Primary Care Case Study

The case study is about Mrs. R who is a 56-year-old Hispanic female who reported to the clinic with a chief complaint of extreme fatigue and a gradual weight gain since her menopause last year. Her symptoms began three months ago; she exercises twice a week by walking on the treadmill for 30 minutes in an attempt to lose weight but has been unsuccessful.

The purpose of this paper is to examine the analysis of the provided information of subjective and objective findings collected to diagnose and create a management plan that includes the application of the national diabetes guidelines into her management plan. The paper will also discuss the assessment, primary, secondary and differential diagnoses as well as the diagnostics; medications, OTC medications, education, referrals, and follow-up care for Mrs. R.

Assessment

According to the information, Mrs. R reports her concerns of symptoms, which include extreme fatigue, increase in thirst, hunger, urination and the inability to lose weight regardless of her attempts to exercise. Her BMI is 29.7 which shows that she is obese, her urine analysis showed glucose and + protein, fasting glucose is 126 mg/dL, and her HbA1C is 6.9%, meaning she is diabetic. Mrs. R’s lipid panel results showed elevated cholesterol, which places her at risk for a stroke and cardiovascular disease (American Diabetes Association, 2018).

Primary Diagnosis

 Type 2 Diabetes Mellitus (E11) this is also known as adult-onset diabetes and is indicated by hyperglycemia, insulin deficiency, insulin resistance that can lead to the development of vascular and neurologic complications. T2DM is caused by hyperglycemia due to decreased function of the beta cells in the pancreas to produce insulin, which controls blood sugar. Symptoms that should prompt consideration of diabetes include obesity, elevated glucose reading, fatigue, frequency, polydipsia, polyphagia, tingling of hands and lower extremities, and polyuria and A1C of greater than 6.5 (ADA, 2017). According to the ADA, T2DM can lead to cardiac and vascular disease, renal failure, blindness and amputation of the limbs.

    Rationale: The primary diagnosis of T2DM is chosen because of Mrs. R’s pertinent (+) symptoms of (polydipsia) extreme thirst (polyphagia), extreme hunger, (polyuria) frequent urination during the daytime, obesity, her age, her and lab results, which includes HBA1C is 6.9%, fasting plasma glucose 126, and elevated cholesterol levels all suggest T2DM. She goes to the gym twice a week and walks on the treadmill to lose weight, but she has not been successful, which were all part of her chief complaint. According to ADA 2017, other factors such as certain racial/ethnic subgroups such as those with Hispanic/Latino background can increase the risk of developing T2DM.

Secondary Diagnosis

    Hyperlipidemia (E78.5) or (dyslipidemia). This disorder is classified as elevated or increase in blood cholesterol level, which includes anomalies in LDL receptors and mutations in the Apolipoprotein that lead to an increased production of cholesterol in the bloodstream (ADA, 2017). A high concentration of lipid builds up in the arteries and becomes plaques and can potentially block blood flow thereby increasing the risk of atherosclerosis. The common signs and symptoms of hyperlipidemia are found through blood tests such as elevated triglycerides TGs lesser than 50mg/dL, elevated total cholesterol lesser than 200, high-density lipoprotein (HDL) greater than 60 mg/dL and low-density lipoprotein (LDL) lesser than 100mg.dL (ADA, 2017). 

    Rationale: The second diagnosis for Mrs. R is chosen because of the lab results from her lipid profile, which reveals some pertinent (+) or  low HDL of 38mg/dL, elevated triglycerides 232mg/dL, elevated LDL 144mg/dL, elevated cholesterol 230 mg/dL, VLDL 36mg/dL, her age, ethnicity, gender, weight gain after menopause last year, extreme fatigue, low energy, increased hunger and thirst, her obesity with a BMI of 29.7kg /m2 and T2DM over the past three months. Mrs. R does not present with HTN or CAD carotid bruit, corneal arcus, or xanthomas, described as yellowish skin deposits of cholesterol, and usually found on the eyelids. According to Dumpy et al., 205, HTN and CAD are associated with hyperlipidemia; therefore, Mrs. R has a high risk of cardiovascular disease and will often have metabolic syndrome factors such as hypertension, which could develop later in the disease process (ADA, 2017).

