Diabetes Mellitus and Hyperlipidemia Case Study

The case scenario of this class considers Mrs. W. who is a 59-year-old Asian female. She came to the office for a planned three-month follow-up visit for her diagnosed knee arthritis. The patient reports less pain and increased mobility; it is a sign of the improvement of the right knee condition that was diagnosed with arthritis. Therefore, one may assume that the treatment plan is working well. However, the woman shares a new concern during her visit. She reports that she has experienced increased fatigue for about 12 weeks. In addition, she reports that since her menopause four years ago, she has been experiencing weight gain. She has a health club membership and visits the club twice a week. As a part of her exercise, she works out on the treadmill for at least 30 minutes and lifts lightweights upon the recommendation of the doctor. However, despite these exercises, she lost no weight; instead, she gained another four pounds. Therefore, she does not understand the reason for this gain. More so, she reports that exercise seems to be directly contributing to the high levels of hunger and thirst that she experiences; thus, it does not help in her weight loss. Because of these events, she asks for another health assessment to understand why she is so tired and define the best way to lose weight for her. She reports she has to go to the bathroom oftener; thus, she has to wake up at night to urinate, as well as do the same during the day more frequently. Mrs. W. has struggled with this condition for three months and it has irritated her all the time. The condition has come with negative effects on her overall health and hence the need for a clear diagnosis and recommendation of the best approaches to manage these conditions. Nevertheless, she manages to get back to sleep immediately after urination.

This paper strives to conduct the assessment of the primary, secondary, and differential diagnosis for Mrs. W. The work also outlines different stages of the treatment plan for a defined diagnosis. The management section of the work includes the methods used in the process of diagnosis, medications, education, referrals, and follow-up care, as well as any other activity that could be done under the continuum of care. The paper also covers calculations of the treatment by giving a rough estimate of the treatment costs. The treatment cost estimation will help doctors and clinician to predict what they will need to provide the patient with adequate treatment.

Assessment

The information given by the patient when she came to the office shows that the symptoms of her major presenting clinical problem include the issue of increased fatigue caused by any light activity. It was a new issue in her history of present illness. The fatigue is accompanied by the increase in weight that has progressed for more than four years after her menopause. As a rule, her sleep time is interrupted by the need to urinate at night, but she gets back to sleep immediately afterward.

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Additionally, usually, especially when exercising, she gets extremely thirsty and has to drink a lot of water. According to the assessment by the doctor, her blood pressure is normal at BP 112/76 and the respiration is regular with normal breathing and no breathing complications. With a height of 5 feet and 1.5 inches, she weighs 165 pounds translating to a BMI of 30.67 kg/m2; this figure indicates class I obesity. The patient hence needs to lose a total of 30.5 lbs. to reach the normal BMI of 25. The weight measurement gives a Ponderal Index of 19.63 kg/m3. According to it, she is obese; the problem needs to be managed in the most effective way possible.

Generally, the patient is well-oriented and cooperative; also, she has no cumulative distress. She can answer questions and respond to the doctor well; this ability is an indication of emotional well-being. Her skin has no lesions; it is warm and dry. It is intact with no suspicion of any inflammatory disorders. The heart sounds and the blood pressure is normal. These data suggest the normal functioning of the cardiovascular system without any complications. The Hb level and hematocrit are normal; the white blood cell count indicates that the patient has no signs of infection in the body.

Primary Diagnosis

Undiagnosed diabetes mellitus (E13). Diabetes mellitus is a condition that makes the body unable to regulate the level of sugar normally. In diabetic patients, the blood sugar level increases above the normal level in the human body. The disease prevents the body from using the energy derived from the food that one consumes (Wilding, 2014). Undiagnosed diabetes mellitus is diabetes that has not been categorized to either type one or type two. However, it is determined that it results into a substantial increase in the blood glucose level. Most cases of the undiagnosed blood glucose level do not cause such severe symptoms as coma or hypoglycemia, but contribute to the development of borderline symptoms, including thirst, excessive fatigue, and excessive urination. Thus, it is critical to always monitor these symptoms among patients in the best ways possible. The three symptoms are the key warning signs for diabetes mellitus. Diabetes mellitus can occur in scenarios, which include the production of less insulin or no insulin from the pancreas or in the case when the pancreas is capable of producing insulin but the insulin does not work in the manner that it ought to work. The normal blood sugar level should range from 4.0 to 5.4 mmol/L (72 to 99 mg/dL) (Workman & LaCharity, 2015). In addition, it can rise to 7.8mmol/L (140mg/dl) during two hours after meals.

