BENJAMIN CAVILL I-HUMAN CASE STUDY WK9 CAVILL I-HUMAN DM2 NATA (Contains expert feedback in all the sections)

Benjamin Cavill is a 65-year-old retired white male who presented with a complaint of increased fatigue, polyuria, nocturia, polydipsia, polyphagia, and weight gain for about one month. History of BPH, PSA WNL. The patient complained of being tired and lacking sleep due to increased urination. The patient is not able to be physically active due to fatigue. He takes MVI and Saw Palmetto daily. BP elevated. Obese. The labs revealed elevated non-fasting blood glucose of 230, glucosuria, proteinuria, and hemoconcentration syndrome. The patient denies changes in medications or diet. Management Plan Template– must include these headings • Primary Diagnosis with ICD-10 code, rationale and resources. Include CPT codes, and any procedural codes, including nurse lab draws, vaccinations given, biopsies, etc…10 pts. Diabetes Mellitus Type 2. ICD-Code E11 The phenotypes of type 2 diabetes mellitus (T2DM), a complicated, heritable, and diverse disorder, vary. In the pathogenesis of T2DM, insulin resistance and insulin secretion deficiencies play a crucial role. Insulin secretion is induced more when there is insulin resistance than when there is adequate insulin sensitivity. Hyperglycemia and, subsequently, T2DM are caused by insufficient insulin production, mainly when insulin resistance, glucolipotoxicity, and inflammation are linked to obesity (Ke et al., 2022). Millions of people with diabetes mellitus continue to bear a heavy burden from the well-known conventional consequences of the disease. In some nations or regions, diabetes mellitus patients' leading causes of mortality are now cancer and dementia. Additionally, studies have improved our knowledge of the relationship between diabetes mellitus and infection by demonstrating unique links between diabetes mellitus and a wide range of comorbidities, such as cognitive decline, functional disability, affective disorders, obstructive sleep apnea, and liver disease (Tomic, Shaw, & Magliano, 2022). In the provided scenario, BC presented with a complaint of fatigue, polyuria, polydipsia, polyphagia, nocturia, and exhaustion. The vital signs and physical assessment revealed elevated blood pressure, obesity based on BMI, central adiposity, and large neck circumference. The labs showed Hemoglobin A1C of 8.5% and elevated blood glucose of 230. Based on these clinical findings, the diagnosis of T2DM is appropriate for this patient. CPT Codes Patient sick visit – 99213. The patient visit qualifies for the category of the sick visit of the established patient. The CPT code is 99213: Established patient office or other outpatient visit, 20-29 minutes (American Medical Association & American Medical Association, 2022). Blood glucose finger stick - 82962 HgA1C - 83037 Pneumococcal vaccine – 90669 (AAFP, 2023). Vaccination delivery – 90471 CPT codes were taken from the American Medical Association website (2022). • Guidelines used to develop this primary diagnosis. 5 pts According to the Guidelines and Standards of Care in Diabetes (2023), the typical signs of hyperglycemia include polyuria, polydipsia, polyphagia, nocturia, impaired vision, and weight gain. They are frequently not noticed until after a high blood glucose level has been confirmed. When the renal threshold for glucose reabsorption is exceeded, which results in a considerable rise in serum glucose levels above 180 mg/dL, polyuria, or excessive urine glucose excretion, develops. Hypovolemia and osmotic diuresis (also known as polyuria and polydipsia) are brought on by glycosuria. Patients' hyperglycemia and osmotic diuresis are exacerbated when they replenish their volume losses with liquids that contain concentrated sugar, such as non-diet sodas (American Diabetes Association, 2023). According to the American Diabetes Association and Standards of Care in Diabetes (2023), T2DM is diagnosed when HgA1C ≥ 6.5% and blood glucose ≥126 mg/dL. BC could be diagnosed with T2DM based on his HgA1C of 8.5% and non-fasting glucose of 230. BC also fits the criteria for diabetes based on the following: Signs and symptoms of T2DM. BC presented with the typical signs and symptoms of T2DM: polyuria, polydipsia, polyphagia