Differential Diagnosis

    Obesity (E66.8): Obesity occurs when there is a variation between food intake, absorption, and energy used. Meaning that when the consumption of calories far exceeds the metabolic needs of the body, and the prevalence of obesity among black and Hispanic females is much greater when compared to Caucasian females in the United States. The most common presenting symptoms for obesity are shortness of breath, decreased energy, fatigue, weakness, joint pain, depression, and increased daytime sleepiness, and a BMI greater than 30-35 kg/m2 which is classified as obese (ACC/AHA, 2017).

Rationale: Obesity was chosen for the differential diagnosis due to Mrs. R’s pertinent positive BMI of 29.7kg/m2, weight is 185lbs, which is a (+) sign of obesity. She struggles with reducing her weight while working out at the gym for the past three months with no success. She is fatigued, has decreased energy and weakness, she has gained three pounds despite her effort to lose weight due to the fact that exercising makes her hungrier causing her to eat more. A BMI of 25-29kg/m2 is recognized as overweight and a BMI greater than 30kg/m2 is classed as obese (ACC/AHA, 2017).

Plan

Diagnostics:

Repeat HgbA1c/fasting glucose: According to the ADA 2017, it is recommended for the second test of HbA1C for the confirmation of T2DM unless there is random plasma glucose greater than 200mg/dL such as hyperglycemic crisis. The repeated test must be done without delay using a new blood sample to confirm the diagnosis of DM2. After confirming the diagnosis of her T2DM, the management plan will include pharmacological and non-pharmacological medication will be prescribed to help her control her blood glucose and decrease her HgA1c level.

Urine Albumin Creatinine Ration- this test will be used to screen for diabetic peripheral nephropathy. UACR is also used to detect irregular levels of protein in the urine and is often done annually for the monitoring and diagnosing of kidney damage. This test will contribute to the management plan if kidney disease is detected from the test since Mrs. R’s UA showed +1 glucose and small protein in her urinalysis (ADA, 2017).

Rationale: The UACR is the most reliable screening test that can detect kidney disease in patients with DM. it should be performed yearly to diagnose and monitor kidney disease and damage in patients with type II DM for five years or more (ADA, 2017).

Medication

Rx: Metformin 500mg (Epocrates, 2016)

Sig: take one tablet twice-daily PO with food

Disp: #30 (thirty)

Refill: 0

Rationale: metformin is recommended as the first initial pharmacological treatment of T2DM in older adults, as it is likely to reduce death and can lead to weight loss and improves resistance. This medication is the generic brand and is more cost effective for the patient (ADA, 2017).

Rs: Atorvastatin 20mg (Epocrates, 2016)

Sig: take one tablet at night po

Disp: 30 (thirty)

Refill: 0

Rationale: this medication is used for the treatment of hyperlipidemia and used in coordination with weight loss, diet, and exercise to reduce the chances of a heart attack and stroke. It is used to decrease the level of LDL, and triglycerides in the blood that may be built upon the walls of the arteries and block blood flow throughout the body. This medication is the generic brand and is more cost effective for the patient (ADA, 2017).

OTC: Tylenol 500mg

Sig: 2 tabs daily po with food

Disp: 60 tabs (sixty)

Refill: 0

Rationale: Tylenol is often used to relieve mild to moderate pain, as well as pain from osteoarthritis (Epocrates, 2016).

OTC: Multivitamin

Sig: 1 tab daily po

Disp: 90 tabs

Refill: 0

Rationale: this contains a mix of vitamins that are essential to help the body function properly in individuals who are unable to eat a well-balanced diet or those who are on a special diet. Multivitamins may be used for increasing vitamin B12, as the absorption of vitamin B12 is reduced while patients are on metformin (ADA, 2017).

