Introduction: Patient Information:
- Name: J.D.
- Age: 42.
- Gender at Birth: female.
- Gender Identity: female.
- Source: patient’s words.
- Allergies: No.
- Current Medications: No.
- Immunizations: According to age.
- Preventive Care: J.D. has led a healthy lifestyle since she stopped smoking three years ago.
- Surgical History: No.
- Family History: J.D. is married and has two children, 15 and 17 years old. The patient’s mother was diagnosed with type 2 diabetes mellitus 15 years ago.
- Social History: J.D. does not smoke but engages in recreational alcohol intake. However, the patient has sufficient caffeine intake since she consumes a few cups of coffee and soda or energy drinks daily.
- Sexual Orientation: traditional.
- Nutrition History: J.D. fails to follow a healthy diet, which results in increased consumption levels of fats and sugars.
- Subjective Data:
- Chief Complaint: J.D. states that she suffers from “a lack of energy, tingling in the limbs, and increased urination.”
- Symptom analysis/HPI: The patient firstly noted the symptoms two months ago, shortly after she had received a promotion at the workplace. She believed that the lack of energy and tingling in the limbs were associated with a higher workload and constant emotional tension because she consumed many coffee and energy drinks to keep working. J.D. managed to cope quickly with the new employment challenges, and she entered a normal workflow a month ago. Even though emotional tension and workload were relieved, the symptoms did not disappear. She even tried to reduce her caffeine intake, but it did not help, and J.D. noted increased urination, both during the day and at night.
Review of Systems (ROS):
- CONSTITUTIONAL: an average temperature, no fewer, J.D. denies weight change over the last year.
- NEUROLOGIC: J.D. denies any neurologic problems for her and her family.
- HEENT: J.D. reports rare headache episodes and denies any ear, nose, or throat problems. However, J.D. states that she noted some sight problems two months ago.
- RESPIRATORY: The patient admits the shortness of depth after mild physical exercise.
- CARDIOVASCULAR: J.D. denies any known cardiovascular problems but states that she frequently feels an increased heartbeat.
- GASTROINTESTINAL: J.D. denies abdominal pain or regurgitation.
- GENITOURINARY: The patient suffers from increased urination, urination without pain.
- MUSCULOSKELETAL: J.D. denies joint pain and muscle weakness.
- SKIN: The patient denies skin problems.
- VITAL SIGNS: BP 145/92; HR 101; PR 31, T 97.7º F; Wt. 137; Ht 5’ 2’’; BMI 25.1 (overweight).
- GENERAL APPREARANCE: tidy, standard face skin color, tired.
- NEUROLOGIC: No problems are identified.
- HEENT: the poor sight was confirmed.
- CARDIOVASCULAR: Regular rhythm but an increased rate.
- RESPIRATORY: No wheezes, no coughing.
- GASTROINTESTINAL: The abdomen is soft, non-tender, and without masses.
- MUSKULOSKELETAL: No problems were identified.
- INTEGUMENTARY: A cut was identified that has not healed over a month.
- ASSESSMENT: J.D. came into our clinic c/o of a lack of energy, tingling in the limbs, and increased urination. The patient states that the symptoms started two months ago when she received an employment promotion. The new role was associated with increased workload and emotional tension, and the patient considered these factors the reason for her symptoms. However, once J.D. solved her employment issues, the complaint did not disappear. The patient reports a family history of type 2 diabetes mellitus and denies any medication use. On examination, I noted that J.D. is overweight and has elevated blood pressure. I managed to confirm that the patient’s sight has decreased. Finally, I noted an injury on the patient’s arm, and it was sore that did not heal completely for over a month.
Main Diagnosis: The main diagnosis is type 2 diabetes mellitus. Its ICD10 code is E11.
- I10 Essential (primary) hypertension;
- N39.0 Urinary tract infection, site not specified;
- E66.0 Obesity due to excess calories.
Labs and Diagnostic Test to be ordered (if applicable):
- A 75 g oral glucose tolerance test or glycated hemoglobin (HbA1c) is used to diagnose diabetes mellitus (Forouhi & Wareham, 2018).
- Regular pressure management is required because hypertension is diagnosed if the daytime mean of a person’s blood pressure equals or is higher than 135/85 (Nerenberg et al., 2018).
- Urine analysis is necessary to determine whether the urine has signs of inflammation.
- A cholesterol test should be taken to identify whether specific proteins lead to obesity.
Pharmacological treatment: Since type 2 diabetes mellitus is the main diagnosis, treatment options address this condition:
- Diet and physical exercise are the leading interventions;
- If the two above do not create positive outcomes, metformin is the first-line therapy (Goyal & Jialal, 2022).
- If metformin is not effective, it will be possible to rely on oral sulfonylureas and dipeptidyl peptidase-4 (DPP-4) inhibitors (Goyal & Jialal, 2022).
Non-Pharmacologic treatment: As has been mentioned above, non-pharmacologic treatment (healthy diet and regular physical exercise) should be the first step to curing the disease.
Education: J.D. should understand that type 2 diabetes mellitus is a significant health condition that requires her attention and careful attitude. Lifestyle modification is of significance if the patient wants to fight the symptoms. Furthermore, J.D. should feel free to ask any questions if she wants to learn more about her condition. Another suitable approach is to encourage her to do her own research, and the World Health Organization (WHO, 2021) offers useful information. It is worth highlighting once again that J.D. should be knowledgeable about her condition to control it.
Follow-ups/Referrals: J.D. is asked to come to the follow-up assessment in 14 days. This time is sufficient to determine whether the patient has managed to introduce a lifestyle modification and whether this intervention has eliminated the symptoms. If positive outcomes are not achieved, appropriate medication will be assigned, and additional instructions will be given to J.D.
Forouhi, N. G., & Wareham, N. J. (2019). Epidemiology of diabetes. Medicine, 47(1), 22-27. Web.
Goyal, R. & Jialal, I. (2022). Diabetes mellitus type 2. StatPearls Publishing.
Nerenberg, K. A., Zarnke, K. B., Leung, A. A., Dasgupta, K., Butalia, S., McBrien, K., Harris, K. C., Nakhla, M., Cloutier, L., Felfer, M., Lamarre-Cliché, M., Milot, A., Bolli, P., Tremblay, G., McLean, D., Padwal, R. S., Tran, K. C., Grover, S., Rabkin, S. W., … Daskalopoulu, S. S. (2018). Hypertension Canada’s 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Canadian Journal of Cardiology, 34(5), 506-525. Web.
World Health Organization. (2021). Diabetes. Web.