maria's BMI? Can adult BMI tables be used to
evaluate obesity risk in children? BMI=22.2 According
to adult BMI tables, Maria would have a normal BMI.
(Below 18.5= underweight; 18.5-24.9=normal; 25.029.9=overweight;30.0 and above=obese. However,
adult BMI tables are not valid for children as BMI is
age and sex-specific. Instead, BMI tables that are age
and sex specific are useful to evaluate percentile
rankings.
3) Plot height, weight and BMI on a pediatric
growth chart
3) Plot Maria’s height, weight and BMI on a growth chart
using the CDC website. weight 95th percentile, height
50th percentile, BMI greater than 95th percentile ( well
off the growth chart)
4) Explain why adult BMI tables are not valid
for pediatric patients
4) What are the normal cutoffs for BMI in children? The
5) Interpret the findings of data from pediatric
growth curves
6) Summarize the epidemiologic trends in
childhood obesity
interpretation of BMI in children is evaluated as a
percentile ranking that is both age and sex-dependent.
The cutoffs according to the CDC are:
Underweight=less than 5th percentile; Healthy weight=
5th percentile to less than 85th percentile; At risk of
overweight= 85th percentile to less than 95th percentile;
overweight=95th percentile or greater.
5) Summarize the epidemiologic trends in childhood
obesity. From the CDC website at
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/
Overweight is a serious health concern for children and
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
Social History
Maria’s parents divorced when she was an
infant. She is an only child. She lives in a
home with her mother, her mother’s sister
and her great aunt. She has no contact with
her father. She attends third grade in a
nearby parochial school. Her mother and
aunt smoke in the home. Her mother takes
pride in her ability to provide for Maria
despite financial constraints and describes
herself as a “protective parent.” Maria took
ballet lessons from age 5-7 and has played
softball for the last two summers.
adolescents. Data from two NHANES surveys (1976–
1980 and 2003–2004) show that the prevalence of
overweight is increasing: for children aged 2–5 years,
prevalence increased from 5.0% to 13.9%; for those
aged 6–11 years, prevalence increased from 6.5% to
18.8%; and for those aged 12–19 years, prevalence
increased from 5.0% to 17.4%.1
7) Discuss the risk criteria for high birth
weight infants
6) What is significant about Maria's birth weight? High
Birthweight (HBW) is defined as a birthweight of >4000
grams or 8.8 lbs. This reflects the WIC Nutrition Risk
Criteria (IOM, 1996) which is based on a generally
accepted intrauterine growth reference > the 90th
percentile weight for gestational age at birth (ACOG
Technical Bulletin, 1991). High birthweight usually
occurs in full-term or post-term infants but can occur in
preterm infants. HBW puts infants at increased risk for
birth injuries such as shoulder dystocia and infant
mortality rates are higher among full-term infants who
weigh more than 4000 grams than infants weighing
between 3000 and 4000 grams. (ACOG technical
bulletin). From the CDC website at
http://www.cdc.gov/pednss/what_is/pnss_health_indicat
ors.htm
High Birthweight in a newborn is associated with: risk
of birth injury including shoulder dystocia,
hypoglycemia shortly after delivery, childhood obesity,
increased lifetime risk for DMII
8) List the contributing factors for obesity
7) What are likely contributing factors to Maria's weight
Developmental History
Maria met all developmental milestones on
target.
Family History
Mother, alive, age 29. Obese. Diagnosed
with diabetes and hypertension 6 years ago
Father, alive, age 31. No known chronic
illnesses
Maternal Grandmother, deceased at age 58 of
renal failure. Had diabetes, hypertension,
asthma
Maternal Grandfather, alive, age 60.
Hypertension
Paternal Grandmother, alive, age 62.
Unknown medical history
Paternal Grandfather, deceased at age 55.
