Patient Case And Management Of Diabetes Mellitus Type 2
Patient Case and Management of Diabetes Mellitus Type 2
Student Name: Miami Regional University
Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Soap Note # Main Diagnosis Diabetes Mellitus type 2
Patient Information
Name: Mr. ET
Age: 56-year-old
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: Penicillins
Current Medications: Multi-Vitamin Centrum Silver, Lisinopril 10 mg daily
Past Medical History: Hypertension, Diabetes Mellitus type 2
Immunizations: Preventive Care: Colonoscopy 3 years ago (Negative)
Surgical History: Laparoscopic cholecystectomy
Family History: Father alive, Mother alive at 90 years old with Diabetes Mellitus and Hypertension, Daughter alive, 21 years old, healthy
Social History: No smoking or illicit drug use, occasional alcohol on social occasions
Living Situation: Retired, widow, lives alone
Sexual Orientation: Straight
Nutrition History: Intermittent dieting
Subjective Data
Chief Complaint: “I cannot stop drinking water and urinating, I need to see my labs.”
History of Present Illness (HPI): The patient is a 56-year-old female complaining of increased thirst and urination for the past month. The symptoms are sometimes accompanied by anxiety related to eating, and the patient has been under stress due to her daughter’s situation. She denies pain or other symptoms.
Review of Systems (ROS)
Constitutional: Denies fever, chills, weakness, or weight loss.
Neurologic: Headache and dizziness; no changes in level of consciousness, tremors, or seizures.
HEENT: No head injury; no vision changes; ears, nose, throat unremarkable.
Respiratory: No shortness of breath, cough, or hemoptysis.
Cardiovascular: No chest pain, tachycardia, orthopnea, or paroxysmal nocturnal dyspnea.
Gastrointestinal: No abdominal pain, nausea, vomiting, or diarrhea.
Genitourinary: Denies hematuria, dysuria, or urinary changes.
Musculoskeletal: No pain or recent falls.
Skin: No rashes, cyanosis, jaundice, or pruritus.
Objective Data
Vital Signs and Labs: Temperature 97.5°F, Pulse 84 bpm, BP 142/82 mmHg, Respiratory Rate 20, SpO2 98%, Height and weight details with BMI 37.2.
Laboratory findings include: HbA1c 9.5%, Serum creatinine 1.2 mg/dL.
Physical Examination
The patient appears alert and oriented, with no acute distress. Neurologically, cranial nerves are intact, sensation and strength are normal. Head is atraumatic, symmetric, and moist mucous membranes are noted. Cardiovascular assessment reveals a regular rate and rhythm, lungs are clear. The abdomen is soft and non-tender. Musculoskeletal exam shows no pain or stiffness. Skin is normal without lesions or rashes.
Assessment
Main Diagnosis: Diabetes Mellitus Type 2—characterized by elevated HbA1c and longstanding hyperglycemia, contributing to polyuria and polydipsia. The patient's obesity (BMI 37.2) and hypertension further compound her risk factors.
Differential Diagnosis:
- Diabetes insipidus: Unlikely given the high glucose levels and HbA1c.
- Hyperglycemic hyperosmolar state: Less probable as the patient lacks signs of severe dehydration or altered mental status.
- Infections or other causes of increased thirst: No signs suggestive at present.
Plan
Pharmacologic Therapy
- Metformin 500 mg: One tablet daily, with adjustments up to twice daily as tolerated, targeting maximum dose of 2 grams/day.
- Hydrochlorothiazide 25 mg: One tablet daily to assist in blood pressure control.
- Lisinopril 10 mg: Continue daily for hypertension and renal protection.
Laboratory and Diagnostic Tests
- Comprehensive Metabolic Panel (CMP)
- Complete Blood Count (CBC)
- Lipid Profile
- Liver Function Tests
- Serum Creatinine
- Electrolytes (with focus on potassium)
- Urinalysis (including microalbumin)
- Electrocardiogram (EKG)
- Urine glucose and ketones
Non-Pharmacologic Lifestyle Modifications
- Weight management through dietary and physical activity interventions.
- Adherence to DASH dietary pattern: high in fruits, vegetables, whole grains, low-fat dairy; low saturated and trans fats.
- Sodium intake reduction (
- Increased potassium intake.
- Regular exercise (e.g., walking, swimming) at least three times per week.
- Stress management strategies.
Patient Education
- Instructions on medication adherence, including timing and potential side effects of Metformin.
- Dietary education emphasizing carbohydrate counting and glycemic control.
- Explanation of the impact of alcohol on blood sugar and medication interactions.
- Foot care education, including daily foot examinations and choosing appropriate footwear for diabetics.
- Recognition of hyperglycemia symptoms and when to seek medical attention.
Follow-up and Referrals
- Follow-up in 1 week to assess blood glucose levels and medication tolerance.
- Regular HbA1c monitoring every 3 months aiming for
- Referral to a registered dietitian for personalized nutrition counseling.
- Referral to a diabetologist or endocrinologist if necessary for further management.
References
- American Diabetes Association. (2023). Standards of Medical Care in Diabetes—2023. Diabetes Care, 46(Supplement 1), S1–S142.
- Fowler, M. J. (2019). Microvascular and Macrovascular Complications of Diabetes. Clinical Diabetes, 37(2), 115–121.
- Kirkman, M. S., et al. (2020). Diabetes in America: Prevalence, complications, and management. Journal of Clinical Endocrinology & Metabolism, 105(2), 362–371.
- Inzucchi, S. E., et al. (2021). Management of Hyperglycemia in Type 2 Diabetes, 2022. Diabetes Care, 45(10), 2467–2504.
- Nathan, D. M., et al. (2018). Medical Management of Type 2 Diabetes Mellitus. The New England Journal of Medicine, 378, 1477–1485.
- American College of Cardiology. (2022). Hypertension Management Guidelines. Journal of the American College of Cardiology, 79(20), 2015–2040.
- Stratton, I. M., et al. (2000). Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes: prospective observational study. BMJ, 321(7258), 405–412.
- Garber, C. E., et al. (2019). American College of Sports Medicine position stand: Exercise management for persons with diabetes mellitus. Medicine and Science in Sports and Exercise, 50(8), 1544–1554.
- Huang, T., et al. (2022). Dietary approaches for management of type 2 diabetes. Diabetes & Metabolic Research, 38(4), e3470.
- Owens, D. M., et al. (2020). Obesity, hypertension, and metabolic syndrome: an integrated approach. Journal of Clinical Hypertension, 22(2), 254–263.