NR601_Week_5_Case_Study1.Primary Care Of The Maturing And Aged Family Practicum

NR601_Week_5_Case_Study1.Primary Care Of The Maturing And Aged Family Practicum. Week 5 Case Study: Mrs. R. The case study scenario introduced the class to Mrs. R., a 56-year old Hispanic female who reported to the office clinic with complaints of extreme fatigue and experiencing a gradual weight gain. The onset of her symptoms started three months ago. She exercises twice a week by walking on the treadmill for 30 minutes in an attempt to lose weight but has been unsuccessful. The intention of this paper is to examine the analysis of the subjective and objective findings that was collected to diagnose and create a management plan for Mrs. R. In addition, the application of national diabetes guidelines will be included into the patient’s management plan. This paper will also discuss the assessment of the primary, the secondary, and the differential diagnoses for Mrs. R., as well as the management plan for treatment of the primary, the secondary, and the differential diagnoses, which consists of diagnostics, medications, education, referrals, and follow-up care. This paper also includes a discussion on medication costs of all prescribed and over-the-counter (OTC) medications. Assessment According to the information provided by Mrs. R., she has symptoms of major concerns, which includes extreme fatigue, the inability to lose weight regardless of her attempts to exercise, her increase in thirst, hunger, and urination. Per the Center for Disease Control and Prevention BMI calculator (CDC) (2015), her calculated BMI of 29.7 showed that she is overweight for her given height. The result from her urine analysis showed glucose and small concentration of protein. Her HgbA1C is 6.9% and her fasting glucose is 126 mg/dL, which according to the American Diabetes Association (ADA) (2018), she meets the conditions for the diagnosis of diabetes. Mrs. R’s CBC values, TSH and Free T4 levels were unremarkable, which WEEK 5 CASE STUDY 3 ruled out hypothyroidism and anemia. Her lipid panel results revealed she has hyperlipidemia. Her elevated cholesterol places her at risk for a stroke and cardiovascular disease (AACE, 2017). Primary diagnosis Diabetes Mellitus Type 2 (DM2) (E11.9). Type 2 diabetes or DM2 is referred to as adult-onset diabetes and is indicated by hyperglycemia, insulin deficiency, insulin resistance that can lead to the development of vascular and neurologic complications (American Diabetes Association [ADA], 2018). According to Goroll (2014), there is an insufficient amount of insulin being excreted by the pancreas to meet the metabolic needs of the body causing hyperglycemia. Goroll (2014) also states that the disease is more apparent later in life in most cases, with fatigue as the leading sign. Manifestations of DM2 consist of polyuria, polydipsia, polyphagia, and weight gain (Goroll, 2014). Some pertinent positives include: extreme thirst (polydipsia), extreme hunger (polyphagia), frequent urination during the day (polyuria), extreme fatigue, difficulty losing weight regardless of exercise, obesity, her age, and Hispanic ethnicity. Her lab results, which includes Hemoglobin A1c=6.9%, fasting plasma glucose=126, and elevated cholesterol levels are indicative of diabetes mellitus type 2. Per Pippitt, Li, and Gurgle (2016), DM2 can lead to blindness, renal failure, amputation of the limbs, vascular and cardiac disease. Rationale. The diagnosis of diabetes mellitus type 2 is chosen as the primary diagnosis due to Mrs. R.’s symptoms of fatigue, her inability to lose weight regardless of incorporating exercise in her lifestyle, her increased frequency of urination, and increased thirst and hunger. Also, her lab results, which includes her HA1c, are indicative of the diagnosis of diabetes type 2. Additional risk factors associated with Mrs. R. is her age, and her Hispanic ethnicity. According to the ADA (2018), the factors, such as obesity, age, and certain racial/ethnic subgroups, which WEEK 5 CASE STUDY 4 includes those with Hispanic/Latino background can increase the risk of developing type 2 diabetes. The ADA (2018) also states that the excess of weight can cause some degree of insulin resistance. Over the past 3 months, her presentation of excessive hunger, excessive thirst, frequent voiding, weight gain, and extreme fatigue maybe an indication of slow progression of diabetes. Secondary diagnosis Hyperlipidemia (E78.5). Hyperlipidemia, which is referred to as dyslipidemia is termed as elevated concentrations of lipids that could potentially block blood flow due to plaques build up in the arteries (Dunphy et al., 2015). Hyperlipidemia is a heterogenous metabolic disorder that increases the risks of atherosclerosis involving levels of lipids and lipoprotein (Dunphy et al., 2015). Desirable values for cholesterol according to Dunphy et al. (2015) are as follows: triglycerides (TGs) ¿ 150 