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NR601 Case Summary Presentation Week 6 Patient Information: Ms. S., 62 year-old , Black female S. CC “Reports increased thirst, hunger, frequent urination and fatigue” HPI : Ms. S. is a 62-year-old black female, returned to the clinic today to discuss her concerns about her difficulty to lose weight despite her lifestyles changes. She reports feeling extremely thirsty and hungry with increased exercises. She has increased urination, and feeling tired all the time. O nset: Three months ago L ocation: General and genitourinary D uration: She feels tired all the time. C haracteristics: Weight unchanged despite lifestyles changes A ggravating Factors: She feels more thirsty and hungry with exercises, thus eats and drinks more secondary to that. R elieving Factors: none reported Treatment: None reported S everity: She eats and drinks more due to increased exercise, which is causing her not to lose the weight that she wants to lose. The increase in thirst has her urinating more as well and has interfered with her outings with her friends. Current Medications : None reported. Allergies: NKDA PMHx : Unknow Social Hx : None reported.
Fam Hx : Unknown. ROS : Constitutional: Reports no fever, chills/or malaise. She said she had hard time losing weight despite exercising.
Thyroid panel: normal LFTs: normal Cholesterol: total cholesterol (206), LDL elevated; HDL is low EKG: normal A Primary Diagnosis: Diabetes mellitus type 2 (E11) : metabolic diseases characterized by hyperglycemia due to insulin resistance and inadequate compensatory resulting insulin secretory response and it’s common among obese people (Pippitt, Li, & Gurgle, 2016). Type 2 diabetes is due to a progressive loss of b-cell insulin secretion frequently on the background of insulin resistance. Symptoms that should prompt consideration of diabetes include: urinating often- feeling very thirsty -feeling very hungry even though you are eating- extreme fatigue- blurry vision- cuts/bruises that are slow to heal - tingling, pain, or numbness in the hands/feet (American Diabetes Association, 2017). Ms. S. cannot lose or lost very little weight- complaints of extreme thirst, hunger, and frequent urination (polydipsia, polyphagia, polyuria), and fatigue all the time. Being an African American, the risk of diabetes is 77% higher. DM type 2 is the primary diagnosis because based on the subjective data: Ms. S. cannot lose or lost very little weight- complaints of extreme thirst, hunger, and frequent urination (polydipsia, polyphagia, polyuria), and fatigue all the time. Being an African American, the risk of diabetes is 77% higher. In addition, the lab results revealed: glucose of 300 mg/dL and hemoglobin A1C of 12 %. Secondary Diagnoses: Diabetic Nephropathy: (E11.21 ) + 1+ protein in the urine. + Glucose 300 mg/dL. Hypertension: (I10): BP: 145/90 mmg/Hg Hyperlipidemia : (E78.5): +Total Cholesterol: 206, LDL: elevated, HDL: low. Obesity (Z68.41): diagnosed according to BMI. Individual with a BMI >= Individuals with a BMI equal to 30 kg/m2 are classified as obese, and those with a BMI of 25 to <30 kg/m2 are overweight
(AACE/ACE, 2015; ADA, 2017).
Major depressive disorder, recurrent, mild (F33.0) - mental disorder that causes changes in mood, thoughts, behavior and physical health such as loss of interest in activities (anhedonia), sleep disturbances, fatigue or energy loss (Gayness, Jackson, & Rorie, 2015). Patients with specific medical co-morbidities such as diabetes, congestive heart failure, dementia, cerebral vascular accident or myocardial infarction, chronic pain, and cancer are at higher risk of having or developing a depressive disorder than the general population (Siu, & USPSTF, 2016). Additional lab work/screenings: Serum B12 level for screening of B12 deficiency because metformin has been reported to cause a decrease in serum B 12 concentrations. 2-hour glucose tolerance test (Abnormal 2-hr PG 200 mg/dL (11. mmol/L) during OGTT (75-g) (Goroll, & Mulley, 2014; Kennedy-Malone, Fletcher, & Plank, 2014). eGfr for screening of chronic kidney disease (AACE/ACE, 2015). Screening for microalbuminuria (AACE/ACE, 2015). Screening for depression (PHQ9) (AACE/ACE, 2015). Plan Pharmacological treatment
• Oral antidiabetic such as Glucophage 850 mg po BID.
Glucophage has a hypoglycemic effect and also causes a decrease in appetite that will promote weight loss.
• Metformin 500 mg 1 tablet by mouth twice a day.