Rx: Lancet

Sig: 1 box 100 count

Dips: 100 lancets

Refill: 5

Rx: Glucometer

Disp: 1 meter

Rx: blood glucose test strips

Sig: 1 box 100 count

Dispense: 100 strips

Refill: 5

Rx: Alcohol pads

Sig: 1 box

Dispense: 100 count (Epocrates, 2016).

Rationale: the use of the glucose-monitoring device along with the lancets and strips alcohol pads increases the frequency of self-blood glucose monitoring and improves glycemic control in patients with diabetes (Martz, Stewart, Davies, Hellmund, Polonsky, and Kerr, 2017).

Education

    Education for Diabetes (E11)

•    As Mrs. R is Hispanic it is important to find out if she is able to understand and communicate in English, as well as any cultural belief she may have (Smith-Miller, Berry, Dewalt, and Miller, 2016). Use a Cyracom video interpretation and translation solutions that are exclusively endorsed by American Hospital Association for Mrs. R’s better understanding of diabetes and all her disease process teaching that she needs (Smith-Miller, Berry, Dewalt, and Miller, 2016).

•    Educate Mrs. R on how increasing her physical activity can help reduce her weight, decrease her total cholesterol, reduce her blood triglycerides, and lower her elevated blood sugar. She should be assisted in developing a specific workout that would match her lifestyle needs such as aerobic fitness and muscle strengthening and also to find out what her level of fitness is (Asif, 2014). Lifestyle changes will help Mrs. R to lose weight and achieve target A1C, prevent the risk of cardiovascular disease and provide benefits in terms of renal protection that may lead to organ damage (Asif, 2014). Reducing her weight by 5% will shown improvement in glycemic control and lower the need for medication (ADA, 2017).

•    Teach Mrs. R how to check blood sugar, and inform her to check blood sugar daily before taking medication and to write it down in a journal. She needs to bring the journal for the follow-up appointment in four weeks (ADA, 2017).

•    Before checking her blood sugar she should wash her hands, prepare the lancet, prepare the glucose meter and test strip, clean the site, lance finger, wipe away first drop of blood, and place blood on the test strip for glucose result (ADA, 2017).

•    Educate Mrs. R that when she gets sick or ill, the blood sugar can be more elevated while the body is fighting off virus or infection.

•    Educate Mrs. R to take metformin as prescribed as it is the medication that will control her blood sugar. The common side effects of metformin include nausea, vomiting, and abdominal bloating (ADA, 2017).

•    Teach Mrs. R to inspect both of her feet daily for cuts, scrapes, wounds, bruises, or any changes in the skin or coloring of the feet. Instruct her against soaking her feet, she should avoid hot water, avoid putting lotion between her toes, not to walk barefoot and to be cautious when clipping her nails (ADA, 2017).

•    Mrs. R will be provided with printed information on the management of diabetes symptoms (ADA, 2017).

Education for Hyperlipidemia (E78.5)

•    Educate Mrs. R to take Atorvastatin daily for her hyperlipidemia; the common side effect for atorvastatin is constipation, nausea, diarrhea, headache, and mild muscle pain. Teach Mrs. R on immediately reporting symptoms of dark urine, weakness or muscle pain, alcohol use and consumption of grapefruit should also be avoided or limited (ADA, 2017).

•    Educate Mrs. R on decreasing her sodium intake to less than 2-8mm Hg a day

• Recommend the DASH diet, which will be individualized for Mrs. R’s specific caloric needs. The Dash Diet will focus on educating Mrs. R on decreasing her intake of fat, less than 30% of total calories and less than 7% should be from saturated fat including minimizing the use of trans-fatty acids; increase her intake of fiber, vegetables, fruits and other whole grains (ADA, 2017).

