Diabetes Mellitus Type II

NR 601 Week 5 Case Study

NR 601 Week 5 Case Study

The World Health Organization (WHO) defines diabetes as a disease that affects the body’s ability to prepare or produce the hormone insulin, resulting in abnormal metabolism of blood glucose and elevated levels of the same in the blood (WHO, 2021). When an individual has diabetes, their body either does not make sufficient insulin or fails to make use of insulin as it should, causing elevated levels of blood sugar in the bloodstream. There are three types of diabetes: Type 1 diabetes, Type 2 diabetes, and Gestational Diabetes (CDC, 2020). The Center for Diseases Prevention and Control (CDC) estimates that 34 million (representing 1 in every 10) Americans have diabetes, and 90-95 percent of these patients have Type 2 diabetes (CDC, 2020). The high prevalence of diabetes calls for adequate understanding on the part of healthcare providers to ensure effective diagnosis and management. This week’s case study reviews the subjective and objective information provided by a 63-year-old Cuban male client who presents for weight loss advice and shows some classical signs of diabetes. It interprets lab results, identifies a primary and secondary diagnosis, analyzes the costs of identified medication, and provides pertinent patient education to enhance the client’s quality of life.

Assessment

Primary Diagnosis: Type II Diabetes Mellitus (ICD-10-CM E11.9)

Pathophysiology

Type II Diabetes Mellitus (T2DM) is caused by the inability of the body tissues to respond appropriately to insulin (insulin-resistance) (Galicia-Garcia, 2020). The pancreas makes more insulin in an attempt to get the body to respond, causing elevated levels of blood sugar that could cause other serious medical conditions such as kidney disease, vision loss, and heart disease (Galicia-Garcia, 2020).

Pertinent positive findings

The client complains of worsening fatigue, excessive thirst and fluid intake (polydipsia), nocturia two to three times a night, poor vision (evident from the use of contact lenses) and worsening weight gain despite working out twice a week. The CDC identifies excessive urination, excessive thirst, worsening hunger, vision loss, and excessive fatigue as some of the classical symptoms of T2DM (CDC, 2021). The lab finding of glucose in the urine (gycusoria) as shown in the urinalysis (glucose 1+) points to the presence of T2DM as it implies that there is too much blood sugar for the body to reabsorb, causing some of it to pass into the urine (Storey et al., 2018).

Pertinent negative findings

The client’s blood glucose levels are normal at 95mg/dL. A person with T2DM will usually report blood glucose levels above 126mg/dL, while one with pre-diabetes will report glucose levels of between 100 and 125mg/dL (Huang et al., 2017). Further, the client reports negative ketones in the urine. T2DM patients are at a higher risk of developing ketones because of insufficient insulin levels. The client does not report experiencing neuropathy or very dry skin, both of which are classical symptoms of T2DM (CDC, 2021). The family history is also not indicative of T2DM (ADA Standards of Medical Care, 2020).

Rationale for the diagnosis

The lab finding of glycusoria, coupled with the positive findings of visual abnormalities, polyuria, polydipsia, and worsening fatigue point to the likelihood of T2DM. The ADA Standards of Medical Care further point out that a T2DM diagnosis could be considered in obese with a high-risk race/ethnicity, hypertension and cardiovascular disease (CVD) ((ADA Standards of Medical Care, 2020). The client‘s BMI is 33.3, indicating obesity

Secondary Diagnosis: Hyperlipidemia (ICD-10-CM E78.5)

Pathophysiology

Hyperlipidemia is a medical term used to refer to abnormally high levels of lipids or fats in the blood (Hill & Bordoni, 2021). It mostly results from unhealthy lifestyle choices such as fatty diets that cause cholesterol to build up on the walls of the blood vessels, increasing the risk of atherosclerosis (Hill & Bordoni, 2021).

Pertinent positive findings:

Hyperlipidemia has no symptoms. However, several factors place the individual at a high risk of hyperlipidemia. These include obesity and a family history of coronary artery disease (CAD), which results from cholesterol build-up within the coronary artery (Hill & Bordoni, 2021). The client’s total cholesterol (TC), LDL, HDL, and triglycerides are all outside normal levels, indicating high cholesterol. Healthy levels of Total Cholesterol are between 100 and 200mg/dL (as compared to the client’s 230mg/dL), LDL is less than 100mg.dL (as compared to the client’s 144), HDL (good cholesterol) is 40mg/dL or higher (as compared to the client’s 38 mg/dL), and less than 150mg/dL for triglycerides (as compared to the client’s 232mg/dL) (Bibiloni et al., 2016).

