Case Study: Diabetes Type 2 & Hyperlipidemia Management in 56-year-old Hispanic Female, Exams of Nursing

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NR-601 WEEK 5 CASE STUDY 1 LATEST 2024

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Week 5 Case Study: Mrs. R. The case study scenario introduced the class to Mrs. R., a 56-year old Hispanic female who reported to the office clinic with complaints of extreme fatigue and experiencing a gradual weight gain. The onset of her symptoms started 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 intention of this paper is to examine the analysis of the subjective and objective findings that was collected to diagnose and create a management plan for Mrs. R. In addition, the application of national diabetes guidelines will be included into the patient’s management plan. This paper will also discuss the assessment of the primary, the secondary, and the differential diagnoses for Mrs. R., as well as the management plan for treatment of the primary, the secondary, and the differential diagnoses, which consists of diagnostics, medications, education, referrals, and follow-up care. This paper also includes a discussion on medication costs of all prescribed and over-the-counter (OTC) medications. Assessment According to the information provided by Mrs. R., she has symptoms of major concerns, which includes extreme fatigue, the inability to lose weight regardless of her attempts to exercise, her increase in thirst, hunger, and urination. Per the Center for Disease Control and Prevention BMI calculator (CDC) (2015), her calculated BMI of 29.7 showed that she is

overweight for her given height. The result from her urine analysis showed glucose and small concentration of protein. Her HgbA1C is 6.9% and her fasting glucose is 126 mg/dL, which according to the American Diabetes Association (ADA) (2018), she meets the conditions for the diagnosis of diabetes. Mrs. R’s CBC values, TSH and Free T4 levels were unremarkable, which ruled out hypothyroidism and anemia. Her lipid panel results revealed she has hyperlipidemia. Her elevated cholesterol places her at risk for a stroke and cardiovascular disease (AACE, 2017). Primary diagnosis Diabetes Mellitus Type 2 (DM2) (E11.9). Type 2 diabetes or DM2 is referred to as adult-onset diabetes and is indicated by hyperglycemia, insulin deficiency, insulin resistance that can lead to the development of vascular and neurologic complications (American Diabetes Association [ADA], 2018). According to Goroll (2014), there is an insufficient amount of insulin being excreted by the pancreas to meet the metabolic needs of the body causing hyperglycemia. Goroll (2014) also states that the disease is more apparent later in life in most cases, with fatigue as the leading sign. Manifestations of DM2 consist of polyuria, polydipsia, polyphagia, and weight gain (Goroll, 2014). Some pertinent positives include: extreme thirst (polydipsia), extreme hunger (polyphagia), frequent urination during the day (polyuria), extreme fatigue, difficulty losing weight regardless of exercise, obesity, her age, and Hispanic ethnicity. Her lab results, which includes Hemoglobin A1c=6.9%, fasting plasma glucose=126, and elevated cholesterol levels are indicative of diabetes mellitus type 2. Per Pippitt, Li, and Gurgle (2016), DM2 can lead to blindness, renal failure, amputation of the limbs, vascular and cardiac disease. Rationale. The diagnosis of diabetes mellitus type 2 is chosen as the primary diagnosis due to Mrs. R.’s symptoms of fatigue, her inability to lose weight regardless of incorporating exercise in her lifestyle, her increased frequency of urination, and increased thirst and hunger. Also, her lab results, which includes her HA1c, are indicative of the diagnosis of diabetes type 2. Additional risk factors associated with Mrs. R. is her age, and her Hispanic ethnicity. According

to the ADA (2018), the factors, such as obesity, age, and certain racial/ethnic subgroups, which includes those with Hispanic/Latino background can increase the risk of developing type 2 diabetes. The ADA (2018) also states that the excess of weight can cause some degree of insulin resistance. Over the past 3 months, her presentation of excessive hunger, excessive thirst, frequent voiding, weight gain, and extreme fatigue maybe an indication of slow progression of diabetes. Secondary diagnosis Hyperlipidemia (E78.5). Hyperlipidemia, which is referred to as dyslipidemia is termed as elevated concentrations of lipids that could potentially block blood flow due to plaques build up in the arteries (Dunphy et al., 2015). Hyperlipidemia is a heterogenous metabolic disorder that increases the risks of atherosclerosis involving levels of lipids and lipoprotein (Dunphy et al., 2015). Desirable values for cholesterol according to Dunphy et al. (2015) are as follows: triglycerides (TGs) ¿^150 mg/dL, low-density lipoprotein (LDL) ¿^ 100 mg/dL, high-density lipoprotein (HDL)

