Diabetes Management Plan: Diagnosis and Development Case Study

The purpose of this paper is to analyze the provided subjective and objective information to diagnose and develop a management plan for the patient in the case study. The paper intends to apply national diabetes guidelines to the management plan. The mastery of SOAP note writing will also be demonstrated.

Assessment

Primary Diagnosis

Type 2 diabetes mellitus (E11.9)

Pathophysiology

Type 2 diabetes is an endocrine and metabolic disorder that arises due to acquired resistance to insulin action or loss of function of pancreatic beta cells that produce insulin, which is responsible for the metabolism of glucose. Inadequate regulation of blood sugar levels causes hyperglycemia that often leads to the manifestation of the classical symptoms of diabetes mellitus, including include polyphagia, polyuria, and polydipsia (Qureshi et al., 2017).

Pertinent positive findings

The patient reports that she has experienced increased fatigue for the last 12 weeks. She has also gained weight disproportionately despite her efforts to exercise. She also experiences extreme thirst and hunger after exercise, which complicates her weight loss process. The patient also reports that she urinates frequently at night as well as during the day. Therefore, the patient presents with the classical symptoms of diabetes mellitus: polyphagia, polyuria, and polydipsia, which confirms this diagnosis (Acuna, Labinson, & McDermott, 2017).

Additionally, the laboratory tests are indicative of type 2 diabetes. For example, the urinalysis shows glycosuria, whereas the blood glucose level is elevated at 130mg/dl, which is a symptom of hyperglycemia. Hemoglobin A1C level is 6.8 %, which is a symptom of type 2 diabetes (Chatterjee, Khunti, & Davies, 2017). Normal levels of glycated hemoglobin should be 5.7% and below, whereas hemoglobin A1C between 5.7% and 6.4% show prediabetes (American Diabetes Association [ADA], 2018).

Pertinent negative findings

Urine tests are the most reliable way of detecting ketones and microalbumin. The urinalysis did not indicate the presence of ketones or protein, which are usually present in severe hyperglycemia (Fayfman, Pasquel, & Umpierrez, 2017).

Rationale for the diagnosis

ADA (2018) recommends that type 2 diabetes should be diagnosed based on the three classical symptoms of diabetes with additional backing from laboratory tests. The diagnosis was made based on the presenting symptoms (polydipsia, polyphagia, and polyuria), high fasting blood glucose levels, the presence of glucose in urine, fatigue, and unexplained weight gain despite exercise. BMI of 31.17 is an indication of obesity, which is a known risk factor for type 2 diabetes mellitus. These findings confirmed the diagnosis of type 2 diabetes.

Secondary Diagnosis

Hyperlipidemia (E78.5)

Pathophysiology

Hyperlipidemia refers to the presence of high levels of lipids in the blood, which arises from the consumption of food items that are rich in fats thereby increasing the amount of lipids that are circulating in the blood (Navar-Boggan et al., 2015). Hyperlipidemia does not have any distinctive symptoms and can only be diagnosed by conducting a lipid panel.

Pertinent positive findings

Total cholesterol of 215 mg/dl (less than 200 ng/dl is desirable), LDL of 144 mg/dl (less than 100 mg/dl is optimal); VLDL 36 mg/dl (normal range is 2 to 30 mg/dl); HDL 32mg/dl (levels of 40 mg/dl is desirable), and triglycerides 229 (200 mg/dl and above is considered high) (ADA, 2018).

Pertinent negative findings

The patient had normal blood pressure values despite having elevated lipid levels. Cholesterol could accumulate in the inner walls of the blood vessels thus elevating blood pressure in the affected individuals (Rafieian-Kopaei, Setorki, Doudi, Baradaran, & Nasri, 2014). However, in the case study, the patient had normal blood pressure values. In addition, hyperlipidemia could occur due to the consumption of a high-fat diet and hypothyroidism. However, the thyroid function test as indicated by the TSH and free T4 values were within the normal range. TSH was 2.31 (normal range is 0.35 to 5), whereas the free T4 was 0.9 ng/dl (normal range 0.7 to 1.9 ng/dl).

Rationale for the diagnosis

The lipid profile showed elevated levels of cholesterol, LDL, VLDL, triglycerides, and low levels of HDL, which are the main indicators in hyperlipidemia diagnosis (Rafieian-Kopaei et al., 2014).

