Introduction
Mrs. G is a 55-year-old Hispanic female who had visited the office for her annual wellness exam. She complained of fatigue and lethargy for the last three months. The patient had also gained weight since menopause in the previous year. She exercised for 30 minutes twice a week expecting to lose weight but instead, she gained 3 pounds. Mrs. G also complained of extreme hunger, thirst, and increased urination. She wanted to know why she had these symptoms and how to lose weight. This paper evaluates the subjective and objective findings of Mrs. G and develops appropriate diagnoses. The paper also formulates an evidence-based treatment guideline.
Assessment
Primary Diagnosis
Type 2 diabetes mellitus without complications (E11.9)
Pathophysiology. Type 2 diabetes occurs following a reduction in the efficiency of beta cells of the pancreas, which results in low production of insulin, insulin resistance, and high blood glucose levels. The classic indications of the disorder include polydipsia (increased thirst), polyuria (increased urination), and polyphagia (elevated hunger), and weight loss (American Diabetes Association [ADA], 2019).
Pertinent positive findings. The patient complained of fatigue, lethargy, increased hunger, and thirst. Mrs. G also admitted that she passed more urine than usual at night. These symptoms had persisted for the last 3 months (subjective findings). The objective findings included hemoglobin A1C of 6.9% and urinalysis of 1+ glucose. The patient had a major risk factor for type 2 diabetes (obesity) as indicated by a BMI of 33.8 (ADA, 2019).
Pertinent negative findings. The patient did not have a family history of type 2 diabetes. Her urine was negative for ketones, whereas her fasting blood glucose level was 95 mg/dL (within the normal range of 71 to 99 mg/dL) (ADA, 2019).
Rationale for the diagnosis. The patient exhibited the classic indications of type 2 diabetes, namely, polyphagia, polydipsia, and polyuria that have been occurring for the last 3 months. The patient had risk factors for the disorder such as being obese, Hispanic ethnicity, and age. The hemoglobin A1C was increased at 6.9% instead of 6.5% or lower, whereas urinalysis indicated glucosuria. ADA (2019) recommends that a diagnosis of type 2 diabetes should be made when a patient meets the above criteria in the absence of the hallmarks of hyperglycemia devoid of repeat testing.
Secondary Diagnosis
Hyperlipidemia, unspecified (E78. 5)
Pathophysiology. Hyperlipidemia is a metabolic disorder characterized by the presence of high levels of lipids and lipoproteins (such as total cholesterol, very-low-density lipoproteins (VLDL), low-density lipoproteins (LDL), and triglycerides) that elevate the risk of atherosclerosis and low amounts of beneficial lipoproteins such as high-density lipoproteins (HDL). The disorder is a common complication of other health problems such as type 2 diabetes mellitus, hypertension, and coronary artery disease and presents with symptoms such as corneal arcus, carotid bruit, and yellowish deposits of cholesterol beneath the skin (xanthomas) or around the eyelids (xanthelasma) (Li et al., 2019).
Pertinent positive findings. The patient had a diagnosis of type 2 diabetes, obesity, a positive family history of hypercholesterolemia (father), and high blood pressure (129/80 mmHg). She also had an abnormal lipid profile as follows: total cholesterol 230 mg/dL (<200 mg/dL), LDL 144 mg/dL (optimal range < 100 mg/dL or 70 mg/dL in people with diabetes or cardiovascular disease), VLDL 36 mg/dL (2-30 mg/dL), HDL 38 mg/dL (40-50 mg/dL), and TG 232 mg/dL (<150 mg/dL) (Karr, 2017).
Pertinent negative findings. The patient had no history of smoking or atherosclerosis. She had been exercising regularly (for at least 30 minutes twice a week) (Karr, 2017).
Rationale for the diagnosis. The lipid profile confirmed high levels of bad cholesterol (TC, VLDL, LDL, and TGs) and low levels of good cholesterol (HDL). The patient also possessed risk factors for hyperlipidemia such as her Hispanic ethnicity, a diagnosis of diabetes, obesity, and hypertension (Karr, 2017).
