Patient Management Plan: Diabetes Mellitus

 Diabetes mellitus (DM) is a leading cause of morbidity and mortality in the United States. Over 86 million Americans have prediabetes and 90% are undiagnosed or unaware of the condition and its effects on their health (Watson, 2017). The purpose of this paper is to outline a comprehensive management plan supported by evidence-based guideline for the management of type 2 DM. In this paper information provided, was utilized to establish, support or eliminate a diagnosis. Additionally, diagnostic test, management approach and pharmacological cost associated with managing this condition were identified and discussed. Early intervention can prevent and or delay complications associated with DM, therefore, it is imperative that a management plan be inclusive.

Assessment

Primary Diagnosis

Type 2 DM without complications (E11.9) is the primary diagnosis.Type 2 DM affects

men more frequently than women, and is more prevalent among Asian Americans,

 African Americans, Native Americans, Pacific Islanders and Hispanics (Kennedy-

Malone, Fletcher & Marin-Plank, 2014).

Pathophysiology: Type 2 DM is a condition where there are impaired insulin secretion and insulin resistance (Dunphy, Windland-Brown, Porter & Thomas, 2015). Classical signs and symptoms of DM are weight gain or loss, polyphagia, polydipsia, polyuria, ketonuria, proteinuria and glycosuria (Kennedy-Malone et al., 2014).

Pertinent positive findings: weight gain, fatigue, polydipsia, polyuria, polyphagia and glycosuria. Risk factors for type 2 DM are age (over 45), family history, elevated lipid levels, gestational DM, women delivering large for gestational age infant (>9lbs), obesity, impaired glucose tolerance (Kennedy-Malone et al., 2014).

Pertinent negative findings:no family history of type 2 DM, no history of gestational DM, no acanthosis nigricans, no ketones or protein in the urine (Kennedy-Malone et al., 2014).

Rationale for the diagnosis: The patient has type 2 DM because she is Asian and has a BMI> 23kg/m² in addition to several pertinent positives which include fatigue, weight gain, polydipsia, polyuria and polyphagia. Fasting plasma glucose (FPG) was 130 g/dl, A1C 6.8% and glucose was in the patient’s urine. An A1C>6.4% and FPG >125 is adequate to diagnose DM (ADA, 2018). 

Secondary Diagnosis:

Hyperlipidemia (87.5).This is a secondary diagnosis because the patients total cholesterol, low-density protein, elevated triglycerides and low high-density lipoprotein. 

Pathophysiology Hyperlipidemia is a condition where circulating lipids in the blood are abnormal (Hollier, 2018).There is no symptom of hyperlipidemia, however, physical examination may reveal xanthoma, arterial bruit, xanthelasma and evidence of claudication (Kennedy-Malone et al., 2014).

Pertinent positive findings: obesity, sedentary life, menopausal women, diabetes mellitus, excessive alcohol intake (Hollier, 2018; Kennedy-Malone et al., 2014)

 Pertinent negative findings: hypothyroidism, hepatic or renal disorder and family history of hyperlipidemia (Hollier, 2018).

Rationale for the diagnosisI chose this diagnosis because she is postmenopausal, obese, has a sedentary job and drinks 1-2 glass of wine.  Her laboratory results showed elevated cholesterol, low-density protein, elevated triglycerides and low high-density lipoprotein (Hollier, 2018; Last, Ference & Menzel, 2017).

Differential Diagnosis  

Cushing’s syndrome (E24.9) a condition that is three times more common in women than men (Hollier, 2018).It is caused by excessive secretion of adrenocorticotropic hormone (ACTH) from the adrenal or pituitary gland (Dains, Baumann & Scheibel, 2016).