Myocardial infarction
problem? Summarized from CDC website at
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/con
tributing_factors.htm 1) Genetic factors-certain genetic
characteristics may increase an individual’s
susceptibility to overweight. However, the rapid rise in
the rates of overweight and obesity in the general
population in recent years cannot be attributed solely to
genetic factors. The genetic characteristics of the human
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
Physical Exam
Vital signs: T 98.4, Pulse 86, BP 130/80, R
18, ht 50.3 inches, wt 80 pounds
General- Well developed/ well nourished
Hispanic female child in no acute distress
HEENT- TMs with good color and position,
conjunctiva pink, oropharynx clear, moist
mucosal membranes, Neck- No thyromegaly,
no masses
CV- RRR without murmur, rub, gallop
Chest- Clear to auscultation bilaterally
Abdomen- rounded, soft, nontender, no
organomegaly or masses
GU- Tanner stage I
Musculoskeletal- Joints nontender, no
scoliosis, muscle strength and mass age
appropriate. Full range of motion throughout
Skin- No rashes or open lesions
Neuro- Alert, appropriate, vision and hearing
screening wnl
population have not changed in the last three decades,
but the prevalence of being overweight has tripled
among school-aged children during that time. 2)
Behavioral Factors- a) excessive and/or unhealthy food
intake b) Lack of physical activity and sedentary
activities 3) Environmental Factors- a) within the home
b) within the school c) within childcare d) within the
community
9) Discuss the long-term effects of childhood
obesity
8) What health concerns do you have for Maria's future?
Overweight children and adolescents are at risk for
health problems during their youth and as adults. For
example, during their youth, overweight children and
adolescents are more likely to have risk factors
associated with cardiovascular disease (such as high
blood pressure, high cholesterol, and Type 2 diabetes)
than are other children and adolescents. Overweight
children and adolescents are more likely to become
obese as adults. For example, one study found that
approximately 80% of children who were overweight at
aged 10–15 years were obese adults at age 25 years.3
Another study found that 25% of obese adults were
overweight as children. The latter study also found that
if overweight begins before 8 years of age, obesity in
adulthood is likely to be more severe. From the CDC
website at
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/
10) Describe the health consequences of
exposure to second hand smoke on children
9) What affects, if any, does Maria's second-hand smoke
exposure have on her health? On September 18, 2007,
the Surgeon General reemphasized that secondhand
smoke causes premature death and disease in children
and that US children are more heavily exposed to
secondhand smoke than nonsmoking adults. The 2006
Surgeon General's report noted that 60 percent of US
children aged 3-11 years—nearly 22 million young
people—are exposed to secondhand smoke.
According to the Surgeon General:
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
• Because their bodies are developing, infants and young
children are especially vulnerable to the poisons in
secondhand smoke.
• Both babies whose mothers smoke while pregnant and
babies who are exposed to secondhand smoke after birth
are more likely to die from sudden infant death syndrome
(SIDS) than babies who are not exposed to cigarette smoke.
• Mothers who are exposed to secondhand smoke while
pregnant are more likely to have lower birth weight babies,
which makes babies weaker and increases the risk for many
health problems.
• Babies whose mothers smoke while pregnant or who are
exposed to secondhand smoke after birth have weaker lungs
than other babies, which increase the risk for many health
problems.
• Secondhand smoke exposure causes acute lower
respiratory infections such as bronchitis and pneumonia in
infants and young children.
• Secondhand smoke exposure causes children who already
have asthma to experience more frequent and severe
attacks.
• Secondhand smoke exposure causes respiratory
symptoms, including cough, phlegm, wheeze, and
breathlessness, among school-aged children.
• Children exposed to secondhand smoke are at increased
risk for ear infections and are more likely to need an
operation to insert ear tubes for drainage.
• Children aged 3-11 years have cotinine levels (a
biological marker for secondhand smoke exposure) more
than twice as high as nonsmoking adults.
• Children who live in homes where smoking is allowed
have higher cotinine levels than children who live in homes
where smoking is not allowed.