Secondary Diagnosis
Obesity, unspecified (E66.9)
Pathophysiology. Obesity is the accumulation of excess body fat in the adipose tissues, which results from an imbalanced caloric intake and expenditure, as well as impaired balance between lipid and glucose metabolism. The excess stored triglycerides hamper lipogenesis whose role is to facilitate serum clearance of triacylglycerols, contributing to hyperlipidemia, excess free fatty acids, and insulin resistance alongside symptoms such as fatigue and joint pains (Heymsfield & Wadden, 2017).
Pertinent positive findings. Objective findings included the patient’s obese appearance, a BMI of 33.8 kg/m2 that signified obesity class I (normal BMI is 18.5-25), left knee arthritis, and high blood pressure (129/80). Subjective findings indicative of obesity included fatigue, weight gain of 3 pounds, as well as increased appetite and eating (polyphagia) (Heymsfield & Wadden, 2017).
Pertinent negative findings. The patient exercised for 30 minutes twice a week (subjective). The thyroid function tests were normal: TSH 2.35 (normal range 0.5-4.5 mU/L) and Free T4 0.7 (normal range 0.7-1.9 ng/dL) (Heymsfield & Wadden, 2017).
Rationale for the diagnosis. The subjective and objective findings indicate obesity. An unsuccessful weight loss attempt was an indication of impaired lipid and glucose metabolism due to insulin resistance that is associated with obesity. The patient had other health complications such as hypertension, hyperlipidemia, and type 2 diabetes where obesity plays a significant role as a risk factor (Heymsfield & Wadden, 2017).
Plan
Diagnostics
Hemoglobin A1C. Blood samples should be drawn and retested for hemoglobin A1C levels after 3 months.
Rationale. ADA (2019) recommends that HbA1C levels should be tested every 3 months to assess the patient’s glycemic control and management of diabetes. This test determines the efficiency of the treatment plan and directs the clinician’s decision to modify the regimen. The patient’s condition at the time of testing determines the future frequency of testing.
Complete metabolic panel (CMP). This test should be repeated after 6 weeks (ADA, 2019).
Rationale. CMP determines blood sugar levels, fluid-electrolyte balance, and assesses liver and renal function. ADA (2019) requires diabetic patients on metformin to undergo a CMP annually to monitor the possibility of megaloblastic anemia following vitamin B12 deficiency in protracted metformin use. However, for patients taking statins for the treatment of hyperlipidemia, this test should be performed sooner to assess liver function. An initial test was performed during the annual visit. Nonetheless, given that the patient had hyperlipidemia and was to be treated with statins, a CMP would be required after 6 weeks (ADA, 2019).
Urinary albumin to creatinine ratio. ADA (2019) requires all patients diagnosed with type 2 diabetes to undergo annual testing of urinary albumin to creatine ratio. This test should be scheduled during the patient’s next annual visit.
Rationale. Type 2 diabetes is associated with kidney failure (diabetic nephropathy). The presence of albumin in the urine (albuminuria) is a sign of renal complications and should be evaluated regularly. The patient’s urinalysis showed traces of proteins, which could be indicative of renal failure. A normal test should give an albumin-to-creatinine ratio of 30 mcg/L or less. Levels ranging from 30 to 300 mcg/L indicate microalbuminuria while values exceeding 300 mcg/L are considered macroalbuminuria. However, given the possibility of false-positive results, the test should be repeated every three to six months. Microalbuminuria is confirmed if two positive tests are obtained in a span of 3 to 6 months (ADA, 2019).
Medications
Medication. Rx: Metformin 500 mg tablets
Sig: Take one (1) tablet by mouth twice daily
Disp: #60 (Sixty). RF: 2 (ADA, 2019).
Rationale. Metformin is the first-line treatment for type 2 diabetes. All patients diagnosed with type 2 diabetes should receive this drug unless there are any contraindications (ADA, 2019).
Medication. Rx: Simvastatin 20 mg tablets
Sig: Take one (1) tablet by mouth once daily
Disp: #30 (Thirty). RF: 2 (Rhee et al. 2018).
