AB is a 69 year old retired assympomatic male who has been battling Type 2 diabetes for the last five years. The patient was dignosed in 1997 after he exhibited symptoms that suggested that he had had hyperglycemia for two years before being diagnosed. His records showed that he had a fasting blood glucose of values 118–127mg/dl described as borderline diabetes indicative. The patient reported that he had been experiencing episodes of nuctoria in the past.Nuctoria is attributed to cponsuming large pasta meals and Italian pastries. He was advised, at his forst diagnosis, to lose some weight by 10lb but did not take any further action.
The patient presents recent weight gain, foot pain, and suboptimal diabetes control. He has been unsuccessful in his efforts to lose weight and increase his exercise for the past six months. His medical history shows that he has been taking glyburide 2.5mg(Diabeta) each morning but stooped when he started experiencing dizziness, sweating and mild agitation feeling in the afternoon. The patient also adheres to a daily medication of atorvastatin (Lipitor) and 10 mg hypercholesterolemia. He had also taken pancreas exilir, Gymnema Sylvestre, and chromium picolinate to control his diabetes but stopped using the supplements after seeing no positive results. H e was also not testing his blood glucvose leves at home and cats doubt on the effectiveness of the procedure in controlling his diabetes.
The patient states that all his life he had never fallen ill. He sold his business and embaked on active volunteer activities in several organizations. He lives with his wife of 48 years with whom they have two married children. His parents had type 2 diabetes. The patient has minimal knowledge about self-care management and complains about why he developed diabetes despite eating no sugar. He has gained 22lb in the past year despite getting more physically active after retirement playing golf and gardening. The patient reports that he has never visited a dietician and the history of his diet shows excessive carbohydrate intake, admits he takes a lot of bread and pasta. His medical document shows that the patient’s haemoglobin has never gone below 8% and his blood pressure is 148/92, 166/88, and 150/70mmHg at different reading times through last year. His feet have never been examined, and he does not know preventive foot care. His medical records show that he has never been hospitalized or had any surgeries perrfomed on him. The records also show that his immunizations are up to date, he has no history of allergy and that he has been healthy for many years.
The results of a physical examination shows that he has a height of 5”2’, weight of 178lb, BMI of 32.6 kg/m2. His fasting capital glucose is at 166mg/dl. The patient’s blood pressure was 154/96mmHg right arm lying and 140/90mmHg at his right-arm sitting. The pulse rate was at 88bpm, respiration 20 per minute. The patient had corrective lenses on his eyes. Pupils were equal, recreative to light, fundi-clear, and had no arteriovenous nicking or retinopathy. The patient’s thyroids were nonpalpable and longs clear for auscultation, regular heart rhythm with no gallops or murmurs. Vascular assessment reveal no carotid bruits, poptical, frmoral, and dorsalis pedis pulses 2+ bilaterally. A neurological assessment reveal a diminished vibratory sense on the forefoot, no uncle reflexes and monofilament of 5.07 Semmes-Weinstein only felt above the ankles (American Diabetes Association, 2017).
Laboratory test results showed that his fasting glucose level was 178mg/dl, outside the normal range of 65–109mg/dl. His creatinine was 1.0 mg/dl, which was within the normal range of 0.5–1.4mg/dl. The blood urea nitrogen was 18mg/dl, within the normal range of 7–30mg/dl. His sodium level was 141mg/dl, which was within the normal 135–146mg/dl range. His potassium level was at 4.3 mg/dl, within the normal range of 3.5–5.3 mg/dl. His lipid panel showed that the total cholesterol was 162mg/dl, within the normal range of less than 200mg/dl. The HDL cholesterol was at 43mg/dl, within the normal range of equal to or greater than 40 mg/dl. The triglycerides were 177mg/dl, which was also outside the normal range of less than 150mg/dl, and Cholesterol to HDL ratio was 3.8, which was within the normal range of less than 5.0. The patient had an AST of 141IU/1 falling within the normal 0–40IU/1 range, his ALT of 19 IU/1 falling within the normal 5–40 IU/1 range. The alkaline phosphatase was 56 IU/1, which was within the normal range of 35–125 IU/1. The A1C was 8.1% and exceeded the normal range of 4–6%, and the Urine microalbumin was at 45 mg, which was out of the less than 30mg normal range.
Assessment and Listed Problems
From the medical records and history, physical examination, and laboratory test results, the patient was assessed. This diagnosis reveals that the patoient suffers from uncontrolled type 2 diabetes (A1C>7%) and obesity of BMI 32. The patient also had hyperlipidemia controlled with atorvastatin, peripheral neuropathy, hypertension, and elevated urine microalbumin level. Also, the patient had self-care management, limited exercise, high carbohydrate intake, and no SMBG program and poor understanding of diabetes (Abdul-Ghani and DeFronzo, 2017).
Plan of Care
Further tests and work up plans are recommended including liver function tests; blood pressure tests repasts to confirm hypertension, CBC to rule out the possibility of infections and monitor any, and request for a more detailed history (Chellappan, Yap, Gupta and Dua, 2017). The complete history should include a list of all medications, a more in-depth family history, previous immunizations, and medical Regimen adherence and barriers to adherence.
The plan of care includes ensuring effectiveness and safe treatment through insulin therapy, wellness promotion by identifying risk factors and placing them on dietary plans and provision of information on resources, support groups, and diabetic indicators(Cichosz et al, 2016).
The patient was prescribed metfromin 500mg to be taken twice with food twice daily and avoid any form of acohol intake to reduce the occurrence of GI side effects and liver toxicities. He was also scheduled for titration that would increase his metfromin dosage to 1000mg twice daily for a four week period (American Diabetes Association, 2017). The patient recived further patient counseling, for medication efficiency, to increase physical activity and to gradually lose weight as these will be more helpful than taking drugs only. Exercises recommended include swimming, walking, or running for at least three days a week (Yakarylmaz and Öztürk, 2017).
The next follow up visit will be after two weeks of liver function tests, urine monitoring for glucose, ACE inhibitor therapy, blood pressure, renal function, and BUN. Weight changes, carbohydrate, and fat intake will also be monitored along with dietary restriction adherence. He was also scheduled for routine diabetes progression therapy efficacy evaluation tests. These will include annual eye examinations, foot examination, and neuropathy screening.
Abdul-Ghani, M., & DeFronzo, R. A. (2017). Is it time to change the type 2 diabetes treatment paradigm? Yes! GLP-1 RAs should replace metformin in the type 2 diabetes algorithm. Diabetes Care, 40(8), 1121–1127.
American Diabetes Association. (2017). 2. Classification and diagnosis of diabetes. Diabetes care, 40(Supplement 1), S11-S24.
Chellappan, D. K., Yap, W. S., Bt, N. A. S., Gupta, G., & Dua, K. (2018). Current therapies and targets for type 2 diabetes mellitus. Panminerva medica, 60(3), 117–131.
Cichosz, S. L., Lundby-Christensen, L., Johansen, M. D., Tarnow, L., Almdal, T. P., & Hejlesen, O. K. (2016).)Prediction of excessive weight gain in insulin treated patients with type 2 diabetes. Journal of diabetes, 9(4), 325–331.
Yakaryılmaz, F. D., & Öztürk, Z. A. (2017). Treatment of type 2 diabetes mellitus in the elderly. World journal of diabetes, 8(6), 278.