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Critical Thinking Skills in Patient Diagnosis and Care

Info: 6130 words (25 pages) Nursing Case Study
Published: 7th May 2020

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Tagged: diabeteshyperlipidemiaobesitydiagnosis

Case Study: Mrs. Wong

The basis of this paper is to enhance critical thinking skills when it comes to diagnosis and plan of care for Mrs. Wong by utilizing the information in the case study to formulate a primary diagnosis, secondary diagnosis, and differential diagnoses based off positive and negative findings in subjective and objective data from the case study. Based on diagnoses, then a plan of care will be done to include further diagnostic testing, medications, referrals, and follow-up care. Providing the patient education regarding diagnosis, exercise, diet, medicines, and warning signs of medication and diagnoses. An assessment of medication prices and the best medications to prescribe based on affordability.


Primary Diagnosis DiabetesMellitus TypeII (E11.9)


 Diabetes mellitus type II is an endocrine disorder that causes increased blood glucose in the body due to decreased insulin excretion and the destruction of insulin receptor sites casing insulin resistance in is a metabolic disorder which causes increased blood sugars in the body because of the lack of proper insulin secretion as well as the destruction of insulin receptor sites causing insulin resistance in specific receptor site tissue (Bigelow and Freeland, 2017).  Typical manifestation include obesity, fatigue, hyperglycemia,increased thirst, increased hungry, an increase in urination, proteinuria, glucosuria, blurry vision, recurrent dermatological infections, balanitis in men especially over 65 years old and candida vulvovaginitis in women (Bigelow and Freeland, 2017).

Pertinent positive findings: (Subjective Findings) Fatigue, increased hunger and thirst (Bigelow and Freeland, 2017).  (Objective Findings) Glucose 1+ in urine, Weight 165 lbs. and BMI 30.7 (obese), Hemoglobin A1C of 6.6%, fasting glucose of 127 (Bigelow and Freeland, 2017).

Pertinent negative findings (Subjective Findings) An increase in weight and appetite from the use of CBD oil (Stinnett & Kuhlmann, 2018).  (Objective Findings) Blood sugar 127 on one day only, proteinuria negative(Bigelow and Freeland, 2017).

Rationale for the diagnosis Mrs. Wong has characteristic symptoms of diabetes type II that include weight gain, increased thirst, fasting glucose at 127, increased hunger, and a HgbA1C at 6.6% (Bigelow and Freeland, 2017). The blood glucose obtained during fasting that is exceeding 126 mg/dL and the lab hemoglobin surpassing the 6.5% marker are considered diagnostic standards for a diagnosis of diabetes type II as noted in statement two of the American Diabetic Association diabetic practice guidelines (ADA 2019).

Secondary Diagnosis Hyperlipidemia (E78.5)


Hyperlipidemia is a disorder in which bad fats are elevated in the blood mainly from dietary intake which causes a narrowing and blocking or arteries which places Mrs. Wong at high risk for a cardiovascular event and stroke (Grundy and Stone, 2019). Common symptoms of hyperlipidemia are xanthomata, bruits, xanthelasma, angina pectoris, and corneal arcus (Grundy and Stone, 2019).

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Pertinent positive findings (Subjective Findings) Mrs. Wong was a former smoker, increased weight gain (Objective Findings) obesity at 165 pounds, total cholesterol reported at 215, LDL elevated at 144, VLDL in high range at 36 and HDL in low range of 32 and Triglycerides of 229 (Grundy and Stone, 2019).

 Pertinent negative findings (Subjective Findings) physically active (Grundy and Stone, 2019).    (Objective findings) Eyes with no drainage, sclera noted white with no corneal arcus, skin warm and dry with no xanthomata or xanthelasma (Grundy and Stone, 2019). No abdominal bruits, No cardiovascular complaints, or neurovascular complaints(Grundy and Stone, 2019).

Rationale for the diagnosis

Hyperlipidemia was selected as a secondary diagnosis based on all the lipid levels indicating hyperlipidemia such as a total cholesterol over 200, an LDL of 144 in a diabetic which signifies the use of statin therapy, VLDL of 36 and Triglycerides of 229 which all lab levels are supported by the 2018 American Heart Association/American College of Cardiology guidelines for hyperlipidemia (Grundy and Stone, 2019).