¿

60 mg/dL and a total cholesterol (TC)

¿

200 mg/dL. Patients may initially present without symptoms but often exists concurrently with coronary artery disease (CAD) or hypertension (HTN) (Dunphy et al., 2015). Dunphy et al. (2015) also states that obesity, DM, nephrotic syndrome, end stage renal disease (ESRD), hypothyroidism, hepatic disorders, too much alcohol consumption, estrogen administration, Cushing’s syndrome, and glycogen storage disease are secondary causes of dyslipidemia. Secondary causes of hyperlipidemia should be assessed prior to initiating a treatment because treating the primary disorder often corrects the dyslipidemia (Dunphy et al., 2015). Some pertinent positives include: elevated triglycerides (TGs=232mg/dL), elevated LDL (144mg/dL), decreased HDL (38mg/dL), elevated total cholesterol (TC= 230mg/dL), gender, ethnicity, generalized fatigue, tired, feeling of no energy, weight gain, increased hunger, diabetes

mellitus, and obesity. There are no presenting symptoms of hyperlipidemia and is often detected during a physical examination when blood work is ordered (Dunphy et al., 2015). Over the past 3 months, her symptoms of weight gain, increased hunger, increased thirst may be an indication of a slow progression of her diabetes that is slowing the body function and metabolism. Some pertinent negatives include: hypertension and coronary artery disease, which are both associated with hyperlipidemia. In addition, her physical assessment does not reveal a carotid bruit, corneal arcus, or xanthomas, described as yellowish skin deposits of cholesterol, and usually found on the eyelids (Dunphy et al., 2015). Rationale. Due to the patient’s chief complaint of gradual weight gain in the past 3 months and the result of her lipid profile, which indicated elevated cholesterol, the diagnosis of hyperlipidemia is chosen as the secondary diagnosis. Hyperlipidemia is a treatable disorder and can be divided into primary and secondary. Patient’s gender and symptoms, as well as her physical assessment also play a factor. Furthermore, Mrs. R.’s cholesterol and LDL are elevated. According to Chaker et al. (2017), patients with hyperlipidemia have a high risk of cardiovascular disease and will often have metabolic syndrome factors such as hypertension, increased waist circumference, and diabetes mellitus. According to Bullock-Palmer (2015), hyperlipidemia places Mrs. R at a high risk of CAD due to her ethnicity because of the failure to identify at-risk females, and the discrepancy is highest among minority females. Hispanics and African American have a greater prevalence of CVD and its risk factors. In addition, Bullock- Palmer (2015) also states that about 40%-50% of females in the United States have an elevated total cholesterol

¿

200 mg/dL.

Differential diagnosis Obesity (E66.9). a body mass index (BMI) of 30kg/m^2 or higher indicates obesity and is defined as an excess of body fat (Dunphy et al., 2015). According to the AACE/ACE (2017), a BMI of

≥

30kg/m^2 is classified as obese, where as a BMI = 25-29kg/m^2 are identified as overweight. Obesity occurs when the consumption of calories far exceeds the metabolic needs of the body (Dunphy et al., 2015). Bullock-Palmer (2015) stated that the prevalence of obesity is greater among black and Hispanic females when compared to Caucasian females in the United States. CVD risk in females increases proportionately with the increase in BMI (Bullock- Palmer, 2015). Rationale. Mrs. R’s calculated BMI=29.7, which identifies her as overweight for her given height. The most common presenting symptoms for obesity are shortness of breath, decreased energy, fatigue, weakness, joint pain, depression, and increased daytime sleepiness (Dunphy et al., 2015). Its treatment consists of lifestyle interventions and behavioral modifications (Cefalu et al., 2015). Some pertinent positives for Mrs. R.’s obesity are fatigue, decreased energy, and weakness. Over the past 3 months, she has gained 3 pounds despite going to the gym and walking on the treadmill. Exercising makes her hungrier and therefore causing her to eat more. Pertinent negatives are daytime sleepiness, shortness of breath and depression. Management Plan Diagnostics Repeat HgbA1c/fasting glucose. Since Mrs. R.’s HgbA1c is elevated to 6.9%, a repeat HgbA1c or a fasting glucose and a 2-hour glucose tolerance test should be obtained to continue establishing the diagnosis of DM2. The ADA (2018) recommends a second test is required for