Differential Diagnosis

Metabolic syndrome (E88.81)

• Pathophysiology. Metabolic syndrome is an array of risk factors attributed to insulin resistance. The typical symptoms include abdominal obesity, elevated fasting blood glucose, high triglyceride levels, high blood pressure, and low levels of LDL (Furukawa et al., 2017).
• Rationale for the diagnosis. The patient presents with all these symptoms except high blood pressure, which is why this disorder is considered a differential diagnosis (Furukawa et al., 2017).

Adjustment disorder with depressed mood (F43.21)

• Pathophysiology. Depression is a psychological disorder that is attributed to numerous causes and interaction of factors that interfere with the balance of essential neurotransmitters such as dopamine, serotonin, and norepinephrine or significant changes in the life of an individual (O’Donnell et al., 2016). The indications of depression may include fatigue, changes in appetite, mood changes, feelings of disappointment and frustration, and disturbed sleep.
• Rationale. This diagnosis was chosen because Mrs. Wu experiences fatigue and weight gain despite her efforts to lose weight, which could contribute to depression. Her attempts to exercise are frustrated by her hunger and thirst pangs, particularly after exercising. She is also unhappy about the fact that she has to use the bathroom more than usual, which at times interrupts her sleep. This diagnosis may not be adequate to account for the observed signs and symptoms. However, it should be considered when treating the patient (O’Donnell et al., 2016).

Pertinent positive findings

Mrs. Wu is frustrated about her weight gain and the need to pass urine frequently, which affects her sleep. She was recently diagnosed with knee arthritis and has had to deal with pain and difficulties walking, which can be considered a significant life change (O’Donnell et al., 2016).

Pertinent negative findings

Mrs. Wu does not have a significant hormonal change. She underwent menopause 4 years ago and has currently adjusted to the hormonal modifications associated with menopause, which rules out the likelihood of hormonal involvement in depression (Albert, 2015).

Treatment Plan

Diagnostics

Spot urinary albumin-to-creatinine ratio

Rationale: For additional assessment of renal function. The test should be conducted every year together with eGFR. Diabetes mellitus, which is associated with high blood glucose levels, damages kidneys over time and causes diabetic nephropathy (ADA, 2018). Therefore, a thorough assessment of renal function should be done regularly in patients diagnosed with diabetes mellitus.

HgbA1C test

Rationale: Hemoglobin A1C test is used to measure the average blood glucose levels over 3 months to determine the effectiveness of glycemic control. The findings help clinicians to decide whether there is a need for adjustments in the patient’s treatment (ADA, 2018). This test should be conducted every three months until normal levels are attained.

Annual fasting CMP

Rationale: This test assesses fasting blood glucose and electrolyte levels. Assessment of liver functioning should be done yearly because Metformin is contraindicated in instances of decreased liver function (ADA, 2018).

Foot exam

Rationale: To evaluate foot health because diabetic foot ulcers are among the most common complications in diabetic patients. Persistently elevated blood glucose levels often lead to vascular and nervous problems, which in turn lead to peripheral neuropathy and foot ulcers (Armstrong, Boulton, & Bus, 2017). A thorough foot exam is required for the patient and should include a detailed skin inspection: checking for foot defects, neurological assessment using a 10-g monofilament and a temperature or pinprick exam. The monofilament test should be conducted yearly.

Additionally, a vascular evaluation of the feet should be done. Mrs. Wu should have a brief foot inspection at every subsequent to facilitate the prompt diagnosis of peripheral neuropathy and avoid the need for amputations in the future (ADA, 2018).

Lipid profile

Rationale: Repeat lipid profile tests should be done t least three months following the commencement of statin therapy to monitor the efficacy of the treatment. The lipid profile would also ascertain that Mrs. Wu is receiving the correct dosage of atorvastatin dosage and prompt necessary adjustments as the need arises (ADA, 2018).

Becks Depression Inventory

Rationale: Depression and diabetes mellitus are two commonly co-occurring disorders in primary care. Healthcare providers in primary settings are mainly responsible for the diagnosis and management of these two disorders. Consequently, affected patients do not get the opportunity to receive specialized care. The occurrence of depression in diabetes has a negative effect on glycemic control and is linked to the development of diabetic complications (Semenkovich, Brown, Svrakic, & Lustman, 2015).

Nonetheless, it is often untreated, which could be attributed to the fact that most symptoms of depression such as changes in appetite, excess weight loss or gain, fatigue are often associated with diabetes. Therefore, it is not easy to confirm whether these symptoms are due to diabetes or depression. Diabetes patients should undergo screening for depression to enable the commencement of well-timed intermediations.