Rationale. A moderate statin such as simvastatin should be selected for patients with a 10% risk of atherosclerotic cardiovascular disease. This risk was computed for Mrs. G and found to be 6.3%. The US Preventive Service Taskforce (USPSTF) recommends that adults aged between 45 and 75 years who have no indications of stroke or coronary artery disease but have risk factors for heart disease such as diabetes, an abnormal lipid profile, and elevated blood pressure should be treated with statins (Fay et al., 2019).
Education
Diagnoses
Your lab results for hemoglobin A1C indicate that you have type 2 diabetes. This test measures the mean blood sugar levels for the last 3 months and is at 6.9%, which is higher than the recommended level of 6.5% in healthy people (ADA, 2019). These outcomes mean that your body is unable to use up glucose efficiently, which is why you have been experiencing symptoms such as increased thirst, hunger, and urination. The amount of fats in your blood is also high, meaning you have a condition known as hyperlipidemia. Specifically, your blood contains high volumes of bad cholesterol and low quantities of good cholesterol. Another health problem is obesity, which means that the proportion of fat in your body is higher than normal (ADA, 2019).
Medication. To manage diabetes effectively, you are expected to take metformin orally, twice daily after breakfast and dinner. This drug will help you to control your blood sugar levels and weight. You are also expected to take simvastatin to lower the levels of bad cholesterol and boost the good cholesterol in your blood. This drug should be taken once a day with your evening meal (Rhee et al., 2018).
Diet. The effective management of diabetes requires you to choose your meals carefully. It will also help you to lose weight, reduce harmful cholesterol, and increase the good cholesterol. You should make healthy food choices and cut down your portions of carbohydrates and fats. ADA (2019) recommends that you should take between 1,200 and 1,500 calories per day. Important guidelines for your meals include cutting down your intake of sugar, salt, and trans-fats (animal fats) and increasing the consumption of fruits and vegetables, whole grains, nuts, and legumes. About half of your plate should comprise vegetables, whereas the remaining half should be split between proteins and carbohydrates. You should also reduce the intake of wine or try to avoid it altogether (ADA, 2019).
Exercise. Exercising regularly helps your body to use up glucose and will improve your diabetic symptoms as well as help with weight and cholesterol issues. You should try aerobic exercises and strength training, which may entail specific exercises like hinges, squats, pulls, pushups, and core work. You should do these exercises for at least 30 minutes for 5 days a week. If possible, you can prolong the time to 45 minutes or an hour (ADA, 2019).
Warning signs for diagnosis and medication. The two major problems that you should watch out for are hyperglycemia (very high blood sugar levels) and hypoglycemia (very low blood sugar levels). The indications of hyperglycemia include fatigue, restlessness, queasiness, and dizziness, whereas the signs of hypoglycemia encompass hunger, shaking, dizziness, confusion, and anxiety. To avoid these issues, you should take your medications as prescribed and adhere to a specific eating pattern (ADA, 2019). Diabetes can result in other health problems such as eye issues, foot sores, and damage to the nerves and kidneys. Hyperlipidemia increases your risk of heart attack or stroke. Therefore, you should watch out for any chest pains and shortness of breath and seek medical attention. Obesity increases your risk of coronary heart disease and worsens other conditions that you already have such as diabetes, hypertension, and hyperlipidemia (ADA, 2019).
Metformin may cause side-effects such as queasiness, vomiting, stomach upset, and diarrhea (ADA, 2019). Conversely, simvastatin may cause side effects such as muscle pain, headache, flatulence, constipation, and vertigo (RxList, 2020). However, these effects will resolve with time as your body gets used to the drug.
Referral
Registered Dietitian. Mrs. G was referred to a competent dietitian for help with customizing her meals. Personalized nutritional therapy promotes the attainment of glycemic goals in diabetes (ADA, 2019).