Rationale for the diagnosis:This diagnosis is been considered because the patient has

signs and symptoms suggestive of Cushing’s syndrome. These include obesity, fatigue glycosuria, polyuria and polydipsia (Hollier, 2018). Additional testing would be required to rule out the condition. For a diagnosis to be made and of the following two of three tests should be done (Dunphy et al., 2015). These tests are 24 hours urine free cortisol excretion, late night salivary cortisol levels and one milligram overnight dextrose suppression test 

Plan

Diagnostics

Lab test Complete blood count (CBC), White blood cell count (WBC), Comprehensive

 metabolic panel (CMP), Hemagobin (Hb) A1C, Thyroid stimulating hormone (TSH),

 Lipid panel, clinical urine test (UA) and electrocardiogram (EKG).

Rationale: CBC is done to identify if the patient fatigue is related to anemia (Hollier, 2018). CMP was done to evaluate FPG and assess renal and liver (Hollier, 2018). WBC is done to rule out an infection or possible malignancy (Hollier, 2018).Hb A1C was done to identify if the patient had DM (ADA, 2 018). TSH was done to asses for hypothyroidism which can present as fatigue and weight gain (Hollier, 2018) Lipid panel was done to detect if there was elevated circulating lipids (Late et al., 2017). An EKG was done to evaluate if the patient was having an abnormal heart beat (Kennedy-Malone et al., 2014).

A primary diagnosis of Type 2 DM was diagnosed based on an elevated A1C and FPG (ADA, 2018). The secondary diagnosis of hyperlipidemia was from the abnormal lipids (ADA, 2018).

Medications      

Diagnosis: Type 2 DM

1)     Metformin 500mg tablets.

Sig: Take one (1) tab PO once daily.

Disp: #30 tabs,

Refills: three (3).

Metformin is the drug of choice for type 2 DM (ADA, 2018).

Diagnosis: Unilateral primary osteoarthritis, right knee

2)     Acetaminophen extra strength 500mg tablets.

Sig: Take two (2) tablets in AM

Disp: #60

Refills: three (3).

Acetaminophen is an analgesic effect for pain relief (Micromedex, 2017)

Diagnosis: Hyperlipidemia

3)     Atorvastatin 10 mg PO tablets

Sig: Take one (1) tablet at bedtime.

Disp: #30

Refills: three (3).

Moderate intensity statin to decrease elevated circulating lipids (ADA, 2018).

Supplement:

4)     One a day Women 50+  PO tabs

Sig: Take one (1) tablet daily.

Refills: none. Medication OTC

It is recommended that women over 50 years old take supplements to prevent fractures (Kennedy-Malone et al., 2014) and boost their immune system.

Blood glucose test machine and supplies

 One Touch Glucometer

 Test blood glucose 1 times per day (before breakfast).

 Dis: one (1).

 No refils.

 To monitor blood glucose daily and when necessary.

Education  

Diagnoses and Medications

If you experience any of the mentioned side effects discussed below, call or return to the clinic. If you start experience a rash, blood in your urine, muscle pain life threating symptoms discontinue the medication and go to your nearest emergency room

1)     Type 2 DM: is a condition where there in insulin resistance or impaired secretion. You have been prescribed Metformin, take one tablet daily with food (Hollier, 2018). Metformin is recommended as the first-line treatment for blood glucose control (ADA, 2018). It also prevents cardiovascular disease in patients with diabetes (Kianoush & Mirbolouk, 2017). Metformin causes weight loss and lower lipids (ADA, 2018;Hollier, 2018). The side effects are flatulence and diarrhea however they usually resolve after two weeks of therapy (Hollier, 2018). If you experience anorexia, nausea, abdominal pain, and increased thirst these are signs of lactic acidosis which is serious adverse effect of Metformin (Hollier, 2018) which require urgent medical attention.

2)     Hyperlipidemia: Hyperlipidemia is elevate circulating lipoproteins in the blood. You have been prescribed Atorvastatin, take one tablet daily at bedtime. Atorvastatin is a moderate to a high-intensity statin that is the drug of choice and it will lower your cholesterol 30% to 50% (ADA, 2018) reducing your risk of a stroke. This medication should not be taken with grapefruit juice. Rhabdomyolysis and myopathy are major adverse effects of statins (Last et al., 2017). Stop taking the medication if you have muscle cramps, fever, dark urine and yellowing of the skin or eyes and seek medical attention.

