Primary Care of the Maturing and Aged Family Diabetes Case Study

Primary Care of the Maturing and Aged Family Diabetes case study The purpose of this paper is to evaluate a case study base on the subjective information provided by the patients and objective information such as vital signs and blood work. The patient diagnosis will be developed from the information proved and the management plan of the diagnosis with be applied based on the American Diabetes Association’s (ADA) 2019 Standards of Medical Care in Diabetes. This paper will also help the FNP prepare for collaborative care with other healthcare providers. Assessment Primary Diagnosis- Type 2 Diabetes Mellitus without complications (E11.9) pathophysiology: Type 2 diabetes Mellitus (T2DM) is characterized by decrease function of the pancreas beta islet cells which cause impaired insulin secretion and insulin resistance (Dunphy et al. 2019). The clinical presentation for T2DM included increased urination, increased thirst, increased hunger, increase occurrence of infection (Dunphy et al., 2019). pertinent positive findings: very fatigued with low energy, weight gain, increase in hunger and thirst with exercise, increases urination at night and frequent urinations during the day, this has been going on for the past 3 months. Mrs. G is 55 years old, Hispanic, BMI of 33.3 kg/m2, UA: +1 glucose with small protein, HgA1C: 6.9 % pertinent negative findings: No family history of diabetes, Mrs. G exercise for at least 30 minutes twice a week (subjective findings). UA: negative for ketones, and glucose is 95 (objective findings) (Kennedy-Malone et al., 2019). rationale for the diagnosis: Lab values and subjective information contribution to the diagnosis are: fatigue, increased hungry, increase thirst, weight gain and frequent DIABETES CASE STUDY urination, age (55-years-old), ethnicity (Hispanic), obesity (BMI 33.3 kg/m2) (ADA, 2019). Lab result: HgA1C level of 6.9 %. According to ADA (2019) A1C ≥ 6.5 % with signs and symptoms of hyperglycemia are sufficient to diagnoses diabetes, urinalysis with small protein and 1 + glucose, elevated triglyceride level indicated dyslipidemia (ADA, 2019). Secondary Diagnosis: Hyperlipidemia, unspecified (E78.5). Pathophysiology: Hyperlipidemia is a metabolic condition that increased the risk of atherosclerosis due to overproduction of lipoproteins (Dunphy et al., 2019). Common signs and symptoms of hyperlipidemia include BMI ≥ 25, central obesity, diabetes, xanthoma (fatty growth underneath the skin), xanthelasma (yellow plaques around the eyelids), and thyroid dysfunction; and diagnoses is based on lab values(Kennedy-Malone et al., 2019) pertinent positive findings: T2DM. obesity, father has high cholesterol (family history), age (55-years-old of women), race (Hispanic) (subjective finding). Objective findings include blood pressure (129/80), the lipid panel result include: TC 230 mg/dl (desirable level), LDL 144 mg/dl (high) ; VLDL 36 mg/dl; HDL 38mg/dl (low), Triglycerides 232 (high) (Dunphy et al., 2019., 2019; Soran et al., 2018) pertinent negative findings: no medical history of premature coronary artery disease, or peripheral vascular disease, no smoking history (subjective finding) (Soran, et al., 2018). rationale for the diagnosis: According to the (Kennedy-Malone et al., 2019), Hispanic are at higher for hyperlipidemia, they have higher TC and low HDL than other races. Based om Mrs. G’s lipid panel results or LDL 144 mg/dL and HDL 38 mg/dL she is at an increased risk for cardiovascular disease, obesity, T2DM, and hypertension (Soran, et al., 2018) DIABETES CASE STUDY Secondary Diagnosis: Obesity (E66.0) Pathophysiology: Obesity is a large amount of body fat and a chronic disease (Dunphy et al., 2019). According to (Dunphy et al., 2019), symptoms of obesity include BMI ≥30 kg/m2, fatigue, reduce energy. Weakness, shortness of breath, joint pain, depression, and daytime sleepiness. pertinent positive findings: fatigue, decrease energy, increased tiredness, gain 3 pounds with attempt to lose weight, increase in hungry. Patient weight 185 pounds with a height 5’2.5” (BMI 33.3 kg/m2), left knee arthritis, blood pressure 129/80 (Dunphy et al., 2019). Pertinent negative findings: at least 30 minutes exercise twice a week, TSH 2.35 and Free T4 0.7 (normal), thyroid disease is not a secondary cause (objective finding) (Dunphy et al., 2019). rationale for the diagnosis: The patient complains of fatigue, low energy, increase hungry and weight gain. According to (Dunphy