Maturing and Aged Family
Running head: WEEK 5 CASE STUDY 1
2
Running head: WEEK 5 CASE STUDY
Week 5 Case Study
University
NR 601 Primary Care of the Maturing and Aged Family
Week 5 Case Study
This case study involves Mrs. Wu, a 59-year-old Asian female who present to the clinic for a follow up visit for her recently diagnosed right knee arthritis. She presents with new concerns that will be need to be addressed. This paper will examine the pertinent subjective and objective data that was collected in order to diagnose and cultivate a treatment plan for Mrs. Wu. This paper will discuss the assessment of a primary, secondary, and differential diagnosis, including the pathophysiology, pertinent positive findings, pertinent negative findings, and the rationale. A treatment plan for each diagnosis, which consists of diagnostics, medications, education, referrals, and follow up will also be discussed. A discussion on medication costs will be presented and conclude with a summarized SOAP note.
Assessment
According to the subjective and objective data collected from Mrs. Wu, there are concerns that need to be addressed. She came in to the office today with new concerns of increased fatigue for 12 weeks, weight gain of 4 lbs., increased hunger and thirst, and frequently urination during the day and at night. According to the Centers for Disease Control and Prevention (2018), her BMI is 30.7, which classifies her as obese. Her lab work resulted with a fasting glucose of 136, HbA1c 6.8%, UA with 1+ glucose, total cholesterol 215 mg/dl, LDL 144 mg/dl, VLDL 36 mg/dl, HDL 32mg/dl, and Triglycerides of 229. All other lab values were within normal limits, ruling out hypothyroidism and anemia.
Primary Diagnosis
Diabetes Mellitus type 2 (E11.9)
Pathophysiology
Diabetes Mellitus Type 2 (DM2) accounts for 90-95% of all diabetes (American Diabetes Association, 2018). It is a “heterogeneous disease caused by a combination of genetic factors related to inadequate insulin secretion and insulin resistance as well as environmental factors such as obesity, stress, overeating, lack of exercise, and aging” (Dunphy, Winland-Brown, Porter, & Thomas, 2011). Common signs and symptoms are increased urination during the day (polyuria), increased urination during the night (nocturia), increased thirst (polydipsia), increased hunger (polyphagia), and weight gain (Goroll, 2014).
Pertinent Positive Findings
Pertinent positives include: increased fatigue for about the last 12 weeks, tiredness, weight gain of 4 lbs. since menopause 4 years ago despite exercising twice a week, polyphagia, polydipsia, polyuria and nocturia, obesity with a BMI of 30.7, her age of 59, and Asian race (ADA, 2018). Her lab work resulted with an elevated fasting glucose of 130, Hemoglobin A1C of 6.8%, and 1+ glucose in urine, which also support the diagnosis of DM2.
Pertinent Negative Findings
Pertinent negatives include: acanthosis, oropharynx moist without erythema, and peripheral neuropathy (Dunphy, Winland-Brown, Porter, & Thomas, 2011).
Rationale for the Diagnosis
A primary diagnosis of DM2 was chosen based on the patient’s symptoms and lab work. According to American Diabetes Association (2018), the risk of developing DM2 increases with age, obesity, racial/ethnic subgroups, such as Asian Americans, and those with hypertension or hyperlipidemia. Mrs. Wu displays a clear presentation of DM2 with increased fatigue, polydipsia, polyphagia, weight gain, nocturia, and polyuria. Obesity also enhances insulin resistance and predisposes patients to DM2 (Dunphy, Winland-Brown, Porter, & Thomas, 2011).
Secondary Diagnosis
Hyperlipidemia (E78.5)
Pathophysiology
Hyperlipidemia is a heterogeneous metabolic disorder involving elevated levels of cholesterol in the blood. The levels of lipids and lipoproteins in the blood increase the risk of atherosclerosis (Dunphy, Winland-Brown, Porter, & Thomas, 2011). Clinically, patients are asymptomatic and hyperlipidemia is undetected unless the patient’s lipid panel is checked via lab work. However, common diseases such as hypertension (HTN) or coronary artery disease (CAD) exist alongside with hyperlipidemia (Dunphy, Winland-Brown, Porter, & Thomas, 2011). According to Dunphy, Winland-Brown, Porter, & Thomas (2015), desirable levels include: total cholesterol <200 mg/dL, low-density lipoprotein (LDL) <100 mg/dL, triglycerides <150 mg/dL, and high level lipoprotein (HDL) <40 mg/dL.
Pertinent Positive Findings
Pertinent positives include: gender, ethnicity, weight gain, increased hunger, increased thirst, DM2, and obesity (Dunphy, Winland-Brown, Porter, & Thomas, 2011). Her lab work resulted with elevated TC 215 mg/dL, LDL 144 mg/dL, VLDL 36 mg/dL, triglycerides 229 mg/dL, and a low HDL 32 mg/dL. In her case, hyperlipidemia was detected by completing lab work during a physical exam.