Secondary Diagnosis Obesity (E66.9)

Pathophysiology                                                                                                                                  Obesity is a medical problem that happens when an excessive amount of fat accumulates in the body, especially subcutaneous and visceral fat, that can lead to adverse health outcomes (Kahan and Manson, 2019).  Signs and symptoms can include increased weight gain, joint pain, and fatigue (Kahan and Manson, 2019).

Pertinent positive findings (Subjective Findings) Right knee discomfort, fatigue, works from home (Sedentary work). (Kahan and Manson, 2019). (Objective Findings) Height 5’1 with a weight of 165 pounds, which places the patient in the obesity category, four-pound weight gain, round belly

 Pertinent negative findings (Subjective Findings) physically active twice a week at the gym, decreased knee pain. (Objective findings) Normal blood pressure of 112/76 (Kahan and Manson, 2019).

Rationale for the diagnosisObesity was selected as a secondary diagnosis due to the patient being overweight for her height of 5’1 weighing 165 (Kahan and Manson, 2019). Mrs. Wong’s body mass index (BMI) was calculated using Mrs. Wong’s weight and height is at 30.1, the 30.1% BMI according to the American Association of Endocrinology medical practice guidelines for obesity puts Mrs. Wong in the classification of obese class one (Garvey et al., 2014).

Differential Diagnosis Metabolic Syndrome (E88.81)


Metabolic syndrome is described as a cluster of interrelated risk factors that are related which can promote the development of atherosclerosis, diabetes mellitus type 2, and hypertension (Grundy et al., 2006).

Pertinent positive findings (Subjective findings) Weight gain (Grundy et al., 2006).  (Objective Findings) Elevated fasting glucose level 127 mg/dL, triglycerides 299, HDL 32 mg/dL (Grundy et al., 2006).

Pertinent negative findings (Objective findings) Normotensive, blood pressure 112/76, waist circumference not obtained (Grundy et al., 2006).

Rationale for the diagnosis The diagnosis of metabolic syndrome was obtained from gathering information relayed to provider by the patient, weight gain, laboratory levels such as fasting glucose level, triglycerides, and HDL (Grundy et al., 2006).  Patient, however, has normotensive blood pressure of 112/76 currently.  To confirm diagnosis waist circumference measure, serum albumin level, and glucose tolerance test should be performed.



Lab test

  1. Waist circumference measurement, today.
  2. Serum albumin level today.
  3. Glucose tolerance test today.
  4. HgbA1C within three months.
  5. A complete metabolic panel in one year.
  6. Lipid Panel in six weeks.
  7. Liver function test to collect in six to twelve weeks.


  1. Waist circumference measurement should be taken to help rule out metabolic syndrome (Grundy et al., 2006).
  2. Serum albumin level should be taken to help rule metabolic syndrome (Grundy et al., 2006).
  3. Glucose tolerance test should be used for the confirmation and also for the diagnosis of diabetes mellitus and metabolic syndrome (ADA, 2019).
  4. Hemoglobin A1C should be done every three months until glycemic control of less than 6.5% is met, then HgbA1C can then be done biannually (ADA, 2019).
  5. The complete metabolic panel will be collected again in one year in order to evaluate electrolytes but more importantly, creatinine and GFR level to ensure it is above 30ml/min (ADA, 2019).
  6. A lipid panel is to be completed within four to twelve weeks after the initiation of lipid lowering medication in order to ensure the prescribed statin is lowering bad lipid levels which is a care guideline from the American Heart Association/American College of Cardiology on hyperlipidemia treatment (Grundy & Stone, 2019).
  7. Liver function panel should be done on patients who are started on Simvastatin because it can affect liver function, which should be checked at four to six weeks then again at twelve weeks then with each medication dosage increase then at least every six months as noted in the American Heart Association/American College of Cardiology on management of cholesterol (Grundy & Stone, 2019).