• Rationale. The patient has a glycosylated hemoglobin level of 6.8%, which is higher than the normal range of 4% -5.6% (Wilding, 2014). The diabetes is undiagnosed because the blood glucose level is still low at 130 mg/dl. The presence of three constitutional symptoms, including extreme fatigue or the lack of energy, weight gain, unusual thirst, and frequent urination, are clear indicators that the patient is developing diabetes mellitus. However, it is worth noting that Mrs. W. is only on the verge of developing the disease and it has not caused any serious symptoms yet. Coupled with old age, diabetes is one of the clearest health conditions that the patient has.
• Hyperlipidemia (E78.5). Hyperlipidemia is also referred to as dyslipidemia, which is a collective term for disorders that develop because of the impaired lipid metabolism and cause the unbalanced blood composition. In the case of this condition, the patient has an increased concentration of lipids in the blood, which makes the patient vulnerable to the blockade of blood vessels because of the development of atheroma (Jafri, et al., 2015). The normal values of lipids in the blood are the following; low-density lipoprotein (LDL) – more than 100 mg/dL, triglycerides (TGs) – more than 150 mg/dL, total cholesterol (TC) – more than 200 mg/dL, and high-density lipoprotein (HDL) – more than 60 mg/dL. When the blood values of a patient are higher than the provided lipid figures, the patient is said to have hyperlipidemia. Initially, the patient may face only symptoms of the increased lipid level; however, with time, the patient can develop the coronary artery disease or hypertension. In most cases, the condition progresses to result in heterogeneous diseases and other lifestyle diseases. There are other disorders that can cause dyslipidemia, including hepatic disorders, obesity, nephrotic syndrome, end-stage renal disease (ESRD), Cushing’s syndrome, estrogen administration, alcohol overuse, and the glycogen storage disease (Jafri, et al., 2015). When dyslipidemia is caused by other diseases in the body, it is termed as secondary dyslipidemia. The disease can make an individual gain weight and develop a general feeling of tiredness, thus complicating the routine life of a patient. In most cases, this condition predisposes an individual to hypertension.
• Rationale. One of the major complaints of the patient is the weight gain in the past three months despite working out hard in the gym and lifting weight upon the recommendation of the nurse. This complaint is obvious in the lipid pattern that influences her treatment plan. The hyperlipidemia can be treated by both the pharmacological means and changes in the lifestyle (Jafri, et al., 2015). The hyperlipidemia can be divided into two types, namely secondary hyperlipidemia and secondary hyperlipidemia. Primary hyperlipidemia comes independently of the underlying condition, while the secondary hyperlipidemia is caused by another underlying condition that makes the patient vulnerable to the condition of abnormal metabolism of lipids. The lipid pattern of the patient exceeds the normal parameters. For example, her LDL is 144 mg/dl, the triglyceride is 229, and VLDL was 36 mg/dl, while her HDL is 32mg/dl. These figures confirm that Mrs. W. has issues with the regulation of lipids.

Secondary Diagnosis

Unilateral primary osteoarthritis, right knee (M17.11). It is one of the degenerative diseases that come with old age. The disease affects the synovial joints that result from the increased predisposition to trauma or infection in the joints. The disease causes achy stiff joints that come with pain. The disease does not come at once but develops gradually to reach chronicity (Jotanovic, Mihelic, Gulan, Sestan, & Dembic, 2015). In such cases, the patients may experience some symptoms but disregard them for a long time because of the minor effect they have in the beginning. However, it may develop into serious conditions when not taken care of at the initial stages. The seriousness of the disease begins to manifest when the cartilage that covers the bone starts to wear out, thus losing smooth movement. The breakdown makes the bones in these areas react; it may happen through the development of the growth and spurs. In most cases, the cartilages fail to stretch and become more susceptible to being injured. Inflammation in the joints leads to damages in these tissues. Intense pain is often felt when the bones come into contact with one another. The fact that the patient experiences fatigue could be a consequence of the influence of the body weight on the joints, which are already affected by arthritis.