Education for Obesity (E66.8)

•    Educate Mrs. R on decreasing her sodium intake to less than 2-8mm Hg a day, recommend the DASH diet, which will be individualized for Mrs. R’s specific caloric needs. Develop an eating plan with a diet rich in fruits, vegetables, low fat or non-fat dairy, whole grains, lean meats, fish and poultry, nuts and beans, high fiber, low to moderate fat (ADA, 2017).

•    Mrs. R will be educated on decreasing her intake of fat to less than 30% of total calories less than 7% should be from saturated fat (ADA, 2017).

•    Mrs. R should minimize the use of trans-fatty acids; increase her intake of fiber, vegetable, fruits, and other whole grains. She should be educated on eating foods high in mono-saturated fats, which can improve glucose control and blood lipids (ADA, 2017).

Continue OTC Tylenol and Multivitamin for her arthritis: Educate Mrs. R on taking Tylenol with a full glass of water and she should not drink alcohol while taking this medication. Make Mrs. R aware of the side effects of Tylenol such as constipation, nausea vomiting, agitation, headache, and atelectasis, she should also be made aware to not take this medication on an empty stomach. Advise Mrs. R that it is unsafe to take more than 400mg of Tylenol in a 24hr period (ADA, 2017).

Referral

Dietician/Certified Diabetic Educator: Asses Mrs. R’s current eating pattern and how much she knows about diabetes, go over information for her immediate needs such as what foods containing carbohydrates have the most effect on her blood glucose. Set goals for Mrs. R by helping her work out objectives that are right for her needs and health care concerns. This promotes and supports healthful eating patterns and highlights nutrition dense meals in proper portion sizes to help Mrs. R obtain and maintain body weight goals, slow down or stop complications of diabetes and achieve glycemic blood pressure and lipid goals.

Rationale: Diabetic educators work in cooperation with patients to provide counseling after diagnosis to address diabetes topics in depth. When patients are able to receive help from diabetic educators they are able to achieve better outcomes (ADA, 2017).

Ophthalmologist: The ophthalmologist provides early detection of eye damage to the vessels of the retina or the back of the eye before the eyes are harmed.

Rationale: Diabetes can increase the risk of glaucoma and therefore the ophthalmologist can use a special camera to take photos of the retina without dilating the eyes to detect early glaucoma. This is an annual eye exam performed when a patient has been diagnosed with diabetes. If there is no evidence of damage to the eyes then the exam is conducted every two years (ADA, 2017).

Podiatry: This occurs on an outpatient basis and is successful in healing a high percentage and preventing amputations, which in turns decreases the number of hospitalizations while cutting costs for the patient.

Rationale: This is an annual foot exam done to identify risk factors may predict ulcers and amputations. It plays an important role in the early detection and diagnosing of diabetes because the early symptoms often appear in the feet and limbs (ADA, 2017).

Follow- up

1.    Mrs. R should return to the clinic if the same symptoms continue with medication including fatigue, increased thirst, increased urination, and increased hunger. She should return if her symptoms worsen or she has a reaction to the medication.

2.    Mrs. R should return to the clinic in four weeks for medication management for T2DM and recheck lipids and BUN/creatinine.

3.    She should return in 3 months for diabetic follow up to recheck her HgA1C, CBC with diff, CMP, lipid panel, TSH, and T4 (ACC/AHA, 2017).

Rationale: The follow up will help her as she may have less access to preventative health services and fewer options, which will help make changes in adopting healthful eating and increase her activity patterns to prevent Mrs. R’s health consequences through control of high cholesterol and type 2 diabetes (ADA, 2017).

Medication Cost

(Walmart.com).