et al., 2019), obesity diagnosis is based on a BMI ≥30 kg/m2, Mrs. G’s have a BMI of 33.3 kg/m2. Plan Diagnostics Lab test (#1) HgA1C repeat in 3 month for T2DM (ADA, 2019) rationale: According to the ADA (2019), patient with T2DM diabetes will need A1C testing done routinely as an initial assessment and a continuing care, measuring of A1C every 3 months can help define if the patient has reach and maintaining glycemic targets. A1C testing regularity is based on the clinical situation, judgment, and the treatment plan (ADA, 2019) Lab test (#2): spot urinary albumin-to-creatinine (UACR) annually DIABETES CASE STUDY Rationale: According to ADA (2019), A UACR check for urinary albumin or microalbuminuria, an indicator of kidney damage, the test should be performed annually for a patient with T2DM. Mrs. G is an appropriate patient for the UACR test because her urinalysis result indicate small protein and the patient primary diagnosis of T2DM. According to ADA (2019), normal UACR results are <30 mg/g Cr and increased levels of urinary albumin are results ≥30 mg/g Cr (ADA, 2019). Lab test (#3) complete metabolic panel (CMP) should be repeat within 6 weeks (Hollier, 2018) Rationale: CMP and CBC need to be performed initially to establish a baseline. A CMP need to be repeated annually in diabetic patient to monitor kidney and liver function; when using statin for the treatment of hyperlipidemia liver function test within 4 to 6 weeks from the initiation of treatment (Hollier, 2018). For patient with T2DM treated with metformin, CBC is recommended at least annually due to the potential for vitamin B12 deficiency (ADA, 2019). Medications Medication (#1): Rx: Metformin 500 mg tablet Sig: Take one (1) tablet by mouth twice daily Disp: 60 (Sixty). RF: 2 (ADA, 2019). Rationale. The first line of medication for the treatment of T2DM is metformin, metformin therapy can prevent diabetes in patient with prediabetes, and have been approved for weight loss (ADA, 2019). According to ADA (2019), metformin can safely be use for long-term, it is less expensive with less side effect, and effective. Medication (#2) : Rx: Atorvastatin 20 mg tablet Sig: Take one (1) tablet by mouth once daily Disp: #30 (Thirty). RF: 2 (ADA, 2019). Rationale. The selected medication for the hyperlipidemia is Atorvastatin. According to ADA (2019), a moderate dose of statin therapy is the primary prevention for patient with DIABETES CASE STUDY diabetes aged 40-70 years and LDL ≥70 mg/dL. The ACC/AHA is a prevention risk assessment tool used to assess patients with or at risk for developing cardiovascular diseases within 10-years; Mrs. G’s ACC/AHA was 6.3%, ADA (2019), recommend that she be started on moderate statin. The patient can continue taking these medication Rx: Tylenol 500 mg Sig: Take 1-2 tablet(s) by mouth as needed for knee pain. Disp: 60 Refills: 0 (Epocrates, 2020). Rx: Multivitamin Sig: Take 1 tablet by mouth daily. Disp: 90 Refills: 3 (Epocrates, 2020). Education Diagnoses: Mrs. G, you were diagnose with diabetes bases on your lab result, your hemoglobin A1C is 6.9%, which is higher than the recommended value of 6.5% or lower, the A1C is a blood test that measure your average blood glucose over the past 3 months to diagnose T2DM or prediabetes (ADA, 2019). You were also diagnose with hyperlipidemia because of your lipid panel result which include TC 230 mg/dl (desirable level), LDL 144 mg/dl (high), VLDL 36 mg/dl; HDL 38mg/dl (low), Triglycerides 232 (high) (Dunphy et al., 2019). You were also diagnosis with obesity because of your weight your BMI is 33.3 kg/m2, obesity is diagnosed with BMI ≥30 kg/m2 (Dunphy et al., 2019). Medications: Mrs. G, bases on your lab result your hemoglobin A1C is 6.9%, which is higher than the recommended value of 6.5% or lower, the A1C is a blood test that measure your average blood glucose over the past 3 months to diagnose T2DM or prediabetes (ADA, 2019). Based on your A1C you were prescribe metformin, metformin is the first line of treatment for T2DM, it helps with weight loss, can be used for long-term, and not expensive. Long-term use of metformin may cause vitamin B12 deficiency including side effect such as: bloating, abdominal DIABETES CASE STUDY discomfort, nausea and diarrhea (ADA, 2019) Medication should be taken with meals and staying hydrated is important and side effects should subside in a few week (ADA). Mrs. G you were diagnosis with hyperlipidemia, which occur when the level of lipid in your blood is high, this increased the risk of