Rationale. The patient applies to the clinic with fatigue and weight gain as the major disturbing symptoms. Fatigue is the most troublesome symptom of arthritis, and the fact that the patient is recovering cannot make one erase arthritis from the list of the major diagnosis of the patient (Woo & Robinson, 2016).

Differential Diagnosis

Post-menopausal syndrome (E13). Postmenopausal syndrome is common in the period after menopause; it is mainly caused by the deficiency of certain hormones. This condition is more common in women as compared to men. At this age, most females throw off certain symptoms, including hot flashes, since the patient has low levels of estrogen now. However, the low level of estrogen makes patients vulnerable to other health conditions, including heart diseases and osteoporosis (Kothiyal & Sharma, 2013). Normally, the post-menopausal symptoms start approximately one year before menopause and proceed up to five years after the beginning of menopause. Some women may exhibit longer-lasting symptoms; the intensity of effects depends on the hormonal balance in the body.

Rationale. This diagnosis is anchored on the understanding that the patient is at a menopausal age. However, the diagnosis cannot be conclusive due to the lack of enough subjective and objective data to prove that the patient experiences the mentioned symptoms because of the lack of estrogen (Kothiyal & Sharma, 2013). Thus, the current condition of the patient based on the menopause she experienced four years ago is a significant indicator of the condition.

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Management Plan

Diagnostics

Repeat the HgbA1c/fasting glucose test. It is crucial to verify the blood sugar regulation ability of the patient. In order to achieve this aim, the clinician repeats either the HgbA1c or the fasting glucose level tests. The rationale for this decision considers the fact that the patient has increased HgbA1c of 6.8%; in its turn, it is an indicator of the chronic blood sugar dysregulation. The two tests should be combined with a 2-hour oral glucose tolerance test (OGTT) for the holistic diagnosis of diabetes mellitus type II (Thent, Srijit, & Henry, 2013). To test the patient for diabetes type II comprehensively, the second test is to be utilized. It is a sound decision if a patient experiences special conditions, for example, a hypertensive crisis or the random plasma glucose level of over 200mg/dL. The test should be repeated again for the confirmation of the diagnosis of the DM II for the nurse to decide on the medications to be included in the management plan.

PHQ-9 questionnaire. Before administering the questionnaire, it is imperative to review the medical history of the patient. The medical history will provide the ground for this test. Not all points in the questionnaire are meant to evaluate depression as some are asked to determine other mental conditions (Woo & Robinson, 2016). From the social history, Mrs. W’s parents are dead, has no siblings, is a former smoker, and is divorced. All these factors could be significant contributors to the possible stress and depression. In such a manner, Mrs. W. should be screened for stress and depression. Her social life predisposes her to psychological challenges. For example, she asserts that she separated from her spouse a few years ago and now lives as a divorced woman. She is also a working-class female; therefore, it is possible that she faces additional challenges in her place of work. Patients that have challenges in their marital life, experience the loss of major properties, financials crisis, lose a job, or develop terminal illnesses are more vulnerable to the development of depression. Patient Health Questionaire-9 can assist in diagnosing the severity of depression in the patient in the case she has any (Woo & Robinson, 2016). The test is convenient and takes the patient a few minutes to go through it; also, it is not invasive and is likely to be accepted by the client together with other prescribed tests.

Urine glucose test during 24 hours. The urine analysis of the patient revealed +1 glucose; the figure encourages the clinician to test the urine of the patient again during the next 24 hours in order confirm whether the patient has glucose in urine or not.

Vitamin D and folate levels. The lab test should be conducted on the folate and vitamin D levels in the patient’s serum. The fatigue that the patient complains could be caused by the insufficient levels of these two important elements in the body (Woo & Robinson, 2016). The examination can also extend to testing the patient for anemia. If the two levels were stable, it would be easy to narrow down the diagnosis.

Serum vitamin B12: For diabetic patients, the long-term use of Metformin leads to a deficiency in serum vitamin B12. Thus, it would be important to conduct a serum vitamin B12 screening on Mrs. W. to ensure that the concentration is at the normal levels. Notably, vitamin B12 is critical in keeping the body’s nerve and blood cells in a heathy state while also ensuring that DNA is generated in the cells (Aroda et.al, 2016). It also helps in the prevention of megaloblastic anemia that is responsible for tiredness and weakness among individuals (Aroda et.al, 2016). Therefore, Mrs. W. should have normal levels to have normal body functioning.

