Nursing homework help
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 has a great effect on lowering TGs (Dunphy, Winland-Brown, Porter, & Thomas, 2011).
Atorvastatin 10 mg tablet
Sig: Take one tablet by mouth daily
Disp: 30 tablets
Refill: 2
Aspirin has been proven to decrease cardiovascular events in diabetic patients (Dunphy, Winland-Brown, Porter, & Thomas, 2011).
Aspirin EC 81 mg tablet
Sig: Take one tablet by mouth daily
Disp: 30 tablets
Refill: 2
Education
Diagnoses
DM2: The treatment for DM2 includes medication, diet, and exercise combined. Compliance is key. Mrs. Wu will need to understand the difference between hypoglycemia and hyperglycemia. Hypoglycemia is blood glucose level 70 mg/dL or lower, and can cause fatigue, pale skin, anxiety, sweating, hunger, and irritability and blurry vision. Treatment for low blood glucose includes drinking a cup of orange juice or a piece of candy to increase blood glucose levels. Hyperglycemia is blood glucose above 180 mg/dL. Symptoms include fatigue, polydipsia, polyphagia, headache, and polyuria (ADA, 2018). Symptoms should be monitored and reported immediately.
Hyperlipidemia: Its important to make Mrs. Wu aware of the importance of lowering her cholesterol levels. Hyperlipidemia coexists with DM2, therefore, puts her at a higher risk for CAD. Medication, diet, and exercise should strongly be addressed. In her case, a repeat LDL level will be checked in 3 months, then every 6-12 months until normal, then yearly once controlled (ADA, 2018).
Depression: Since Mrs. Wu now has to make lifestyle changes; she is at risk for depression and should be screened annually. It is important to educate on the signs and symptoms are depression, which include, increased fatigue, appetite changes, sleep disturbances, and mood changes. These symptoms should be reported immediately (Dunphy, Winland-Brown, Porter, & Thomas, 2011).
Medication
Metformin: Metformin is an antihyperglycemic agent that improves glucose tolerance. It is best to be taken with food or milk. Common signs and symptoms include diarrhea, flatulence, nausea, vomiting, metallic taste in mouth, weight loss, and can cause lactic acidosis as a severe adverse effect. It is important to seek medical attention if experiencing malaise, respiratory distress, or severe abdominal pain (Metformin, 2018).
Atorvastatin: Atorvastatin is used to treat high cholesterol and high triglycerides. It reduces the risk of CAD (Atorvastatin, 2018). Common side effects include diarrhea, arthralgia, myalgia, extremity pain, and UTI’s. Patients should avoid grapefruit and be instructed to report signs and symptoms of muscle pain, weakness, and fever (Atorvastatin 2018).
Aspirin: Aspirin reduces the formation of platelets in the blood, reducing the risk of blood clot formation (Aspirin, 2018). Patients should report any type of bleeding. Side effects include “dyspepsia, agitation, confusion, dizziness, lethargy, and seizures” (Aspirin, 2018). Patients should take aspirin with a full glass of water, at the same time every day, usually in the morning (Aspirin, 2018).
Glucagon kit: Glucagon is used in the prevention of hypoglycemia, (Glucagon, 2018). Gluconeogenesis and glycogenolysis in the liver are stimulated resulting in an increase in blood sugar (Glucagon, 2018). It should be administered if a blood glucose reading drops below 54mg/dL or if the patient is unconscious (ADA, 2018). Common signs and symptoms include nausea and vomiting, hypotension, and tachycardia (Glucagon, 2018). Mrs. Wu’s should keep this medication with her at all times and her family should be instructed on how to give this medication in case of an emergency.
Diet
Obesity contributes to diabetes, and considering that Mrs. Wu is obese, it is important to educate her on her diet. Healthy low calorie eating patterns should be encouraged. It is important for patients with DM2 to reduce their calorie intake by at least 500 calories per day, decreasing carbohydrates, high salt foods, saturated fats, trans fats, and cholesterol (ADA, 2018). According to the ADA (2018), the Mediterranean diet involves eating more vegetables, fruits, whole grains, cereals, nuts, seeds, and beans, which has shown to protect against heart disease, improve blood glucose and loss weight. Avoiding fats and cholesterol will improve her blood glucose levels and cholesterol levels.
Exercise
Exercise and weight loss can improve ones blood glucose level and cholesterol level. It is recommended to participate in 150 minutes per week of moderate intensity physical activity in order to improve insulin sensitivity. “Both aerobic exercise and strength training can improve glucose control, lipid levels, decrease the risk of falls and fractures, improve functional capacity and well-being” (ACCE, 2018). Although Mrs. Wu states she is experiencing less pain and increased mobility with her right knee and has been newly diagnosed with arthritis, I would initially recommend for her to participate in water aerobics or another low impact activity instead of walking on the treadmill.