3)     Continue taking taking extra strength acetaminophen for arthritis and vitamin supplements as directed.

Diet

Type 2 DM: Individualized diet therapy has been effective in reducing weight, achieving better glycemic control and cardiovascular outcomes (Kianoush & Mirbolouk, 2017). When a patient has DM and or hyperlipidemia dietary restrictions is necessary however the restrictions vary for each patient. Women require 1,200 to 1,500 kcal/day (ADA, 2018) this should be taken into consideration when selecting a diet plan. It is recommended to restrict high-carbohydrate and or high-fat foods (ADA, 2018).

Hyperlipidemia: A diet high in monosaturated fat (olive oil), vegetables, whole fruits, berries, nuts and enriched whole grains promote weight loss and maintain a healthy weight (Watson, 2017). The patient’s personal goals, preferences and culture is to be considered when developing a meal plan. Decrease of eliminate alcohol intake

Exercise

Physical activity and exercise, when included with lifestyle modifications, are effective to

 decrease the risk of cardiovascular disease which are complications of type 2 DM. This

 activity should be at least 30 minutes per day for 5 days a week of moderate-intensity of brisk walking (ADA, 2018; Baill & Castiglioni, 2017). I recommended that you go to the gym three times per week and incorporate aquatic exercises to help reduce arthritic pain,  lose weight (Quintrec et al., 2014) and improve quality of life. I recommend that you increase daily physical activity while you are working..

Warning Signs for diagnoses and mediations.

 I would recommend that you discontinue taking Turmeric. This medication decrease Hb A1C level and blood glucose by decreasing hepatic glucose production and glycogen synthesis and stimulation of glucose uptake (Ghorbani, Hekmatdoost & Mirmiran, 2014). This drug can cause bleeding and there is insufficient strong evidence to support it use in DM management. Furthermore to prevent polypharmacy and adverse drug reaction it would be best to limit her medications to three at this time and revaluate at her follow-up appointment.

The patient should be educated on the signs and symptoms of hepatic and renal failure. Lactic acidosis, rhabdomyolysis and myopathy which are adverse effects that can occur when taking these medications (Hollier, 2018). She is thought about the signs and symptoms of hypoglycemia/hyperglycemia and how to perform blood glucose checks

Referral

1)     Diabetes self-management support (DSMES) to help the patient achieve best outcomes such as improve self-management, glucose control and satisfaction with goals (ADA, 2018).

2)     Podiatrist for lower extremity evaluation (ADA, 2018). 

3)     Additionally, the patient needs to be educated and encouraged to visit the dentist every six months and an ophthalmologist annually (ADA, 2018). A dentist will perform periodontal examination and the ophthalmologist will assess the eyes for complications of DM.

Follow up

 My follow-up appointment for Mrs. Wu is February 26, 2019, at 0800 AM to return to the office to see me for her next appointment. This will allow for assessment and re-evaluation of her medication regime. Follow-up visit should be every 3-6 months (ADA, 2018). Her A1C needs to be checked to determine her glycemic target and this should be done every 3 months (ADA, 2018) however her renal and liver function needs to be evaluated because of Metformin and Atorvastatin cause impairment in these systems. Metformin should be discontinued if the glomerular filtration rate is less than 30 (ADA, 2018). Also, a lipid profile should be evaluated 4-12 weeks after initiating therapy (ADA, 2018; Last et al., 2017). I will order a repeat CMP laboratory within 30 days of initiating treatment to assess the patient’s liver and renal function and call the patient with the results.