Health maintenance

Advancing age is a risk factor for many diseases in women, including type 2 diabetes mellitus, breast cancer, and colorectal cancer. The United States Preventive Service Task Force [USPSTF] (2016) recommends that women between the ages of 50 and 74 years undergo annual mammograms. Since Mrs. Wu’s last annual mammogram was normal, she should be reminded to schedule her next appointment. ADA (2018) recommends that diabetic patients should be vaccinated against influenza, Hepatitis B, and pneumococcal diseases. The patient’s immunizations are up-to-date. However, she should be reminded to honor her upcoming vaccinations.

Medications

Type 2 diabetes mellitus

Metformin 500 mg tablets (Extended-release)

Sig: Take 1 (one) tablet twice every day with food. Disp: #30. RF: 2

Diabetic Lancets

Sig: Test blood glucose BID, more frequently as needed. Disp: 200 (2 boxes). RF: 4

Glucometer

Sig: Test blood glucose BID, more frequently as needed. Disp: 1 kit. RF: 1

Glucagon Emergency Kit

Sig: Inject 1mg IM as directed. Disp: 1 kit. RF: 2

Test strips

Sig: Test blood glucose BID, more frequently as needed. Disp: 100 (1 box). RF: 4

Multivitamin (over-the-counter)

Sig: Take 1 (one) tab daily

Mrs. Wu will receive a prescription of oral Metformin, which is the recommended first-line pharmacological treatment for type 2 diabetes in symptomatic patients with HbA1C levels less than 9% and eGFR that is greater than 99 mL/min/1.73 (ADA, 2018). Metformin works by lowering hepatic production of glucose, increasing the uptake of glucose in the small intestines, and enhancing insulin sensitivity, which ultimately boosts the uptake and utilization of peripheral glucose. An additional benefit of metformin is the capacity to reduce LDL cholesterol, which could help in weight loss and hyperlipidemia. The initial dose of extended-release metformin will be 500 mg, which can then be increased to an upper limit of 2000 mg daily until the desired blood glucose level is attained.

Sometimes, the management of blood glucose levels may lead to inadvertent hypoglycemia, which may be life-threatening. Emergency glucagon kits are important for diabetics for such eventualities (ADA, 2018).

The management of blood glucose levels in diabetes involves obtaining regular measurements of blood glucose. Therefore, Mrs. Wu will require a glucometer, lancets, and test strips. Studies show that the long-term use of metformin in the management of blood glucose results in vitamin B12 deficiency, which manifests as peripheral neuropathy in approximately one-third of patients using this drug (Niafar, Hai, Porhomayon, & Nader, 2015; Aroda et al., 2016). Therefore, it is necessary to avoid this consequence by administering multivitamins to patients on metformin (ADA, 2018).

Hyperlipidemia

Atorvastatin 10mg

Sig: Take 1 (one) tab daily. Disp: #30. RF: 2

ADA (2018) recommends statins as the drug of choice in the reduction of blood cholesterol levels as well as cardioprotection in diabetic patients. Atorvastatin is the most commonly used drug for this purpose. However, its effectiveness in reducing LDL levels depends on the dose administered. At doses of 40 to 80 mg, high-intensity therapeutic effects are observed by at least 50% reductions in LDL cholesterol levels. However, at doses of 10 to mg, moderate effects are noted in the form of 30 to 50% reductions in LDL cholesterol. In this case, a 30 to 50% reduction would bring down the LDL cholesterol levels to the normal range.

Osteoarthritis

Acetaminophen 500 mg (over-the-counter)

Sig: Take 1 (one) tab every 4-6 hours prn. Do not exceed 4000mg in 24 hrs.

Arthritis is a long-term condition without a permanent cure. Therefore, its management involves the management of associated symptoms such as pain and swelling, as well as improving mobility. Nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, corticosteroids, and hyaluronic acid are commonly used to manage pain and inflammation in arthritis (Arthritis Foundation, 2018).

Acetaminophen is an endorsed first-line medication for the pharmacologic management of osteoarthritis of the knee, which may be desirable for diabetic patients on metformin because acetaminophen has minimal gastric effects. Therefore, Mrs. Wu will be asked to use acetaminophen for pain relief. Alternative medications will be considered if she no longer obtains relief when using acetaminophen.

