Diabetes Type II Lecture Notes

Diabetes Type II Mr. Rodgers, DOB 1/1/1952, age 70, is a Hispanic male, accompanied by his daughter. Mr. Rodgers seems to be a good historian. Subjective CC: "I had blood work done two weeks ago and I am here to review the results." HPI Mr. Rodgers is a 70-year-old Hispanic male with PMH of Hypertriglyceridemia, anxiety, and hypertension presenting to the clinic with his daughter to review routine blood tests that were completed two weeks ago. Patient reports feeling well and has no chief complaints at this time. He reports no medication refills are needed at today’s visit. Past Medical History: ● Medical: ○ Hypertriglyceridemia ○ Hypertension (HTN) ○ Anxiety ● Surgeries: ○ Left total knee replacement (2000) ● Hospitalizations: ○ none ● Preventative care: ○ Moderna Covid Vaccine: 5/1/2020, 6/1/2020, 12/1/2020 ○ Eye exam: 5/1/2022 - Normal ○ Colonoscopy: 2/1/2022 – Normal ○ Prostate Exam: 3/1/2019 – Mildly enlarged prostate Allergies: No known drug allergies Medications: Losartan 25 mg PO daily for HTN Gemfibrozil 600mg PO BID before breakfast and dinner for Hypertriglyceridemia Propranolol 10 mg PO PRN every 4 hours for anxiety Multivitamin PO daily Tylenol 650 mg PO PRN 4-6 hours for pain Social History: Reports drinking 1 beer every evening. Reports smoking ½ pack of cigarettes daily Denies recreational drug use Reports 1 cup of coffee every morning Employment: Retired mechanic. Family History: Father passed away at the age of 89 from pneumonia. Mother is living. Reports DM, HTN, and HLD. ROS Constitutional: Denies fevers, fatigue, lightheadedness, and feeling unwell. Neurological: Denies numbness and tingling in upper and lower extremities. HEENT: Denies blurred vision, vision loss, headaches, rhinorrhea, and sore throat. Cardiovascular: Denies lower extremity edema, palpitations, and chest pain. Pulmonary: Denies coughing, shortness of breath, and wheezing. Genitourinary: Denies painful urination. Reports polyuria and polydipsia. Gastrointestinal: Denies nausea, vomiting, constipation, and diarrhea. Musculoskeletal: Denies muscle and joint aches. Denies feet pain. Denies loss of range of motion. Endocrine: Denies cold and heat intolerance. Objective Vital Signs HR 94 BP 123/69 RR 16 Height 58 inches (147.32 cm) Temp 97.9 F SpO2 93% room air Pain 0/10 Weight 220 lbs. (99.79 kg) BMI 33.5 (Obese – Class I) Physical Exam General survey: Appears tired, and in pain. Well groomed. Neurological: Alert and oriented X 4. Follows commands and responds appropriately. Patient denies numbness and tingling in bilateral upper and lower extremities. HEENT: Cardiovascular: Radial and dorsalis pedis pulses 2+ bilaterally. No gallops, murmurs, or rubs heard. S1and S2 are present. No leg swelling noted. Pulmonary: Respiration rate within normal limits. Clear lung sounds in all lung fields. No Shortness of breath noted. Genitourinary: Deferred Gastrointestinal: Normoactive bowel sounds in all four quadrants. Moderate umbilical hernia. Musculoskeletal: Normal ROM. Denies pain and tenderness to joints. Sensation to light touch intact on BLE. Labs, radiology, and other pertinent studies 1. CBC a. Normal 2. CMP a. Glucose 172 3. HbgA1c a. 7.9 4. Lipid panel a. LDL 80 b. Triglycerides 602 5. TSH a. Normal Assessment Differentials 1. Type II Diabetes Mellitus without complications [ICD-10: E11.9] a. This patient has many risk factors for diabetes mellitus type II including obesity, race, age, hypertriglyceridemia, and a sedentary lifestyle (Malkani & Ayyoub, 2021). Furthermore, his symptoms of polyuria and polydipsia, along with his elevated hemoglobin A1C of 7.9, indicate that the correct diagnosis for this patient is diabetes mellitus type II (Malkani & Ayyoub, 2021). 2. Drug induced diabetes [ICD-10: E09.65] a. Beta blockers such as propranolol, which this patient is taking, is known to have a moderate effect of decreasing insulin sensitivity (Laffel & Svoren, 2022). However, because this patient is on a low dose of propranolol as needed, it is unlikely that this medication is the cause of this patient’s high hemoglobin A1C result. 3. Diabetic hyperosmolar hyperglycemic state (HSS) [ICD-10: E13] a. While this patient has symptoms of polyuria and polydipsia, which is present in patients with diabetic hyperosmolar hyperglycemic states, this diagnosis is unlikely due to lack of dehydration, hypotension, tachycardia, and decreased mentation which are normal findings in HSS (Hirsch & Emmett, 2022). Furthermore, patients with HSS generally have a plasma blood glucose greater than 250 mg/dL, and this patient’s glucose was only 172 (Hirsch & Emmett, 2022). Plan Diagnosis 1. Type II Diabetes Mellitus without complications a. Diagnostics: i. HbgA1C 1. 7.9 b. Medications and supplies: i. Metformin 500mg PO daily in the evening ii. Continue Gemfibrozil 600mg PO BID before breakfast and dinner for hypertriglyceridemia iii. Continue Losartan 25 mg PO daily for HTN iv. Order glucometer v. Order test strips vi. Order lancets c. Patient education i. Dietary 1. The patient should be educated on decreasing carbohydrate consumption and limiting alcohol consumption. Because this patient is Hispanic, cultural preferences to food should be taken into account when educating the patient on foods that he should eat. ii. Lifestyle modifications 1. Lifestyle modifications need to be discussed including losing weight and adding an exercise regime. Weight loss and exercise will help with lowering the hgbA1C. Furthermore, weight loss and exercise will help lower this patient’s blood pressure and lipid levels. iii. Glucose monitoring 1. The patient needs to be taught how to check his blood glucose with a glucometer. He should also be taught to keep a glucose log to bring to his next appointment to assess how the medications and lifestyle modifications are affecting his glucose readings. iv. Hyperglycemia and Hypoglycemia symptoms 1. Symptoms of high and low blood glucose levels should be taught including symptoms that would warrant a trip to the emergency room such as extreme sweating, confusion, drowsiness, clammy skin, or extreme hunger or thirst. If his glucose levels are low at home without emergency symptoms, the patient should be taught how to manage his symptoms by consuming some form of sugar. v. Diabetic complications 1. The patient should be educated on diabetic complications that could arise if his blood glucose remains to stay high, such as peripheral neuropathy, vision changes, gastroparesis, erectile dysfunction, kidney disease, and non-healing wounds (Malkani & Ayyoub, 2021). He should understand the symptoms of these complications so he knows what symptoms to report to a physician. Furthermore, he should be taught how to check his feet everyday for injuries to prevent diabetic ulcers on his feet from forming. vi. Follow up 1. The patient should have a follow visit in three months to have his hgbA1C re-evaluated or sooner if he is having complications (Malkani & Ayyoub, 2021).