Medications

The treatment of diabetes mellitus type 2 (E11.9). The first-line treatment of type 2 diabetes after the diagnosis is the metformin immunotherapy. The reason as to why metformin is preferred is that of the benefits it offers in reducing the levels of HgbA1C, mitigating the risk of the development of cardiovascular conditions, and losing the weight. The patient will receive Metformin ER, 500 mg tablets for the oral use twice a day. The dosage will mean 60 tablets a month (Workman & LaCharity, 2015).

However, in many cases, the use of Metformin reduces the level of vitamin B12; therefore, it is crucial to supplement the level of this vitamin and screen the patient periodically to check any adverse effects of the metformin on the patient (Woo & Robinson, 2016). As a result, the clinician will make an additional prescription, including Cyanocobalamin (vitamin B12), one 1000 mcg capsule for the oral use daily. The patient must take a capsule on an empty stomach. The total dosage is 30 capsules a month

The treatment of hyperlipidemia (E78.5). The drugs chosen for this condition are statins, for example, simvastatin atorvastatin. They are popular for their effectiveness in protecting the heart and lowering the LDL cholesterol. Patients, aged 40 and older, benefit from the high-statin therapy because it helps decrease the LDL-C levels by at least 50%. The patient is treated with Simvastatin 40mg tablets; one tablet a day for the oral use at the bedtime (Fuster, 2016). The total dosage is thirty tablets a month. In addition, to prevent cases of the platelet aggregation, the patient should be given Aspirin EC, 81mg tablet per day for the oral use. The total number is 30 tablets a month.

Treatment to reduce kidney damage due to Diabetes Type II: Any patient suffering from diabetes is at risk for kidney damage and should be given an ACEI to guard their kidneys against this damage. The medications that I will recommend for Mrs. W. in regard to protecting the kidney will include;

Rx: Lisinopril, 2.5mg tablet (Epocrates, 2018)

Sig: take one (1) tablet by mouth daily

Disp: #30 (thirty), Ref: 2

Nonpharmacological treatment. The patient should take a keen interest in exercises to force weight loss and improve the diet by developing balanced nutrition. These measures will help in slowing down the weight gain even in the case of the treadmill activity only. When the patient can successfully monitor the two Nonpharmacological aspects, the morbidity associated with diabetes is likely to reduce (Fuster, 2016). The patient can have evening runs twice a week and also engage in aerobic exercises for at least 30 minutes thrice a week. The patient can also lift manageable weights for manageable repetitions twice a week. The vigorous aerobic program should be developed to help the patient improve the glycemic index.

In addition, the patient should monitor proper sleeping hours to avoid predisposing herself to complications caused by dysmetabolism. The amount of salt used in the diet should also be limited or the patient should choose the right kind of salt in own meals. The patient should have a convenient means of checking her blood sugar on the daily basis and ensure that it remains at the constant level between 70 to 130 mg/dl before meals and < 180mg/dL after meals. When it goes beyond this range, the patient can experience a serious hyperglycemia or hypoglycemia that will require immediate medical attention. For managing the blood glucose level, the patient should use medication on a daily basis (Woo & Robinson, 2016). The equipment that will be needed includes Rx, Glucometer x1, Lancets- Disp #100 (1 box), and Test Strips- Disp #100 (2 boxes).

Education

Diagnosis. Mrs. W. should be educated on the best ways of managing various complications that she faces as a person living with diabetes and dealing with weight gain. Notably, most of the complications that come with diabetes can be very limited; yet, they can easily lead to the death of the patient if not managed properly. The possible complications that Mrs. W. needs to be made aware of in the management of diabetes include obesity, hyperlipidemia, and hypertension, which can increase morbidity if not managed properly and timely (Thent, Srijit, & Henry, 2013). In addition, Mrs. W. needs to receive information about the pathophysiology of type 2 diabetes so that she can understand how the disease affects various parts of her body and the implications of not adhering to the medications that she is given.

Accordingly, diabetes is a disease that impairs the regulation of blood sugar, which is thus either too low or high in the blood. When the sugar level in the blood rises, symptoms of hyperglycemia including hunger, headache, and frequent urination are always bound to be experienced by the patient. Therefore, a nurse should teach the patient about the symptoms that are related to hyperglycemia and hypoglycemia so that the patient is in a position to administer the drugs when she feels that her levels approach these limits (Woo & Robinson, 2016). The patient will also know the right time to take her oral supplements for the blood sugar control to avoid sinking into a coma because of the disease.