Education Plan

Diagnoses

Type 2 diabetes

The management of type 2 diabetes mellitus encompasses a combination of pharmacological and non-pharmacological interventions. Therefore, the patient should receive education on these two aspects. Additionally, the effectiveness of these interventions depends on the patient’s adherence to the treatment regimen. Consequently, there is a need to provide Self-management education in addition to problem-solving skills for all facets of diabetes management (ADA, 2018).

However, the medical provider should consider the patient’s preferences, values, and goals when developing a diabetes management regimen. Pharmacological interventions in type 2 diabetes include taking medications as recommended, whereas non-pharmacological intermediations include healthy diets, regular exercise, and blood sugar monitoring. Mrs. Wu should be educated on checking her blood sugar levels, including how to use the prescribed test kit, lancets, and glucometer. For insulin-independent diabetes, the frequency of blood sugar checks is less than in type 1 diabetes.

The initial recommendation based on ADA (2018) is to check blood sugar at least twice a day (in the morning and before going to bed). She should also strive for HbA1C levels of 5.7% or less, fasting blood glucose of 80 to 130 mg/dL, postprandial blood glucose less than 180 mg/dL, and bedtime levels of 90 to 150 mg/dL (ADA, 2018). It is also important for the patient to be aware of the impact of stress and dehydration on her blood glucose levels and the need to check the sugar levels at those times.

Hypoglycemia is a possible complication in diabetes. Therefore, Mrs. Wu should be educated about the symptoms of hypoglycemia, for example, irritability, wobbliness, tachycardia, confusion, and hunger. She should be advised to check her blood glucose whenever she experiences these symptoms and act appropriately. For instance, blood glucose readings of 70 mg/dL or below warrant the intake of 15 to 20 g of glucose. Readings less than 54 mg/dl necessitate the use of glucagon.

Nonetheless, there is a likelihood that she may become unconscious once her blood sugar reaches these levels. Moreover, the patient should recheck her blood glucose level following 15 minutes of oral glucose or glucagon injection and act accordingly based on the previous recommendations. Once her sugar levels have been stabilized, she can eat a meal or a snack to aver another incident of hypoglycemia. It is important to educate the patient about possible triggers for hypoglycemia, for example, intense exercise, fasting, and delayed meals. Small snacks and sweets are handy in such situations.

The patient should also be educated on important aspects of foot care, for example, regular examination of her feet for any signs of injury. She should seek medical treatment promptly for treatment if she notices any injury. Diabetic retinopathy is a possible complication in diabetes. Therefore, the patient should report any alterations in vision and see an optician regularly (ADA, 2018).

The patient should receive education on the interactions between hypertension and renal function in diabetes. Hyperlipidemia also increases her risk of cardiovascular events. Even though her current blood pressure was within the normal range, she should strive to maintain it that way to reduce her risk of chronic renal disease and cardiovascular disease (ADA, 2018).

Hyperlipidemia

Mrs. Wu should be educated about the importance of lowering her cholesterol levels. Hyperlipidemia predisposes her to the development of atherosclerosis and other cardiovascular diseases. Apart from taking her medications as recommended, the patient needs to watch her diet by cutting down the consumption of fatty foods, reduce her caloric intake, and exercise regularly. She should strive to attain LDL levels less than 70 mg/dl (ADA, 2018).

Depression

Mrs. Wu was educated about the signs of depression and advised to seek medical assistance if she experienced those symptoms. She was informed that it was normal to feel overwhelmed by the new diagnosis. Additionally, she would be required to make significant modifications to her lifestyle. These factors would increase her risk for depression, which would hamper her glycemic control goals if not addressed (ADA, 2018).

Medications

• Metformin. The patient was informed about the mode of action of metformin and advised to take it with food, especially in the evenings to prevent hypoglycemia. She was also informed about the side effects of the drug, which include queasiness, weight loss, and diarrhea. Therefore, she should not be alarmed by these symptoms and should continue taking the drug because gastrointestinal indications would resolve on their own (McCreight, Bailey, & Pearson, 2016).
• Glucagon. Mrs. Wu was taught how to use the glucagon kit. She was also asked to educate her family and close friends on how to do the same in the event that she fell unconscious due to hypoglycemia. She was asked to have the kit with her at all times and discard it if it expires. She was also informed about the correct storage of the kit, which was at room temperature away from extreme temperatures.
• Atorvastatin. Atorvastatin can cause side effects such as muscle weakness and myalgias (Ramkumar, Raghunath, & Raghunath, 2016). The patient was informed about these possibilities and asked to seek medical help promptly if she experienced them.
• Acetaminophen. The patient was asked to ensure that she did not exceed the maximum daily limit of acetaminophen. Additionally, she was advised against taking other medications that contained acetaminophen, for example, over-the-counter drugs for cold and flu. An overdose of acetaminophen could cause liver toxicity (Kheradpezhouh, Ma, Morphett, Barritt, & Rychkov, 2014).

