Mr.

Moray Blunt is a 76-year-old white male who has been referred to the clinic for assessment and diabetes
management.
Chief complaint: increasing exacerbations of asthma and the need for prednisone tapers. He reports that
during her last round of prednisone therapy, his blood glucose readings increased to the range of 300–400
mg/dl despite large decreases in his carbohydrate intake. He reports that he increases the frequency of his
fluticasone MDI, salmeterol MDI, and albuterol MDI to four to five times/day when he has a flare-up.
Mr. Blunt has been retired for several years, and their only source of income is his and his wife’s social
security check and little savings. Therefore, he is sometimes unable to purchase the Advair and so has only
been taking prednisone and albuterol for recent acute asthma exacerbations.
Mr. Blunt reports eating three meals a day with a snack between supper and bedtime. The largest meal is
supper.
He states that he counts his carbohydrate servings at each meal and is “watching what he eats.” He has not
been able to exercise routinely for several weeks because of bad weather, pain and his asthma.
The memory from his blood glucose meter for the past 30 days shows a total of 53 tests with a mean blood
glucose of 241 mg/dl (SD 74).
Past Medical History:
Type 2 diabetes diagnosed in 1995
Hypertension
Hyperlipidemia
Asthma
Coronary artery disease
Musculoskeletal pain secondary to a motor vehicle accident.
Atrial fibrillation with cardioversionAnemia
Multiple emergency room (ER) admissions for asthma
He says he occasionally “takes a little more” insulin when he notes high blood glucose readings.
His medications include:
Insulin lispro protamine suspension with insulin lispro preparation (Humalog 75/25), 33 units before breakfast
and 23 units before supper.

 Advair 250/50 inhalations bid

 Naproxen (Naprosyn), 375 mg twice a day;
 Enteric-coated aspirin, 325 mg daily;
 Pioglitazone (Actos) 45 mg po daily;
 Pravastatin 20mg at bedtime.
 Albuterol MDI (Proventil, Ventolin), two to four puffs every 4–6 hours for shortness of breath.

Social HX
He denies use of nicotine quit 10 years ago or recreational drugs
He does drink alcohol socially.
No known drug allergies
Up to date on his immunizations.
Physical Exam
B.G. is well-appearing but obese and is in no acute distress. A limited physical exam reveals:

 Weight: 302 lb; height 5'9"

 Blood pressure: 160/98 mmHg using a large adult cuff
 Pulse 88 bpm; respirations 22 per minute
 Lungs: clear to auscultation bilaterally without wheezing, rales, or rhonchi
 Lower extremities +1 pitting edema bilaterally; pulses good

Lab Results Range

• Hemoglobin A1c (A1C) 6 months ago: 7.7% normal range: <5.9%; target: <7%)

• Creatinine: 0.7 mg/dl normal range: 0.7–1.4 mg/dl)

• Blood urea nitrogen: 16 mg/dl normal range: 7–21 mg/dl)

• Sodium: 140 mEq/l normal range: 135–145 mEq/l)

• Potassium: 3.5 mg/dl normal range: 3.5–5.3 mg/dl)

• Calcium: 8.2 mg/dl normal range: 8.3–10.2 mg/dl)

Lipid panel

• Total Cholesterol: 211 mg/dl normal range <200 mg/dl)

• HDL Cholesterol: 52 mg/dl normal range: 35–86 mg/dl; target:

• LDL cholesterol (calculated): 148 mg/dl Initial LDL

normal range: <130 mg/dl; target: <100 mg/dl)
was 174 mg/dl.

• Triglycerides: 154 mg/dl normal range: <150 mg/dl; target: <150 mg/dl)

• Liver function panel: within normal limits

• Urinary albumin: <30 _g/mg normal range: <30 _g/mg)

 Poorly controlled, severe, persistent asthma

 Diabetes; control recently worsened by asthma exacerbations and treatment
 Dyslipidemia elevated LDL cholesterol despite statin therapy
 Hypertension
 Coronary artery disease
 Obesity
 Chronic pain secondary to occupation and previous injury, stable
 Status post–atrial fibrillation with cardioversion

 Financial constraints affecting medication behaviors

 Insufficient patient education regarding purposes and role of specific medications
 Wellness, preventive, and routine monitoring issues: calcium/vitamin D supplement, magnesium
supplement, depression screening, osteoporosis screening, dosage for daily aspirin

Result suggestion:

As you have probably guessed by now Moray Blunt has COPD.