The patient has reported a high level of cholesterol in her blood with the total cholesterol (TC) level of 215 mg/dl; also, she is obese with a weight of 165 pounds. According to her history, this condition can be caused by the fact that she is working from home, is likely to consume a lot of junk food, and not exercising regularly because of the sedentary lifestyle. As such, the nurse should explain the case of Mrs. W. and give her appropriate advice concerning the need to exercise frequently and take care of her diet by cutting down on junk food and carbohydrates that possess high calories. The high level of cholesterol in the blood can deposit on the artery walls and harden them, thus preventing the smooth flow of blood. These cases are likely to put the patient at risk of developing a stroke or even death (Workman & LaCharity, 2015). In such a manner, the patient will need to embrace a healthy lifestyle with little to no-fat diet while increasing stimulating exercises. Another change considers the social lifestyle, for example, limiting alcohol consumption and sedentary life.

Medications. According to the diagnosis, Mrs. W. has diabetes type 2 that prevents her from losing weight. Therefore, the prescription of Metformin is rational for the management of diabetes by regulating her blood sugar level. It is advisable for the patient to take medications judiciously with the view of maximizing the effectiveness of the management plan. The intake of Metformin is usually associated with certain adverse effects; however, the patient should not worry about them since they are not detrimental. In such a manner, adverse effects of the drug include nausea and vomiting, abdominal bloating, and pernicious anemia. In addition, Metformin reduces Vitamin B12 in the body, thus causing pernicious anemia. To prevent the development of pernicious anemia, the patient will have to take Vitamin B12 supplements as prescribed. It is easy to define when one develops pernicious anemia since its symptoms include general weakness, lightheadedness, rapid heartbeat, fatigue, and increased breathing. Because the functions indexes of kidneys are on the borderline, Mrs. W. will receive Lisinopril to help in protecting the kidney since diabetes will predispose her to the kidney damage (Woo & Robinson, 2016). However, this drug may have some side effects, including hypotension, which will make the patient experience lightheadedness or dizziness. In the case of any of these symptoms, the patient should apply to the office. Nevertheless, Lisinopril is crucial since it will help in preventing the damage of the kidney and improve the function of the kidney and its ability to excrete Metformin, which is used in the management of diabetes.

Diet. A serious diet modification for the patient is needed. Meals are to be appropriate to the diabetic diet. An appropriate diet will also help the patient lose weight and manage the high cholesterol levels that are exposing her health to the increased risk (Workman & LaCharity, 2015). With the view to managing type-2 diabetes, increased weight, and the high cholesterol level, Mrs. W. is highly suggested to adopt a diet consisting of high fiber content and moderate levels of complex carbohydrates, for example, the oatmeal and brown rice. To prevent high cholesterol and the gain of weight, she will need to avoid saturated fats in her diet. Lean proteins are also recommended. The patient should consume more vegetables and fruit that will help in improving glucose tolerance.

Exercise. The patient reported to have been exercising according to recommendations given during her previous visits to the hospital because of her chronic comorbid with arthritis. With the use of the treatment medications in diabetes and hyperlipidemia, the patient should be in a position to achieve some changes with the help of exercise. Exercise will assist the patient in improving the glycemic control. A combination of aerobic training and resistance exercises will be vital in helping Mrs. W. reduce glycosylated hemoglobin levels. The exercise will also help the patient to improve her insulin resistance (Workman & LaCharity, 2015). The patient is also recommended to try the water aerobics due to arthritis of her right knee to improve the management of the condition.

