NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE

No Longer Living the Sweet Life:

Losing Control of
Diabetes
by
Noura Farih, Lauren T. Lund, Sara E.
Johnny
Morgan,M. Turner, and Breanna N.
Harris*
Part I – Annual Consultation
Jorge Alvarez had come to the docotr’s office for his annual consultation. About ten years ago, when he was 45
years old, he was officially diagnosed with Type II diabetes mellitus (TIIDM) and assigned to the care of Dr.
Neha Gupta, an endocrinologist. Dr. Gupta had been working with Jorge to manage his disease. Over the past
ten years, Jorge had made exercise a priority and had also worked with a dietician to help him make healthy
eating choices. After implementing his new diet and exercise regimen, Jorge had even lost several pounds. Jorge
worked a desk job with deadlines that at certain times of the year demanded long hours and caused considerable
stress. Until now, Jorge and his health care team had been able to control his TIIDM using lifestyle
modifications (e.g., diet and exercise) without the need of medication.
During Jorge’s current visit, he complained about a sore on the side of his right foot that wouldn’t heal. He
explained that the injury occurred four weeks ago while doing some yard work; he had accidently hit his foot with
a shovel. Oddly, despite the sore being red, swollen, and puffy, Jorge reported that it didn’t really hurt and he
hadn’t even noticed the injury until he saw blood in his sock. Dr. Gupta asked Jorge if he had experienced any
symptoms such as numbness, tingling, or burning sensation in his hands or feet. Jorge confirmed that in fact he
had, especially in his feet, and it was worse at night when he was lying down. Dr. Gupta asked Jorge if these
tingling and burning pains caused problems with his day to day life. Jorge thought it over and said that sometimes
he woke in the middle of the night because of cold-like pain and pins and needles sensation in his feet. Jorge said
he had also experienced off-and-on general pain and tenderness in both feet over the last four months. Jorge also
reported that he had not felt like himself lately; he felt tired, thirsty, and sluggish. He added that recently it had
become exceptionally difficult to eat healthy and exercise because his work and his family life were increasingly
busy and stressful. Dr. Gupta nodded with an expression of concern. She looked at her laptop to review Jorge’s
current vital signs.

Table 1. Jorge Alvarez – Vital Signs

Measure Healthy Range Jorge Alvarez - Jorge Alvarez - Interpretation Change from
12 Months Ago Current Results Previous Visit?
BMI (Body Mass Index) 18.5–24.9 29.6 35.7 High Yes - increased
Weight (lbs.) -- 195 235 Yes – increased
Height (feet) -- 5’8” 5’8” No
Temperature (ºF) 97.7–99.5 98.6 99.0 okay Yes - increased
BP (mmHg) 90–120/60–80 142/85 159/92 high Yes - increased
Resting Heart Rate 60–100 86 96 okay Yes - increased
(bpm)
 NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
Random (Non-fasting)
< 140 155 305
high Yes - increased
Blood Glucose (mg/dL)

* Noura Farih, Lauren Lund, and Sara Morgan contributed equally to the creation of the case study and are undergraduate students at Texas
Tech University. Johhny Turner is a certified physician assistant with Texas Physician’s Group, Lubbock, TX. Breanna Harris is a
research assistant professor in the Department of Biological Sciences at Texas Tech University.

Questions
1. Using the information in Table 1, compare Jorge’s curent results with the normal ranges and fill in the
interpretation column with either “high,” “low,” or “okay.” Use the last column to indicate whether the values
have changed (“yes”or “no”) and, if so, in what direction (“increase” or “decrease”) from the previous year.

2. List all of the new symptoms that Jorge is experiencing. What system in his body is affected the most by these
new symptoms?

O Sistema Nervoso Periférico foi o mais afetado gerando sintomas como: vermelhidão e inchaço no local da
ferida, dormência, formigamento, sensação de queima nas mãos e nos pés (pior à noite e deitado), 4 meses de dor
geral e desconforto nos pés, se sentindo cansado e lento.

3. Based on the information that Jorge has provided and the current results listed in Table 1, what does this tell
you about the management of Jorge’s TIIDM? Is it still under control?

De acordo com a tabela 1, é possível dizer que houve um agravamento do quadro diabético de Jorge, e que esta
não está sob controle. Isso pode ser afirmado já que índices como IMC e taxa de glicose no sangue
aumentaram.

