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 bodys 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 weeks 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 clients 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 clients 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 clients 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 clients total cholesterol (TC), LDL, HDL, and triglycerides are all outside normal levels, indicating high...

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Healthy levels of Total Cholesterol are between 100 and 200mg/dL (as compared to the clients 230mg/dL), LDL is less than 100mg.dL (as compared to the clients 144), HDL (good cholesterol) is 40mg/dL or higher (as compared to the clients 38 mg/dL), and less than 150mg/dL for triglycerides (as compared to the clients 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 clients 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 patients 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 clients 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…