CaseSt4DM21.docx

CASE STUDY: CANDIDIASIS 2

Case Study 4: Diabetes Mellitus 2 #6341180

Andrea Williams, RN, SFNP
NUR 630 Primary Care or Adults & Aged
Charles R. Drew University of Medicine and Science
October 31, 2020

Case Study 4: Diabetes Mellitus 2 #6341180

Name: John Doe Age: 60 Gender: Male

SUBJECTIVE:

CC: Follow up on Diabetes

History of Present Illness: Patient is a 60-year-old male patient came to the clinic for diabetes follow up, patient denies changes in vision, denies numbness to extremities. Fasting blood glucose reveals 180, HgBA1C 7.5. according to patient, finger stick blood glucose normally ranges 160-200mg/dL.

Current Medications: Metformin 850mg PO BID, Atorvastatin 20mg PO QHS

Allergies: NKA

Past medical history: Diabetes Mellitus II, Hyperlipidemia, osteoarthritis

Surgical History: N/A

Social History: Married with 3 children. Does not smoke or drink alcohol. Does not take illicit drugs.

Family History: N/A

REVIEW OF SYSTEM:

General/Constitutional: Patient denies fever, chills, no weakness, or fatigue

HEENT: Denies headache, dizziness, ear, nose, or throat pain/discomfort. No discharge noted.

Neurologic/Psychiatric: Denies changes in memory, Denies suicidal ideation

Respiratory: Denies shortness of breath, cough, wheezing

Cardiovascular: Denies chest pain, palpitation

Gastrointestinal: Denies Nausea or vomiting, denies changes in bowel habits

Genitourinary: Denies painful urination, No changes in bladder pattern

Musculoskeletal: Denies muscle pain, Denies contractures

Lymphatics: Denies Lymph nodes tenderness

Integumentary: Denies rashes, itchiness, bruises

Endocrine: Denies cold or heat intolerance, denies polyuria, denies polydipsia

Extremities: Denies contractures, intact range of motion

OBJECTIVE:

Vital Signs:
BP:120/77 HR:83 RR:18 Temp: 98.0 Ht.66(in) Wt.171(lbs) BMI:27.6

PHYSICAL EXAMINATION:

GENERAL APPEARANCE: in no acute distress, denies fever chills or weight loss

NEUROLOGIC: patient is awake, alert, oriented to person, place and time; speech is clear and concise, cranial nerves intact; normal muscle tone, no loss of sensation; deep tendon reflexes are 2/4, no problems with motor coordination.

HEENT: Normocephalic, no facial swelling noted, no scalp lesion or tenderness; No thinning of the eyebrows noted. PERRLA, EOM intact, pink palpebral conjunctiva, present red reflex on fundoscopy; no periorbital swelling noted, no external ear lesions, tympanic membrane is translucent with positive cone of light on both ears, no ear discharge noted; midline nasal septum, no tongue lesions noted, no swelling of the tongue noted, no gum bleeding noted; tonsils and pharyngeal walls not swollen. Throat is pink, no supraclavicular lymphadenopathy.

RESPIRATORY: Normal breath sounds. normal respiratory rate and effort with no distress, no rales, rhonchi, wheezes or rubs

CARDIOVASCULAR: Regular rhythm. Normal S1 & S2 PMI normal at Left 5th ICS-MCL, no heaves or thrills noted. No murmur gallops or rubs.

GASTROINTESTINAL: Abdomen is soft, nontender, rounded, Normo-active bowel sounds in all quadrants. non-tender upon palpation, no guarding noted.

GENITOURINARY: No bladder distension, no dysuria, no hematuria

MUSCULOSKELETAL: no cyanosis, no clubbing of the nails, no edema, pulses normal with regular rhythm, Full ROM to both upper and lower extremities

INTEGUMENTARY: No warm and intact, no rashes, no discolorations

Laboratory and Diagnostic Tests

· Complete Blood Count (CBC): White Blood cells Count – 4.4, Hb – 12.2 and platelets count – 179
· Basic Metabolic Panel (BMP) – Glucose – 519, Bicarb – 25, Calcium – 99, potassium level – 4.6, Sodium level – 130, Phosphorus – 2.8 and Creatinine level – 1.08, Glucose levels – 518
· Liver Function Tests: Albumin levels – 4.1, alanine aminotransferase (ALT) levels – 13, aspartate aminotransferase (AST) levels – 15, Bilirubin Levels (TBili) – 0.3, Alkaline Phosphatase Test (ALP) – 110
· Lipids Test – Low-Density Lipoprotein (LDL)- 221, High-Density Lipoprotein (HDL) – 44, Total Cholesterol (TC) – 305, and Triglycerides (TG) – 202.
· Urine Glucose (UG) – More than 500mg/day
· Thyroid-stimulating hormone (TSH) test – TSH 16.04
· Head CT Scan – No hemorrhagic event or acute ischemic.

Differential Diagnoses

Primary Diagnosis: Diabetes Mellitus Type 2

The patient was diagnosed with Diabetes Mellitus over 10 years ago. The primary diagnosis was reached given the patient’s glucose level is 519 and HbA1c of 10 years. As such, the patient’s condition is poorly controlled characterized by missed doses. According to recommendations from the American Diabetes Association, patients above the age of 45 years should be screened for type 2 diabetes annually. The diagnosis of diabetes mellitus is epitomized by a fasting plasma glucose level of 126 mg per dL or above and levels of HbA1c is 6.5% or more and a random level of glucose of 200mg/dL or more (Pippitt, Li & Gurgle, 2016). Based on the results provided on admission, the patient has a random glucose level of 518mg/dL above 200mg/dL. The U.S. Preventive Services Task Force recommends screening for all adults, who are overweight or obese, aged between 40 and 70 years of age and have a family history of diabetes or members of specific racial or ethnic groups including blacks, Alaska Natives, or American Indians (Pippitt, Li & Gurgle, 2016). The patient is a 60-year-old lady African American lady with a rich family history of diabetes and also overweight with a BMI of 30.0. As such, the patient satisfies the primary differential diagnosis of type 2 diabetes epitomized by being of African American origin, abnormal blood glucose, predisposing factors such as the age of 60 years, and being obese.