Assessment of Comorbidities
ADA (2019) recommends that patients with type 2 diabetes be assessed for hip fractures because diabetes increases the risk of this condition. The relative risk is 1.7 and persists in diabetic patients despite having a high bone mineral density (BMD). Diabetes causes hyperglycemia that is accompanied by increased generation of advanced glycation end-products, development of reactive oxygen species, and inflammation. These factors elevate the numbers of osteoclasts and reduce the populations of osteoblasts, thereby interfering with bone formation (Jiao et al., 2015). Studies show that the risk of osteoporosis and hip fractures increases in females after menopause (Boschitsch et al., 2017; Peng et al., 2020). Mrs. G is post-menopausal and diabetic, implying that her fracture risk is compounded. Her history of arthritis and obesity further aggravate the risk. Therefore, the patient’s BMD should be measured.
Follow-Up
Mrs. G will be required to return to the hospital for follow-up after 4 weeks to be evaluated for the remission of symptoms and adherence to treatment. The side effects and tolerability of the drugs will also be evaluated (ADA, 2019). Any other concerns of the patient will be addressed at this time.
Medication Cost
The cost of 30 tablets of simvastatin 20 mg with a Costco free coupon is $5.16 (GoodRx, 2020a), whereas the price of 60 tablets of metformin 500 mg at Walmart pharmacy is $4 (GoodRx, 2020b). The approximate monthly cost of the new prescription drugs for Mrs. G is $9.16. Managing diabetes is a costly affair, and most patients become non-adherent to treatment due to cost implications. Therefore, generic formulations of drugs were chosen to minimize costs (ADA, 2019).
Conclusion
Type 2 diabetes is a longstanding health disorder that is characterized by impaired blood glucose metabolism. The risk factors for the development of the disorder include age, ethnicity (Hispanics are at higher risk), body weight (obesity), high blood pressure, physical inactivity, aberrant triglyceride and cholesterol levels, and positive family history, whereas its complications include cardiovascular disease, neuropathy, nephropathy, skin conditions, retinopathy, depression, foot disorders, and hearing impairment. The effective management of type 2 diabetes requires the concerted effort of a primary care provider, the patient, and specialists such as dieticians, ophthalmologists, or podiatrists as the patient’s needs dictate.
References
- American Diabetes Association. (2019). Standards of medical care in diabetes-2019. Diabetes Care, 42(Supplement 1), S1-S193. Web.
- Boschitsch, E. P., Durchschlag, E., & Dimai, H. P. (2017). Age-related prevalence of osteoporosis and fragility fractures: Real-world data from an Austrian menopause and osteoporosis clinic.Climacteric, 20(2), 157-163. Web.
- Fay, K. E., Farina, L. A., Burks, H. R., Wild, R. A., & Stone, N. J. (2019). Lipids and women’s health: Recent updates and implications for practice. Journal of Women’s Health, 28(6), 752-760. Web.
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- GoodRx. (2020b). Metformin.
- Heymsfield, S. B., & Wadden, T. A. (2017). Mechanisms, pathophysiology, and management of obesity. New England Journal of Medicine, 376(3), 254-266. Web.
- Jiao, H., Xiao, E., & Graves, D. T. (2015). Diabetes and its effect on bone and fracture healing. Current Osteoporosis Reports, 13(5), 327-335. Web.
- Karr, S. (2017). Epidemiology and management of hyperlipidemia. The American Journal of Managed Care, 23(9 Suppl), S139-S148.
- Li, X., Chen, W., Lu, R., & Li, F. (2019). The diagnosis and treatment of familial hyperlipidemia combined with midsubstance Achilles tendinopathy in a young woman: A clinical case report. International Journal of Clinical and Experimental Medicine, 12(11), 13018-13022.
- Peng, K., Yao, P., Kartsonaki, C., Yang, L., Bennett, D., Tian, M., Li, L., Guo, Y., Bian, Z., Chen, Y. & Chen, Z. (2020). Menopause and risk of hip fracture in middle-aged Chinese women: A 10-year follow-up of China Kadoorie Biobank. Menopause, 27(3), 311-318. Web.
- Rhee, E. J., Kim, H. C., Kim, J. H., Lee, E. Y., Kim, B. J., Kim, E. M., Song, Y., Lim, J.H., Kim, H.J., Choi, S., & Moon, M. K. (2019). 2018 Guidelines for the management of dyslipidemia in Korea. Journal of Lipid and Atherosclerosis, 8(2), 78-131.
- RxList. (2020). Simvastatin.