Diet

ADA (2018) recommends that diabetic patients should take the Mediterranean diet. Mrs. Wu was asked to watch her diet by reducing the consumption of foods rich in saturated and trans-fats. She should also reduce her carbohydrate portions but increase the intake of omega fatty acids and fiber. This diet would help in the glycemic control and reduction of cholesterol levels.

Exercise

The patient was advised to increase her physical activity to 30 to 60 minutes at least 4 to 6 times a week (ADA, 2018). However, given her knee arthritis, she was advised to engage in mild to moderate exercise. She was asked to check her blood glucose after exercising.

Warning signs for diagnoses and medications

Apart from the indications of hypoglycemia that have already been mention in the previous sections, the patient should also watch out for the indications of hyperglycemia. They include blurred vision, difficulties concentrating, extreme fatigue, and blood sugar that exceeds 180 mg/dl (ADA, 2018). Other warning signs include tingling and numbness of feet as well as slow healing of cuts and wounds. She was also asked to seek urgent medical help if she developed intense abdominal pain, respiratory distress, and malaise, which could be because of lactic acidosis.

Referral

• Nutritionist. Mrs. Wu explains that her weight has increased despite her efforts to exercise. Therefore, she needs the help of a dietician to develop a customized diet plan that will provide her with adequate calories, help with glycemic control, reduce body weight, and reduce hyperlipidemia (Powers et al., 2017).
• Podiatrist. Diabetic foot ulcers and amputations are common problems that contribute to the morbidity and mortality of patients with diabetes. Therefore, it is important to refer the patient to a podiatrist for specialized foot care (Thompson, 2018).
• Eye specialist. Since diabetes is associated with retinopathy, the patient should visit an eye specialist for regular eye checkups to prevent this occurrence (Powers et al., 2017).

Follow up

Mrs. Wu should return to the hospital after three months for a reassessment of her condition. The follow up will also evaluate the efficacy of the treatment options and the appropriateness of pharmacological interventions (ADA, 2018).

Medication Costs

The cost of 30 pills of extended-release metformin 500 mg is $13.58 at most pharmacies using the Drugs.com discount card. However, if the dose is increased to 2000 mg a day, a total of 120 tablets will be needed, which will bring the overall cost to $13.54 (Metformin prices, coupons and patient assistance programs, 2018). The price of the cheapest glucagon kit is about $144.58 (Glucagon prices, coupons and patient assistance programs, 2018). On the other hand, the cost of 30 pills of 10 mg atorvastatin in pharmacies using the Drugs.com discount card is $17.73 (Atorvastatin prices, coupons and patient assistance programs, 2018).

The cost of diabetic supplies for one month will be 2 boxes of lancets (200 pieces) at the cheapest cost of $10, glucometer at $8.99, and test strips at $126 at a rate of 12 strips a day, each costing $0.35 (Glucose meter cost, 2018). The monthly supply of acetaminophen at the maximum dose of 4000 mg a day will be approximately $3.5 for a bottle containing 250 pills at Walmart (Acetaminophen, 2018). The monthly cost of multivitamin tablets would be $12.99 for 50 tablets of multivitamins (One a day women’s menopause formula multivitamin, 2018).

The total monthly cost for the drugs and medical supplies will be $337.33, which can be reduced further if the patient takes advantage of coupons offered on various drug websites. However, the glucometer will only need to be bought once. If Mrs. Wu buys a quality glucometer and takes good care of it, she should be able to use it for a long time. Therefore, the total cost of drugs for the subsequent months will exclude the cost of the glucometer and come down to $328.34.

Furthermore, the glucagon kit is meant to be used only for emergencies. If the patient adheres to the treatment recommendations, it is possible to avoid extreme hypoglycemia thus eliminating the need to use the glucagon kit. Therefore, it is recommended that the patient buys a kit with the farthest possible expiration date to stretch its usability. In such a case, it is possible for the patient to afford her subsequent medications on a monthly budget of $192.75 or less. Depending on the patient’s insurance plan, some or all of these costs can be covered without the need to pay out of pocket.