Warning signs. Mrs. W. should be made to understand the signs and symptoms of the lack of regulation of the sugar level in the body. She requires deep knowledge of her primary condition, which is diabetes. A number of rapid situational management approaches for blood glucose levels management exist including eating crackers with peanut butter that can boost the level of glucose in the blood. In addition, it is vital for the patient to know the signs of high blood sugar, which leads to hyperglycemia (Jafri, et al., 2015). Hyperglycemia causes ketoacidosis in most cases, and close medical attention is needed once it occurs. Because there is a risk of the poor blood circulation with the occurrence of the condition, it is crucial to monitor any wounds and bruises to avoid the excessive blood loss. The lack of the proper circulation can slow down the healing of wounds; in such a manner, any cut needs to be treated as soon as possible with the view to avoiding complications (Wilding, 2014). In addition, Mrs. W. will need to avoid walking barefoot and be careful while clipping the nails not to have deep cuts as it can develop into a serious wound that can be so difficult to heal. It is also vital for Mrs. W. to visit an ophthalmologist often to check if her retina is in good condition since diabetes commonly causes the destruction of blood vessels at the back of the retina, leading to the diabetic retinopathy, which can predispose the patient to blindness.

Referrals

Ophthalmologist/optometrist. Diabetes mellitus is a common cause of blindness in individuals aged between 20-74 years. The complication mainly develops if the disease is not appropriately managed. Random checkups with an ophthalmologist are important to manage the situation early before it progresses to the worse stage when the treatment is problematic (Workman & LaCharity, 2015). Ophthalmologists should perform the dilated eye analysis once a year.

Diabetic educator. Mrs. W. will be referred to a diabetic educator who will teach her about diabetic management in detail. From the diabetic educator, she will also gain the required information on how to manage her glucose levels, as well as monitor, read, and interpret the glucometer (Woo & Robinson, 2016).

Podiatrist. One of the major causes of lower extremity complication that often results in amputation is caused by diabetes mellitus type 2. In the case of any problems involving the feet or those associated with the management of the extremities, the patient should visit a podiatrist as soon as possible.

Nephrologist. Mrs. W. should go for the annual serum creatinine and urinalysis testing since diabetes predisposes the patient to nephropathy (Workman & LaCharity, 2015). The screening should start directly when the patient is diagnosed and be conducted yearly to check the progression of kidney damage.

Registered dietician. For a diabetic patient like Mrs. W., it is vital to pay maximum attention to what she eats. Therefore, she will need a registered dietician to plan her meals according to the dietary scheme effectively (Thent, Srijit, & Henry, 2013). A registered dietician will assist Mrs. W. in losing weight and also managing glucose using appropriate food.

Follow up

Mrs. W. is recommended to come to the office oftener for the checking of her general progress regarding her health condition. In the checkup sessions, the review of the blood glucose log will be done together with the evaluation of the effectiveness of her medication regimen. The review of the medications will involve the checking of the effectiveness of drugs for the blood sugar regulation and the presence of any side effects regarding whether the patient can manage the side effects of the drugs effectively or not (Wilding, 2014). In case some side effects cannot be managed effectively by the patient, the drug will be substituted with another one. In the case symptoms persist because of taking the prescribed drugs, the patient should apply to the office urgently. All the events will be managed gradually to avoid overlooking important tests and conditions.

Medication Cost

All drugs in Mrs. W’s scheme are highly interrelated; for that reason, I decided to use Walmart $4 prescriptions. I believe that the patient will be able to get all the medications at Walmart because of a wide product offering and based on the fact that it is a convenient shopping center with both online presence and stores all over the U.S (Walmart, 2018). In addition, upon the evaluation of the situation of the patient, the only place that the woman can get the medications conveniently is Walmart. In such a manner, the consequences of non-adherence to drugs can be avoided. The alternative medication list was not given to the patient.

Walmart will supply the patient with metformin for 30 days. For Aspirin EC, 81mg tablet for a diabetic patient is a matter of urgency that they are to have in their diet. For the supply of simvastatin 40mg for a period of 30 days, the store will charge $4; the same price was requested for vitamin B 12 1000mcg with 60 tablets per bottle (Walmart, 2018).

SOAP Note

Patient Information: Mrs. W., a 59-year-old Asian female

S: (Subjective): She experiences less pain and increased mobility with the earlier prescribed treatment plan, but reports some new concerns today. She reports has experienced increased fatigue for about the last 12 weeks. She has also gained weight since her menopause four years ago. She has a health club membership and attends it twice a week. Despite the 30-minute treadmill activity and lifting weights, she has not lost any pound but gained four pounds instead.

Chief Complaint: The weight gain despite exercise; polydipsia, polyuria, severe fatigue, polyphagia,

HPI: The patient applies to the clinic for her regular follow-up every three months although she shows obvious improvement in the previously diagnosed arthritis that she has recently managed. In addition, she reports fatigue most of the times. She also reports the persistent gain of weight despite exercising according to recommendations of the clinician. While exercising, she often gets hungry and thirsty.