The total cost for a month’s worth of prescription and OTC medications for Mrs. R is $30.29. The goal was to find the most affordable location for Mrs. R to purchase her medication. Prescriptions were not adjustable because Wal-Mart offered the medications she needs at an already discounted price, which would control costs and improve patient compliance. In addition, Wal-Mart stores are all over the country and it does not matter where Mrs. R travels to, she can always get her medicine. In the future when prescribing medication I will use the GoodRx website as it compares prices of medications from multiple pharmacies and provides coupons for additional discounts on medication especially with the monitory supplies such as lancets, blood glucose strip, and the glucometer. From my clinical experience, I have noticed that affordable medication increases patient compliance with their medications. ADA 2017, guidelines recommend to start newly diagnosed patients with a low dose of medication and re-evaluate them before increasing the dosage, therefore Mrs. R’s medication will be started on the lowest dose initially as she has been newly diagnosed diabetes patient (ADA, 2017).

SOAP Note

Patient Information: Mrs. R, 56-year-old Hispanic female

S:

Chief Complaint: severe fatigue, polyuria, polydipsia, polyphagia, and weight gain despite exercise

HPI:

Patient presented to the clinic for a follow up visit and reports of being very fatigued and has no energy at all. The onset of her symptoms was 3 months ago and she reported that she gained weight despite her exercise attempts.  She walks o the treadmill for 30 minutes twice per week.

Current Medications:  Tylenol 500mg, po, 2 tabs in am for knee pain, daily multivitamin

Allergies: NKDA, No latex allergy, she is allergic to cats and pollen.

Primary Medical History:

She has arthritis in her left knee and previous case of mumps as a child. All her vaccines are up to date.

Health screening: no history of abnormal Pap smear

Social History:

Recently separated and works from home part-time as a wedding coordinator, non-smoker, she occasionally has 1-2 glasses of wine on the weekends and no illicit drug use.

Family History:

Parents and child are alive and well. She has no siblings. Mother has HTN and father has high cholesterol.

ROS

General: she denies having headaches, vision changes, night sweats and fever. She reported difficulty-losing weight despite exercising

Respiratory: No SOB, no cough

Musculoskeletal: arthritis on the left knee

O

Physical Exam:

BP: 118/80. HR 76; R 16; Height: 5’2. 5; Weight: 165lbs; BMI: 29.7 (3lb weight gain in 3 months)

General: No acute distress

HEENT: Head normocephalic. Hair thick and evenly distributed throughout the scalp. Eyes are without exudate, sclera is white. Wears contact. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph non-tender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.

Skin: warm, dry and intact. No lesions noted

CV: S₁/S₂, RRR, no murmurs, no rubs

Lungs: Clear to auscultation bilaterally, respirations unlabored

Abdomen: soft, round, non-tender, BS present x4, organomegaly. No abdominal bruits. No CVAT.

Musculoskeletal: left knee arthritis

Diagnostic results:

CBC: WBC (6,00/mm³), Hgb (12.5 gm/dl), Hct (41%), RBC (4.6 million), MCV (89fl), MCHC (34g/dl), RDW (13.8%).

Cholesterol: TC (230mg/dl), LDL (144mg/dl); VLD (36mg/dl); HDL (38mg/dl); Triglycerides (232).

CMP: Sodium (139), Potassium (4.3), Chloride (100), CO₂ (29), Glucose (126), BUN (12), Creatinine (0.7), GFR est non-AA (99 ml/min/1.73), Calcium (9.7), Total protein (7.6) Bilirubin total (0.6), Alkaline phosphatase (72), AST (25), ALT (29), Anion gap (8.10), BUN/Creat (17.7), Hemoglobin A1C (6.9%), TSH (2.35), Free T (40.9ng/dL)

UA: pH (5), SpGr (1.012), leukocyte esterase (-), nitrites (-), +1 glucose, small protein, ketones (-)

EKG: normal sinus rhythm

A

Primary diagnosis: Diabetes Mellitus type II (E11)

Secondary Diagnosis: Hyperlipidemia (E78.5)

Differential Diagnosis: Obesity (E66.8)