confirmation, unless there is a hyperglycemic crisis or a random plasma glucose of

≥

200mg/dL. In addition, the ADA (2018) recommends the same test be repeated or a different test be performed without delay using a new blood sample to confirm the diagnosis of DM2. By confirming the diagnosis of DM2, Mrs. R’s management plan will include medication that helps control her blood glucose and decrease her HgA1c level. PHQ-9 questionnaire. Mrs. R. will also need to be screened for depression using the PHQ-9 to determine if she has depression. Her social history states that she has recently separated from her spouse. According to Slavich and Irwin, major life events involving major health-related events, ending of romantic relationships, significant financial loss, and job loss have been found to have a strong co-relation to depression (Slavich & Irwin, 2014). Patient Health Questionaire-9 (PHQ-9) is a multipurpose tool to assess the severity of depression. The main focus is on the 9 diagnostic criteria for major depression listed in the DSM-5, which only takes a few minutes to perform (Ng, C. et al., 2016). The PHQ-9’ sensitivity and specificity are 61% and 94%, respectively (Ng, C. et al., 2016). Vitamin D and folate. Additional labs that Mrs. R. will need are Vitamin D, and folate levels to check for deficiencies, which could also be contributing to her fatigue (Hollier, 2016). Serum vitamin B12. A serum B12 level screening should also be performed due to Metformin causing a decrease in serum B12 concentration (Gorroll & Mulley, 2014; Kennedy- Malone et al., 2014). Vitamin B-12 and other B vitamins play a role that affect mood and other brain functions. Decreased levels of B-12 and other B vitamins such as vitamin B-6 and folate may be linked to depression (Ng, C. et al., 2016). 24-hr urine sample and random spot albumin/creatinine ratio. Since Mrs. R’s UA showed +1 glucose and small protein, screening for microalbuminuria with a 24-hour urine

sample and a random spot albumin/creatinine ratio will need to be performed to check for chronic kidney disease (CKD) (AACE/ACE, 2017). Medications Treatment for diabetes mellitus type 2 (E11.9). Per the ADA (2018), the first line treatment for type 2 diabetes mellitus upon diagnosis is Metformin monotherapy. Metformin is reported to have beneficial effects on HgbA1C levels, weight reduction, and reduces the risk of cardiovascular event and death (ADA, 2018). Rx: Metformin ER, 500 mg tablet Sig: Take one (1) tablet, by mouth, twice daily Disp: #60 (sixty), Ref: 2 (AACE/ACE, 2017; ADA, 2018; Epocrates, 2018) The use of Metformin has been proven to decrease the levels vitamin B12 deficiency; supplementation and a periodic screening should be performed (AACE/ACE, 2017; ADA, 2018). Rx: Cyanocobalamin (vitamin B12), 1000 mcg capsule Sig: Take one (1) capsule, PO, daily on empty stomach Disp: #30 (thirty), Ref: 2 (AACE/ACE, 2017; ADA, 2018; Epocrates, 2018) Treatment for hyperlipidemia (E78.5). The drug of choice is statins for lowering LDL cholesterol and protecting the heart (AACE, 2017). Patients age

≥

40 years old with DM can benefit from high-intensity statin therapy that can reduce the LDL by

≥

50% (ADA, 2018).

