NR 601: Primary Care of the Maturing and Aged Family WEEK 5 CASE STUDY

Week 5 Case Study The World Health Organization (WHO) defines diabetes as a chronic metabolic disease with increased blood glucose that eventually causes damage to the heart, nerves, blood vessels, kidneys, and eyes (WHO, 2020). The CDC reported 34.2 million Americans having diabetes, which is 10.5% of the U.S. population (CDC, 2020). Type 2 diabetes mellitus (T2DM) is the most common form that is a result of insulin resistance or loss of insulin secretions from the beta cells (ADA, 2020). The prevalence in initial diagnosis is highest among ages 45-64 and all patients should be screened annually after the age of 45. Any patient with the initial diagnosis of prediabetes or T2DM should be screened and treated for any modifiable CVD risk factors (ADA, 2020). The case study patient is high risk for T2DM and CVD because her BMI is 33.3 and is considered obese. Dyslipidemia is correlated directly with T2DM, and refers to any increased levels of lipids in the plasma. Individualized treatment goals are best to optimize compliance, improve overall health, and well-being for this patient. The treatment goal is to regain control of blood glucose, decrease LDL and triglycerides, increase HDL, improve or maintain quality of life, and delay progression of comorbidities. Assessment Primary Diagnosis: Type 2 diabetes mellitus (E11.9) Pathophysiology T2DM will commonly present with fatigue, polyuria, polyphagia, and polydipsia just as Mrs. G has. As we age, there is a loss of beta cell function and impaired insulin action in the pancreas that is further damaged with obesity because of increased circulation of free fatty acids. The liver then overcompensates with glucose because it develops a resistance to the suppressed insulin effects resulting in a hyperglycemic state that is enhanced by a decreased glucose uptake from inactive muscle use or sedentary lifestyle (Dunphy et al., 2019). Pertinent positive findings 3 WEEK 5 CASE STUDY Mrs. G presents with polydipsia, polyuria, polyphagia, and fatigue for 3 months (Hollier, 2018). She is obese with a BMI of 33.3 and 3 lb. weight gain despite walking treadmill 30 minutes two times/week. Diagnostically she has 1+ glucose and small amount of protein in urine, HbA1C 6.9%, and LDL 144 mg/dl (ADA, 2020). Pertinent negative findings Fasting glucose is in normal range at 95, no ketones in urine, no family history of diabetes, and exercise with walking treadmill 30 minutes two times/week. Rationale for the diagnosis T2DM is the primary diagnosis with a HbA1C ≥ 6.5% with classic symptoms such as polydipsia, polyuria, polyphagia, and fatigue (ADA, 2020). The HbA1C is an average glucose control measure for the past 3 months and could indicate why there is excess glucose spilling out in the urine. Ketones are a byproduct from the fat breakdown for energy because the insulin insufficiency. Protein in the urine is a finding with stress, acute infection, or kidney disease that is a common complication in diabetic patients (ADA, 2020). Obesity is a high risk factor for diabetes and both are correlated to an elevated LDL. Secondary Diagnosis: Hyperlipidemia (E78.5) Pathophysiology Hyperlipidemia is a metabolic disorder that has abnormal levels of lipids and lipoproteins. The lipoproteins carry cholesterol through the bloodstream and vary by size, density, and atherogenicity. LDL (low density) is primarily deposited as plaque on the vessel walls and HDL (high density) removes excess cholesterol from the blood while also blocking LDL oxidation as a cardioprotective measure (Dunphy et al., 2019). Pertinent positive findings 4 WEEK 5 CASE STUDY Mrs. G is obese, has family history of high cholesterol, and lab values show elevated total cholesterol (TC) 230 mg/dl, elevated LDL 144 mg/dl, elevated VLDL 36 mg/dl, elevated triglycerides 232, and lower HDL 38 mg/dl (AHA, 2020). Pertinent negative findings Mrs. G has a normal EKG, BP 129/80, normal heart sounds with no murmurs, and no bruits noted. Rationale for the diagnosis