From the CDC website at
http://www.cdc.gov/Features/ChildrenAndSmoke/
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
11) Summarize the physical and psychological
1)
consequences of childhood obesity
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
What are some of the physical and psychological
consequences of childhood obesity? Consequences
Childhood overweight is associated with various healthrelated consequences. Overweight children and adolescents
may experience immediate health consequences and may be
at risk for weight-related health problems in adulthood.
Psychosocial Risks
Some consequences of childhood and adolescent overweight
are psychosocial. Overweight children and adolescents are
targets of early and systematic social discrimination.39 The
psychological stress of social stigmatization can cause low
self-esteem which, in turn, can hinder academic and social
functioning, and persist into adulthood.40
Cardiovascular Disease Risks
Overweight children and teens have been found to have risk
factors for cardiovascular disease (CVD), including high
cholesterol levels, high blood pressure, and abnormal
glucose tolerance.39 In a population-based sample of 5- to
17-year-olds, almost 60% of overweight children had at
least one CVD risk factor while 25 percent of overweight
children had two or more CVD risk factors.2
Additional Health Risks
Less common health conditions associated with increased
weight include asthma, hepatic steatosis, sleep apnea and
Type 2 diabetes.
Asthma is a disease of the lungs in which the airways
become blocked or narrowed causing breathing difficulty.
Studies have identified an association between childhood
overweight and asthma.41, 42
Hepatic steatosis is the fatty degeneration of the liver
caused by a high concentration of liver enzymes. Weight
reduction causes liver enzymes to normalize.39
Sleep apnea is a less common complication of overweight
for children and adolescents. Sleep apnea is a sleepassociated breathing disorder defined as the cessation of
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
15)
breathing during sleep that lasts for at least 10 seconds.
Sleep apnea is characterized by loud snoring and labored
breathing. During sleep apnea, oxygen levels in the blood
can fall dramatically. One study estimated that sleep apnea
occurs in about 7% of overweight children.43
Type 2 diabetes is increasingly being reported among
children and adolescents who are overweight.44 While
diabetes and glucose intolerance, a precursor of diabetes,
are common health effects of adult obesity, only in recent
years has Type 2 diabetes begun to emerge as a healthrelated problem among children and adolescents.45 Onset
of diabetes in children and adolescents can result in
advanced complications such as CVD and kidney failure.45
From the CDC website at
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/conse
quences.htm
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
CASE MATERIAL
Day 1, Part 2
Maria Gonzales returns to clinic after many
years lost to follow-up in your office. She is
now 15 years old, a sophomore at a local
high school. She has received sporadic
medical care for acute childhood illnesses
over the years but has not followed with a
primary physician. She comes in today with
her mother.
PMH: Diagnosed with childhood obesity at
the age of 8. No hospitalizations since birth.
She has taken antihistamines periodically for
the last 3 years for environmental allergies
that are more problematic in the spring and
summer months. She first menstruated at age
13. Her cycles are very irregular, about 5
cycles a year. She had ACL repair to her
right knee last summer and feels that her
function is back to normal after outpatient
rehabilitation.
SH: Maria plays softball for her high school
team. She is a pitcher and hopes to receive a
softball scholarship for college. She dances
with a local group that celebrates Mexican
culture through dance and music. She is an
average student in school and receives
additional tutoring for her poor math
performance. She has a close group of
female friends that she occasionally sees
outside of school. She has not had a
boyfriend, although she would like to have
one. She denies any sexual activity. Her
mother describes herself as a “strict parent”.
LEARNING OBJECTIVES
DISCUSSION QUESTIONS
1) Calculate BMI
1.
What is Maria's BMI? BMI-34.3. Obese by adult BMI
tables.(Below 18.5= underweight; 18.5-24.9=normal; 25.029.9=overweight;30.0 and above=obese. However, adult
BMI tables are not valid for children as BMI is age and sexspecific. Instead, BMI tables that are age and sex specific
are useful to evaluate percentile rankings.
2) Plot weight, height and BMI on a pediatric
growth chart
2.
Plot Maria's weight, height and BMI on a pediatric growth
chart. Weight greater than 97%; height between 50th and
75th percentile. BMI well above 95th percentile.