Medication Costs:

Metformin 500mg tablets X 30 days: $2.50 X 30 tabs at Kroger with free coupon (GoodRx, 2018a). Tylenol extra strength 500mg 2 tabs X 30days (OTC): $2.80 X 60 tabs at Kroger with free coupon (GoodRx, 2018b).  Atorvastatin 10 mg PO X 30 days: $7.90 X 30 tabs at HEB/$10.88 at Kroger (GoodRx, 2018c). OneTouch Glucometer and 100 strips: $ 132.62 at Walmart with a discount (GoodRx, 2018d). One A Day Women 1 tab PO X100tabs (OTC) $10.99 (Kroger, 2018). Her first month expense will be $179.38 because this includes the glucose machine and supplies and medication. This will decrease in subsequent months to $37.76 if she purchase her medications at Kroger.

Glucometer and 100 blood glucose supplies should last more than a month. The prices listed were the lowest cost found for these medications on GoodRx website within this zip code. If the patient has insurance then they may benefit from more savings. I believe it would be time-consuming for the patient to travel to different pharmacies so I would recommend she evaluate the total cost if she was to purchase all items at one pharmacy location.

Conclusion

 Type 2 diabetes mellitus is a major healthcare problem which causes disability and increased mortality. Early identification and treatment can prevent and or delay disease progression. The public should be educated on the risk factors and strategies they can employ to prevent type 2 DM. Resources are available such as the American Diabetes Association Standards of medical care (ADA, 2018) to help healthcare providers to identify, diagnose and manage type 2 DM effectively. In the primary care setting a family nurse practitioner (FNP) will interact with a patient who is pre-diabetic or has diabetes mellitus. As for cost-effective and efficient providers FNPs must consider the total patient when providing healthcare services. This case study assignment was very educational and I am certain I will apply information learnt to my clinical practice in the future. I now understand how providers decide on managing type 2 DM.

Clinical Chart SOAP note.

Patient Information:

Ms. W. 59 yrs. female Asian.

Subjective:

CC: unintentional weight gain.

HPI: Mrs. W 59 old Asian reports unintentional weight gain since menopause 4 years ago. She reports exercising two times per week, 30minutes on treadmill and lifts light weights. Reports gaining 4lbs recently despite adhering to exercise schedule.

Current medications: Tylenol 500mg 2 tabs in AM for knee pain.

Daily Multivitamin and Turmeric (supplements).

Allergies: Bactrim, cats and pollen.

PMHx: Right knee arthritis (diagnosed 3mths ago). German measles and a child. Vaccination current. LMP 4 years ago. PSHx: None.

Health screening: Colonoscopy WNL (done 4yrs ago). Mammogram benign (last year). LMP 4years ago, ASCUS pap 1998, subsequent PAPs WNL.

Soc Hx: Divorced. Administer assistant (works from home). Former smoker (quit 10yrs ago).Drinks 1-2 glasses wine daily. Denies illicit drug use.

Fam Hx: Parents deceased. No siblings. 1 child (daughter) alive & well.

ROS: General: reports increased fatigue for 12 weeks, As per HPI.

Musculoskeletal: reports less right knee arthritis pain and increased mobility.

Endocrine: reports increased hunger, thirst and frequency for the past 3 months.

Psychiatry: report been irritated by these symptoms.

Objective:

Vital signs: BP 112/76; HR 80, regular; RR 16, regular. Hgt 5’1.5”, Wt: 165lbs.

General: female in no acute distress. Alert, oriented and cooperative.

Skin: warm dry and intact. No lesions noted.

HEENT: Head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender.  Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Nontender cervical and anterior lymph node.  No lymphadenopathy. Thyroid midline, small and firm without palpable masses.

CV: S1 and S2 RRR without murmurs or rubs.

Lungs: Clear to auscultation bilaterally, respirations unlabored. 

Abdomen- soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.

Musculoskeletal: Full ROM both knees. Nontender to palpation bilaterally. Gait normal.