Pertinent Negative Findings
Pertinent negatives include: HTN and CAD, and yellowish skin deposits of cholesterol called xanthomas (Dunphy, Winland-Brown, Porter, & Thomas, 2011). Her BP is 112/76 and her HR is 80. HTN and CAD are both associated with hyperlipidemia and she has no history of either disease.
Rationale for the Diagnosis
Mrs. Wu had lab work resulted with elevated TC of 215 mg/dL, LDL of 144 mg/dL, VLDL of 36 mg/dL, triglycerides of 229 mg/dL, and a low HDL of 32 mg/dL, which is indicative of a secondary diagnosis of hyperlipidemia. Hyperlipidemia is a significant part of metabolic syndrome. In Mrs. Wu’s case, her increased BMI, hyperglycemia, hypertriglyceridemia, and low levels of HDL establish a diagnosis of hyperlipidemia (Dunphy, Winland-Brown, Porter, & Thomas, 2011).
Differential Diagnosis
Depression (F32.9)
Pathophysiology
Depression is a mood disorder caused by “psychological, social, biologic factors that can contribute to the onset include genetic predisposition, central nervous system disorders, hormonal changes, stress, and ineffective coping strategies” (Boling & Smith, 2018). Norepinephrine and serotonin are the two neurotransmitters that are associated with the cause of mood disorders. Also, there is evidence that drugs that antagonize N-methyl-D-aspartate (NMDA) receptors have antidepressant effects (Dunphy, Winland-Brown, Porter, & Thomas, 2011). There is also a correlation between the hyper secretion of cortisol and depression.
Rationale for the Diagnosis
Depression is chosen as a differential diagnosis due to the pertinent positives upon examination, which include increased fatigue for about the last 12 weeks, tiredness, weight gain of 4 lbs., obesity, menopause 4 years ago, divorced, and alcohol use of 1-2 glasses of wine daily. Given that she has life changes, hormonal changes, and has been newly diagnosed with right knee arthritis and now diabetes and hyperlipidemia, she is at risk for depression, which needs to be closely considered and monitored (Goroll, & Mulley, 2014).
Plan
Diagnostics
Lab test
Additional lab tests will need to be completed for Mrs. Wu. In 3 months a repeat fasting CMP, blood glucose, HbA1c, lipid panel, and UA will need to be obtained as a follow up for DM2 and hyperlipidemia. Additional labs that I would include would be LFT, vitamin D, folate, and serum vitamin B12. It is important to assess her liver function because metformin is contraindicated with liver disease (ADA, 2018). Vitamin D and folate could be related to her fatigue and tiredness, and vitamin B12 could be decreased due to metformin. Also, decrease levels of B vitamins and folate can be associated with depression (Gorroll & Mulley, 2014).
I would screen Mrs. Wu for depression using the PHQ-9 tool. This is a fast instrument used to screen, diagnose, monitor, and measure the severity of depression in the following areas: pleasure, mood, sleep, fatigue, appetite, self-blame, concentration level, restlessness, and thoughts of suicide (Peres, Mercante, Tobo, Kamei, & Bigal, 2017). She is newly diagnosed with arthritis, DM2, and hyperlipidemia, divorced, drinks 1-2 glasses of wine a day, and has increased fatigue for 12 weeks.
Medications
I would have Mrs. Wu continue current medications of Tylenol 500mg 2 tabs in AM and a daily multivitamin. I would prescribe Metformin, as it is the first line medication for DM2. It can be used a monotherapy or combined with sulfonylureas and insulin. Metformin is beneficial for obese patients because he has a neutral effect on weight. It should only be used in patients with adequate renal function (Dunphy, Winland-Brown, Porter, & Thomas, 2011). In this patient’s case, her renal function is within normal limits, BUN 12 and creatinine 0.7.
Metformin 500 mg tablet
Sig: Take one tablet by mouth twice daily with meals
Disp: 60 tablets
Refill: 2 (Metformin Hydrochloride, 2018). Since Mrs. Wu is newly diagnosed with DM2, she would need a glucometer, lancets, and test strips in order to check and monitor her blood glucose levels (ADA, 2018).
Glucagon Emergency Kit 1mg
Sig: Inject 1mg IM as directed.
Disp: 1 kit.
RF: 2 (Glucagon, 2018).
First line drug of choice are statins for lowering LDL and also for cardio protection (American Diabetes Association, 2018). Atorvastatin treats hyperlipidemia and triglyceride levels. Atorvastatin also reduces the risk of angina, heart attack, and certain heart and blood vessel diseases. It reduces LDL levels by 40-60% and h
