General Overview
Type 2 diabetes mellitus is a serious chronic metabolic disorder characterized by high blood glucose levels. This disorder is caused by a loss of effective b-cell insulin secretion and insulin resistance (Galicia-Garcia et al., 2020). The patient is a 66-year-old male with a history of diabetes who reports fatigue, blurry vision, frequent urination, a feeling of hunger, and pain in the fingers. Poorly managed diabetes leads to cardiovascular, gastrointestinal, and joint complications (Banday et al., 2020). This paper focuses on discussing differential diagnoses, lab and medication orders, educational aspects, referrals, and follow-ups to learn from the experience.
Differential Diagnoses
- Hyperglycemia
- Osteoarthritis
- Obesity
Primary Diagnosis
Pathophysiology: Primary diagnosis, Type 2 Diabetes Mellitus (ICD 10 E11.9), is a complex illness. It requires continuous care, glycemic control, and self-management education to reduce the growth of additional health risks (American Diabetes Association, 2022). B-cell dysfunction occurs and provokes the reduction of insulin secretion, which affects the body’s possibility to maintain glucose levels (Galicia-Garcia et al., 2020).
Significant Positives: According to the American Diabetes Association Professional Practice Committee (2022a), elevated HbA1c (12.4%), creatinine level (1.92), and glucose level (240) are the signs of type 2 diabetes. The patient also experiences fatigue and blurred vision during the last three weeks.
Significant Negatives: ALT 26, total-C (248 mg/dL), and HDL (55 mg/dL) are within normal limits. The patient does not have unexplainable weight-related changes, and no diabetes family history is reported (Ismail et al., 2021).
Interpret Abnormal Labs
- LDL-C (188 mg/dL) and total-C (248 mg/dL) are high although most diabetic patients have normal or low LDL levels. It may be explained by a slower turnover rate and the possible lipid deposition in artery walls (Thambiah & Lai, 2021).
- Glucose (250) and creatinine (1.92) are high because if diabetic patients do not control their glucose level, the filtering system is challenged and cannot clean all blood waste (Thambiah & Lai, 2021).
Hyperglycemia
Pathophysiology: Hyperglycemia (ICD 10 E78.5) is a secondary diagnosis of diabetes, which proves a high level of sugar in the blood. The body lacks insulin because of diabetes, and hyperglycemia may provoke increased hunger or thirst, vision problems, and heart attacks (Galicia-Garcia et al., 2020).
Significant Positives: The patient reports fatigue, blurred vision, and frequent urination during the last three weeks. His LDL-C (188 mg/dL) and Total-C (248 mg/dL) are high (Galicia-Garcia et al., 2020).
Significant Negatives: There is no chest pain or cardiovascular complications in the patient’s report. His HDL-C (55 mg/dL) and triglycerides levels (184 mg/dL) are acceptable or at the borderline high, which is also acceptable for diabetic patients (Banday et al., 2020).
Interpret Abnormal Labs
- Blood pressure (168/80 and 166/82) is high in the patient, which is explained by high glucose levels and damage to blood vessels (Thambiah & Lai, 2021).
- The American Diabetes Association Professional Practice Committee (2022a) proves that high glucose (240) level is hyperglycemia’s characteristic.
Osteoarthritis
Pathophysiology: Primary osteoarthritis, right hand (ICD 10 M19.041) is a secondary diagnosis of the diabetic patient. It is a common musculoskeletal disability observed in the aged population (Eitner & Wildemann, 2021).
Significant Positives: pain in a couple of fingers almost daily and X-ray (right-hand index & middle finger deformation) are reported (Eitner & Wildemann, 2021).
Significant Negatives: The patient has no problems with the left hand and demonstrates good activities.
Interpret Abnormal Labs
Degenerative joint disease is evidenced on X-ray through the deformation of two fingers on the right hand. Increased BMI is not responsible for the connection between diabetes and osteoarthritis (Eitner & Wildemann, 2021).
Obesity
Pathophysiology: Obesity, unspecified (ICD 10 E66.9), is another secondary diagnosis of the patient’s condition. When BMI is higher than 30, people are considered obese. This condition is defined as an exaggeration of normal adiposity that affects the homeostatic regulation of glucose levels related to insulin resistance (Banday et al., 2020).
Significant Positives: The patient’s weight is 226 lbs, and his height is 5’10’’. His blood pressure is high, 168/80, and he cannot control his feeling of hunger.
Significant Negatives: No shortness of breath is reported at the moment of the examination.
Interpret Abnormal Labs
1. BMI is 38.16, which is a sign of obesity in the patient. The patient does not take any physical exercises, drives the car, and eats outside to meet his physiological needs (Banday et al., 2020).
Lab Orders
Fasting plasma glucose (FPG) value is effective for monitoring diabetes in patients before and after interventions (Ismail et al., 2021).
Lipid panel should be regularly tested to predict and monitor diabetic dyslipidemia and other changes in LDL and cholesterol levels (American Diabetes Association Professional Practice Committee, 2022a).