GU: bladder nontender upon palpation

Labwork: (fasting labs drawn this morning)

CBC: WBC 6,300/mm3  Hgb  12.8 gm/dl  Hct 42%  RBC 4.6 million MCV 93 fl  MCHC 34 g/dl  RDW  13.8%

UA: pH 5, SpGr 1.010, Leukocyte esterase negative, nitrites negative, 1+ glucose; negative protein; negative ketones

CMP: Sodium 136, Potassium 4.4, Chloride 100, CO2 29, Glucose 130, BUN 12, Creatinine 0.7

GFR est non-AA  99 mL/min/1.73, GFR est AA 101 mL/min/1.73, Calcium 9.4,Total protein 7.6

Bilirubin, total 0.5, Alkaline phosphatase 72, AST 25, ALT 29, Anion gap 8.10, Bun/Creat 17.7

Hemoglobin A1C: 6.8 %

TSH: 2.31, Free T 4 0.9 ng/dL

Cholesterol: TC 215 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 32mg/dl, Triglycerides 229

EKG: normal sinus rhythm

Assessment:

Primary Diagnosis:  Type II Diabetes Mellitus without complications (E11.9).

Differential Diagnosis: Cushing’s syndrome (E24.9).

Secondary Diagnosis: Hyperlipidemia (E78.5).

Plan:

Diagnostics:

EKG, CBC, CMP, A1C, Lipid Panel, TSH & UA.

Medications:

 Metformin 500 mg tablets take 1 tablet daily, #30 tabs, 3 refill. For diabetes.

Tylenol 500 mg 2 tablets in AM, # 60 tabs (OTC). No refill needed. For arthritis

Atorvastatin 10mg tablets, take 1 tab PO at bedtime, #30, 3 refills. For cholesterol.

One A Day Women’s 50+, take 1 tab PO daily # 100 tabs (OTC). No refill needed. Vitamin supplement

Education:

Diagnosis: discussed diet, exercise, signs and symptoms of hyper and hyperglycemia. Discuss Metformin, Tylenol and Atorvastatin mechanism of action and side effects. Patients concerns addressed and handouts given as discussed. Educated on health promotion and maintenance. 

Referrals: Diabetes educator and podiatrist.

Follow-up: Repeat CMP in 1 mth and schedule office visit February 26, 2019.

References

• American Diabetes Association [ADA]. (2018). Standards of medical care in diabetes – 2018. Diabetes care, 41(1), S1-S159. Retrieved from https://diabetesed.net/…/12/2018-ADA-Standards-of-Care.pdf
• Baill, C., & Castiglioni, A. (2017). Health maintenance in postmenopausal women. Am Fam Physician, 95(9), 561-570. Retrieved from https://www.aafp.org/afp/2017/0501/p561.html
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• GoodRx. (2018d).OneTouch medical supply. Retrieved from https://www.goodrx.com/onetouch
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• Kianoush, S., & Mirbolouk, M. (2017). The new 2017 American diabetes statement on standards of medical care in diabetes: Reducing cardiovascular risk in patients with diabetes. American College of Cardiology. Retrieved from https://www.acc.org/latest-in-cardiology/articles/2017/05/22/11/00/new-2017-american-diabetes-statement-on-standards-of-medical-care-in-diabetes
• Kroger. (2018). One-A-Day Women’s 50+ healthy advantage multivitamin supplement. Retrieved from https://ship.kroger.com/p/016500565314/one-a-day-womens-50-healthy
• Ghorbani, Z., Hekmatdoost, A., & Mirmiran, P. (2014). Anti-hyperglycemic and insulin sensitizer effects of turmeric and its principle constituent curcumin. International journal of endocrinology and metabolism, 12(4), e18081. doi:10.5812/ijem.18081
• Last, A., Ference, J., Menzel, E. (2017). Hyperlipidemia: Drugs for cardiovascular risk reduction in adults. Am Fam Physician, 95(2), 78-87. Retrieved from https://www.aafp.org/afp/2017/0115/p78.html
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