• Glipizide 5mg orally daily
• Vitamin B12 50mcg orally daily for prevention of B12 deficiency
vaccine as well (AACE/ACE, 2015). Patient education: Disease specific teaching (Hollier, 2016). Dietary management is crucial, and its effect on lowering blood sugar (AACE/ACE, 2015; ADA, 2017). Reduce caloric and sugar intake and increase healthy foods such as plenty of fruits, vegetables and whole grains and foods that are high in nutrition and low in fat and calories (AACE/ACE, 2015; ADA, 2017; Erlandson, Ivey, & Seikel, 2016). Emphasizing portion control and healthy food choices (AACE/ACE, 2015; ADA, 2017; Erlandson, Ivey, & Seikel, 2016) Educate patient to limit sodium consumption to <2,300 mg/day (Model, 2015; Erlandson, Ivey, & Seikel, 2016). Keep a food diary starting today to better assess his diet (AACE/ACE, 2015; ADA, 2017; Model, 2015; Erlandson, Ivey, & Seikel, 2016). Increase high fiber content and decrease intake of refined carbs and animal fats. Increase cereals, grains, fruits and vegetables to improve glucose tolerance (AACE/ACE, 2015; ADA, 2017). Educate patient about Diabetes Mellitus and the possible complications if blood sugar levels are not well-controlled (AACE/ACE, 2015; ADA, 2017). Per American Diabetes Association, diet should be low in calories, low in saturated fats and liberal in complex carbohydrates (ADA, 2017). Educate patient on how to use the glucometer to effectively check and record her BS readings daily (AACE/ACE, 2015; ADA, 2017). Educate on the signs and symptoms of low and high blood sugar, and when to call 911 in case of an emergency (Dunphy et al., 2015).
Recommend patient to check blood glucose values before meals and at bedtime, during (if prolonged activity), and after exercise (Model, 2015). Encourage physical activity (Regular activity will improve insulin sensitivity and lipid levels, lower blood pressure, assist in weight loss) (AACE/ACE, 2015; ADA, 2017; Model, 2015; Erlandson, Ivey, & Seikel, 2016). Increase activity to minimum of 30 min/day or more of moderate or vigorous intensity aerobic activity (Model, 2015). Educate patients the importance of maintaining ideal body weight (AACE/ACE, 2015; ADA, 2017; Model, 2015). Encourage patient to be compliant with medications prescribed for disease control and complications prevention. Patient should be educated about side effects of metformin such as diarrhea, nausea, vomiting, flatulence, indigestion, abdominal discomfort, anorexia, headache, and metallic taste. Lisinopril S.E include dizziness, headache, diarrhea, hypotension, cough, and fatigue (AACE/ACE, 2015; ADA, 2017). Educate patient that Statins such as Lipitor can cause digestive problems, blood sugar problems, muscle aches and stiffness, muscle injury, kidney damage, or liver damage. She has to report symptoms immediately to the provider or stop taking this medicine if these problems occur. Let patient know that she is at higher risks for theses side effects if she takes more than one medicine for cholesterol, or have liver disease, kidney disease, or diabetes. Instruct patient that eating grapefruit or drinking grapefruit juice can raise her risk of liver damage while taking Lipitor (Bolin, 2016). Educate about skin examination especially feet for pulses, cleanliness, odor, swelling, nail thickness, bruises, and pressure points (Dunphy et al., 2015). Encourage to join community groups dedicated to a healthy lifestyle for emotional
ophthalmologist to evaluate for the presence of retinopathy (Dunphy et al., 2015; Model, 2015). Consider referring patient to an endocrinologist if patient is unable to achieve glycemic control despite treatment regimen compliance. References American Diabetes Association (2017). Standards of Medical Care in Diabetes. Diabetes Care 2017; 40(Suppl. 1):S11-S24. doi: 10.2337/dc17-S American Association of Clinical Endocrinologists and American College of Endocrinology (2015). Clinical practice guidelines for developing a diabetes mellitus comprehensive care plan. Endocr Pract 2015; 21(Suppl 1):1-87. doi: 10.4158/EP15672.GL Bolin, C. S. (2016). Evaluation of Treatment for High Cholesterol and Prevention of Cardiovascular Disease in Primary Care. Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: The art and science of advanced practice nursing (4th ed.). Retrieved from http://online.vitalsource.com Erlandson, M., Ivey L.C., & Seikel, K. (2016). Update on Office- Based Strategies for the Management of Obesity. American Family Physician ; 94(5):361-8. Retrieved from http://www.aafp.org/afp/2016/0901/p361.html Gaynes, B. N., Jackson, W. C., & Rorie, K. D. (2015). Major depressive disorder in the
primary care setting: Strategies to achieve remission and recovery. Journal of Family Practice , 64(9), S4-S4. doi: 10.1370/afm. Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and management of the adult patient (7th ed.). Retrieved from http://online.vitalsource.com Kennedy-Malone, L., Fletcher, K., & Plank, L. (2014). Advanced practice nursing in the care of older adults. Retrieved from https://bookshelf.vitalsource.com Model, C. C. (2015). Standards of medical care in diabetes: 2015 abridged for primary care providers. Diabetes care , 38(1), S1-S94. doi: 10.2337/diaclin.33.2. Pippitt, K., Li, M., & Gurgle, H. (2016). Diabetes mellitus: Screening and diagnosis. American Family Physician , 93(2), 103-109. Retrieved from http://www.aafp.org/afp/2016/0115/p103.html Siu, A. L., Bibbins- Domingo, K., Grossman, D. C., Baumann, L. C., Davidson, K. W., Ebell, M., & Krist, A. H. (2016). Screening for depression in adults: US Preventive Services Task Force recommendation statement. Jama, 315(4), 380-387. doi:10.1001/jama.2015.