3) Interpret the results of the data from a
pediatric growth chart
3.
What health risks are associated with this BMI? Overweight
children and adolescents are at risk for health problems
during their youth and as adults. For example, during their
youth, overweight children and adolescents are more likely
to have risk factors associated with cardiovascular disease
(such as high blood pressure, high cholesterol, and Type 2
diabetes) than are other children and adolescents.
Overweight children and adolescents are more likely to
become obese as adults. For example, one study found that
approximately 80% of children who were overweight at
aged 10–15 years were obese adults at age 25 years.3
Another study found that 25% of obese adults were
overweight as children. The latter study also found that if
overweight begins before 8 years of age, obesity in
adulthood is likely to be more severe. From the CDC
website at
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/
4) Describe the association between
childhood obesity and development of
diabetes in adulthood
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
Maria is not allowed to attend most parties
and tends to socialize primarily with family
outside of school. She denies that she has
ever tried alcohol, cigarettes, marijuana or
other drugs. She has not started driving
education.
PE: Vitals- T98.7, P90, BP 142/90,R 20, Wt
206 pounds, Ht 5ft 5inches
Gen- Obese young woman in no acute
distress
HEENT- TMs with good color and position,
conjunctiva pink, anicteric sclera, OP clear,
slightly dry mucosal membranes. Teeth in
good repair, moderate acne on cheeks, mild
hirsuitism noted to face.
Neck- Supple, no cervical lymphadenopathy,
no thyromegaly
CV- Regular rate and rhythm. No murmurs,
strong pedal and radial pulses
Chest- Clear to auscultation bilaterally
Abdomen- obese in a centripetal
distribution, soft, nontender, nondistended
PE:
EXT- no edema, brisk capillary refill
Musculoskeletal- Strength +5/5 in all
extremities, muscle mass wnl, Joint exam
wnl, No scoliosis
Breast- Tanner stage 4
GU-Tanner stage 4
Skin- Multiple skin tags noted along
neckline. Acanthosis nigricans in axillae,
and inguinal region, stria noted on abdomen
and thighs
Neuro- No focal deficits
5) Define metabolic syndrome and list the
diagnostic criteria of this disorder
4.
List Maria's risk factors for developing diabetes.
Risk Factors for DMII 1) Family history of diabetes
(i.e.,parent or sibling with type 2 diabetes) 2) Obesity (BMI
> 25 kg/m2) 3) Habitual physical inactivity 4)
Race/ethnicity (e.g.,African American, Hispanic American,
Native American, Asian American, Pacific Islander) 5)
Previously identified IFG (impaired fasting glucose) or IGT
(impaired glucose tolerance) 6) History of GDM
(gestational diabetes mellitus) or delivery of baby >4 kg (>9
lb) 7) Hypertension (blood pressure > 140/9/ mmHg) 8)
HDL cholesterol level < 35 mg/dL (0.90 mmol/L) and/or a
triglyceride level >250 mg/dL (2.82 mmol/L) 9) Polycystic
ovary syndrome or acanthosis nigricans 10) History or
vascular disease
http://www.accessmedicine.com.proxy.kumc.edu:2048/conte
nt.aspx?aID=99068
5.
Does Maria have metabolic syndrome? The metabolic
syndrome (syndrome X, insulin resistance syndrome)
consists of a constellation of metabolic abnormalities that
confer increased risk of cardiovascular disease (CVD) and
diabetes mellitus (DM). The criteria for the metabolic
syndrome have evolved since the original definition by the
World Health Organization in 1998, reflecting growing
clinical evidence and analysis by a variety of consensus
conferences and professional organizations. The major
features of the metabolic syndrome include central obesity,
hypertriglyceridemia, low HDL cholesterol, hyperglycemia,
and hypertension. In general, the prevalence of metabolic
syndrome increases with age. The highest recorded
prevalence worldwide is in Native Americans, with nearly
60% of women ages 45–49 and 45% of men ages 45–49
meeting National Cholesterol Education Program, Adult
Treatment Panel III (NCEP:ATPIII) criteria. In the United
States, metabolic syndrome is less common in AfricanAmerican men but more common in Mexican-American
women. Based on data from the National Health and
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
Nutrition Examination Survey (NHANES) III, the ageadjusted prevalence of the metabolic syndrome in the United
States is 34% for men and 35% for women.
