A male patient who is diagnosed with type 2 diabetes

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Case Bill McDonald is 58 years of age and is a male patient who is diagnosed with type 2 diabetes. He has smoked one pack per day of cigarettes for 35 years and has a history of heavy alcohol use but quit both after he was diagnosed with diabetes 1 year ago. He was started on metformin 500 mg oral twice daily, was increased to 1000 mg twice daily 6 months ago. His latest HbA1c level is 7.2 %. Morning fasting glucose in the past week ranging from 4.5 to 7 mmol/L, however his glucose control has been unstable, fluctuating over in the last 3 months. Bill’s mother had diabetes and died of heart failure at age 65 years. Bill is running a juice bar and loves fresh fruits, especially banana. He has a sedentary lifestyle. A week ago, he presented for a regular GP visit and was noted to have a blood pressure of 170/100 mmHg, he was asymptomatic, with no headache, dizziness or blurred vision, but reported his eyes get tired easily. On examination, he is 175 cm tall, weight of 123 Kg (from 156 kg two years ago), had regular resting pulse rate at 82 /min, respiratory rate 18, temperature 37. The review of physical systems was unremarkable. No skin or nail lesions were noted but there was pitting oedema in both lower legs. Urine analysis revealed increased level of protein (4+). Blood test showed increased level of urea (25 mg/dl) and serum albumin (6.1 mg/dl) and increased Estimated Glomerular Filtration Rate. A 24 hour urine test revealed higher than normal rate of urinary albumin excretion. After visiting the GP, Bill took a 4 day business trip in Sydney. He constantly felt fatigued, nauseated and had painful feet during the trip. Bill also lost his supply of metformin and glucose testing kit. He presented to the emergency department today after returning from Sydney. On examination, Bill is 175 cm all, weight of 120 Kg. His temperature is 39, irregular deep laboured breathing rate of 40 breaths/min, pulse 130/min. The review of systems shows clear lung and heart sounds. Left ankle open ulcers are noted. His blood glucose currently is 28mmol/L. Bill was conscious but drowsy. He has decreased skin turgor and dry mucosa. Urinalysis test reveals 3+ of ketones and 4+ of glucose. Blood gas result shows pH of 7.20, bicarbonate 9.7 mmol/L. Blood test shows increased leucocyte and creatinine. QUESTIONS: -Analyse the immediate management approaches (nursing) for Bill. – Identify support resources available in Australia and develop an education plan for Bill, particularly his learning and treatment/care needs associated with his acute complications and recovery. Search for and identify the key literature related to best practice in the topic area.