Rx: Simvastatin, 40mg tablet Sig: take one (1) tablet by mouth at bedtime Disp: #30 (thirty), Ref: 2 (AACE/ACE, 2017; ACC/AHA, 2017; ADA, 2018; Epocrates, 2018) Rx: Aspirin EC, 81mg tablet Sig: take one (1) tablet by mouth daily Disp: #30 (thirty), Ref: 2 (AACE/ACE, 2017; ACC/AHA, 2017; ADA, 2018; Epocrates, 2018) Patients with DM2 and hyperlipidemia are at risks for CAD and should be on a daily enteric- coated aspirin, unless contraindicated or a serious adverse event (Bullock-Palmer, 2015; ACC/AHA, 2017).

Treatment to reduce kidney damage due to microalbuminuria. Patients with DM and microalbuminuria are at risk for kidney damage and should be given an ACEI to protect the kidneys (ADA, 2018) Rx: Lisinopril, 2.5mg tablet Sig: take one (1) tablet by mouth daily Disp: #30 (thirty), Ref: 2 (AACE/ACE, 2017; ADA, 2018: Epocrates, 2018) Nonpharmacological treatment. Recommendations for lifestyle interventions such as diet and weight loss can significantly improve morbidities associated with obesity (Cefalu et al., 2015). The AACE/ACE (2017) suggests a minimum of 150 minutes/week of moderate aerobic exercise or 75 minutes/week of vigorous aerobic exercise to improve glycemic index. Incorporating a diabetic and heart healthy diet, which includes servings of fresh fruits and vegetables and limited amount of sodium to 2000mg/day can help reduce risks for a cardiovascular event and help balance the glycemic index (AACE/ACE, 2017). Monitoring blood sugar daily is highly recommended to keep a blood glucose level between 70-130 mg/dL before meals and after meals, a blood sugar of < 180mg/dL for diabetic management (AACE/ACE, 2017; ADA, 2018). Rx: Glucometer x Lancets- Disp #100 (1 box) Test Strips- Disp #100 ( boxes) Alcohol pads- Disp # 1 box Sig- Test BG twice daily before breakfast and dinner, Disp# as indicated, Ref: # Education Diagnosis. Mrs. R. will need to be educated on the management and the possible complications associated with DM2, hyperlipidemia, and obesity, if not managed (Redmon et al., 2014). Diabetes occur when there is not enough insulin being produced by the pancreas to break down the sugar in your blood and convert it into energy (ADA, 2018). Teach Mrs. R. about signs and symptoms of hypoglycemia and hyperglycemia and when to seek medical attention (Redmon et al., 2014). When your blood glucose is elevated, usually above 180 mg/dL, this is known as hyperglycemia, and symptoms of fatigue, increased hunger, increased thirst, headache, and

frequent urination are present (Redmon et al., 2014). Hypoglycemia is the opposite of hyperglycemia, where you have low blood sugar, usually the level is 70 mg/dL or below. Your body does not have enough glucose to use as fuel and symptoms present as an irregular heart rate, fatigue, pale skin, shakiness, anxiety, sweating, hunger, and irritability (Redmon et al., 2014). You will need to monitor your blood glucose level using a glucometer and I recommend you keep a log journal of your glucose readings. You will need to bring the journal at your next follow up visit, so we can see the trends and adjust your treatment plan as needed (Redmon et al., 2014). Your lab results show you have an elevated cholesterol level, and along with obesity and diabetes, places you at a high risk for coronary artery disease (Bullock-Palmer, 2015). Coronary artery disease is the thickening of the arterial wall, which if not managed, could block the blood flow and could lead to a stroke and even death (Bullock-Palmer, 2015). In addition, the leading cause of death among minority females is heart disease, which can be prevented by following a healthy lifestyle, such as eating a heart healthy diet, minimizing alcohol intake, exercise and weight loss (Bullock-Palmer, 2015). Medications. You will need to take your medications as prescribed to manage your diabetes and cholesterol. I will place you on Metformin for diabetes management to control blood sugar levels (ADA, 2018; Epocrates, 2018). Common adverse effects of Metformin include nausea, vomiting and abdominal bloating (Epocrates, 2018). Taking Metformin can cause vitamin B levels to decrease, which could lead to pernicious anemia, therefore, it is imperative that you take vitamin B12 supplement as prescribed (ADA, 2018). Symptoms of pernicious anemia are rapid breathing, weakness, fatigue, light-headedness, and rapid heartbeat, (Hollier, 2016).

