Patient A arrives at her primary care provider's office for a routine examination. She is a Native American woman, 45 years of age, who is 5 feet 4 inches tall and weighs 205 pounds, with a body mass index of 35.3 kg/m². Her physician is concerned because of her family history of type 2 diabetes, heart disease, and stroke. Patient A has a past medical history of hypertension and hyperlipidemia. Her blood work reveals an HbA1c of 8.0% (estimated average glucose: 183 mg/dL) and a fasting blood glucose level of 173 mg/dL. A diagnosis of type 2 diabetes is confirmed by further blood work. Patient A is reluctant to start medications and asks her primary care provider if he knows of any alternative therapies she could use instead. After a thorough explanation regarding the benefits of glycemic control in respect to her family and personal past medical history, Patient A agrees to start taking metformin. She is also referred to a diabetes self-management education program recognized by the American Diabetes Association (ADA) for information regarding SMBG, medication management, exercise, blood glucose goals and behavior change, and culturally sensitive meal planning.

Patient A returns in three months for a follow-up evaluation of her progress. Her HbA1c remains 8.0% (estimated average glucose: 183 mg/dL), and she states her fasting blood glucose levels are 185–220 mg/dL. She states she has been adherent to her meal plan and has been working outside more often to increase her activity level. She appears frustrated with the lack of improvement.

Her primary care provider decides to add a sulfonylurea to the patient's therapy to increase insulin production. Patient A is started on glipizide 10 mg twice per day. Additional education is completed regarding the action of glipizide as well as the potential side effects and the importance of eating meals on a consistent schedule to prevent hypoglycemia. The patient and her daughter were both instructed on recognition of signs and symptoms of hypoglycemia and treatment options. Patient A is able to verbalize all instructions given.

One month later, Patient A's daughter calls the primary care provider in the mid-morning to report that her mother was working out in the yard and became dizzy, shaky, sweaty, and confused. She is instructed to check Patient A's blood glucose level and treat for possible hypoglycemia. After the patient's blood glucose levels are stabilized, the daughter is told to bring the patient to the clinic. The initial blood glucose level is 43 mg/dL. After Patient A consumes 6 ounces of orange juice, the blood glucose is rechecked in 15 minutes. The result is 87 mg/dL.

At the clinic, the certified diabetes educator assesses Patient A's medication understanding and adherence. No adverse practices are identified, so further information gathering is completed.

Rationale and comments: From the information gathered so far, it is unclear what caused Patient A's hypoglycemia. Additional areas should be explored, including:

The diabetes educator requests Patient A recall her breakfast, which reveals the intake of two scrambled eggs, one slice of whole-wheat toast with butter, half of a banana, 8 ounces of fat-free milk, and a cup of tea. The educator also inquires about any use of holistic or herbal remedies. Patient A becomes quiet and is hesitant to answer, but finally reveals she has been drinking bilberry tea every morning and using nopal and bitter melon in most of her meals. The patient indicates she did not share this with her primary care provider because she did not feel it was important. The diabetes educator informs Patient A about the potential interactions of many herbal medications and the impact they could be having on her diabetes and other conditions. The importance of including these medications in her conversations with all of her healthcare providers is stressed. As a result, Patient A's primary care provider decides to decrease her glipizide to 5 mg twice a day. The patient is also instructed to call the diabetes nurse with a week of blood glucose levels to determine the success of the change in therapy.

Patient B is a White adolescent, 15 years of age, with a five-year history of type 1 diabetes. He is on multiple daily injections of insulin glargine for his background insulin and a rapid-acting insulin analog for meal and correction boluses. Patient B has experienced a roller-coaster effect with his glucose levels, and he has had difficulty in school recently due to fatigue and headaches. Patient B states he has not been sleeping well at night and wakes up exhausted. When asked to recall his blood glucose levels, he states his morning glucose levels have ranged between 189 mg/dL and 215 mg/dL. The primary care physician suspects nocturnal hypoglycemia and possible Somogyi phenomenon.

Rationale and comments: Nocturnal hypoglycemia is indicated by several signs and symptoms. The patient has experienced:

These are all signs of nocturnal hypoglycemia.

The physician instructs Patient B to assess his blood glucose level at 3 a.m. to identify if Somogyi phenomenon is an issue. She also prescribes the use of a continuous glucose sensor to assess blood glucose patterns and hyperglycemia/hypoglycemia events that may be occurring without being noticed.

Patient I is an African American man, 72 years of age, with a 15-year history of type 2 diabetes. He has experienced diabetes-related complications, including a transient ischemic attack, angioplasty for coronary heart disease, renal impairment, and hypertension. His glycemic control has diminished steadily over the past two years to a current HbA1c of 8.9% (estimated average glucose: 209 mg/dL). Patient I has been very hesitant to start insulin therapy because of the experiences of past family members. He states, "As soon as I start on the needle, my life is over." After multiple educational opportunities regarding the benefits of good glycemic control and how it can diminish the adverse effects of his diabetes, Patient I ultimately agrees to a change in treatment therapy to include insulin injections. The physician prescribes neutral protamine Hagedorn (NPH) insulin 10 units twice per day due to cost factors over the more expensive long-acting insulin.