4. If you were Jorge’s doctor, which of his symptoms would you be most concerned with and why?

“No Longer Living the Sweet Life” by Farih, Lund, Morgan, Turner, & Harris Page 2
 NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
O sintoma que mais estaríamos preocupados seria a não cicatrização da ferida do pé, já que um hematoma
aberto apresenta um ambiente propício para o desenvolvimento de bactérias, podendo levar à uma infecção.

“No Longer Living the Sweet Life” by Farih, Lund, Morgan, Turner, & Harris Page 3
 NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
Part II – Blood Work
After reviewing Jorge’s records, Dr. Gupta looked up from her laptop. She paused for a moment and then said,
“Jorge, I’m concerned about your new neurological symptoms and the return of symptoms typical of TIIDM,
namely the increased thirst, tiredness, sluggish, weight gain, increased blood pressure. Have you been monitoring
your blood glucose at home like I instructed?”
“Yes I have, but not as consistently as I should.” Jorge looked down at the floor. “I hate to make excuses, Doc,
but almost a year ago, my wife, Cecilia, had to quit her job so she could care for her sick and elderly parents full
time. We wanted to hire someone, but the cost of the in-home care service was too high. Additionally, my
insurance changed and with my new plan the co-pay for the test strips increased a lot. With the loss of income
and having three daughters in college, money has been tight in our household. I just couldn’t afford the strips. I
can tell you that our financial troubles have added a lot of stress.”
Dr. Gupta nodded symmpathetically. In order to get a better idea of Jorge’s condition she decided to order some
additional blood work (Table 2).

Table 2. Jorge Alvarez – Lab Results

Test Normal Range Jorge Alvarez - Jorge Alvarez - Interpretation Change from
12 Months Ago Current Results Previous Visit?
Triglycerides (mg/dL) <150 215 253 High Yes- increased
Fasting Blood Glucose 75-105 115 162 High Yes- increased
(mg/dL)
GTT Glucose at 2hr <200 195 230 High Yes- increased
Urinary Glucose (ug/dL) 0-15 5 33 High Yes- increased
Urinary Ketones <20 20 30 High Yes- increased
(mg/dL)
C-peptide test (ng/ml) 0.5-2 2.0 0.5 Okay Yes- decreased
Hemoglobin A1c (%) < 6.5 6.2 7.5 high Yes- increased

Questions
5. Using the information in Table 2, compare Jorge’s curent results with the normal ranges and fill in the
interpretation column with either “high,” “low, ”or “okay.” Use the last column to indicate whether the values
have changed (“yes”or “no”) and, if so, in what direction (“increase” or “decrease”) from the previous year.

6. Based on the additional results listed above, does it seem like Jorge’s current plan is working to manage his
TIIDM? Explain your answer and include test results in the explanation.
O plano de Jorge não está funcionando para tratar a sua doença, já que algumas taxas diretamente ligadas à
diabetes, como a que resepresenta a quantidade de glicose no sangue, na urina e alto nível de triglicerídeos no
sangue, aumentaram significantemente.

Part III – The Nervous System Connection

Jorge had returned to the office to learn the reults of his blood work. Dr. Gupta was increasingly concerned. She
cleared her throat before sharing the news. “As you know, Jorge, TIIDM is defined as the inability to regulate
blood glucose, typically due to insulin resistance. There is still much about the on-set and progression of TIIDM
that the medical profession does not yet understand. What has been well demonstrated, though, is that TIIDM can
lead to several, sometimes serious, health complications including problems with the skin, eyes, nervous system,
kidneys, stomach, and feet. TIIDM can also increase the risk for stroke. These complications are more likely to
arise when TIIDM is not well managed, or is uncontrolled, meaning blood glucose levels are consistently too high