(http://www.accessmedicine.com.proxy.kumc.edu:2048/cont
ent.aspx?aID=2887926&searchStr=metabolic+syndrome+
x#2887926)
NCEP:ATPIII 2001 Criteria: Metabolic Syndrome
a) 3 or more of the following:
b) Central obesity: Waist circumference >102 cm (M), >88 cm
(F)
c) Hypertriglyceridemia: Triglycerides >150 mg/dL or specific
medication
d) Low HDL cholesterol: <40 mg/dL and <50 mg/dL,
respectively, or specific medication
e) Hypertension: Blood pressure >130 mm systolic or >85 mm
diastolic or specific medication
f) Fasting plasma glucose >100 mg/dL or specific medication
or previously diagnosed type 2 diabetes
http://www.accessmedicine.com.proxy.kumc.edu:2048/content.as
px?aID=2887926&searchStr=metabolic+syndrome+x#2887926
Laboratory Studies
Chem 7
Serum Creatinine 0.8 mg/dL (0.6 - 1.1)
BUN 16 (7 go 24 mg/dL)
Sodium 138 (136-144mEq/L)
Potassium 4.0 (3.7-5.2mEq/L)
Bilirubin, Conjugated 0.2mg/dL (<0.3)
Fasting glucose 106 mg/dL (60-110)
HgbA1C 5.2 (4.0-6.0%)
Fasting Lipid Panel
Total Chol 246 mg/dL
HDl 50 mg/dL
VLDL 54 mg/dL
LDL 142 mg/dL
Triglycerides 240 mg/dL
6) Interpret the clinical significance of
physical exam findings of acanthosis
nigricans, multiple skin tags, stria
6. What is acanthosis nigricans and its significant as a physical
exam finding? Acanthosis nigricans (AN) is a velvety
thickening and hyperpigmentation of the skin, chiefly in
axillae and other body folds, the etiology of which may be
related to factors of heredity, associated endocrine
disorders, obesity, drug administration, and
malignancy.Associated with endocrine disorders including
insulin resistance: insulin-resistant diabetes mellitus,
hyperandrogenic states, acromegaly/gigantism, Cushing's
disease, hypogonadal syndromes with insulin resistance,
Addison's disease, hypothyroidism. Epidermal changes may
be caused by hypersecretion of pituitary peptide or
nonspecific growth-promoting effect of hyperinsulinemia.
Type 5: associated with transforming growth factor and
epidermal growth factor receptors in skin.
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
(http://www.accessmedicine.com.proxy.kumc.edu:2048/cont
ent.aspx?aID=762608&searchStr=acanthosis+nigricans)
7. What is the clinical significance of multiple skin tags? A skin
tag is a very common, soft, skin-colored or tan or brown,
round or oval, pedunculated papilloma (polyp); it is usually
constricted at the base and may vary in size from >1 mm to
as large as 10 mm. Histologic findings include a thinned
epidermis and a loose fibrous tissue stroma. It occurs more
often in the middle aged and in the elderly. A skin tag is
usually asymptomatic but occasionally may become tender
following trauma or torsion and may become crusted or
hemorrhagic. More common in females and in obese
patients and most often noted in intertriginous areas
(axillae, inframammary, groin) and on the neck and eyelids;
it occurs in acanthosis nigricans as an obligatory lesion.