Because you have protein in your urine from your lab results, I will also prescribe Lisinopril, which is a blood pressure medication that could cause dizziness or lightheadedness, which are signs of hypotension and you should notify me or my office if any of these symptoms occur (Redmon et al., 2014). ACE inhibitors, such as lisinopril, can help protect your kidneys from being damaged as Metformin is excreted through the kidneys (ADA, 2018). I would like you to take Simvastatin daily to manage your cholesterol and reduce your risks of CAD (Bullock- Palmer, 2015). Because you have DM2 and hyperlipidemia, your risk for CAD is very high, therefore you will need to take a daily aspirin to prevent or reduce the risk of a cardiovascular accident (CVA) (Bullock-Palmer, 2015). Aspirin helps slow down the formation of the platelets in your blood, which in turn reduces the risk of getting a blood clot (Dunphy et al., 2014). Diet. You will need to modify your diet to a diabetic and heart healthy diet to achieve weight loss, as well as manage your diabetes and cholesterol. The ADA (2018) does not recommend a rigid diet but rather recommend a low-calorie diet, a low saturated fat diet, and liberal in complex carbohydrates. In addition, the ADA (2018) recommends increasing high fiber content, cereals, grains, fruits and vegetables to improve glucose tolerance. Simple carbohydrates are discouraged, and intake of refined carbs and animal fats should be decreased (ADA, 2018). Exercise. Weight loss through diet and exercise can improve your glycemic control. According to Goroll (2014) and the ADA (2018), a combined aerobic and resistance training has been proven to be more effective than by doing either training alone to reduce glycosylated hemoglobin levels. Recommended exercise for a patient with DM2 is a minimum of 150 minutes/week of moderate aerobic exercise or 75 minutes/week of high intensity aerobic exercise to improve insulin resistance (AACE/ACE, 2017; ADA, 2018). Since you have arthritis on your

left knee, I would recommend water aerobics or any type of exercise that has low impact activity (Kennedy-Malone, 2014). Warning signs. You will need to know the associated signs and symptoms of hypoglycemia and you should be aware of the treatment, such as drinking a cup of orange juice or eating crackers with peanut butter to increase your blood glucose level. Also, it is important that you are aware of the signs and symptoms of hyperglycemia, as high blood sugar could lead to diabetic ketoacidosis, which will require medical intervention (AACE/ACE, 2017; ADA, 2018). DM2 can cause poor circulation to the extremities therefore you will need to monitor your feet daily for cuts, scrapes, wounds, or any changes in the coloring of your skin and feet. Avoid soaking your feet in hot water, and do not apply lotion between your toes. Also, do not walk barefoot and be cautious with clipping your nails. Let me know if any wounds are present (Redmon et al., 2014). With DM2, you are at risk for diabetic retinopathy, which is damage to the blood vessels in the light-sensitive tissue located in the back of the eye, known as the retina (Dunphy et al., 2014) According to the ADA (2018), diabetic retinopathy is the most common cause of blindness in adults aged 20-74 years. You will need to see an ophthalmologist or an optometrist to examine your eyes as the ADA (2018) recommends a comprehensive eye examination and initial dilated eyes performed by an ophthalmologist or optometrist at the time of diagnosis. Referrals Diabetic educator. Mrs. R. should be referred to a diabetic educator for diabetes self- management education and for glucose management (ADA, 2018). The diabetic educator can also teach Mrs. R. about the proper way to monitor her blood glucose level using a glucometer (ADA, 2018).

