Patient Information
Client X is a 48 years old Non-Hispanic White American male with a history of diabetes mellitus type 2.
Subjective
The patient complains that he is not feeling his toes in the left foot and numbness and tingling sensation in the right foot. Although he establishes that he does not feel pain, it is a concern due to the discomfort poised from the lower back of the body, whether stationary or moving.
HPI
- Location: the toes of the left foot and the right foot’s heel
- Onset: 5 days ago
- Character: numbness and tingling feeling around the left and right feet
- Associated signs and symptoms: difficulty in movement.
- Timing: after a long durational rest or walk
- Exacerbating/relieving factors: the man rests his legs on a basin full of warm salted water.
- Severity: 8/10 pain scale
- Current Medications: patient X takes a 500mg tablet of metformin to assist with the glucose regulation in the body. The patient further consumes one 500mg tablet of Abroma Augusta as a homeopathic treatment strategy.
- Allergies: patient X shows no allergic reactions to environment, food, and medication.
- PMHx: positive history of type 2 diabetes mellitus is controlled.
- Soc Hx: patient X is positive for tobacco and alcohol abuse with a lack of a support system. He is a widower with 3 children. However, the patient’s successors are grown-ups and married across different countries. Patient X attests that he disregards wearing a seat belt and exercising to live a healthy life. The individual further indicates that he is a workaholic with one day off.
- Fam Hx: the father died at 80 years due to a heart attack, the mother at 67 years of blood hypertension.
ROS
- General: patient X denies weight loss, fatigue, chills, or fever.
- HEENT: Eyes: patient X denies visual loss, yellow sclerae, or blurriness. Ears, nose, throat: the patient denounces sneezing, loss of hearing, sore throat, or runny nose.
- Skin: the patient denies itching or rashes.
- Cardiovascular: patient X denies pressure, discomfort, or pain in the chest.
- Respiratory: the patient further denounces experiencing coughs, sputum, or shortness of breath.
- Gastrointestinal: patient X rebuts anorexia, diarrhea, vomiting, or nausea. Further, the individual detests experiencing blood spot excretions or abdominal pains.
- Genitourinary: the patient attests to no burning sensation on urination.
- Neurological: patient X affirms numbness and tingling feelings on the right and left feet. However, there was no change in the bladder or bowel control.
- Musculoskeletal: patient X denies stiffness in joints, muscles, and back pain.
- Hematologic: the patient denounces anemia, bruising, or bleeding.
- Lymphatics: the patient affirms no enlarged nodes or history of splenectomy.
- Psychiatric: the patient attests to a history of anxiety and depression.
- Endocrinologic: the patient affirms no experience of polydipsia, polyuria, hot or cold intolerance.
- Allergies: the patient denies a history of hives, asthma, rhinitis, or eczema.
Objective
Physical exam
- General: the patient appears uncomfortable especially while resting or moving.
- Cardiovascular: PMI is in its 5th inter-costal space optimally functioning healthy.
- Gastrointestinal: the abdomen is symmetric without an indication of distortion and normal bowel sounds.
Laboratory tests
Laboratory test 1 enshrines the A1C test encompassing the measure of the average blood sugar within eight weeks. It is an essential examination since it renders the insight concerning the range of the element that should be 5.7% (American Diabetes Association, 2021). A slight difference to at least 6.4% showcases the prediabetes condition while the mark 6.5% justifies an individual with diabetes illness.
Laboratory test 2 engulfs the fasting blood sugars evaluation. The main aim of the assessment encompasses the measure of the about of blood sugar after fasting overnight. The average levels indicate 99mg/dl, while prediabetes involves the 100-125mg/dl levels, and diabetic condition encompasses 126mg/dl and above (American Diabetes Association, 2017).
Laboratory test 3 involves the random blood sugar assessment. A patient gets a random measure of the blood sugar, and an indication of 200mg/dl and above justifies the individual’s diabetic condition (Grundy et al., 2018).
Differential Diagnoses
Type 2 diabetes mellitus
The primary diagnosis of type 2 diabetes enshrines the test of glycated hemoglobin (A1C). The evaluation fosters an indication of the average blood sugar level in a span of two and three months. Secondary diagnoses include the random blood sugar test, fasting blood sugar test, oral glucose tolerance, and screening (Barron et al., 2020). The significant outlier encompasses assessing the amount of blood sugar levels among individuals relative to the comorbidity platform.
Hypertension
The primary diagnosis of hypertension is a heartbeat rate test, while the secondary diagnosis enshrines the consideration of cholesterol levels and cardiovascular disorders. Researchers indicate that the prominent factor leading to high blood pressure encompasses genetic conditions and poor lifestyle practices (Arnett et al., 2019). It is crucial to assess the dynamic factors influencing the functioning of the heart to implement initiatives alleviating the risk of high blood pressure.
Hyperlipidemia
The primary diagnosis of hyperlipidemia involves the determination of hereditary genetic conditions. Apart from genetic expression, the secondary diagnosis enshrines the illness from diabetes among the victims (American Diabetes Association, 2021). Researchers primarily argue that there is a higher risk of an individual with diabetes developing hyperlipidemia fostering the comorbidity essence. As a result, it is crucial to establish the critical value of preventing an optimal therapeutic remedy from the conditions.
Multiple Sclerosis
The primary diagnosis of multiple sclerosis is long-term numbness and tingling feeling to the hands and legs. Research indicates that the core variant enshrines indicating the consistency and pain scale of the health problem (Arnett et al., 2019). It is vital to identify the differential baseline through the assessment of the patient’s medical and family history.
Fibromyalgia
The primary diagnosis of the illness involves tenderness of the tissues in addition to the comparison of laboratory tests. Research establishes that the core wellness solution engulfs comparing the X-rays to comprehend the patient’s condition (Arnett et al., 2019). The disease poses prominent risk to the locomotive abilities of an individual hence the importance of its consideration as a differentiating diagnosis.
Reference
American Diabetes Association. (2021). Diabetes Care: Standards of medical care in diabetes-2021. Journal of Clinical and Applied Research and Education. 44(1). Web.
American Diabetes Association. (2017). Comprehensive medical evaluation and assessment of comorbidities. American Diabetes Association: Diabetes Care. 40(1). Web.
Arnett, D. K., Blumenthal, R. S., Albert, M. A., Buroker, A. B., Goldberger, Z. D., Hahn, E. J., Himmelfarb, C.D., Khera, A., Lloyd-Jones, D., McEvoy, J.W., Michos, E.D., Miedema, M.D., Munoz, D., Smith, S.C., Virani, S.S., Williams, K.A., Yeboah, J., & Ziaeian, B. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American college of cardiology/American heart association task force on clinical practice guidelines. Journal of the American College of Cardiology, 74(10), e177-e232. Web.
Barron, E., Bakhai, C., Kar, P., Weaver, A., Bradley, D., Ismail, H., Knighton, P., Holman, N., Khunti, K., Sattar, N., Wareham, N.J., Young, B., & Valabhji, J. (2020). Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: A whole-population study. The Lancet Diabetes & Endocrinology, 8(10), 813-822. Web.
Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L.T., Ferranti, S., Tommasino, J.F., Goldberg, R., Heidenrich, P.A., Jones, D.W., Lloyd-Jones, D., Pajares, N.L., Saseen, J.J., Smith, S.C., Sperling, L., Virani, S.S., & Yeboah, J. (2018). Guideline on the management of blood cholesterol: A report of the American college of cardiology/American heart association taskforce on clinical practice guidelines. J Am Coll Cardiol, 73(24), e285-350. Web.