Rx: Metformin 500 (five hundred) mg tablet

Sig: Take one (1) tablet by mouth twice daily with meals

Disp: #180 (one hundred and eighty)

RF: 3 (three)

(ADA, 2019)

Rationale. Current American Diabetic Association guidelines for any patient with a diagnosis of diabetes type II  with a Hemoglobin A1C less than 9% requires monotherapy with Metformin that is considered the first-line choice for treatment starting at a dose of 500 mg one tab by mouth daily then increasing dosage by 500 mg weekly if more glycemic control is needed (ADA, 2019). Metformin is also a good choice because it can support weight loss in diabetic patients who are overweight or obese (ADA, 2019).


Rx: Simvastatin 20 (twenty) mg tablet

Sig: Take one (1) tablet by mouth at bedtime

Disp: #180 (one hundred and eighty)

RF: 3 (three)

(Grundy & Stone, 2019)

Rationale: The 2018 American Heart Association/American College of Cardiology guidelines states that Asian patients especially those of Japanese descent may be sensitive to statin dosing so starting these patients off on a lower dose then titrating up would be beneficial for combating hyperlipidemia (Grundy & Stone, 2019).

Nonpharmacological Prescription.

Rx: Dispense Glucometer x1 (one)

Lancets – Disp# 100 (1 box)

Alcohol pads– Disp# 100 (1 box)

Glucose Test Strips – Disp# 100 (1 box)

Alcohol pads– Disp# 100 (1 box)

Sig: Check fingerstick glucose once before breakfast and lunch using supplies given.

Disp# as indicated above

RF: 2 (supplies only)

(ADA, 2019)

Rationale: Good glycemic control begins with the patient assuming an active role in monitoring their blood sugars at home which has been shown to improve compliance of diabetes plan of care and improve overall HgbA1c levels (ADA, 2019).



Type 2 diabetes mellitus management can be achieved by Mrs. Wong at home using daily monitoring of blood sugars and keeping an accurate log to share at medical appointments with the primary care physician. Instructing that diabetes type two occurs because a lack of insulin production in the body or the insulin receptor sites fail to pick up insulin, which causes altered blood sugars (ADA, 2019). The importance of teaching Mrs. Wong to eat a well-balanced, healthy diet without heavy starches or refined sugars and avoid drinking which includes her wine which may negatively affect blood sugars and may interact with medications (ADA, 2019). The importance of weight loss plan and setting goals to be met, such as ten pounds in two months (ADA, 2019). Importance of examining feet every day and reporting any nonhealing wounds immediately, which can be caused by neuropathy (ADA, 2019). Mrs. Wong should keep here regular follow-ups and have a physical exam and labs done regularly to prevent complications of diabetes like heart disease, strokes, eye problems, skin problems and neurological problems (ADA, 2019). Reviewing with Mrs. Wong the signs of hyperglycemia such as dry skin, polydipsia, polyuria, polyphagia, blurred vision and fatigue with the need to report these symptoms and blood sugar readings higher than 200 mg/dl to the provider (ADA, 2019). Instructing patient always to have a diabetic snack or quick glucose gel near in case hypoglycemia occurs, which transpires with a blood sugar that is usually less than 70 mg/dl (ADA, 2019). Risk factors for diabetes type two include family history, obesity, hypertension, hyperlipidemia, macrosomic infant delivery, and gestational diabetes (Hollier, 2018).

Hyperlipidemia is caused because of a high-fat diet or heredity, which creates an abnormal amount of unhealthy fat to stay in the body (Jellinger et al., 2017). Hyperlipidemia can be reduced through a low saturated fat diet with more intake of fiber, vegetables, fruits, and grains (Jellinger Et al., 2017). Educating Mrs. Wong that exercise is another essential factor which can help with weight loss and increase healthy fats in the body (Jellinger et al., 2017). Instructing Mrs. Wong on contributing risk factors like alcohol usage, physical inactivity, obesity, diabetes family history of hyperlipidemia and diets high in fat can all lead to hyperlipidemia (Hollier, 2018).

Obesity is considered for any person who has body mass index exceeding 30% which causes increased body fat and leads to systemic disease such as diabetes, stroke, myocardial infarction, cholelithiasis, decreased mobility and thromboembolism (Hollier, 2018). Mrs. Wong must be instructed that she is considered obese because of her BMI of 30.1 (Hollier, 2019). Obesity can be reduced through proper diet that does not contain a lot of saturated fat, well balanced, and exercise (Hollier, 2019).  Obesity can be the cause of fatigue, especially after exercising or even make exercising difficulty (Hollier, 2019).