Current Medications: Tylenol 500 mg 2 tabs in AM for the knee pain. Daily multivitamin and turmeric

Allergies: Allergic to Bactrim, cats, and pollen. No latex allergy

PMH: Has right knee arthritis diagnosed three months ago. Had German measles as a child. Vaccination up-to-date. Colonoscopy WNL four years- repeat in ten years

PSHX: none stated

Health screening: No hx of abnormal Pap smear

Soc Hx: She is divorced, works from home as an administrative assistant, takes 1-2 glasses wine daily, she is a former smoker, quit 10 years ago, and no illicit drug use

FM Hx: Parents deceased, child alive. No siblings…

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

Respiratory: No SOB, no cough

Musculoskeletal: full ROM both knees. Nontender to palpation bilaterally. Gait normal.

GU: bladder nontender upon palpation

O: (Objective)

Physical Exam:

BP: BP 112/76; pulse 80, regular; respiration 16, regular; height 5’1.5”, weight 165 pounds.

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

HEENT: Head normocephalic. Hair thick and distributed throughout the scalp. Eyes without exudate; sclera white. Wears contacts. Tympanic membranes gray and intact with the 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.

GYN hx: G1 P1: daughter delivered@37 weeks, wt 8lbs 15oz. LMP 4 years ago. ASCUS pap 1998, all further paps WNL. Mammogram last year benign.

Skin: warm dry and intact. No lesions noted

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.

Diagnostic or Lab results: (Fasting labs)

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); Bilirubin, total (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)

EKG: normal sinus rhythm

A: (Assessment)

Primary Diagnosis: Diabetes mellitus type 2 (E11.9), Hyperlipidemia (E78.5)

Secondary Diagnosis: Unilateral primary osteoarthritis, right knee (M17.11).

Differential Diagnoses: Post-menopausal syndrome (E13)

P: (Plan)

Diagnostics:

Repeat HgbA1c/fasting blood glucose

PHQ-9 questionnaire

Vitamin D and folate levels

Urine glucose test after 24 hours

Vitamin B12 level

Medications:

Metformin ER 500 mg tablet (treatment of DM2)

Sig: Take 1 tablet orally twice a day,

Disp: 60 Refill: 2

Cyanocobalamin (Vit B12) 1000 mcg capsule (supply for the B12 deficiency caused by Metformin)

Sig: Take one (1) capsule, orally, daily on an empty stomach,

Disp: #30 (thirty), Refill: 2

Aspirin EC, 81mg tablet (the treatment/preventative for CVD)

Sig: Take one (1) tablet, orally, daily

Disp: #30 (thirty), Refill: 2

Simvastatin, 40 mg tablet (the treatment for hyperlipidemia)

Sig: Take one (1) tablet, orally, daily at bedtime,

Disp: #30 (thirty), Refill: 2

Lisinopril, 2.5 mg tablet (treatment/preventative for CKD)

Sig: Take one (1) tablet, orally, 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: First, I discussed with the patient diabetes mellitus type-2 and hyperlipidemia diagnosis. To make the patient contextualize the treatment, I focused on the diagnostic repeat labs to confirm and manage the diagnosis. Together with the patient, I took the time to review the list of medications and emphasized the need to take them as prescribed stressing compliance. I then recommended the modification of diet and lifestyle by starting with the diet adjustments and later proceeding to the whole lifestyle. As a takeaway note, I advised the patient to monitor her glucose level twice a day and check on things that can help in weight loss, including appropriate food and exercise to improve her glycemic index. I emphasized to the patient the danger of keeping the diagnosis unmanaged and the health risks that this attitude can cause the patient in the future. Lastly, I took the patient through the list of referrals and provided her with contacts to be used in case of emergency.

Referrals: Diabetic educator, registered dietician, podiatrist, ophthalmologist/optometrist, and nephrologist

Follow-up: The follow-up for the patient will be done closely as she is expected to return in a week for the review of the lab results, appropriate medications, and any changes in the blood glucose levels. It will be critical for the patient to be alert with her health and ensure that she urgently visit my office in the case of a problem, for example, negative reactions to medications.