atherosclerosis or CVD (Dunphy et al., 2019). Your lipid panel result showed: TC 230 mg/dl (desirable level), LDL 144 mg/dl (high); VLDL 36 mg/dl; HDL 38mg/dl (low), Triglycerides 232 (high). You were prescribed atorvastatin, which help to lower LDL and triglycerides (ADA, 2019). We will check your LDL cholesterol level 4-12 week after staring treatment or making changes to the dose. The side effect for atorvastatin include diarrhea, nausea, insomnia, and joint pain (ADA, 2019). The first line treatment of osteoarthritis of the knee is Tylenol (Dunphy et al., 2019). Continue to take Tylenol 500 mg as need for your osteoarthritis. Remember to not take too much Tylenol and avoid medication with Tylenol added to it because of the risk of over-dose and liver damage; and keep doses below 3,00 mg per day (Dunphy et al., 2019). Mrs. G continue to take your multivitamin as you were before. Multivitamins help supply the body with nutrients and minerals that are not taken your diet. Multivitamin can help patient will vitamin deficiency (Epocrates, 2019). Diet Nutritional planning is an important part of managing you T2DM. The recommended caloric intake for women is 1,200-1500 per day to help with weight loss management (ADA 2019). Eat food that are high in fiber such as vegetable, whole grains, dairy products, fruits, and legumes, avoid sugar sweetened drinks, high protein, and minimize foods with added sugar, a Mediterranean style diet can improve blood sugar and lower heart disease (ADA, 2019). Limit your salt intake to less than 2,300 mg/day. To address your drinking of alcohol 1-2 glasses on the DIABETES CASE STUDY weekends; the ADA (2019) recommend that women should not drink more than one drink per day and alcohol intake may increased the risk of hypoglycemia in diabetes patient. Exercise: Physical activity is an important part of diabetes and osteoarthritis management. Exercising help decrease blood glucose, lower cholesterol level, and assist with weight loss. It is good that you have started exercising twice a week for 30 minutes, but you will need to increase your time of exercise. According to ADA (2019), adult with diabetes need to involve in 150 minutes or more of aerobic activity 3 day per week with no more than 2 uninterrupted days without activity. Decrease and interrupted the amount of sitting every 30 minutes (ADA, 2019). Exercise that is beneficial for your osteoarthritis include Walking, aquatic activities, tai chi, resistance exercises, cycling, and heated pool (Kennedy-Malone et al., 2019) Warning Signs for diagnoses and mediations Diabete: Being a new diabetic, I want to discuss warning signs and symptoms that are associated with T2DM. It is important that you know and understand that signs and symptoms associated with high blood sugar and low blood sugar and how to manage them. Sign and symptoms of hyperglycemia is like some of the symptoms you are experiencing now, include frequent urination, increase in thirst, increase hungry, fatigue, and dizziness (Dunphy et al., 2019). Hypoglycemia can happen for many reasons such as missing a meal or not eating much; signs and symptoms include sweating, dizziness, weakness, and confusion (Dunphy et al., 2019). To manage hypoglycemia, you will need to drink 6 to 12 ounces of orange or fruit juice without adding external sugar, if juice is not available drink 8 ounce of milk (Dunphy et al., 2019). Warning signs for diagnosis and mediation Hyperlipidemia: Mrs. G based on your lipid panel levels you were diagnoses with hyperlipidemia (increase lipid in your blood) meaning you cholesterol levels are high (Dunphy et DIABETES CASE STUDY al., 2019). Hyperlipidemia increase risk for CVD and acute coronary syndrome (Dunphy et al., 2019). To help control you manage and control your cholesterol, decrease you risk for heart attack and stroke, I prescribe atorvastatin, that should be taken once a day before bedtime. For this medication to work you will need to modify your diet by eating healthy and exercising. watch out for some warning sign for your high cholesterol which can led to stroke or heart attack. Call 911 or go to the emergency if you have chest pain, weakness on one side of your bod, or slurred speech. Atorvastatin is the medication prescribe, watch out for the following warning signs and side effect such as diarrhea, join pain, cramping, or fatigue (ADA, 2019) Warning signs for diagnosis and mediation Diabetes: Based on you your height and weight your BMI was calculated; you have a BMI of 33.3 kg/m2 which