Metabolic syndrome is considered for patients who are obese, with an increased waist circumference, a diagnosis of diabetes mellitus, as well as a sedentary lifestyle (Grundy et al., 2006).  Atherosclerosis, hypertension and an elevated blood glycose level are risk factors for metabolic syndrome.  Patients with these manifestations have an increase in inflammatory markers (Grundy et al., 2006).


Metformin should be taken one tablet with breakfast and dinner (Hollier, 2018).  Weight loss may occur with the use of Metformin and may also improve lipid levels (Hollier, 2018). Metformin must be held if Mrs. Wong is going to have any radiological procedures that use iodinated contrast to prevent kidney damage (Hollier, 2018).  Metformin may cause flatulence and diarrhea, which are the most commonly reported side effects and that symptoms should resolve within two weeks.  Mrs. Wong should be taught to refrain from heavy drinking because alcohol in large amounts can reduce the effectiveness of Metformin (Hollier, 2018). Mrs. Wong should inform the provider if a severe illness with vomiting or diarrhea occurs before taking Metformin to avoid hypoglycemia (Hollier, 2018).

Simvastatin should be taken at night before bedtime and is used for the treatment of hyperlipidemia and doses range from 5-40 mg (Grundy & Stone, 2019).  Based on the patient being Asian, patient was started on a lower dose of the moderate-intensity statin (Grundy & Stone, 2019).  Mrs. Wong should be aware that she should report an elevated heart rate, dysrhythmias, muscle pain, weakness or tenderness to physician immediately as Simvastatin could cause adverse side effects such as rhabdomyolysis and myopathy (Uribe, 2018). Symptoms of rhabdomyolysis include tea colored urine, muscle pain, nausea, vomiting, weight loss, severe abdominal pain, abnormal color of feces, or jaundice (Uribe, 2018). Mrs. Wong should limit her consumption of grapefruit juice to a glass or less per day due to interaction with Simvastatin (Uribe, 2018).


Mrs. Wong needs to adhere to a 1600 calorie, diabetic and cardiac diet which should also be well balanced and can aide in weight loss (ADA, 2019). A reasonable goal weight loss plan for Mrs. Wong would be to lose one to two pounds a week (ADA, 2019). The patient should avoid foods that are refined carbohydrates. processed sugars and stick to carbs that come from fruits, vegetables, legumes, and milk (ADA, 2019). Mrs. Wong will be taught about carbohydrate counting and try to remain below 150 grams of carbs a day or less to help maintain reasonable glycemic control (ADA, 2019). Mrs. Wong should avoid foods that are high in sodium, greasy, fried or fatty foods as they can increase her lipid levels (ADA, 2019).


Mrs. Wong should increase physical activity to 150 minutes per week of moderate intensity workouts (water aerobics, ballroom dancing, or walking on a treadmill) or 75 minutes per week of vigorous intensity workouts (swimming laps, race walking, or aerobic dancing) (Grundy & Stone, 2019).

 Mrs. Wong will be instructed on the importance of moderate exercise with walking, aquatic activities such as swimming, water aerobics, tai chi, resistance exercises like resistance bands or bike riding which have all been shown to decrease joint pain, improve joint strength and joint flexibility due to her right knee arthritis (Kennedy-Malone, Plank & Duffy, 2019).  A personal exercise plan for Mrs. Wong would be to attempt five days of thirty-minute moderate-intensity aerobic activity on five days each week and avoid high-intensity workouts due to a history of arthritis in the right knee (Kennedy-Malone, Plank & Duffy, 2019).