Remember: Chronic Lung Diseases Affects the airways and the alveoli.
Diseases that affect the airways include:
Asthma: The airways are persistently inflamed, and may occasionally spasm, causing wheezing and shortness
of breath. Allergies, infections, or pollution can trigger asthma's symptoms.
Chronic obstructive pulmonary disease (COPD): Lung conditions defined by an inability to exhale normally,
which causes difficulty breathing.
Chronic bronchitis: A form of COPD characterized by a chronic productive cough.
Emphysema: Lung damage allows air to be trapped in the lungs in this form of COPD. Difficulty blowing air
out is its hallmark.
Acute bronchitis: A sudden infection of the airways, usually by a virus.
Cystic fibrosis: A genetic condition causing poor clearance of mucus from the bronchi. The accumulated
mucus results in repeated lung infections.
Disease that affect the aveoli include:
Pneumonia: An infection of the alveoli, usually by bacteria.
Tuberculosis: A slowly progressive pneumonia caused by the bacteria Mycobacterium tuberculosis.
Emphysema results from damage to the fragile connections between alveoli. Smoking is the usual cause.
(Emphysema also limits airflow, affecting the airways as well.)
Pulmonary edema: Fluid leaks out of the small blood vessels of the lung into the air sacs and the surrounding
area. One form is caused by heart failure and back pressure in the lungs' blood vessels; in another form, direct
injury to the lung causes the leak of fluid.
Lung cancer has many forms, and may develop in any part of the lungs. Most often this is in the main part of
the lung, in or near the air sacs. The type, location, and spread of lung cancer determines the treatment
options.
Acute respiratory distress syndrome (ARDS): Severe, sudden injury to the lungs caused by a serious illness.
Life support with mechanical ventilation is usually needed to survive until the lungs recover.
Pneumoconiosis: A category of conditions caused by the inhalation of a substance that injures the lungs.
Examples include black lung disease from inhaled coal dust and asbestosis from inhaled asbestos dust.

https://spectrum.diabetesjournals.org/content/16/1/41#T1

1. What are reasonable outcomes for this patient?

 Mortality outcomes: To avoid and prevent mortality due to respiratory failure, cardiovascular, and
thromboemboli events, and diabetes related complication in order to achieve life expectancy of age
86.3 for 76-year-old Caucasian male
 Morbidity outcomes:
 To prevent disease progression and related complications by controlling blood sugar, blood
pressure, hyperlipidemia, and preventing asthmatic exacerbations.
 To identify early signs of complications to DM such as neuropathy, ocular/retinal diseases (annual
eye exam), renal disease, peripheral vascular disease, foot hygiene and health, and hypoglycemia.
 Monitor and prevent complications of CAD and recurrence of a-fib, such as additional ischemic
episodes, dvt and embolic disease.
 Monitor drug related side effects and toxicity by preventing drug to drug /to food interactions, and
over/under dosing of medications.
 Behavioral outcomes
 Help maintain support system through family and friends and community outreach
 Maintain healthy diet and regular exercise.
 Adhere to medication and treatment regiments.
 Pharmacoeconomic outcomes
 Make sure the medications and treatment account for patient’s available resources.
 Quality of life outcomes
 Offer treatments and alternatives ways of delivering therapy in which works best with the
patient’s life style and allow for best adherence to therapies and treatments.

2. Based on current guidelines and literature, pharmacology, and pathophysiology, what changes
would be needed to achieve these outcomes?

 Blood sugar HgbA1C <7%

 LDL <100
 HDL >60
 Triglyceride <150
 Total cholesterol <200
 Calcium 8.3-10.2 mg/dL
 Respiration 12-20
 Weight loss to reach normal BMI 18.5-24.9 by moderate exercise as tolerated and modification of diet
including decreasing supper portion
 Self-monitoring of blood glucose with proper prevention of hypoglycemia
 Self-monitoring of blood pressure <140/90 for people with comorbidity based on JNC-8
recommendation and prevention of orthostatic hypotension
  Self-monitoring peak expiratory flow value, improve asthma symptoms, prevent asthma exacerbation
including exercise-induced asthma
 Maintain biochemical measures including CBC, CMP, LFTs, Calcium, urinary albumin, and etc. within
normal limit
 Improve peripheral edema
 Achieving all goals above to prevent complications requiring ER visit or hospitalization

3. Are there potential medication-related problems that prevent these endpoints from being achieved?

 fluticasone:
 SE: swelling ankle/feet, increase blood sugar
 Adverse effect: liver disease, fracture (decrease bone density)
 Interaction: albuterol, ASA
 salmeterol:
 SE: palpitations, tachycardia, elevated blood pressure
 Adverse effects: chest pain or tightness, irregular heart beat, decrease urine output, faintness or
light-headacheness when getting up suddenly from a lying or sitting position
 Use of long acting drugs like salmeterol may increase the risk of asthma-related death
 If overdose: fainting, fast, pouncing or irregular heart beat
 Interaction: albuterol (increase risk for cardiovascular side effects), alcohol
 Albuterol
 SE: tachycardia, wheezing (rare), dizziness/vertigo (less common)
 If overdose: possible cause peripheral vasodilation may lead to hypotension, palpitations,
tachycardia
 Interaction: Advair, insulin, pioglitazone
 Naproxen
 SE: drowsiness, risk for ulcer/GI bleeding, raise blood pressure, fluid retention
 If overdose: ulcer/GI bleeding may lead to anemia, increase blood pressure, liver damage, risk for
heart attack/stroke, kidney injury
 Interaction: other NSAID including ASA
 ASA
 SE: drowsiness, risk for ulcer/GI bleeding
 If overdose: ulcer/GI bleeding may lead to anemia, increase blood pressure, liver damage, risk for
heart attack/stroke, kidney injury
 Interaction: other NSAID including Naproxen
 Pioglitazone
 SE: swelling (when use combine with insulin), hypoglycemia, fluid retention may lead to heart
failure, fracture of bone, aggravated diabetes
 Adverse effects: liver injury
 Interaction: insulin
 pravastatin
 SE: worsen diabetes, liver/kidney injury
 If overdose: serious symptoms such as passing out or trouble breathing
 Interaction: alcohol
 Lispro Humalog
 SE: weight gain, peripheral edema, injection side reactions
 Adverse effect: hypoglycemia, hypokalemia
  Interaction: albuterol and corticosteroids may decrease the blood glucose lowering effect of
Humalog