place you as overweight. According to (Dunphy et al., 2019) obesity is based on body fat and BMI, the normal BMI is 30 kg/m2. Obesity can occur from consuming more calories and being unable to participated in exercise or physical actives. Obesity can lead to many health problems such as stroke, heart disease, T2DM, and hyperlipidemia.I will encourage you follow previous discuss calorie and diet restriction and exercise and weight loss regimens (ADA, 2019). No mediation will be prescribed for obesity. Referral Diabetes Educator. Mrs. G will be referred to a diabetes educator because she is newly diagnosis with diabetes. According to ADA (2019), diabetes education and support help educate patient by enabling the patient with skill need for self-management, which have shown to improve patient glucose outcome and satisfaction. Registered Dietitian: Because you are a newly diabetic with hyperlipidemia, you will need nutrition counseling to help with her new diet management. The ADA (2019), DIABETES CASE STUDY recommended that patient with diabetes needs nutrition education and annual updates by a registered dietitian to evaluate nutrition and caloric intake in relation to weight status and risk factors for cardiovascular disease; dietary management is individualized. Ophthalmologist: Mrs. G I am going to refer you to an ophthalmologist because you wear contacts. I do not know when Mrs. G last visited an eye doctor. According to ADA (2019), patient diagnoses with T2DM, need a thorough eye assessment and examination by an ophthalmologist or optometrist during initial diagnoses, and annually. Follow up: Mrs. G will be schedule for a follow up visit in 4-weeks. During the follow up visit metformin and atorvastatin will be evaluated for compliance and side effects, along with exercise, diet, weight, BMI, and blood pressure. Mrs. G will get answers to any question she may have concerning her current health problems (diabetes, hyperlipidemia, and obesity). I would advise Mrs. G to keep a log and monitor her blood glucose level, she should bring the log to her next visit. If the Mrs. G blood glucose continue to be within the therapeutic rang, she will need to follow up every 3 months (ADA, 2019). Assessment of comorbidities Comorbidities of diabetes discuss condition that affect people with diabetes more than those without the disease. One comorbidity that patient with diabetes exercise is depression. According to ADA (2019), one in four patients with T2DM are affected by increase depressive disorder and symptoms. According to Darwish, Beroncal, Sison, & Swardfager (2018), the common cause for T2DM and depression are lack of exercises, poor diet and sleep. Depression affects diabetes patient with the burden of being sick may trigger anxiety and depression in a new diagnosis patient. Depression cause diabetic patient to have poorer glycemic control, eating habits, and exercise adherence (Darwish, Beroncal, Sison, & Swardfager, 2018). Last depression DIABETES CASE STUDY can affect the patient ability to perform tasks, communicate and think clearly, which can interfere with the patient ability to manage their diabetes (Darwish, Beroncal, Sison, & Swardfager, 2018). According to Darwish, Beroncal, Sison, & Swardfager (2018), depression is diagnosed with clinical interviews, the accurate method to screen depression is PHQ-9. The PHQ-9 is a self-report questionnaire that contain 9 items that are based on symptoms the patient experience over the past two weeks (Darwish, Beroncal, Sison, & Swardfager, 2018). The patient will be referred to an experience mental health provider (ADA, 2019). Medication Cost The retail price for sixty tablets of 500 mg metformin is $4.00 and 30 tablets of atorvastatin 20 mg is $15 at Walmart (GoodRx, 2020). A monthly supply of Tylenol 500 mg would cost $6.31 and multivitamins for women cost around $10 for OTC at Walmart (GoodRx, 2020). The total monthly cost for Mrs. G prescriptions would be $35.31 per month. When prescribing Mrs. G’s medications, I consider the benefit, cost, and availability. Generic are cheaper, available and were the drug of choice. Conclusion Mrs. G was assess based on the information she provided and objective information (lab work and vital signs). Mrs. G is diagnosis with T2DM, hyperlipidemia, and obesity. Management and treatment plans were developed from evidence-based practice guideline related to the diagnosis. The cost of Mrs. G’s prescribe medication were evaluated and only generic formulations were prescribed.