mg/dL, low-density lipoprotein (LDL) ¿ 100 mg/dL, high-density lipoprotein (HDL) ¿ 60 mg/dL and a total cholesterol (TC) ¿ 200 mg/dL. Patients may initially present without symptoms but often exists concurrently with coronary artery disease (CAD) or hypertension (HTN) (Dunphy et al., 2015). Dunphy et al. (2015) also states that obesity, DM, nephrotic syndrome, end stage renal disease (ESRD), hypothyroidism, hepatic disorders, too much alcohol consumption, estrogen administration, Cushing’s syndrome, and glycogen storage disease are secondary causes of dyslipidemia. Secondary causes of hyperlipidemia should be assessed prior to initiating a treatment because treating the primary disorder often corrects the dyslipidemia (Dunphy et al., 2015). Some pertinent positives include: elevated triglycerides (TGs=232mg/dL), elevated LDL (144mg/dL), decreased HDL (38mg/dL), elevated total cholesterol (TC= 230mg/dL), gender, ethnicity, generalized fatigue, tired, feeling of no energy, weight gain, increased hunger, diabetes WEEK 5 CASE STUDY 5 mellitus, and obesity. There are no presenting symptoms of hyperlipidemia and is often detected during a physical examination when blood work is ordered (Dunphy et al., 2015). Over the past 3 months, her symptoms of weight gain, increased hunger, increased thirst may be an indication of a slow progression of her diabetes that is slowing the body function and metabolism. Some pertinent negatives include: hypertension and coronary artery disease, which are both associated with hyperlipidemia. In addition, her physical assessment does not reveal a carotid bruit, corneal arcus, or xanthomas, described as yellowish skin deposits of cholesterol, and usually found on the eyelids (Dunphy et al., 2015). Rationale. Due to the patient’s chief complaint of gradual weight gain in the past 3 months and the result of her lipid profile, which indicated elevated cholesterol, the diagnosis of hyperlipidemia is chosen as the secondary diagnosis. Hyperlipidemia is a treatable disorder and can be divided into primary and secondary. Patient’s gender and symptoms, as well as her physical assessment also play a factor. Furthermore, Mrs. R.’s cholesterol and LDL are elevated. According to Chaker et al. (2017), patients with hyperlipidemia have a high risk of cardiovascular disease and will often have metabolic syndrome factors such as hypertension, increased waist circumference, and diabetes mellitus. According to Bullock-Palmer (2015), hyperlipidemia places Mrs. R at a high risk of CAD due to her ethnicity because of the failure to identify at-risk females, and the discrepancy is highest among minority females. Hispanics and African American have a greater prevalence of CVD and its risk factors. In addition, BullockPalmer (2015) also states that about 40%-50% of females in the United States have an elevated total cholesterol ¿ 200 mg/dL. WEEK 5 CASE STUDY 6 Differential diagnosis Obesity (E66.9). a body mass index (BMI) of 30kg/m2 or higher indicates obesity and is defined as an excess of body fat (Dunphy et al., 2015). According to the AACE/ACE (2017), a BMI of ≥ 30kg/m2 is classified as obese, where as a BMI = 25-29kg/m2 are identified as overweight. Obesity occurs when the consumption of calories far exceeds the metabolic needs of the body (Dunphy et al., 2015). Bullock-Palmer (2015) stated that the prevalence of obesity is greater among black and Hispanic females when compared to Caucasian females in the United States. CVD risk in females increases proportionately with the increase in BMI (BullockPalmer, 2015). Rationale. Mrs. R’s calculated BMI=29.7, which identifies her as overweight for her given height. The most common presenting symptoms for obesity are shortness of breath, decreased energy, fatigue, weakness, joint pain, depression, and increased daytime sleepiness (Dunphy et al., 2015). Its treatment consists of lifestyle interventions and behavioral modifications (Cefalu et al., 2015). Some pertinent positives for Mrs. R.’s obesity are fatigue, decreased energy, and weakness. Over the past 3 months, she has gained 3 pounds despite going to the gym and walking on the treadmill. Exercising makes her hungrier and therefore causing her to eat more. Pertinent negatives are daytime sleepiness, shortness of breath and depression. Management Plan Diagnostics Repeat HgbA1c/fasting glucose. Since Mrs. R.’s HgbA1c is elevated to 6.9%, a repeat HgbA1c or a fasting glucose and a 2-hour glucose tolerance test should be obtained to continue establishing the diagnosis of DM2. The ADA (2018) recommends a second test is required for WEEK 5 CASE STUDY 7 confirmation, unless there is a hyperglycemic crisis or a random plasma glucose of ≥ 200mg/dL. In addition, the ADA (2018) recommends the same test be repeated or a different test be performed without delay using a new blood sample to confirm the diagnosis of DM2. By confirming the diagnosis of DM2, Mrs. R’s management