4. What patient self-care behaviors and medication changes are needed to address the medication-
related problems?

 Self-monitoring of blood glucose with proper prevention of hypoglycemia

 Self-monitoring of blood pressure <140/90 for people with comorbidity based on JNC-8
recommendation and prevention of orthostatic hypotension
 Self-monitoring peak expiratory flow value, improve asthma symptoms, prevent asthma exacerbation
including exercise-induced asthma
 Consistent with one combination inhaled corticosteroid/long-acting bronchodilator
fluticasone/salmeterol
 Short-acting bronchodilator Albuterol inhaler should be used to rescue only
 Consider leukotriene blocker (Singulair)
 Proper use of peak flow meter every morning
 Avoidance of asthma triggers if possible
 Use of asthma action plan
 Ongoing patient education about asthma disease, management, especially Use of long acting drugs
like salmeterol alone may increase the risk of asthma-related death
 Refer weigh loss counseling. Weight loss to reach and maintain normal BMI
 Stress management. Community social activity
 Start aerobic exercise as tolerated to lose weight, cardio exercise to increase cardiac endurance, and
weight-bearing exercise to prevent/improve osteoporosis. Exercise 150 minutes or more, at least 5
days per week, and no more than 2 consecutive days without activity; modification lifestyle, avoid
secondary lifestyle. Recommend in-house exercise to prevent asthma triggers
 Refer nutrition counseling. Keto diet, carbohydrate-controlled diet, low fat, low sodium, low calorie
diet, diet containing source of vitamin D and calcium
 Consider applying Medicaid/Medicare and Harris County also offer Gold Card for low income or/and
old people to maintain financial ability to afford medication. Good Rx app or other discount drug cards
give a good discount. Consider applying manufacture drug program for cost effective
 Food bank provides high quality nutrient foods and Food Stamp for hungers or low-income people
 Stop Actos. Prescribe insulin glargine 100units/mL 10units SQub daily. Consider sliding scale for
insulin for better control blood sugar
 Elevate extremities for 30 minutes, 2-3 times per day. Consider compression stockings
 The patient is not on any antihypertensive medication. Prescribe lisinopril 10mg/day po daily initially.
Continue monitoring for therapy repose and adverse effects; re-evaluate the necessary of increased
dosage or change to other antihypertensive. Max dose of lisinopril is 80mg/day
 Stop enteric coated ASA 325mg daily. Prescribe low dose ASA 81 mg per day. Stop Naproxen.
Prescribe acetaminophen 650mg po 4-6hrs per day PRN for pain. No exceed more than 4000mg per
day
 Maintain calcium OTC 1000mg/day po and vitamin D 600IU/day po, magnesium 420mg/day po
 Evaluate the effects of treatment therapy and periodically thereafter. Monitor effectiveness,
toxicity/adverse effects including biochemical labs and other tests such as bone density, especially
close monitoring for kidney/hepatic injury, rhabdomyolysis, hypokalemia/hyperkalemia,
hypoglycemia, and etc.
 Screening for depression, osteoporosis including DEXA scan and 25-hydroxyvitamin D
 Order FOBT to screening for colon cancer
5. What patient education interventions would help achieve the desired outcomes?

 Adherence to medication regimen and possible complications if inadherent treatment plan

 Medication SE, adverse effects, Black Box Warning, complications
 Notify a provider immediately if there are signs of adverse effects, liver or kidney injury
 The importance of maintaining lipid panels within normal limit and controlled hypertension to prevent
the risk for CV events
 Proper peak flow monitoring and how to read the peak flow, use of asthma action plan
 avoidance of asthma triggers. The importance of use combination inhaled corticosteroid/long-acting
bronchodilator instead of single ones and albuterol for rescue only. Wash mouth after use of inhaler.
 The importance of proper exercise to improve and maintain the current disease
 Avoid alcohol and do not start smoking again
 Self-monitoring of blood glucose with proper prevention of hypoglycemia
 Self-monitoring of blood pressure <140/90 for people with comorbidity based on JNC-8
recommendation and prevention of orthostatic hypotension
 Stress importance of prevention
 How to apply for Medicare, gold card, manufacture drug program, food stamps, and other funds for
cost effective and high-quality nutrient
 The importance of weight loss, exercise and diet modification

6. What monitoring parameters are needed to verify achievement of goals and detect side effects and
toxicity, and how often should these parameters be monitored?

Case Challenge 6 Mr. Moray Blunt

 What is Moray's diagnosis?

 How did you come to this conclusion?
 What is the recommended plan of treatment?