Warning Signs for diagnoses and medications

Patients with diabetes mellitus type II will need to be aware of signs and symptoms of hyperglycemia that include dry skin, polydipsia, polyuria, polyphagia, blurred vision and fatigue which could indicate poorly controlled sugars and these symptoms need to be communicated to the provider immediately (ADA, 2019). Mrs. Wong must also be aware of the signs and symptoms of hypoglycemia such as diaphoresis, cool skin, confusion, headache, dizziness, and fatigue which could mean a low blood sugar level (ADA, 2019). Education on keeping some candy near or oral glucose to give to herself should her blood sugar drop to less than 70 mg/dl (ADA, 2019).  Should a hypoglycemic episode occur, then Mrs. Wong should give herself a carbohydrate with protein like a piece of cracker with peanut butter to maintain blood sugar and avoid another bout of hypoglycemia (ADA, 2019). Fruity breath, confusion, wounds that won’t heal, dark colored urine, foul-smelling urine and abdominal pain with severe vomiting may be indicative of an emergency, and one must report to the local emergency room or call 9-11 (ADA, 2019).

Metformin use can lead to hepatotoxicity, lactic acidosis and anemia that can cause symptoms that include easy bruising, yellowish color to skin, yellowish color to sclera, confusion, reduced urine output, dark urine output, bleeding that won’t stop or trouble breathing all require immediate trip to the local emergency department for evaluation ((Hollier, 2018).

Regarding hyperlipidemia, or elevated triglyceride levels, Mrs. Wong should monitor for any serious complications such as a stroke, transient ischemic attack, or myocardial infarction (Hollier, 2018).  Mrs. Wong will be educated on the importance of calling 9-11 if she has any trouble speaking, one-sided weakness, especially in arms and facial paralysis (Hollier, 2018).  Mrs. Wong so also be instructed to call 9-11 if she has chest pain, shortness of breath, increased anxiety, fear of impending doom. Increased nausea, vomiting, jaw, or neck pain (Hollier, 2018).

Simvastatin should only be taken once daily before bedtime.  Patients should monitor for signs and symptoms of muscle wasting or rhabdomyolysis.  Mrs. Wong will need to report muscle pains, tea colored or discolored urine, tachycardia, dysrhythmias, nausea, vomiting, as well as pale stools, severe abdominal pain and jaundice to provider immediately as this could be life threatening, she will need to go to nearest emergency department (Uribe, 2018).

Obesity can lead to health problems like heart issues such as hypertension or myocardial infarction, diabetes, stroke, endometrial cancer, esophageal cancer, gastroesophageal reflux and sleep apnea (Hollier, 2018). Mrs. Wong should be aware of all these possible complications and report any symptoms to her provider such as extreme fatigue, shortness of breath, chest pain, snoring, voice changes, trouble swallowing, blurred vision, polydipsia, polyuria, polyphagia and headaches (Hollier, 2018).

Metabolic syndrome can lead to cardiovascular events. Patients diagnosed with diabetes mellitus are more likely to experience cardiovascular events or metabolic syndrome (Grundy et al., 2006).  Asian patients have an increased risk for metabolic syndrome and insulin resistance (Grundy & Stone, 2019).  Metabolic syndrome, which is a cluster of issues, such as hypertension, diabetes, and hyperlipidemia can cause an increase in embolic events due to elevated inflammatory markers (Grundy et al., 2006).


Specialty practice or service 

A referral to a diabetic educator is indicated for Mrs. Wong because using a diabetic educator is beneficial in overcoming knowledge barrier deficits by getting diabetic education that will allow Mrs. Wong to maintain reasonable glycemic control at home (ADA, 2019).  A referral to a registered dietician was necessary for Mrs. Wong because it allows for an increase in knowledge regarding foods that are best for diabetics and meal plans that may even be able to incorporate personal cultural food preferences (ADA, 2019).  A referral to an ophthalmologist must be done as soon as possible to rule out any diabetic retinopathy and then eye exams with dilation of the eyes must be done annually on all diabetic patients or more frequently if complications are identified (ADA, 2019).

Follow up

Mrs. Wong needs to follow up in one week to ensure that she is adhering to plan of care (ADA, 2019).  Mrs. Wong will be asked to bring in her blood sugar logs to review to see if the plan of care is being effective at maintaining good glycemic control. The one-week follow up can assess to see if Mrs. Wong needs further education or community referrals for things such as medication assistance, home health and social worker (Kennedy-Malone et al, 2019).  Mrs. Wong will return in four weeks to have her lipid panel and liver function panel levels drawn again (ADA, 2019).  