Registered dietician. According to Dunphy et al. (2015), meal planning and nutrition therapy is the most fundamental and the most challenging in managing diabetes. A registered dietician can help Mrs. R. meet the goal of maintaining blood glucose level, lipid, and blood pressure goals with the proper nutrition. Podiatrist. According to the AACE/ACE (2017) and Dunphy et al. (2018), the leading cause of non-traumatic lower extremity complications, such as an amputation due to peripheral vascular disease (PVD), is DM2. Dunphy et al. (2015) recommends a referral to a podiatrist for problems involving the feet. Ophthalmologist/optometrist. The leading cause of blindness is DM2 in adults 20- years old, in which 25% of newly diagnosed patients presents with retinopathy (ADA, 2018; Dunphy et al., 2015). The ADA (2018) recommends that a comprehensive dilated eye examination should be performed annually by an ophthalmologist or optometrist to evaluate for diabetic retinopathy. Nephrologist. According to Dunphy et al. (2015), annual screening for serum creatinine and urinalysis for patients with DM2 is key to protecting the progression of renal damage. The ADA (2018) recommends screening should begin at the time of diagnosis and followed every year because among those diagnosed with DM2, 20%-40% will progress to hyperalbuminuria and about 15%-20% will progress to renal disease. Follow-up I would recommend that Mrs. R. follow up with me in two weeks to review her blood glucose log and effectiveness of her medication. I will advise her to come in to the office sooner or seek medical emergency care if her symptoms persist or if adverse reactions to medication occurs. A stepwise approach to managing Mrs. R’s DM2 is recommended to allow evaluation of drug efficacy, possible drug adverse reactions, and avoiding prolonged treatment with medications, which are ineffective or unnecessary drugs with concomitant side effects and safety issues at high costs (Raz, 2013; ADA, 2018).

Medication costs For Mrs. R’s medications, I decided to use Walmart pharmacy’s $4 prescription list because medications listed in the $4 prescription list do not require insurance coverage. In addition, Walmart is located nationwide, which will allow Mrs. R. to have access to her medication if and when she travels. The medications that I had ordered for Mrs. R. are all listed in the $4 prescription list with the exception of the OTC medication, which are the aspirin and vitamin B12. According to Walmart (n.d.) a 30-day supply of Metformin ER 500mg (60ct.) is $ and Lisinopril 2.5mg (30ct.) cost $4 each. A 30-day supply of Simvastatin 40mg (30ct.) is $ (Walmart, n.d.). Walmart (n.d.) also sells 300ct bottle of their generic brand of OTC low dose aspirin enteric coated 81mg for $4. Vitamin B12 1000mcg is also available OTC at 60ct tablets per bottle manufactured by Nature Made for $5.09/bottle. Calculating Mrs. R.’s monthly cost for her medication without insurance coverage will be a total of $21.09. She would save more by getting the 90-day supply which would be a total of $39.09. As for her blood glucose monitoring supplies, Walmart pharmacy carries the supplies she will need to monitor her blood glucose. The ReliOn Prime glucometer is their best seller and is priced for $9 (Walmart, n.d.). The test strips (100ct./box) are priced for $17.88 (Walmart, n.d.). The lancets are $2.52 for a box of 200 count and the alcohol swab of twin pack (200 ct./pack) for $3.74 (Walmart, n.d.). Her monitoring supplies will total to $33.14 for the first month and will decrease by $9 due to her not needing to buy another glucometer. So, the total for both the medications and the monitoring supplies for the first 30-day supply is $54.23. The medications ordered for Mrs. R. was not adjusted because of cost. I will most likely use medication pricing resources in my future practice. From my clinical experience, patients are more apt to be compliant with their medication if the medication is affordable.

SOAP Note Patient Information: Mrs. R., 56-year-old, female, Hispanic S: (Subjective) Chief Complaint: Severe fatigue, polyuria, polydipsia, polyphagia, weight gain despite exercise HPI: Patient present to the clinic for a follow up visit and reports of being very fatigued and have no energy at all. The onset of her symptoms was 3 months ago. She also reports that she gained weight despite her attempts to exercise. She walks on the treadmill for 30 minutes twice per week. Current Medications: Tylenol 500 mg, PO, 2 tabs in AM for left knee pain, daily multivitamin Allergies : NKDA, allergic to cats and pollen. No latex allergy PMHx: She has left knee arthritis. Had mumps as a child All vaccines up to UTD PSHX: none stated Health screening: No hx of abnormal pap smear Soc Hx: Recently separated, works from home part time as a wedding coordinator, non-smoker, occasionally has 1-2 glass of wine on weekends, no illicit drugs use. Fam Hx: Parents alive, well, child alive, well. No siblings. Mother has HTN and father has high cholesterol. ROS: General: Denies headache, vision changes, night sweats, fever. She reports difficulty losing weight despite exercising. Respiratory: No SOB, no cough