Pertinent negative findings:

The client has no history of tobacco use (smoking) and reports engaging in frequent physical exercise. Smoking, lack of exercise, and fatty diets are classical risk factors for hyperlipidemia (Bibiloni et al., 2016). Further, the client’s sinus rhythm on the EKG and pulse rate are both normal, symbolizing a healthy heart.

Rationale for the diagnosis:

The patient presents with elevated levels of cholesterol and good cholesterol below the normal range. The elevated cholesterol levels coupled with the weight gain and family history of CAD point to the likelihood of hyperlipidemia.

Plan

Diagnostics

Lab test (#1): The Glycated Hemoglobin (A1C) Test:

Rationale

The A1C Test indicates the average blood sugar level over the past two to three months (Bigelow & Freeland, 2017). It measures the percentage of blood sugar attached to the hemoglobin in the red blood cells (Bigelow & Freeland, 2017). High blood sugar levels will often translate to more hemoglobin with blood sugar attached. HgA1C levels of 5.7 percent or below are considered to be within normal range, while those above 6.5 percent are indicative of diabetes (Bigelow & Freeland, 2017). The client exhibits a good number of classical symptoms of diabetes, but their blood glucose levels are within normal range and there is no family history of diabetes. The baseline Hg A1C test will help to ascertain the presence of type II diabetes. It needs to be administered immediately, with a repeat test after 3 months (Bigelow & Freeland, 2017). The ADA Standards of Medical Care recommend the administration of a baseline Hg A1C test for adults over 45 years with obesity and one or more risk factors for diabetes and pre-diabetes, including family history of diabetes, high-risk ethnicity, high cholesterol, CAD history, physical inactivity and hypertension (ADA Standards of Medical Care, 2021). If the test is normal, the patient is to be kept under observation and a repeat test conducted every 3 years or earlier depending on risk status and initial results (ADA Standards of Medical Care, 2021).

Lab test (#2): Fasting Plasma Glucose Test

Rationale

The fasting plasma glucose (FPG) test measures a patient’s blood glucose levels at a single point in time, preferably in the morning, after fasting for at least 8 hours (NIH, 2016). Fasting means having nothing to drink or eat, except sips of water. Given the high cost of diabetes medication and treatment, it may be prudent to ascertain the presence of diabetes through conducting several diagnostic tests. Studies have shown the A1C test to have low levels of accuracy in anemic persons and those of African, Mediterranean, or Southeast Asian descent (NIH, 2016). The client’s lab results are indicative of anemia from the Hgb levels of 12.5gm/dL. An FPG test may be crucial to verify the results of the A1C test for the presenting client, with fasting glucose levels above 126mg/dL indicating the presence of diabetes (ADA Standards of Medical Care, 2021). The clinician would need to conduct the fasting glucose test after a least 8 hours to obtain the best results (NIH, 2016). The ADA standards recommend that tests on separate samples be conducted without delay and repeated in 3 to 6 months if test results are near the margins of the diagnostic threshold (ADA Standards of Medical Care, 2021).

Medications

Medication (#1)

Metformin (Glucophage) 500mg

Sig: Take 1 tablet twice daily, in the morning and at night

Disp: #60

Refill: 0

Rationale

Metformin is the recommended fits-line treatment for patients with type II diabetes mellitus (ADA Standards of Medical Care, 2021). Melformin is particularly appropriate for the presenting client as it has been shown to have the effect of decreasing body weight in clinical trials (FDA, 2017). The client presents to obtain weight loss advice and is likely to adhere to a treatment plan that helps to reduce body weight or maintains it at stable levels.

Medication (#2)

Simvastatin (Zocor) 10mg tablets

Sig: Take 1 tablets twice daily

Disp: #60

Refill: 0

Rationale

Simvastatin is a reductase inhibitor (statin) and is used along with a proper diet and exercise to lower elevated lipid levels, raise good cholesterol (HDL) in the blood and hence, decrease the risk of arteriosclerosis. It works by reducing the amount of cholesterol produced by the liver (ADA Standards of Medical Care, 2021).

The patient could take an aspirin 81mg as OTC to further reduce their risk of heart attack and stroke given their obesity, elevated cholesterol and family history of CAD, all of which place him at risk of arteriosclerosis.

Education

Diagnoses

The diagnosis of diabetes and successful care requires a systematic approach to supporting the patient’s behavior change efforts through support and education (ADA Standards of Medical Care, 2021). For this reason, the patient needs to be educated about the importance of informing their family about the diagnosis and allowing them to play an active role in the treatment plan.

Medications.