“No Longer Living the Sweet Life” by Farih, Lund, Morgan, Turner, & Harris Page 4
 NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
and not maintained within healthy ranges. One of the most common complications among diabetics is disruption
of the nervous system; roughly 50% of diabetic patients experience some form of nerve damage.”
Jorge understood what she was saying, but replied, “I’ve been trying to manage my condition, but life is so
stressful with my job and kids and everything else going on. I’ve been exercising once a week, but I know I need
to do more. I’ve been cooking healthy meals to take for lunch, but that doesn’t seem to be helping.” He paused for
a moment, and then with a look of embarrassment, confessed, “I’ve also been smoking again. I quit for a while,
but life has been very
stressful and smoking helps. It also reduces my cravings for sweets and gives me a reason to take a break from my
desk at work. But I don’t drink alcohol.”
Dr. Gupta continued, “You were doing a great job previously and we had your TIIDM in a manageable, controlled
state. But sometimes things change. Based on your results and new symptoms, I’m worried about changes in
your blood glucose and secondary complications to other physiological systems, especially your nervous system.
Consistently high blood glucose over an extended period of time can damage the blood vessels throughout the
body, which can result in damaged nerve cells (neurons), and the nerves themselves, leaving them unable to
function properly. It doesn’t seem like our plan of diet and exercise is working anymore. We’ll want to continue
with this behavioral intervention, but I will likely add medication to your treatment plan. I also want to find a
way to help you manage stress and stop smoking. Why don’t we schedule a follow-up appointment to run some
additional tests. In the meantime, I’d like you to read through some pamphlets about the nervous system and
TIIDM.”

Questions
7. The nervous system is generally split into two branches: the central nervous system (CNS) and the peripheral
nervous system (PNS). These two systems are always in communication with one another. Additionally,
information is always being processed; signals sensed by the PNS are sent to the CNS and the CNS integrates
that information and initiates a response, if necessary. On the following page there is a flow chart and a word
bank (Word Bank 1). Place the words into the flow chart so that they accurately describe the CNS and PNS. All
words should be used and some may be used more than once.
8. Now use the words in Word Bank 2 to complete the two tables on the next page to describe the sensory system
in more detail. All words will be used and some may be used more than once. The first column of “Special
Senses” is filled in as an example.
9. Neurons are the basic functional units of the nervous systems. Multiple neurons, combined with astrocytes,
glial cells, and other components, comprise a nerve. The stereotypical neuron displayed in textbooks is
typically a multipolar motor neuron. Draw a basic motor neuron below. Label the nucleus, cell body, dendrites,
axon, axon terminal, myelin sheath, and nodes of Ranvier.

“No Longer Living the Sweet Life” by Farih, Lund, Morgan, Turner, & Harris Page 5
 NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE

Word Bank 1
Brain
Sympathetic Central Nervous System
Sensory Parasympathetic
Spinal Cord Peripheral Nervous
Autonomic Somatic Motor
Enteric System
Acetylcholine Norepinephrine
“Rest and Digest” Neuromuscular Junction
Afferent Efferent
“Fight or Flight”

Peripeheral Nervous System

Special Senses

Sense Vision

Receptor Type Photoreceptors

Sends Signal to Optic nerve

CNS
Somatic Senses
Sense

Receptor Type

Sends Signal to
CNS
Word Bank 2 Hearing Taste Smell Equilibrium
Vision Optic nerve Photoreceptors Chemoreceptors Mechanoreceptors
Itch Temperature Proprioception Nociceptors Proprioceptors

“No Longer Living the Sweet Life” by Farih, Lund, Morgan, Turner, & Harris Page 6
 NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
Touch Cochlear nerve Adelta Olfactory bulb/nerve Thermoreceptors
Vestibular nerve C fibers Receptor axons Pain Cranial nerves VII, IX,
X
Abeta

10. Draw a simple (typical of somatic senses) and a complex (typical of special senses) sensory neuron (receptor).
Where applicable, label the cell body, the axon, the nerve endings, myelin, and the axon terminal.

11. What is myelin? What type of cells makes myelin in the PNS? In the CNS?

12. What is the purpose of myelin?

13. Are all neurons in the human body myelinated?

14. Apply the above information you just reviewed about the nervous system to our patient, Jorge. According to
Jorge’s symptoms, which branch of his nervous system is most affected? How can you tell?

