Clinical Case Presentation Building Blocks of Life Case # 7 Diabetes Mellitus Type 2 Prof. A. Vernillo

Template for CCP Chief Complaint (CC) History of Chief Complaint (HCC) Medications (M) Social History (SH) Family History (FH) Dental History (DH) Medical History (MH) Review of Systems (RS) Diagnosis -Risk Assessment (DRA) Differential Diagnosis (DD) Treatment (Tx) Prognosis (PR)

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Type 2 Diabetes Mellitus A 55-year old obese female has a 15-year history of type 2 diabetes mellitus. She also has high levels of cholesterol, high blood pressure, and anginal pain. She is taking oral hypoglycemics for her diabetes, medications for her hypertension, and lipid lowering drugs for her cholesterol (Lipitor®, atorvastatin calcium). She has redness (erythema) on the roof of her mouth. She will need a complete upper and lower denture. She has recently complained of excess urination during the day and at night, dry mouth, fatigue, and swings in her blood sugar levels. She finally admitted to eating cake and cookies.

Patient 55 year old female Chief Complaint (CC) The roof of my mouth burns and feels dry and I need dentures. History of Chief Complaint (HCC) The patient complains of fatigue and says that her blood sugar is very high (over 300 mg%) and at times also very low. She is urinating more than usual. She wants her dentures so she can chew comfortably. Medications Oral hypoglycemic, blood pressure medication, lipid lowering drug

Social History (SH) She has had difficulty controlling her weight most of her life. She is obese. She also admits to eating cake and cookies. She claims to have lost 20 pounds over the past year. Family History (FH) She has a mother who is diabetic and a father with high blood pressure. Dental History (DH) She has had many problems with her teeth. Most of her teeth were lost because of caries, periodontal disease, and her neglect. Medical History (MH) She was diagnosed with type 2 diabetes mellitus 15 years ago. She has chest pain (angina), especially after she walks up a flight of steps. Her blood pressure was diagnosed approximately 5 years ago.

Review of Systems (RS) Cardiovascular – Blood Pressure, 140/95. Pulse 80. Respiratory – Rate 17/min. Nervous – No obvious neuropathology. However, the patient is dental phobic and uneasy about being asked questions pertaining to her health. He has seen the movie, Marathon Man, 4 times. Endocrine – Type 2 diabetes mellitus Renal – BUN 15 mg/ml (8 to 23 mg/ml); creatinine 0.8 mg/ml (0.6 to 1.2/dL) Gastrointestinal - unremarkable Skin and mucosa – Color and texture of skin and mucosa WNL. No persistent lesions or moles. Osteoarticular – WNL

Diagnosis and Risk Assessment Diagnosis consistent with uncontrolled diabetes and increased risk for recurrence of oral infection

Dietary Questionnaire Does not carefully match her intake of carbohydrate with her medication. She finally admits to eating cake and cookies.

Diagnosis of Diabetes Mellitus Fasting blood glucose Glucose tolerance test Family history Signs and symptoms

Dental Management of Diabetes Mellitus Modification of diabetes medications, if needed Determine dietary and medication regimen prior to treatment Obtain most recent glycohemoglobin determination Have glucose or other readily absorbable form of carbohydrate available Determine need for antibiotics Know the signs and symptoms of profound hypoglycemia (A first-rate medical emergency) Have a glucometer, test strips, and sterile lancets available to test patient’s blood glucose If patient feels nauseous, weak, or has abdominal cramps or flu-like symptoms, as patient to test for ketones.

Treatment and Prognosis Medications Weight control/blood pressure control Diet and exercise Target glycohemoglobin to 6.0% One hour postprandial glucose excursions (particularly for type 1 DM) “Whenever I get the urge to exercise, I lie down and wait for the feeling to pass.” —Mark Twain

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