One morning, Patient I's wife calls emergency services reporting that Patient I is combative, confused, sweating, and beginning to lose consciousness. She is able to pour a large glass of orange juice in his mouth. She states, "I wanted to make sure it worked, so I put 5 tablespoons of sugar in it." When the patient arrives in the emergency department his blood glucose level is 357 mg/dL and he is complaining of chest pain. The decision is made to admit Patient I for further observation and glucose management. He is ordered weight-based insulin correction for glucose control. His NPH insulin is put on hold. The next morning, Patient I has a blood glucose level of 313 mg/dL. His glucose is covered, and the physician orders his home dose of NPH insulin 10 units. Patient I refuses his dose because it made him, "sicker than I was before. I was brought here because it doesn't work." The nurse explains the action of the insulin in relationship to his blood glucose levels and the action of the NPH, again stressing the benefits of adequate glucose control and the detrimental effects of hyperglycemia. The patient remains adamant that he is not going to take insulin again. His primary care provider discusses the need for the insulin therapy, and Patient I agrees to take the insulin while he is in the hospital and staff is around in case he "gets into trouble." After 24 hours, the patient has blood glucose levels less than 150 mg/dL and states he is feeling better than he has in many months. Through education regarding insulin, the connection is made between the increased perception of health and the decrease in blood glucose levels.

Patient I agrees to try insulin at home again. When it is time for his next dose of NPH, the nurse brings in the vial and a syringe to assess his ability to successfully draw up the 10 units of insulin. Observation reveals that the patient is struggling to complete the task competently and has actually drawn up 16 units of insulin opposed to 10 units. When his attention is drawn to the excessive amount of insulin in the syringe, he states, "Those little lines are so hard to see even with my glasses on. I figured the amount is so small it shouldn't hurt me." Patient I also struggles to manipulate the vial and syringe to the extent of the needle bending within the bottle.

Rationale and comments: There are several options available to Patient I to ensure he is receiving the correct amount of insulin. A Magni-Guide may be helpful to increase visualization of the syringe markings. A refrigerator vial stabilization device may also be considered to allow for greater stabilization of the needle when preparing the insulin syringe. The wife's willingness to learn how to draw up insulin into the syringe should be assessed. Once taught, her ability to accurately prepare the insulin syringe should be observed. Finally, the best option may be utilizing an insulin pen, which can increase patient safety.

The treatment options are discussed with Patient I and his wife, and they decide to investigate the use of an insulin pen. The patient calls his insurance company to evaluate the coverage and is happy to hear the insulin pen is covered due to his recent hypoglycemia experience. Patient I and his wife are both taught how to dial the correct amount of insulin units, how to change insulin pen needles, and how to appropriately dispose of needles. Both individuals are able to perform all vital components taught regarding insulin pen usage and safely return home.

Patient K is a defense attorney in a busy, prestigious law firm. She has dealt with type 1 diabetes since her diagnosis at the age of 13 years. She was started on an insulin pump in order to level out her blood glucose control and improve her overall health and has been happy with the results. Patient K is invited to play in a softball game prior to the barbeque at the annual neighborhood picnic. She feels it would be a good idea to get a little exercise because she has spent much of the day sitting and relaxing while talking with her friends. In the middle of the game, the patient suddenly becomes weak, diaphoretic, shaky, and confused—clear signs of hypoglycemia.

Rationale and comments: Several factors most likely contributed to Patient K developing hypoglycemia, the most significant being her engagement in exercise (unplanned) prior to eating her meal. In addition, the patient is away from the stress of her job and is relaxing, which is lowering her stress hormones. Together, these conditions are to blame for her hypoglycemic episode.

Patient G is a White man, 85 years of age, with a long history of type 2 diabetes. The nurse conducts a home health care visit for home assessment and medication evaluation. The patient indicates that his blood glucose levels are consistently in the high 200s, including in the mornings and at night. The nurse reviews the medications remaining in his weekly pill box to assess medication adherence and notes that he has been missing multiple medications throughout the week, including the medication to help control his blood glucose levels. Patient G states that when he realizes he has missed the medication, he is afraid to take it. The nurse informs the patient's physician of the findings, and the patient's regimen is changed to repaglinide 2 mg just prior to each of the three biggest meals. The instructions are given to Patient G, and he states understanding and is able to verbalize when to take the medication.

The nurse returns to Patient G's home three days later to assess his tolerance to the new medication. When the nurse arrives at 9 a.m., the patient is in a state of confusion, diaphoresis, and shakiness. His blood glucose level is 48 mg/dL. The nurse provides adequate treatment, and Patient G is then able to help determine what precipitated the episode of hypoglycemia. The patient reports that he took the repaglinide pill at 7:15 a.m., but he had not consumed breakfast. The nurse works with Patient G to develop a plan to avoid skipping meals. They decide that the patient will make his breakfast each day and elicit the assistance of his daughter to remind him to take the repaglinide when she talks to him each morning. The daughter also agrees to check in after lunch and dinner to assure that the patient is taking the repaglinide as he should at all meals.