(http://www.accessmedicine.com.proxy.kumc.edu:2048/cont
ent.aspx?aID=763986&searchStr=skin+tag#763986)
7) Describe polycystic ovarian syndrome and
its clinical characteristic
8. What might be a reason for Maria's menstrual irregularities?
Polycystic ovary syndrome (see below) Polycystic ovary
syndrome (PCOS) is a common endocrine disorder affecting
4–7% of women of reproductive age and is a common
source of chronic anovulation. The underlying etiology is
unknown, although most of these women have an aberration
of gonadotropin stimulation. This is manifested by an
increased release of luteinizing hormone (LH) relative to
follicle-stimulating hormone (FSH), resulting in an
increased production of androstenedione and testosterone
by ovarian theca cells. The androstenedione undergoes
aromatization to estrone and is converted to estradiol in the
ovarian granulosa cells. The high estrone levels are believed
to cause suppression of pituitary FSH and constant LH
stimulation of the ovary results in anovulation, multiple
cysts, and theca cell hyperplasia with excess androgen
output. PCOS is manifested by hirsutism (50% of cases),
obesity (40%), and virilization (20%). Fifty percent of
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
patients have amenorrhea, 30% have abnormal uterine
bleeding, and 20% have normal menstruation. In addition,
they show insulin resistance and hyperinsulinemia, and
these women are at increased risk for early-onset type 2
diabetes. The patients are generally infertile, although they
may ovulate occasionally. They have an increased long-term
risk of cancer of the breast and endometrium because of
unopposed estrogen secretion.
http://www.accessmedicine.com.proxy.kumc.edu:2048/conte
nt.aspx?aID=9087&searchStr=polycystic+ovary+syndrome
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
CASE MATERIAL
Day 2
LEARNING OBJECTIVES
Maria Gonzales is a 65 year old Hispanic
female who comes to the office with
complaint of pain in her left 5th toe. She
reports that she stubbed this toe on a piece
of furniture several weeks ago and
sustained a small laceration on the distalmost portion of this toe. She has been
treating the toe with antibiotic ointment but
the wound isn’t getting any better. Review
of systems is also positive for subjective
fevers, fatigue, and frequent nausea
without vomiting, increased thirst, and
dizziness when she stands.
1) Describe the association between
HgA1C value and average daily blood
sugar levels
1.
What average daily blood sugar does a HgA1C represent? Data
from the Diabetes Control and Complications Trial (DCCT)
showed that there is a linear relationship between the HbA1c and
the mean of seven-point capillary blood glucose profiles
(preprandial, postprandial, and bedtime). Thus, mean plasma
glucose levels of 170, 205, 240, and 275 mg/dL approximately
correlate with HbA1c values of 7%, 8%, 9%, and 10%,
respectively.
http://www.accessmedicine.com.proxy.kumc.edu:2048/content.aspx
?aID=15609&searchStr=glucohemoglobin+measurement#15609
2) Discuss the effect of dehydration on
electrolyte levels, Bun and creatinine
2.
How can Maria's poorly controlled diabetes account for her
abnormal chemistry values? Electrolytes near the high end of
normal and BUN high, likely due to hyperosmolar diuresis from
hyperglycemia. Creatinine elevated indicating renal insufficiency.
See further discussion of renal function below.
3.
Why is Maria orthostatic? Maria is likely dehydrated and
intravascularly dry from her uncontrolled diabetes. Hyperglycemia
and hyperosmolarity lead to osmotic diuresis and an osmotic shift
of fluid to the intravascular space, resulting in further intracellular
dehydration.
4.
How does diabetes affect renal function? Diabetic nephropathy is
the most common cause of ESRD in the United States (about 4000
cases a year). Type 1 diabetes mellitus carries a 30–40% chance of
nephropathy after 20 years, whereas type 2 has a 15–20% chance
after 20 years. In patients prone to nephropathy, microalbuminuria
will develop within 10–15 years after onset of diabetes and
progress over the next 3–7 years to overt proteinuria. The most
common lesion in diabetic nephropathy is diffuse
glomerulosclerosis, but nodular glomerulosclerosis (KimmelstielWilson nodules) is pathognomonic. The kidneys in these patients
PMH: Obese since childhood. Knee
surgery in high school. Was told by a
doctor many years ago that her sugar was
high and that she had diabetes. She was
prescribed several medications for this, but
only took them for a short while due to
nausea with the medication. She has a
glucose monitor at home but she has never
used it. She had one spontaneous vaginal
delivery, uncomplicated.