P

Diagnostics:

Repeat HgbA1c/fasting blood glucose

Urine Albumin Creatinine Ratio

 Medications:

Rx: Metformin 500mg

Sig: take one tablet twice daily by mouth with food

Dispense: #60 (sixty)

Refill: 0

Rx: Atorvastatin 10mg

Sig: take one tablet at night by mouth

Dispense: #30 (thirty)

Refill: 0

OTC: Tylenol 500mg

Sig: 2 tabs daily by mouth with food

Dispense: 60 tabs (sixty)

Refill: 0

OTC: Multivitamin

Sig: 1 tab daily by mouth

Dispense: 90 tabs (ninety)

Refill:0

Rx: Alcohol pads

 Sig: 1 box

 Dispense: 100 count

Rx: Lancet

Sig: 1 box

Dispense: 100 lancets

Rx: Glucometer

Dispense: 1 meter

Rx: blood glucose test strips

Sig: 1 box

Dispense: 100 strips

Refill: 5

Education:

Discussed T2Dm diagnosis as it can lead to major complications organ damage

Discussed diagnostic repeat labs to confirm and manage diagnosis of T2DM

Discussed hyperlipidemia diagnosis as it may lead to blockage of major arteries

Discussed possible complication of diagnosis if not managed appropriately

Reviewed medications and to take them as prescribed

Recommend modification of diet and lifestyle changes

Encourage weight loss through diet and exercise to improve glycemic index

Recommend blood glucose monitoring twice daily

Discussed referrals to specialist to help manage DM2

Discussed when to seek for medical emergency

Referrals: Dietician/Certified Diabetic Educator, Podiatrist, and Ophthalmologist.

Follow up: Patient is to return to the office in 2 weeks to review her lab results, blood glucose log and effectiveness of medication. Patient is to return to the office sooner or seek medical emergency care if symptoms persist or if an adverse reaction to medication occurs. Patient should call 911 if experiencing chest pain or shortness of breath.

References

• American College of Cardiology. (2017). Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. A report of the American college of cardiology/American heart association  task force on clinical practice guidelines. Journal of American College of Cardiology, 71. 127-248. Retrieved from: http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/41/2017-guideline-for-high-blood-pressure-in-adults
• American Diabetes Association. (2017). Obesity management for the treatment of type 2 diabetes. Diabetes Care, 40(1), 57-63. doi: https://doi.org/10.2337/dc17-S010
• American Diabetes Association. (2017) Older adults. Diabetes Care, 40(1). 99-104. doi:https://doi.org/10.2337/dc17-S014
• American Diabetes Association. (2017). Pharmacologic approach to glycemic treatment. Diabetes Care, 40(1). 64-74. Doi:https:doi.org/10.2337/dc17-S011
• American Diabetes Association. (2017). Standard of medical care in diabetes. Diabetes Care, 39(1). 1-106. Retrieved from:http://www.ndei.org/ADA-diabetes-management-guidelines-lifestyle-changes-medical-nutrition-therapy-physical-activity.aspx.html
• Asif, M. (2014). The prevention and control the type-2 diabetes by changing lifestyle and dietary pattern. Journal of Education and Health Promotion, 3(1). doi: 10.4103/2277-9531.127541
• Epocrates. (2016). Atorvastatin. Retrieved from:  https://online.epocrates.com/drugs/3697/Fortamet
• Epocrates. (2016). Metformin. Retrieved from: https://online.epocrates.com/drugs/3697/Fortamet
• $4 Prescriptions. (n.d). Retrieved from: https://www.walmart.com/cp/4.prescription/1078664
• Smith-Miller, C., A. Berry, D., C., DeWalt, D., &Miller, C., T. (2016) Type 2 diabetes self-management among spanish speaking hispanic immigrants. Journal of Immigration and Minority Health, 18(6). 1392-1402. doi: 10.1007/s10903-015-0271-4