Diagnosis and Management Plan for Patient

Introduction

Analyzing the information provided by a patient is essential in making the correct diagnosis and formulating an effective care plan. This essay evaluates the information provided by a patient with the objective of providing the right diagnosis based on the present signs and symptoms. Another aim of this essay is to create a management plan through the application of national diabetes guidelines and demonstrate a mastery of writing a clear and concise SOAP note.

Assessment

The patient presents with fatigue and weight gain, which she associates with menopause, and increased hunger and thirst. She also complained of an increased frequency of urination during the night. Based on this assessment the primary diagnosis for this patient is type 2 diabetes mellitus. The ICD code for the disease that is not associated with the development of complication is E11.9. Insulin resistance or inadequate secretion of insulin by the beta cells in the pancreas characterizes the condition. Additionally, its classic symptoms include increased thirst, frequent urination, weight gain, fatigue, and increased hunger, which is present in the patient. The onset of type 2 diabetes mellitus is also common during adulthood, and the progression of age is associated with increased risk of the condition. The results of the patient showed 1+ glucose, which is essential for the diagnosis of the disorder. The absence of ketones based on the test rules out the likelihood of diabetic complications. The diagnosis was selected based on the clinical symptoms and the laboratory findings for this patient (Khardori, 2018; Goldstein & Mueller-Wieland, 2016).

The secondary diagnosis for this patient is a postmenopausal syndrome. The ICD code for this condition is N95.1. It is characterized by amenorrhea that lasts for 12 months. Its symptoms include increased frequency of urination, night sweats, hot flashes, emotional changes, and weight gain. The patient reported that she has been gaining weight since reaching menopausal the previous year. This diagnosis was made based on the clinical assessment of the patient (Dalal & Agarwal, 2015).

The differential diagnoses for this patient include hypothyroidism and type 1 diabetes mellitus. Its ICD code is E03.9. Additionally, it is marked by the decreased production of T4, which in turn causes an increase in the secretion of stimulating thyroid hormone. Hypothyroidism’s symptoms encompass weight gain, fatigue, and increased sensitivity to cold. The weight gain symptom presented by the patient was indicative of this condition. However, it was ruled out since the patient’s TSH levels were within the normal range (Hotze, 2013; Orlander, 2018).

The ICD code for type 1 diabetes mellitus is E10.9. It is a chronic illness that is caused by the body’s inability to produce insulin due to the destruction of the beta cells by autoimmune responses. The main signs and symptoms of the condition are polyuria, polydipsia, weight loss, and polyphagia. The patient reported that she had been experiencing increased hunger and thirst, which are in line with the symptoms presented by patients with type 1 diabetes mellitus. Nevertheless, the illness was ruled out since it normally occurs among younger individuals as compared to type 2 diabetes mellitus, which as mentioned is associated with older patients (Goldstein & Mueller-Wieland, 2016).

Plan

Diagnostics

Some of the diagnostic tests that I wish to conduct on this patient include HbA1c level, random plasma glucose, and a fasting plasma glucose (FPG). HbA1c levels higher than 6.5% will be indicative of diabetes mellitus. A fasting plasma glucose level of 7.0 mmol/l or higher would indicate the possibility of diabetes mellitus. Random plasma glucose of 11.1 mmol.l or higher would confirm the presence of hyperglycemia (Pagana, 2013).

Medication

The first line drug for patients with diabetes is metformin. Metformin HCL 850 mg TID will be prescribed to manage the symptoms of diabetes mellitus. A prescription of Lipitor 80 mg PO QHS would also be made to manage the patient’s cholesterol levels, which were high. Medication Cost

For most patients the use of generic Metformin is covered by Medicare or other health insurance plans. The average retail price for this drug is $27.16 while the lowest treatment price is $4.00 for a standard 30-day treatment plan. The cost for Lipitor, which was prescribed for management of the patient’s cholesterol levels, is approximately $166 for a 30-day supply.

Education

1. Monitoring dietary intake and portion control, particularly in carbohydrate and other macronutrients intake.
2. The patient should be educated on the classical symptoms associated with hyperglycemia and hypoglycemia to reduce the risk of complications
3. Spreading meals out throughout the day to avoid taking large meals in one sitting and using snacks to promote an improved control of blood glucose levels and prevent hypoglycemia.
4. Increasing the intake of vegetables and fruits for weight control and glycemic control
5. Educating the patient on the importance of continuing to indulge in exercise and other physical activities by participating in at least 30 to 45 minutes per day in the aerobic exercise of moderate-intensity for weight loss.
6. Self-monitoring of blood glucose at home to reduce risks of hyperglycemia and hypoglycemia that may be induced by the intake of diabetic drugs
7. Adherence to medication to improve blood glucose control.
8. Nerve damage, infections, and problems related to circulation can contribute to serious foot problems. Therefore, the patient should be educated on how to care for feet and watch out for wounds on the feet.
9. The patient should lookout for possible adverse side effects associated with the use of metformin. Additional oral or injectable drug can be prescribed to reduce the risks of adverse reactions (Khardori, 2018; Goldstein & Mueller-Wieland, 2016).