Warning Signs for Diagnoses and Medications
Mrs. Wu will need to be educated on the warning signs of her diagnoses and medications. Signs and symptoms of hypoglycemia and hyperglycemia should be discussed as well as self-treatment. She should assess her feet daily for any scrapes, wounds, or change in color of skin, due to DM2 causing poor circulation and neuropathy. Retinopathy is another complication and she should be referred to see an eye doctor annually and report any visual changes. Nephropathy, including renal disease, and macrovascular diseases such as PVD should also be monitored closely (Dunphy, Winland-Brown, Porter, & Thomas, 2011).
Referral
At this time I would refer Mrs. Wu to a dietitian for recommendations on individualized meal planning, diet control, and healthier food choices to maintain her blood glucose level and cholesterol with proper nutrition. I would also refer her to a diabetic educator, who empowers patients to manage their diabetes. They teach patients on how to self-monitor blood glucose levels using a glucometer at home (ADA, 2018). Overall, they teach patients how to make behavior-changing goals in order to improve their health. A thorough physical exam, including feet, will be completed at each visit to determine any further referrals. Complications of DM2 that would closely be examined for and monitored are:
Retinopathy: I would have Mrs. Wu follow up with an ophthalmologist, if she does not have one already. It is recommended to have a comprehensive dilated eye and visual exam annually to assess for retinopathy (Dunphy, Winland-Brown, Porter, & Thomas, 2011).
Nephropathy: Screening for a routine serum creatinine, urinalysis, and microalbuminuria should be preformed at the time of diagnosis in order to prevent the progression of renal disease (Dunphy, Winland-Brown, Porter, & Thomas, 2011). Patients with urinary symptoms or impotence should be referred to an urologist.
Macrovascular disease: In diseases such as a stroke, CAD, and peripheral vascular disease (PVD), and experiencing loss of sensation or pain to their feet, patients may need a referral to a podiatrist, orthopedic surgeon, and/or vascular surgeon (Dunphy, Winland-Brown, Porter, & Thomas, 2011).
Follow up
The frequency of patient visits depends on compliance of the disease and controlling blood glucose levels, changes in management, and other medical complications. If Mrs. Wu is competent and compliant with self-managing blood glucose, telephone consultations may be deemed instead of an office visit (Dunphy, Winland-Brown, Porter, & Thomas, 2011). I would follow up with Mrs. Wu in 2 weeks via a telephone call to evaluate her symptoms and review her blood glucose log. I would have her follow up in the office in 3 months to re-evaluate her symptoms and repeat lab work including, CMP, fasting glucose, HbA1c, lipid panel and UA.
Medication Cost
I would assess if Mrs. Wu has insurance or not. If not, Mrs. Wu can get her medication, metformin, atorvastatin, aspirin, Tylenol, and multivitamin from Wal-Mart. For 60 tablets of metformin 500 mg, the cost would be $4.00 with no coupon necessary. Monthly she would be paying $4.00 for metformin. For 30 tablets of atorvastatin 10 mg, the cost would be $9.00 monthly, with no coupon necessary. For 30 tablets of aspirin 81mg it would cost $1.32 monthly (GoodRx, 2018). Tylenol and multivitamins can also be purchased at Wal-Mart or anywhere over the counter. For 250 tablets the cost would be less than $7.00 at Wal-Mart (GoodRx, 2018). If she buys 50 tablets of One A Day Women’s Menopause Formula Multivitamin it would cost $12.99, which would last her one month and twenty days. (Walmart, 2018). A monthly cost for all medication would come out to being a total of $34.31.
In the case of Mrs. Wu not having insurance, she can obtain a coupon for 75% off from www.helprx.com (2018) for a glucagon kit. Glucagon kits are expensive, ranging from $250-$300 without insurance. The ReliOn glucometer from Wal-Mart would cost $9.00, 200 lancets would cost $5.28, 100 test strips would cost $17.88, and 200 sterile alcohol prep pads would cost $2.07 (Walmart, 2018). This is a good resource to use in my future practice as a nurse practitioner. Patients would be more compliant if given the resources for more affordable medication.
Conclusion
This paper examined the analysis of the pertinent subjective and objective data that was collected from Mrs. Wu in order to diagnose and develop a treatment plan for her. This paper also discussed the assessment of the primary, the secondary, and the differential diagnoses, including the pathophysiology, pertinent positive findings, pertinent negative findings, and the rationale for each diagnosis. A treatment plan for each diagnosis, which consists of diagnostics, medications, education, referrals, and follow up was also discussed. A discussion on medication costs for all prescribed and over the counter (OTC) medications was presented.