Medication Orders
Metformin 500 mg, once a day
This medication increases insulin sensitivity, controls glucose production, and activates enzymes for gene expression (Mishra et al., 2021).
Dapagliflozin 10 mg, once a day
This medication improves b-cell capacity, stabilizes blood pressure, and reduces body weight (Mishra et al., 2021).
Personalized Patient Education
Patient Education Primary & Secondary Diagnoses
The patient with type 2 diabetes needs education about the importance of monitoring his vital signs regularly and counseling even if no problems disturb him. Hyperglycemia can process gradually, and structural dysfunctions can be observed (Banday et al., 2020). Osteoarthritis is not common but possible in diabetic patients, and this condition should be reported quickly to predict amputations (Banday et al., 2020). Most diabetic patients are obese, and the task is to take physical exercises and follow diets regularly.
Patient Education Medications
Some diabetic medications provoke some side effects, and it is necessary to be ready for them. Diarrhea, nausea, and vomiting are related to metformin intake, while Dapagliflozin causes dehydration, weight loss, and urination changes (Mishra et al., 2021). The patient should not make independent decisions to stop or use another drug without the doctor’s approval.
Patient Education Diet
A low-calory diet is recommended in this case to manage glucose and predict medication side effects. Dietary changes (no sugar or meat) are necessary to improve the lipid panel (Thambiah & Lai, 2021).
Patient Education Exercise
Physical activity plays an important role in managing diabetes in patients of any age. If a person can complete simple physical exercises, daily walks can help stabilize the condition and reduce fatigue (Mishra et al., 2021).
Referrals & Consults
Dietitian/nutritionist to improve eating habits and increase physical activities (American Diabetes Association Professional Practice Committee, 2022b).
Educational specialist to introduce the main aspects of the technology-assisted program for diabetes care and management (American Diabetes Association Professional Practice Committee, 2022b).
Follow Up
It is better to check the lipid panel at least once a month. However, the effectiveness of lifestyle interventions and diabetes diets need to be observed in 4 months through individual counseling with a therapist and a nutritionist (American Diabetes Association Professional Practice Committee, 2022b).
Assess Comorbidities
Diabetes changes the quality of life in a variety of ways. A reduction in plasma glucose concentration is observed and affects the patient’s mental status, provoking depression, anxiety, and dependence on external factors (Ismail et al., 2021). Patients use a self-rating depression scale to examine their condition and predict the progress of such problems.
Medication Costs
Metformin and Dapagliflozin are not characterized by some polypharmacy concerns. Mishra et al. (2021) reported the effectiveness of these medications to manage diabetes and related complications. Metformin costs about $40 per month, but if 100 tablets are bought at the same time ($100.32), there is a chance to save and pay $33 per one-month course. Dapagliflozin costs $75 (100 tablets), meaning $22.5 per month. In general, $55.5 is the price for the chosen course of pharmacological care.
NP Student Experience
Many people need to live with diabetes because this disease remains incurable. Metformin is a common medication to manage insulin resistance and stabilize the diabetic patient’s condition. This experience help understand the worth of cooperation between physicians and patients. Education, counseling, and self-care play an important role in this process.
References
American Diabetes Association. (2022). Introduction: Standards of medical care in diabetes – 2022. Diabetes Care, 45(1), 1-2. Web.
American Diabetes Association Professional Practice Committee. (2022a). 2. Classification and diagnosis of diabetes: Standards of medical care in diabetes – 2022. Diabetes Care, 45(1), 17-38. Web.
American Diabetes Association Professional Practice Committee. (2022b). 3. Prevention or delay of type 2 diabetes and associated comorbidities: Standards of medical care in diabetes – 2022. Diabetes Care, 45(1), 39-45. Web.
Banday, M. Z., Sameer, A. S., & Nissar, S. (2020). Pathophysiology of diabetes: An overview. Avicenna Journal of Medicine, 10(4), 174-188. Web.
Eitner, A., & Wildemann, B. (2021). Diabetes – Osteoarthritis and joint pain. Bone & Joint Research, 10(5), 307-309. Web.
Galicia-Garcia, U., Benito-Vicente, A., Jebari, S., Larrea-Sebal, A., Siddiqi, H., Uribe, K. B., Ostolaza, H., & MartĂn, C. (2020). Pathophysiology of type 2 diabetes mellitus. International Journal of Molecular Sciences, 21(17). Web.
Ismail, L., Materwala, H., & Al Kaabi, J. (2021). Association of risk factors with type 2 diabetes: A systematic review. Computational and Structural Biotechnology Journal, 19, 1759-1785. Web.
Mishra, V., Nayak, P., Sharma, M., Albutti, A., Alwashmi, A. S., Aljasir, M. A., Alsowayeh, N., & Tambuwala, M. M. (2021). Emerging treatment strategies for diabetes mellitus and associated complications: An update. Pharmaceutics, 13(10). Web.
Thambiah, S. C., & Lai, L. C. (2021). Diabetic dyslipidaemia. Practical Laboratory Medicine, 26. Web.