Referrals

The patient will be referred to a clinical nutritionist for further dietary modification counseling based on the type 2 diabetes mellitus diagnosis.

Follow Up

Follow-ups will be conducted on a monthly basis to assess glycemic control and progress of the treatment offered (Goldstein & Mueller-Wieland, 2016). The next follow up visit will assess the risk of adverse reactions related to Metformin and Lipitor. A research conducted on the efficiency of metformin as a monotherapy for the management of type 2 diabetes mellitus showed that while it is commonly used as a first therapeutic option among these patients, it may present will adverse reactions in some patients. It is however effective in preventing vascular complications, providing better control for glucose levels, and moderating weight (Gnesin, et al., 2018).

SOAP NOTE

SUBJECTIVE

CHIEF COMPLAIN: Feeling sick and in need of weight loss management advice

HISTORY OF PRESENT ILLNESS: Mrs. G. is a 52-year-old Hispanic female who comes to the office with complaints of fatigue and loss of energy. She also states that she has been gaining weight since the previous year after the onset of her menopause. Additionally, she said that she had joined a gym and been working out twice a week on the treadmill for thirty minutes, but has only noticed a slight weight loss. She complains that the exercises make her feel hungry and thirsty which she states affect her weight loss regime. She also complains of increased frequency of urination.

Past Medical History: The patient had left knee arthritis. Previously treated for chick pox and mumps as a child. Her vaccination booklet is up to date.

Gynecological history:  G1 P0. 1 child, full term, wt 9lbs 2 oz.   LMP 15months ago. No history of abnormal PAP

Family History: Both parents are alive and well, child alive and well. No siblings.

Social History:  Works as a telemarketer from home. Married, lives with husband. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use.

Allergies: NKDA, allergic to cats and latex

REVIEW OF SYSTEMS

General: Obese

HEENT: wears contacts

Lungs: Clear

Abdomen: Soft, nontender

OBJECTIVE

Blood pressure 127/70mmHg, Heart rate 80 beats per minute, Respiratory rate 22 breaths per minute, Temperature 98.6^oF, Height 160 cm, Weight 198.42 lbs, Height 160 cm, BMI 35.2 kg/m²

Physical Examination

General: Obese, alert, cooperative

HEENT: head normocephalic. Hair is thick and well distributed throughout the scalp. Eyes do not have exudate, sclera white. Uses eye 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 cervical lymph nontender to palpation.  No lymphadenopathy. Thyroid midline, small and firm without palpable masses.

Cardiovascular: S1 and S2 RRR without murmurs or rubs

Lungs: Clear to auscultation bilaterally, respirations unlabored.

Abdomen: soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.

ASSESSMENT

Type 2 diabetes mellitus: This chronic condition consists of a collection of dysfunctions characterized by hyperglycemia that result from the combination of insulin resistance and inadequate production of insulin by the beta cells in the liver. Excessive production of glucagon has also been seen as a possible contributory factor to the development of type 2 diabetes mellitus. Some of the symptoms common among patients with this condition include hyperglycemia, polyuria, polydipsia, weight gain or weight loss, blurred vision, and polyphagia. Slow healing of wounds and paresthesias of the lower extremities are also common among these patients (Khardori, 2018). The symptoms presented by the patient such as polydipsia, polyuria, and hyperglycemia were supportive of this condition. The laboratory tests and examinations conducted on the patient also provided evidence of this diagnosis.

Differential Diagnosis: Hypothyroidism, Postmenopausal syndrome, and type 1 diabetes mellitus

Plan and Treatment

Medication

1. Tylenol daily for knee pain.
2. Daily multivitamin.
3. Metformin HCL 850 mg TID
4. Lipitor 80 mg QHS

Non-medication/Education

1. Adherence to treatment
2. Participate in physical activity and exercise
3. Dietary modification
4. Assess feet daily for wounds (Gnesin, et al., 2018; Goldstein & Mueller-Wieland, 2016)

Lab and Tests

• Full haemogram test
• Random blood glucose
• Fasting blood glucose
• Lipid test
• Thyroid functioning test

References

Dalal, P. K., & Agarwal, M. (2015). Postmenopausal Syndrome. Indian Journal of Psychiatry, S222-S232.

Gnesin, F., Thuesen, A. C., Kahler, L. K., Gluud, C., Madsbad, S., & Hemmingsen, B. (2018, January 3). Metformin Monotherapy for Adults with Type 2 Diabetes Mellitus. Wiley. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012906/full

Goldstein, B. J., & Mueller-Wieland, D. (2016). Type 2 Diabetes: Principles and Practice, Second Edition. CRC Press.

Hotze, S. F. (2013). Hypothyroidism, Health & Happiness: The Riddle of Illness Revealed. Advantage.

Khardori, R. (2018, March 7). Type 2 Diabetes Mellitus. Medscape. Retrieved from https://emedicine.medscape.com/article/117853-overview#a3

Orlander, P. R. (2018, February 26). Hypothyroidism. Medscape. Retrieved from https://emedicine.medscape.com/article/122393-clinical

Pagana, K. D. (2013). Mosby’s Manual of Diagnostic and Laboratory Tests. Elsevier Health Sciences.