SH: She lives in a home with her adult
daughter, her cousin and her aunt. She has
not worked in several years because she is
“sick all the time.” She is not on disability
3) Discuss the effects of diabetes and HTN
on renal function
DISCUSSION QUESTIONS
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
and her family supports her and her
daughter. The father of her daughter is not
involved in their life. She graduated from
high school. She smokes 1 pack of
cigarettes a day. She rarely drinks alcohol
and denies use of any recreational drugs.
Meds: Prescribed metformin and glipizide
but not taking either. Takes an occasional
ibuprofen for headache.
are usually enlarged as a result of cellular hypertrophy and
proliferation. At the onset of diabetic nephropathy, glomerular
disease will cause an increase in GFR. As the nephropathy
progresses, with the development of macroalbuminuria, the GFR
returns to normal and continues to decrease.
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?aID=11742&searchStr=diabetic+nephropathy
4) Discuss the need for foot exams by
diabetic patients.
5.
Why are diabetics more prone to wounds in their lower extremities?
DM is the leading cause of nontraumatic lower extremity
amputation in the United States. Foot ulcers and infections are also
a major source of morbidity in individuals with DM. The reasons
for the increased incidence of these disorders in DM involve the
interaction of several pathogenic factors: neuropathy, abnormal
foot biomechanics, peripheral arterial disease, and poor wound
healing. The peripheral sensory neuropathy interferes with normal
protective mechanisms and allows the patient to sustain major or
repeated minor trauma to the foot, often without knowledge of the
injury. Disordered proprioception causes abnormal weight bearing
while walking and subsequent formation of callus or ulceration.
Motor and sensory neuropathy lead to abnormal foot muscle
mechanics and to structural changes in the foot (hammer toe, claw
toe deformity, prominent metatarsal heads, Charcot joint).
Autonomic neuropathy results in anhidrosis and altered superficial
blood flow in the foot, which promote drying of the skin and fissure
formation. Peripheral arterial disease and poor wound healing
impede resolution of minor breaks in the skin, allowing them to
enlarge and to become infected. Approximately 15% of individuals
with DM develop a foot ulcer, and a significant subset will
ultimately undergo amputation (14 to 24% risk with that ulcer or
subsequent ulceration).
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5) List bacterial infections commonly
associated with diabetic foot wounds.
6.
What common bacterial pathogens are involved in diabetic foot
wounds? Intravenous antibiotics should provide broad-spectrum
coverage directed toward Staphylococcus aureus , streptococci,
gram-negative aerobes, and anaerobic bacteria. Initial
PE: Vitals- T99.8, P108, R22, BP supine
146/93, BP sitting 130/86, BP standing
117/78
Gen- Obese female in no acute distress
HEENT- dry mucosal membranes, pale
conjunctiva, OP clear, teeth in adequate
repair, TMs wnl
Neck- No thyromegaly, no carotid bruits
CV- Mildly tachycardic, no murmur
Chest- Clear to auscultation bilaterally
Abd- Obese in centripetal distribution,
soft, nontender, nondistended,
Normoactive bowel sounds, no
hepatosplenomegaly or masses
Ext- No edema, left fifth toe moderately
erythematous, and swollen with open
lesion at distal-most tip of the toe with
scant serosanguinous drainage. Painful to
palpation or movement.
Neuro- Alert and oriented X3, negative
The Case of Maria Gonzales
Medicine Across the Lifespan
University of Kansas School of Medicine
monofilament testing in sock and glove
distribution
antimicrobial regimens include cefotetan, ampicillin/sulbactam, or
the combination of clindamycin and a fluoroquinolone. Severe
infections, or infections that do not improve after 48 h of antibiotic
therapy, require expansion of antimicrobial therapy to treat
methicillin-resistant S. aureus (e.g., vancomycin) and Pseudomonas
aeruginosa . If the infection surrounding the ulcer is not improving
with intravenous antibiotics, reassessment of antibiotic coverage
and reconsideration of the need for surgical debridement or
revascularization are indicated. With clinical improvement, oral
antibiotics and local wound care can be continued on an outpatient
basis with close follow-up.