Metformin is associated with a heightened risk of lactic acidosis (FDA, 2017). The patient needs to be educated on the risk of lactic acidosis and advised to immediately discontinue use and notify the clinician if they experience any of the associated symptoms, which include unusual somnolence, malaise, myalgia, and unexplained hyperventilation (FDA, 2017). The patient is further advised that gastrointestinal symptoms occurring once the dosage of Metformin has been stabilized are unlikely to be drug-related and could be due to lactic acidosis (FDA, 2017). Finally, the FDA advises that type II diabetes patients are counseled are cautioned against excessive alcohol intake when taking Metformin or Simvastatin (FDA, 2017).

Diet

Strict diets are a crucial part of effective diabetes management. As a part of the lifestyle modification plan, the patient is advised to initiate a reduction of saturated fats, and increase of plant sterols/stanols intake, viscous fiber, and dietary n-3 fatty acids (ADA Standards of Medical Care, 2021). The appropriate diet for a diabetic would emphasize plant-based foods such as plant-based oils, nuts and seeds, fruits, whole grains, beans, and vegetable, while minimizing on processed foods. However, it may be prudent to tailor diets to the patient’s culture and personal preferences to ensure satisfaction with meals and enhance nutrition status (ADA Standards of Medical Care, 2021).

Exercise.

Exercise is a crucial part of lifestyle management for diabetes patients (ADA Standards of Medical Care, 2021). The ADA standards of medical care recommend intensive lifestyle intervention focused on modest weight loss, physical activity, and dietary changes for obese adults with type II diabetes mellitus (ADA Standards of Medical Care, 2021). While exercise is important in the management of diabetes, the patient is advised to only engage in safe exercises (ADA Standards of Medical Care, 2021). For now, the patient could continue with their 30-minute treadmill exercises twice a week. However, once their Metformin dosage stabilizes, they could additionally engage in resistance training, weight-bearing exercises, and aerobics if they are able to safely engage in the same (ADA Standards of Medical Care, 2021). They are also advised to engage in exercises that increase flexibility, balance, and muscular strength such as tai chi and yoga two to three times a week (ADA Standards of Medical Care, 2021).

Warning Signs for Diagnoses and Mediation

The biggest warning sign in the treatment plan is hypoglycemia. The patient has to be educated about the risk of hypoglycemia, its symptoms, treatment, and conditions that predispose to its development, including old age, pituitary insufficiency, malnourishment, and alcohol intoxication (FDA, 2017). They are to call 911 immediately if they experience any of the symptoms of hypoglycemia. Another warning sign would be cognitive dysfunction, which has been associated with the use of Simvastatin. The client is to notify the clinician if they experience cognitive dysfunction that worries them to aid the clinician plan for discontinuation.

Referral

Specialty practice or service

Refer to cardiologist

Rationale

The ADA Standards recommend referral to a cardiologist for diabetic patients at risk of hypertension (ADA Standards of Medical Care, 2021). The client records an elevated blood pressure of 129/80, a family history of CAD, and high cholesterol indicating the need to refer them to a cardiologist despite the pulse rate and sinus rhythm being normal.

Referral (#2)

Refer to ophthalmologist

Rationale

Vision loss is one of the classic symptoms of diabetes. Although the client does not report experiencing blurry vision, he wears contact lenses. It would be prudent to refer them to an ophthalmologist to assess the actual impact of the disease on their vision and recommend possible dietary changes.

Referral (#3)

Refer to a registered dietician

Rationale

Diet is a crucial element of any patient’s diabetes management plan. Referral to a dietician for the presenting client would be crucial because the effectiveness of Simvastatin in treating hyperlipidemia depends on proper exercising and proper diet (Suraweera, Silva & Hanuela, 2016). A dietician would educate the client about what constitutes a proper diet and what dietary elements would help to increase the efficacy of Simvastatin.

Follow up

A follow-up on the client’s lipid profile is to be made after 4 weeks of initiating treatment (ADA Standards of Medical Care, 2021). The follow-up on Hemoglobin A1C will be made after 3 months, unless medication emergencies requiring immediate changes to the treatment plan arise.

Assessment of comorbidities

Besides type II diabetes mellitus, the client additionally has arthritis, a condition that causes inflammation of the joints. Diabetes places an individual at a heightened risk of certain types of arthritis. A common complication of diabetes is neuropathic arthropathy, where the joint deteriorates due to nerve damage, causing numbness, tingling, and loss of sensation in the affected joint (Piva, 2015). Neuropathic arthropathy increases the risk of arthritis, which means that the client’s knee arthritis is likely to get worse with the progression of diabetes. There may be a need to refer the patient to an orthopedic specialist at the initiation of treatment to assess the extent of the damage on the knee joint and obtain information on the potential impact of the treatment plan on the condition. This would help in developing a treatment plan that does not exacerbate the arthropathy in the knee joint area (ADA Standards of Medical Care, 2021).