Clinical Chart SOAP Note
Patient information: Mrs. Wu, 59, Female, Asian
S (Subjective):
Chief Complaint (CC): increased fatigue, weight gain, polydipsia, polyphagia, polyuria
HPI: Mrs. Wu, a 59 year old female presents to the office for a follow up visit for her recently diagnosed right knee arthritis and reports new complaints of increased fatigue for the last 12 weeks, weight gain of 4 lbs. despite working out on the treadmill for 30 minutes and light weight lifting twice a week. She reports more frequent urination during the day and waking up during the night for about 3 months but is able to fall back asleep immediately.
Current medications: Tylenol 500 mg 2 tabs in AM for knee pain, daily vitamin, turmeric
Allergies: Bactrim, cats, pollen
PMHx: Right knee arthritis, German measles, ASCUS pap (1998), vaccinations up to date
PSHx: Health screening: Mammogram last year benign, colonoscopy WNL
SH: Divorced, works from home as an administrative assistant, drinks 1-2 glasses of wine daily, former smoker, quit 10 years ago, no illicit drug use
FH: Parent’s deceased, child alive and well, no siblings
ROS:
General: reports increased fatigue and tired for last 12 weeks, 4 lb. weight gain since menopause 4 years ago
Skin: no abnormalities reported
HEENT: no abnormalities reported
CV: no abnormalities reported
Respiratory: no abnormalities reported
Abdomen: no abnormalities reported
GU: reports frequent urination during the day, waking up at night to urinate for 3 months
Musculoskeletal: increased mobility and less pain in right knee (newly diagnosed with arthritis)
O (Objective):
PE:
BP 112/76, HR 80, regular, R 16, regular, Ht 5’1.5”, Wt 165 lbs, BMI 30.7
General: Female, alert, oriented, and cooperative, in no acute distress
Skin: Warm, dry, and intact. No lesions noted.
HEENT: Head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior and posterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs
Respiratory: Clear to auscultation bilaterally, respirations unlabored
Abdomen: soft, round, nontender with positive bowel sounds presents; no organomegaly, no abdominal bruits, no CVAT.
GU: bladder nontender upon palpation
Musculoskeletal: full ROM both knees, nontender to palpation bilaterally, gait normal
Lab Work: (fasting labs drawn this morning)
CBC: WBC 6,300/mm3
Hgb 12.8 gm/dl
Hct 42%
RBC 4.6 million
MCV 93 fl
MCHC 34 g/dl
RDW 13.8%
CMP : Sodium 136
Potassium 4.4
Chloride 100
CO2 29
Glucose 130
BUN 12
Creatinine 0.7
GFR est non-AA 99 mL/min/1.73
GFR est AA 101 mL/min/1.73
Calcium 9.4
Total protein 7.6
Bilirubin, total 0.5
Alkaline phosphatase 72
AST 25
ALT 29
Anion gap 8.10
Bun/Creat 17.7
Hemoglobin A1C: 6.8 %
TSH: 2.31, Free T 4 0.9 ng/dL
TC 215 mg/dl
LDL 144 mg/dl
VLDL 36 mg/dl
HDL 32mg/dl
Triglycerides 229
UA: pH 5, SpGr 1.010, Leukocyte esterase negative, nitrites negative, 1+ glucose; negative protein; negative ketones
EKG: normal sinus rhythm
A (Assessment):
Primary diagnosis: Diabetes Mellitus type 2 (E11.9)
Secondary diagnosis: Hyperlipidemia (E78.5)
Differential diagnosis: Depression (F32.9)
P (Plan):
Diagnostics: Repeat CMP, fasting glucose, HbA1c, lipid panel, vitamin D, folate, vitamin B12, UA, 24 hour urine sample, spot albumin/creatinine ratio, and PHQ-9 questionnaire.
Medication:
Continue current medication, Tylenol and Multivitamin
Prescribe:
Metformin 500 mg tablet
Sig: Take one tablet by mouth twice daily with meals
Disp: 60 tablets
Refill: 2
Atorvastatin 10 mg tablet
Sig: Take one tablet by mouth daily
Disp: 30 tablets
Refill: 2
Aspirin EC 81 mg tablet
Sig: Take one tablet by mouth daily
Disp: 30 tablets
Refill: 2
Glucagon kit x 1
ReliOn glucometer x 1
Lancets #200
Test strips #100
Sterile alcohol prep pads #200
Education: Educated on disease specific teaching and complications for DM2 and hyperlipidemia, diagnostic testing, exercise/activity management for weight loss, diet modification, nutrition counseling and therapeutics, medication management, self monitoring blood glucose, referrals and follow up plans
Referrals: Dietitian, diabetic educator; ophthalmologist, urologist, podiatrist, orthopedic surgeon, and/or vascular surgeon if needed
Follow up: In 2 weeks via telephone for evaluation of symptoms and review BS log and in 3 months for re evaluation of symptoms, repeat CMP, fasting glucose HbA1c, lipid panel, UA. Instruct patient to seem medical attention if symptoms continue.
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