The cost of diabetic care may prevent effective glycemic control for uninsured patients with low incomes. To prevent such occurrences, healthcare providers need to educate patients on cost-cutting strategies such as using coupons. However, in type 2 diabetes, effective glycemic control through healthy diets and regular exercise can lower the cost of diabetic care significantly.

Conclusion

Type 2 diabetes mellitus is a longstanding illness attributed to defects in insulin function. Poorly managed diabetes can result in various complications, including diabetic nephropathy, retinopathy, and neuropathy, which may cause kidney disease, eye problems, and diabetic foot ulcers. These complications contribute to morbidity and mortality in diabetes. Attaining optimal glycemic control is the goal of diabetes management, which is possible through a blend of pharmacological and nonpharmacological intermediations. Therefore, healthcare providers should empower patients through comprehensive patient education that covers all aspects of care.

Clinical Chart SOAP note

S:

Chief Complaint: increased fatigue, weight gain, polyuria, polydipsia, and polyphagia

HPI

Mrs. W, a 59-year-old Asian female presents to the clinic with complaints of increased fatigue over the last 12 weeks. She exercises regularly but still gains weight. She experiences increased hunger and thirst, especially after exercise. She also experiences increased urination during the day as well as at night for the last 3 months. Mrs. W requires weight gain advice and evaluation for fatigue.

Current Medications

Tylenol 500 mg 2 tabs in AM knee pain

Allergies: Bactrim, cats, and pollen

PMHx

No chronic illness. German measles as a child. Right knee arthritis 3 months ago

All vaccines up to date

PSHX: None

Health screening:

Colonoscopy WNL 4 years- repeat in 10 years, ASCUS pap 1998, all further Paps WNL, mammogram last year-benign

Soc Hx

Divorced, works from home as an administrative assistant, 1-2 glasses wine daily, former smoker, quit 10 years ago, no illicit drug use, exercises twice a week.

Fam Hx

Parents are deceased, child alive and well, no siblings.

ROS

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

Musculoskeletal: Reports reduced pain

O:

Physical Exam

• BP: 112/76; HR 80; RR 16; Hgt: 5’1.5″; Wgt: 165 lbs; BMI: 31.17
• General: Female in no acute distress, alert, oriented and cooperative
• HEENT: head normocephalic. Hair thick and distribution throughout the 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. Anterior and posterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
• Skin: Warm dry and intact. No lesions.
• 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

Diagnostic or Lab results

• 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, Total Bilirubin 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

A:

• Primary Diagnosis: Type 2 diabetes mellitus (ICD-10 E11.9).
• Secondary Diagnosis: Hyperlipidemia (ICD-10 E78.5)
• Differential Diagnoses:
• Metabolic syndrome (ICD-10 E88.81)
• Adjustment disorder with depressed mood (ICD-10 F43.21)

P:

Diagnostics

1. Spot urinary albumin-to-creatinine ratio
2. HgbA1C
3. Annual fasting CMP
4. Foot exam
5. Lipid profile
6. Becks Depression Inventory

Medications

• Metformin 500 mg tablets (Extended-release)
  • Sig: Take 1 (one) tablet twice every day with food. Disp: #30. RF: 2
• Diabetic Lancets
  • Sig: Test blood glucose BID, more frequently as needed. Disp: 200 (2 boxes). RF: 4
• Glucometer
  • Sig: Test blood glucose BID, more frequently as needed. Disp: 1 kit. RF: 1
• Glucagon Emergency Kit
  • Sig: Inject 1mg IM as directed. Disp: 1 kit. RF: 2
• Test strips
  • Sig: Test blood glucose BID, more frequently as needed. Disp: 100 (1 box). RF: 4
• Multivitamin (over-the-counter)
  • Sig: Take 1 (one) tab daily
• Atorvastatin 10mg
  • Sig: Take 1 (one) tab daily. Disp: #30. RF: 2
• Acetaminophen 500 mg (over-the-counter)
  • Sig: Take 1 (one) tab every 4-6 hours prn. Do not exceed 4000mg in 24 hrs.

Education

1. Discussed diabetes self-care, including blood glucose monitoring and glucagon administration.
2. Reviewed medications
3. Recommended diet change and exercise
4. Becks Depression Inventory: advised to call the hospital if signs of depression are experienced.
5. Referrals: Nutritionist, dietary advice
6. Eye specialist, eye care
7. Podiatrist, foot care
8. Follow up: Return to office in 3 months.

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