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Musculoskeletal- within normal limits
Laboratory Studies
CBC
WBC 13.3(4.5-10.5X103)
HGB 8.8(12.0-16.0 g/dL)
MCV 87 86-89 femtoliters)
70%segs (43-74)
18%bands (0-10)
10%lymphs (15-45)
3% lymphs (0-6%)
Chem
Serum Creatinine 1.9 mg/dL (0.6 - 1.1)
Bilirubin, Conjugated 0.2mg/dL (<0.3)
Bilirubin, Unconjugated 0.2 mg/dL (<0.5)
Total bilirubin 0.5 (0.2 to 1.9 mg/dL)
ALT (Alanine Aminotransferase) 24 (0 –
56)
5) Define osteomyelitis and describe
treatment of this infection
– AST (aspartate aminotransferase): 16 (10
to 34 IU/L)
– Alkaline Phosphatase: 46 (40 – 143
IU/L)
– BUN 42 (7 to 24 mg/dL)
– Calcium serum 9.2 (8.5 to 10.9 mg/dL)
– Serum calcium : 7.8 (8.5-10.9 mg/dL)
– Sodium 142 (136-144 mEq/L)
– Potassium 5.2 (3.7-5.2mEq/L)
Sedimentation Rate33 (0-20mm/hr)
HgA1C 10.4% (4.0-6%)
6) Discuss techniques that may promote
patient adherence to medical
recommendations
7.
How is osteomyelitis treated? Osteomyelitis is best treated by a
combination of prolonged antibiotics (IV then oral) and possibly
debridement of infected bone. The possible contribution of vascular
insufficiency should be considered in all patients. Noninvasive
blood-flow studies are often unreliable in DM, and angiography
may be required, recognizing the risk of contrast-induced
nephrotoxicity. Peripheral arterial bypass procedures are often
effective in promoting wound healing and in decreasing the need
for amputation of the ischemic limb.
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8.
What are likely contributors to Maria's nausea? Hyperglycemia
slows gastric emptying and increases the intensity of perception of
gastric distension during fasting and small intestinal nutrient
stimulation.
Hebbard, G S : Samson, M : Andrews, J M : Carman, D : Tansell,
B : Sun, W M : Dent, J : Horowitz, M: Dig-Dis-Sci. 1997 Mar;
42(3): 568-75
9.
Why might Maria be neglecting her health and not treating her
diabetes? There are many reasons Maria may be neglecting her
medical care, including: depression, denial, lack of trust in medical
community, lack of understanding of the consequences of her
The Case of Maria Gonzales
Medicine Across the Lifespan
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actions, learned helplessness. She has several family members who
have ultimately died of complications of diabetes. She may see this
as her fate regardless of her adherence to medical
recommendations.
10. What might you do to help improve the likelihood that Maria will
adhere to recommendations for her care from this point on? Assure
patient understands the disease process and the reason for each
medication, dietary restriction, behavioral changes and also
understands the consequence of poor compliance to these
medications.2) Provide both verbal and written instructions
3)Customize office visits to best fit patient's schedule 4)use of a pill
box 5) social support of health goals 5) Patient and physician work
together toward a common goal.
11. How might a traditional Mexican diet influence blood sugar
7) Discuss the cultural implications on a
patient’s diet.
control? "Americanized Mexican" food tends to be higher fat,
higher carbohydrate than its authentic Mexican counterpart. Fastfrying has supplanted other cooking techniques in preparing
Mexican food in the US. Authentic Mexican cuisine includes higher
content of fresh fruits and vegetables. Hispanics in Mexico
typically eat more frequent, smaller meals which may normalize
blood sugars more effectively than the "Americanized" tradition of
3 large meals a day.