Musculoskeletal: arthritis to left knee O: (Objective) Physical Exam: BP: 118/80; HR 76; RR 16; Hgt: 5'2.5"; Wgt: 165 lbs; BMI: 29.7 (weight gain of 3 lbs within 3 months) General: Obese female. Alert, oriented and cooperative. No acute distress 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. Anterior cervical lymph nontender 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: CTA bilaterally, respirations unlabored. Abdomen: soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT. Diagnostic or Lab results : (Fasting labs) CBC: WBC (6,000/mm3), Hgb (12.5 gm/dl), Hct (41%), RBC (4.6 million), MCV ( fl), MCHC (34 g/dl), RDW (13.8%) UA: pH (5), SpGr (1.012), Leukocyte esterase (-), nitrites (-), 1+ glucose; small protein; Ketones (-) 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),GFR est AA(101 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 ( 0.9 ng/dL) Cholesterol: TC (230 mg/dl), LDL (144 mg/dl); VLDL (36 mg/dl); HDL (38mg/dl), Triglycerides (232) EKG: normal sinus rhythm A: (Assessment) Primary Diagnosis: Diabetes Mellitus type 2 (E11.9) Secondary Diagnosis: Hyperlipidemia (E78.5)

Differential Diagnoses: Obesity (E66.9) P: (Plan) Diagnostics: Repeat HgbA1c/fasting blood glucose PHQ-9 questionnaire Vitamin D and folate levels Vitamin B12 level 24-hr urine sample and random spot albumin/creatinine ratio Medications: Metformin ER 500 mg tablet (treatment of DM2) Sig: Take 1 tablet, by mouth twice daily, Disp: 60 Refill: 2 Cyanocobolamin (vit B12) 1000 mcg capsule (suppl for B12 deficiency caused by Metformin) Sig: Take one (1) capsule, by mouth, daily on empty stomach, Disp: #30 (thirty), Refill: 2 Aspirin EC, 81mg tablet (treatment/preventative for CVD) Sig: Take one (1) tablet, by mouth, daily Disp: #30 (thirty), Refill: 2 Simvastatin, 40 mg tablet (treatment for hyperlipidemia) Sig: Take one (1) tablet, by mouth, daily at bedtime, Disp: #30 (thirty), Refill: 2

Lisinopril, 2.5 mg tablet (treatment/preventative for CKD) Sig: Take one (1) tablet, by mouth, daily, Disp: #30 (thirty), Refill: 2 Glucometer x1 (for BG monitoring) Lancets- Disp #100 (1 box) (for BG monitoring) Test Strips- Disp #100 (2 boxes) (for BG monitoring) Alcohol pads- Disp # 1 box (for BG monitoring) Sig- Test BG twice daily before breakfast and dinner, Disp# as ordered, Refill: 0 Education: Discussed DM2 and hyperlipidemia diagnosis. Discussed diagnostic repeat labs to confirm and manage diagnosis Reviewed medications and to take them as prescribed Recommend modification of diet and lifestyle Recommend blood glucose monitoring twice daily Encourage weight loss through diet and exercise to improve glycemic index Discussed possible complications of diagnosis if not managed Discussed referrals to specialist to help manage DM Discussed when to seek for medical emergency Referrals : diabetic educator, registered dietician, podiatrist, ophthalmologist/optometrist, and nephrologist Follow up: Patient to return to the office in 2 weeks to review her lab results, blood glucose log and effectiveness of medication. Patient will need to come in to the office sooner or seek medical emergency care if symptoms persists or if adverse reactions to medication occurs. Call 911 if experiencing chest pain or shortness of breath.