Diabetes Type 1 Mellitus

Type 1 diabetes is a chronic autoimmune disease caused by damage of the insulin-producing cells leaving the patient without insulin eventually causing an accumulation of sugar in the blood (Hill & Oliver, 2020). However, the distinction between type and type 2 diabetes is not clear. However, the diagnosis of the disease, especially newly diagnosed patients is an average age of 40 years, a standard BMI of 25.3kg/m2, and an average level of blood glucose being 300 mg/dL and beyond. In differentiating type 1 and type 2 diabetes examining a diabetes definite autoantibody titers or C-peptide test. Notably, HbA1c is not a recommended diagnostic test in patients with type 1 diabetes due to the rapid development of hyperglycemia levels and lack of regular measurement of glucose level (Hill & Oliver, 2020). As such, the patient could not satisfy the diagnosis of type 1 diabetes since she is above 45 years of age and was diagnosed with type 2 diabetes over 10 years ago.

Cushing Syndrome

Cushing Syndrome is a disease caused by endogenous hypercortisolism due to excessive use of glucocorticoids. The Cushing disease has a rare pathology, but it is a serious condition epitomized by metabolic derangements, dyslipidemia, and hepatic steatosis contributed by glucose intolerance and reduces insulin sensitivity (Barbot et al., 2018). However, the patient could not be diagnosed with Cushing syndrome since she does not have a history of using glucocorticoid and she has a deficiency in insulin rather than insulin sensitivity due to chronic exposure to glucocorticoid (Barbot et al., 2018).

Treatment Plan

Ideally, it is crucial to consider the impact of missed medication doses since the values have been provided including glucose level initially, and thyroid hormone or overdose of medications especially muscle relaxants. Furthermore, it is prudent to perform a phenytoin toxicity test related to her altered mental health status (Iorga & Horowitz, 2019). More so, it is crucial to control the patient’s BP from an initial 180/100 to 140 /90, and glucose levels on admission.

Patient Education

The 2017 Standards of Medical Care in Diabetes states that patients diagnosed with diabetes should engage in active education in self-management and treatment planning om healthcare involving collaborative development of a modified eating plan. The patient is advised to have three 15 minutes of clinical visits to be equipped with management skills to use on her daily basis (Chester, Stanely & Geetha, 2018). The goal of diabetes self-management education (DSME) is to teach the patient various aspects of diabetes, identify and distinguish carbohydrates, maintain healthy body weight, regular exercise, and control blood sugars. The patient will be referred to a dietician who will teach the patient how to incorporate the concepts in her daily routine and engage practical tools in meal planning and lifestyle changes (Chester, Stanely & Geetha, 2018).
As well, a smartphone app can be integrated into the patient’s daily living to perform various functions of diabetes self-management such as tracking how the patient takes medications, organization of pills, provision of information, and assessment of adherence (Huang et al., 2019). As well, the patient should continue to take her medication at home including Lantus 35 units qHs and as part 10 TID adhering to patient education, labetalol 100 BID, amlodipine 10 daily, and phenytoin 300mg qHs pending the level of phenytoin to control her seizure-related complications. Since the patient has a history of hypothyroidism epitomized by TSH-16.04, she should continue taking levothyroxine 75mcg qAM accordingly (Mammen et al., 2015).

References
Barbot, M., Ceccato, F., & Scaroni, C. (2018). Diabetes mellitus secondary to Cushing’s disease. Frontiers in endocrinology, 9, 284. https://doi.org/10.3389/fendo.2018.00284
Chester, B., Stanely, W. G., & Geetha, T. (2018). A quick guide to type 2 diabetes self-management education: creating an interdisciplinary diabetes management team. Diabetes, Metabolic Syndrome, and Obesity: Targets and Therapy, 11, 641. DOI: 10.2147/DMSO.S178556
Hill, N. E., & Oliver, N. S. (2020). Evolving type 1 diabetes in distinguishing between type 1 and type 2 diabetes. BMJ, 370. https://doi.org/10.1136/bmj.m3772
Huang, Z., Lum, E., Jimenez, G., Semwal, M., Sloot, P., & Car, J. (2019). Medication management support in diabetes: a systematic assessment of diabetes self-management apps. BMC medicine, 17(1), 127. DOI: https://doi.org/10.1186/s12916-019-1362-1
Iorga, A., & Horowitz, B. Z. (2019). Phenytoin toxicity. In StatPearls [Internet]. StatPearls Publishing.
Mammen, J. S., McGready, J., Oxman, R., Chia, C. W., Ladenson, P. W., & Simonsick, E. M. (2015). Thyroid hormone therapy and risk of thyrotoxicosis in community-resident older adults: findings from the Baltimore Longitudinal Study of Aging. Thyroid, 25(9), 979-986. https://doi.org/10.1089/thy.2015.0180
Pippitt, K., Li, M., & Gurgle, H. E. (2016). Diabetes mellitus: screening and diagnosis. American family physician, 93(2), 103-109.
CASE STUDY: Diabetes Mellitus 2 9