Caso clínico de Diabetes
Autor: Michele Campos Barreto | Publicado: 2011-06-04T06:16:00-07:00

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Caso Clínico DM II23/05/2011N.A.D., 67 anosHD prévias:&nbsp; - DM II-HAS-ICC classe I-coronariopatia-cardiopatia isquemica pós IAM (1987)-angioplastia em 2002-dislipidemia-sobrepeso-hérnias inguinais-depressão em tratamento-HPB (cirurgia em 2002)Perguntei sobre o diagnóstico de DM II, paciente relata que o diagnóstico foi feito em 1987, ao sofrer IAM. Na época, começou o tratamento apenas com controle dietético. Permaneceu assim por alguns anos, mas não se lembra quantos. Depois (em 2001??), começou a utilizar Glibenclamida (2,5 mg, 1 cp pela manhã e ½ a noite). Em 2002, começou a utilizar Metformina (500 mg + 250 mg),&nbsp; e aumentou a dose da Glibenclamida (5mg, 1 cp pela manhã e ½ cp a noite). Em 2003, apresentou glicemia de jejum de 127mg/dl. Foram aumentadas, então as doses dos medicamentos: Metformina (500 mg BID) e Glibenclamida (5 mg BID). Em 2004, a glicohemoglobina apresentada foi de 8,9%. Foi mantida a dose de Glibenclamida, e a dose da Metformina foi aumentada novamente (850 mg BID). Em 2005, a HbA1c foi de 9,0%, e a glicemia de jejum=168mg/dl; porém, as doses dos medicamentos foram mantidas. Em 2006, apresentou glicemia de jejum=171mg/dl, glicemia pós-prandial=155mg/dl, e HbA1c=7,6%; as doses dos medicamentos foram mantidas. Em 2007,a dose de Glibenclamida foi mantida, e a de Metformina aumentada (850 mg TID). Ao final do ano de 2007, apresentou glicemia de jejum=190mg/dl e HbA1c= 7,6%. Em 2008, apresentou glicemia de jejum=135mg/dl, glicemia pos-prandial=154mg/dl e HbA1c=7,1%; os medicamentos foram mantidos. Em 2009, apresentou glicemia de jejum=182mg/dl; a dose de Glibenclamida foi aumentada (?) (5mg pela manhã e 10 mg a noite??) - no prontuário, estava assim: “5mg/10mg BID”. Em 2010, apresentou glicemia de jejum=168mg/dl, e HbA1c=8,8%; havia relato de fraqueza e mal-estar, com melhora após alimentação (seria hipoglicemia, provavelmente devido ao aumento da dose de Glibenclamida?). A Glibenclamida foi então suspensa,&nbsp; a Metformina mantida (850 mg TID), e introduzida insulinoterapia (NPH 10+0+10). No final de 2010, apresentou glicemia de jejum=158 mg/dl, e glicemia pós-prandial=200mg/dl. A dose de Metformina foi mantida, e aumentou-se a dose de NPH (14+0+10).Na atual consulta, dia 23/05/2011, apresentou glicemia de jejum de aproximadamente&nbsp; 160mg/dl (fez curva glicêmica durante a última semana). Medicamentos em uso:-insulina NPH 14+10+10-sinvastatina 40 mg MID-AAS 100mg MID-Carvedilol 25 mg BID-Digoxina 0,25 mg MID ( 1/2 comp)-enalapril 20 mg BID-diazepam 10 mg MID (se necessário)-fluoxetina 20 mg MID-furosemida 40 mg BID-HCTZ 25 mg MID-Metformina 850 mg TIDRelata que houve melhora do estado geral. Continua apresentando dispnéia ao caminhar, além de dor lombar que irradia para os mmii (mas está realizando fisioterapia, e houve melhora do quadro). Assim, quando perguntei sobre a questão da prática de exercícios físicos, ele disse que é praticamente impossível realizá-los. Relata que depois que começou a utilizar fluoxetina, houve melhora significativa do quadro depressivo, inclusive está dormindo melhor (quase não toma diazepam mais para dormir). Toma os medicamentos regularmente, consegue seguir as recomendações alimentares, raramente ingere doces. Sem outras queixas. Resultados de exames:Glicemia de jejum=145mg/dlGlicemia pós-prandial=186mg/dlHbA1c=8,0%Colesterol total 174, HDL 30, LDL 97, VLDL 47Triglicérides 235Creatinina 1,1Potássio 4,8Ácido úrico 7,6Ao exame físico: peso=81,5 kg, altura=1,70m&nbsp; (IMC=28,2), PA=143/87mmHg Bom estado geral, sem alterações significativas.CD: Foi aumentada a dose de NPH (14+0+12), as outras foram mantidas. Solicitados exames: glicemia de jejum, HbA1c, uréia, creatinina, potássio, colesterol total e frações, triglicérides.Retorno: 17/10/2011.CRITICAS: Não encontrei no prontuário informações sobre acompanhamento na oftalmologia. A hipertrigliceridemia poderia ser causada pelo descontrole glicêmico? De qualquer forma, dei uma olhada rápida no prontuário, e vi que ela se mantém ao longo dos anos. Não seria interessante iniciar com um fibrato, por exemplo?