plan will include medication that helps control her blood glucose and decrease her HgA1c level. PHQ-9 questionnaire. Mrs. R. will also need to be screened for depression using the PHQ-9 to determine if she has depression. Her social history states that she has recently separated from her spouse. According to Slavich and Irwin, major life events involving major health-related events, ending of romantic relationships, significant financial loss, and job loss have been found to have a strong co-relation to depression (Slavich & Irwin, 2014). Patient Health Questionaire-9 (PHQ-9) is a multipurpose tool to assess the severity of depression. The main focus is on the 9 diagnostic criteria for major depression listed in the DSM-5, which only takes a few minutes to perform (Ng, C. et al., 2016). The PHQ-9’ sensitivity and specificity are 61% and 94%, respectively (Ng, C. et al., 2016). Vitamin D and folate. Additional labs that Mrs. R. will need are Vitamin D, and folate levels to check for deficiencies, which could also be contributing to her fatigue (Hollier, 2016). Serum vitamin B12. A serum B12 level screening should also be performed due to Metformin causing a decrease in serum B12 concentration (Gorroll & Mulley, 2014; KennedyMalone et al., 2014). Vitamin B-12 and other B vitamins play a role that affect mood and other brain functions. Decreased levels of B-12 and other B vitamins such as vitamin B-6 and folate may be linked to depression (Ng, C. et al., 2016). 24-hr urine sample and random spot albumin/creatinine ratio. Since Mrs. R’s UA showed +1 glucose and small protein, screening for microalbuminuria with a 24-hour urine WEEK 5 CASE STUDY 8 sample and a random spot albumin/creatinine ratio will need to be performed to check for chronic kidney disease (CKD) (AACE/ACE, 2017). Medications Treatment for diabetes mellitus type 2 (E11.9). Per the ADA (2018), the first line treatment for type 2 diabetes mellitus upon diagnosis is Metformin monotherapy. Metformin is reported to have beneficial effects on HgbA1C levels, weight reduction, and reduces the risk of cardiovascular event and death (ADA, 2018). Rx: Metformin ER, 500 mg tablet Sig: Take one (1) tablet, by mouth, twice daily Disp: #60 (sixty), Ref: 2 (AACE/ACE, 2017; ADA, 2018; Epocrates, 2018) The use of Metformin has been proven to decrease the levels vitamin B12 deficiency; supplementation and a periodic screening should be performed (AACE/ACE, 2017; ADA, 2018). Rx: Cyanocobalamin (vitamin B12), 1000 mcg capsule Sig: Take one (1) capsule, PO, daily on empty stomach Disp: #30 (thirty), Ref: 2 (AACE/ACE, 2017; ADA, 2018; Epocrates, 2018) Treatment for hyperlipidemia (E78.5). The drug of choice is statins for lowering LDL cholesterol and protecting the heart (AACE, 2017). Patients age ≥ 40 years old with DM can benefit from high-intensity statin therapy that can reduce the LDL by ≥ 50% (ADA, 2018). Rx: Simvastatin, 40mg tablet Sig: take one (1) tablet by mouth at bedtime Disp: #30 (thirty), Ref: 2 (AACE/ACE, 2017; ACC/AHA, 2017; ADA, 2018; Epocrates, 2018) Rx: Aspirin EC, 81mg tablet Sig: take one (1) tablet by mouth daily Disp: #30 (thirty), Ref: 2 (AACE/ACE, 2017; ACC/AHA, 2017; ADA, 2018; Epocrates, 2018) Patients with DM2 and hyperlipidemia are at risks for CAD and should be on a daily entericcoated aspirin, unless contraindicated or a serious adverse event (Bullock-Palmer, 2015; ACC/AHA, 2017). WEEK 5 CASE STUDY 9 Treatment to reduce kidney damage due to microalbuminuria. Patients with DM2 and microalbuminuria are at risk for kidney damage and should be given an ACEI to protect the kidneys (ADA, 2018) Rx: Lisinopril, 2.5mg tablet Sig: take one (1) tablet by mouth daily Disp: #30 (thirty), Ref: 2 (AACE/ACE, 2017; ADA, 2018: Epocrates, 2018) Nonpharmacological treatment. Recommendations for lifestyle interventions such as diet and weight loss can significantly improve morbidities associated with obesity (Cefalu et al., 2015). The AACE/ACE (2017) suggests a minimum of 150 minutes/week of moderate aerobic exercise or 75 minutes/week of vigorous aerobic exercise to improve glycemic index. Incorporating a diabetic and heart healthy diet, which includes servings of fresh fruits and vegetables and limited amount of sodium to 2000mg/day can help reduce risks for a cardiovascular event and help balance the glycemic index (AACE/ACE, 2017). Monitoring blood sugar daily is highly recommended to keep a blood glucose level between 70-130 mg/dL before meals and after meals, a blood sugar of < 180mg/dL for diabetic management (AACE/ACE, 2017; ADA, 2018). Rx: Glucometer x1 Lancets- Disp #100 (1 box) Test Strips- Disp #100 (2 boxes) Alcohol pads- Disp # 1 box Sig- Test BG twice daily before breakfast and dinner, Disp# as indicated, Ref: #0 Education Diagnosis. Mrs. R. will need to be educated on the management and the possible complications associated with DM2, hyperlipidemia, and obesity, if not managed (Redmon et al., 2014).