Part IV – Nervous System Tests

After handing Jorge the pamphlets about the nervous system and TIIDM to read, Dr. Gupta was ready to share her
thoughts. “I think you have a form of peripheral neuropathy. More specifically, I think your sensory neurons are
being affected as a result of your TIIDM. But, I’d like to run a few more tests to help us determine which neurons
are being affected the most.” Jorge was concerned but also happy that he and Dr. Gupta might be able to pinpoint
what was
wrong so that they could better manage his condition.
“So what exactly is peripheral neuropathy, and what additional tests do I still need to have?”
“Peripheral neuropathy is a generic term to describe damage or lack of function in the neurons, and thus nerves,
of the peripheral nervous system. If you recall, the PNS conveys signals between the CNS and the body. Nerves
are collections of neurons and supporting cell types, such as Schwann cells, glial cells, and astrocytes. Damage
to the nerves can result in several problems, including a failure to transmit signals, sending signals too quickly

“No Longer Living the Sweet Life” by Farih, Lund, Morgan, Turner, & Harris Page 7
 NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
or too slowly, or sending signals at the wrong times. This problem can affect the autonomic, sensory, and/or
motor divisions of the peripheral nervous system. Additionally, this condition can affect a single nerve
(mononeuropathy), more than one nerve in separate areas (multiple mononeuropathy), or can affect multiple
diffuse nerves (polyneuropathy). There are over 100 different types of peripheral neuropathy, but you likely
have what we call diabetic neuropathy. Diabetic neuropathy is a complication of uncontrolled or unmanaged
TIIDM. The continually high blood glucose levels can damage the myelin around the neurons, and also the
blood vessels that carry oxygen to the neurons, or can damage the axons themselves. Diabetic neuropathy can
have various forms, but the most common generally impacts multiple nerves and is termed distal symmetric
polyneuropathy. I want to run some tests to make sure we know exactly which division is being impacted. I also
want to have you tested for Charcot’s joint, also called Charcot neuroarthropathy, due to your foot pains.”
“Okay, I’ll do whatever is necessary. But what is Charcot’s joint?”
Dr. Gupta replied, “Charcot’s joint is a rare foot disorder that can cause pain, deformity, and disability. It can also
lead to ulceration and infection. This can co-occur with peripheral neuropathy, especially in diabetics. Given your
foot pains and sore, and the nerve pain, I’d like to have you evaluated for this as well.”
“Thanks, Dr. Gupta. So what do we do if it turns out that I have diabetic neuropathy? Can it be cured? Is my
insurance going to cover all these tests?”
“Unfortunately, there is no cure for diabetic neuropathy, but we can manage the pain with medications. We would
likely start you on an NSAID and if that doesn’t work we can go to a steroid. We’ll absolutely want to get your
blood glucose under control; if we do that we can help prevent worsening of the condition. You will need to make
sure
you are eating healthy, continuing to limit alcohol intake, and increasing your exercise is important. I’d also like
you to work on cutting out the cigarettes and managing your stress levels. I can get you information on free
smoking cessation and stress management classes at the hospital. Unfortunately, I’m not sure what your insurance
plan will cover, they all differ, so you will have to call your carrier and discuss it with them. But I do want to run
all of these tests to make sure we figure out what is going on with your nerves.”
Dr. Gupta advised Jorge to monitor his blood glucose levels very closely. In addition, he should continue with an
exercise and diet plan. They set another appointment for next week to run the neuropathy tests and to discuss
various medications to help manage his TIIDM. Before leaving the exam room, Dr. Gupta handed Jorge a sheet
describing tests that are used to diagnose different types of neuropathy. She also gave him information about free
classes on
smoking cessation and stress management.

Questions
15. Fill out Table 3 below about the tests you think Dr. Gupta should order for Jorge. We want to maximize data
for diagnosis, but at the same time minimize the number of procedures used (extra tests are costly and time
consuming).
Table 3. Jorge Alvarez – Possible Tests
Test Name Would You Why or Why Not?
Recommend for Jorge?
(Yes/No)

Monofilament Test

Quantitative Sensory Test (QST)

“No Longer Living the Sweet Life” by Farih, Lund, Morgan, Turner, & Harris Page 8
 NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE

Nerve Condition Velocity (NCV)

Electromyography (EMG)

Autonomic – QSART

X-Ray

MRI

CT Scan

Nerve Biopsy

Skin Biopsy

Additional Blood Tests

2
Case copyright held by the National Center for Case Study Teaching in Science, University at Buffalo, State University of New York.
Originally published October 6, 2018. Please see our usage guidelines, which outline our policy concerning permissible reproduction of this
work. Licensed image in title block © Tony Bosse | Dreamstime.com, id 125886300.

“No Longer Living the Sweet Life” by Farih, Lund, Morgan, Turner, & Harris Page 9