Medication Cost

When prescribing medications, one must always consider the price because sometimes the cost of medicines may be too high for patients to afford, and this can cause noncompliance. The lowest medication prices noted was from HEB pharmacy, Walmart and from Amazon.

The patient is taking Tylenol 500 mg two tablets by mouth every morning over the counter. The patient also takes daily multivitamins.  HEB grocery store, which also has pharmacy with $4 prescriptions sells the HEB brand extra strength acetaminophen for $4.12 for 200 tablets.  They also sell the HEB brand Women’s 50 plus once daily multivitamin/multimineral for $4.07 for 80 tablets. Even though she is having pain to her right knee I would let the patient decide if she would like to continue taking her CBD oil.  It is considered illegal here in Texas so that would be at her discretion.  Pricing is not available at this time due to that reason. The total cost of the glucometer testing kit including the meter, the lancer, 100 test strips and 100 lancets would be $32.99 (Amazon, 2019).  The cheapest box of alcohol wipes would be at Walmart for $1.95 for 200 alcohol wipes (Walmart, 2019).   Additional lancets would be $10.99 for 300 count and test strips would cost $10.99 for 300 count test strips for an additional $10.99 (Amazon, 2019).  At HEB, her prescription Metformin 500 mg and Simvastatin 20 mg tablets are both $10 for a 180-day supply of medications.  In total, for the first month medications should be about $63.07, prior to insurance verification.  In future practice, pricing of drugs will be taken into consideration for all patients to ensure the patient can afford the medication and ensure medication plan compliance. Preprinted four-dollar plans will be incorporated in current practicum sites and in future practice to attempt to utilize these drugs on this list when medication effectiveness is not compromised. Medication cost comparing sites will be used in practice to locate the cheapest price of medications for patients.


The importance of utilizing pertinent subjective and objective findings from an assessment cannot be overstated. Using relevant findings allowed for the following diagnoses of diabetes type II, obesity, and hyperlipidemia and metabolic syndrome to be formulated. A proper treatment plan was formulated to treat these conditions based on findings in the case study.  Metformin, Simvastatin, Multivitamins, and glucometer with supplies were ordered for the patient to help manage diabetes and hyperlipidemia. The pertinent lab was ordered according to national guidelines to help support or rule out specific diagnoses.  Patient-based teaching was done regarding diagnoses, medications, exercise plan, warning signs of diagnoses, and medications.  Proper referrals were given to diabetic educator, registered dietician, and ophthalmologist based on diagnoses. Appropriate follow-up in one week was given to assess if the treatment plan is enough or if changes need to be made.  Medications for the patient were chosen based on pricing with lower-priced medication prescribed to ensure Mrs. Wong can afford her medications, which increases patient compliance with the medicines.

Clinical Chart Soap Note

Patient Information:

M.W., 59, F, Asian,


Chief Complaint: follow up for knee pain, increased fatigue, and weight gain for 2 months.


Mrs. Wong, a 59-year-old Asian female presents to clinic for 3 months follow up for newly diagnosed right knee arthritis. Patient now reports lessened knee pain, increasing mobility. Patient now reports increasing fatigue and weight gain for 2 months.  Patient reports being physically active by walking a treadmill for at least 30 minutes twice weekly and lifts weights as directed. Patient reports a 4-pound weight gain. Patient also reports increasing hunger and thirst.  Patient would like weight loss advice.

Current Medications:

Tylenol 1000 mg daily in AM for knee pain.

Multivitamins 1 tablet daily.

Turmeric daily.

CBD oil daily for knee pain.

Allergies: Bactrim, cats, and pollen. No latex allergy.


Right knee arthritis diagnosed 3 months ago. German measles as a child. No previous fractures.

All vaccines up to date

PSHX: Colonoscopy 4 years ago, repeat in 10 years.

Health screening:

Last mammogram 1 year ago WNL, colonoscopy WNL, 4 years ago, repeat in 10 years, no history of DEXA, LMP 4 years ago, pap last year WNL.

Soc Hx:

Divorced, has one daughter, works from home as an administrative assistant, former smoker, quit 12 years ago, drinks 1-2 glasses of wine one to two times weekly, no illicit drugs, walks on treadmill for 30 minutes twice weekly and lifts light weights.

Fam Hx:

Parents are deceased, child alive, well. No siblings.


General: denies headache, vision changes, night sweats, fever, reports weight gain.

CV: No chest pain, palpitations

Respiratory: No SOB, no cough

Musculoskeletal: Reports pain with standing, walking, squatting, no back pain,

Neuro: No numbness, tingling, or weakness noted in extremities.


Physical Exam:

BP: 112/76; HR 80; RR 16; Hgt: 5’1.5″; Wgt: 165 lbs; BMI: 30.7

General: No acute distress. Alert, oriented and cooperative.

HEENT: Head normocephalic without evidence of masses or trauma. PERRLA: EOMs intact, non-injected, wears contacts.  Ear canal without redness irritation, TMs clear, pearly, +light reflex, bony landmarks visible, no discharge, no pain noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist and pink, without erythema. Teeth in good repair, no cavities noted. Neck supple.  Anterior and posterior cervical lymph nodes without lymphadenopathy, nontender to palpation. No JVD distention. Thyroid midline, small and firm without palpable masses.

Skin: intact. No lesions or bruising noted.

CV: S1/S2, RRR, no murmurs or rubs.

Lungs: CTA bilaterally, respirations even, nonlabored.

Abdomen: Soft, round, non-tender, non-distended, BS present x 4, no organomegaly, no bruits. No CVA tenderness.

GU: bladder nontender upon palpation. No CVA tenderness noted.

Musculoskeletal: full ROM to bilateral knees. Nontender to palpation bilaterally. Gait normal.

Diagnostic or Lab results: WBC 6.3, Hgb 12.8, Hct 42%, RBC 4.6, MCV 93, MCHC 34, RDW 13.8, Na 136, K 4.4, Cl 100, CO2 29, Glucose 127, BUN 12, Creatinine 0.5, GFR 99, Ca 9.4, Total Protein 7.6, Total Bilirubin 0.5, Alkaline Phosphate 72, AST 25, ALT 29, Anion gap 8.10, BUN/Create 17.7, HgbA1C 6.6%, TSH 2.31, T4 0.9, TC 215, LDL 144, VLDL36, HDL 32, Triglycerides 229, UA: pH 5, Specific Gravity 1.010, Leukocytes negative, Nitrites negative, Glucose 1+, Protein negative, Ketones negative.



Primary Diagnosis: Diabetes Mellitus, Type 2 (E11.9):

Secondary Diagnosis: Hyperlipidemia (E78.5)           

Differential Diagnoses:

Obesity (E66.9)

Metabolic Syndrome (E88.81)



Waist circumference

Serum albumin

Glucose tolerance test


  • Metformin 500 (five hundred) mg tablet (treatment for Diabetes Mellitus)

Sig: Take 1 (one) tablet by mouth twice daily with meals

Disp: 180 (one hundred and twenty)

RF: 3

  • Simvastatin 20 (twenty) mg tablet (treatment for Hyperlipidemia)

Sig: Take 1 (one) tablet by mouth daily at bedtime

Disp: 180 (once hundred and twenty)



Discussed diagnosis of diabetes mellitus type II with patient and will screen for metabolic syndrome with measurement of waist circumference, serum albumin level, and glucose tolerance test.

Reviewed medications.

Recommend increasing physical activity to 150 minutes per week of moderate intensity workouts (water aerobics, ballroom dancing, or walking on a treadmill) or 75 minutes per week of vigorous intensity workouts (swimming laps, race walking, or aerobic dancing)

Discussed patient eating a heart healthy diet which also improves glucose control such as minimizing the intake of carbohydrates, trans fats, processed meats, or sweetened beverages.

Discussed glucose control. Monitor glucose once in the morning and again before lunch. Keep a glucose diary.

Monitor daily weight.

Pap smear scheduled; yearly mammogram scheduled

Referrals: certified diabetes educator, ophthalmologist, and registered dietitian.

Follow up: return to office in 1 week to review laboratory study results and review daily glucose monitoring diary.


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Once a patient has been diagnosed, a plan of care should be actioned to include further diagnostic testing, medications, referrals, and follow-up care. Patient education should also be provided regarding diagnosis, exercise, diet, medicines, and warning signs of medication and diagnoses.

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