Nursing Assignment Help and Essay Samples - Clinical Case Presentation

Nursing Assignment Sample - Clinical Case Presentation

For Weeks 3 & 7 of the course you will be presenting your own case from clinical. The case should be clear, organized, and meet the following guidelines:]

Initial Case Presentation:

Present only the subjective and objective data only on the patient organized as you would organize them in a SOAP (CC, HPI (no OLDCART for HPI); ROS, PE findings, and any lab or diagnostic findings for your patient.

Criteria for Summary Post should include all of the following required elements: Summary post written in paragraph(s) type format (No SOAP note for Summary Post); discuss primary and any applicable secondary diagnoses along with treatment plan for each diagnosis. Scholarly and evidence based in-text citation support for all of the listed diagnoses; Scholarly and evidence based in-text citation for each treatment plan. Differential diagnoses are eliminated.

Patient Case Study

Introduction

The fundamental goal of health care providers is to promote the individual’s overall health. This is achieved through a comprehensive evaluation of the patient and developing intervention strategies based on the findings. Medical practitioners are tasked with demonstrating competence in identifying the patient’s disease and based on the symptoms, develop a holistic management plan that integrates pharmacological and non-pharmacological strategies. Before identifying the final diagnosis, the primary, secondary, and differential diagnosis are established. As espoused by Okon, Arnold, and Savarese (2016), the next stage is narrowing down to the final condition based on the symptoms and lab test results. In the management plan, it is imperative for the medical professional to consider healthcare models such as person-centred care which entails developing interventions that are in line with the patient’s requirements and needs. As argued by Hack, Muralidharan, Brown, Lucksted, and Patterson (2017), person-centred care is aimed at promoting the patient’s satisfaction and quality outcome. Also, patient education and follow-up are imperative which assist in tracking the patient’s healing process. This case study entails the assessment, plan, medication, and a comprehensive SOAP for a 56-year old who presents with a number of symptoms including hunger, frequent urination, thirst, and fatigue. Among the approaches included in the management are education, lifestyle changes, referrals, and follow-up.

Case Study Overview

The case study follows Mrs. R who is a 56-year old Hispanic female. She presents to the office for a follow-up based on a several symptoms. The chief complaint is that for the last three months, she has no energy and is often very fatigued. She also mentions gaining weight since her menopause last year. As personal management approaches, Mrs. R notes joining the gym and forcing herself to attend twice weekly where she walks on the treadmill for more than 30 minutes. She has not seen any results with regards to losing weight. Rather, she has added 3 pounds. The exercises also make her hungrier and thirstier which are not beneficial for her weight loss target. She, therefore, requests an evaluation to establish the cause of her high thirst and hunger. Another key element as she notes is that she visits the bathroom more often. Her thoughts towards this are that her bladder has fallen. She urinates twice at night and the frequency during the day is higher. This has also been going on for the last three months although she is able to sleep immediately after waking up. Her current medications include Tylenol for knee pain. Considering her social life, a key aspect is that she recently separated.

Assessment

Core elements to inform the primary, secondary, and differential diagnosis include her Body Mass Index (BMI) and symptoms. According to the American Diabetes Association (2018), identifying these elements aids in establishing the most apparent conditions. Besides, it is through these symptoms that the health care provider may order different lab tests to narrow down on the final diagnosis. Using the standard BMI calculator that considers the height and weight, Mrs. R records 29.7 which is overweight and close to obesity. Important to note is the no acute distress aspect. According to Pizzino et al. (2016), the integration of the vital signs and symptoms informs the quality of management plan which determines the patient outcome.

Primary Diagnosis

Metabolic Syndrome. ICD 10: E88.81. Metabolic syndrome is defined as the collection of disorders including high blood pressure, abnormal cholesterol and triglycerides, high level of body fats, and high blood sugar. The concurrence of these conditions results in a wide range of symptoms such as increased hunger and thirst, fatigue, hunger, and blurred vision. According to Aguilar, Bhuket, Torres, Liu, and Wong (2015), metabolic syndrome can be confused with other chronic disorders thus the importance of comprehensive patient evaluation. Metabolic syndrome for Mrs. R is centred on the signs and symptoms as well as the lab test results. the symptoms include increased hunger and thirst, fatigue, lack of energy, and frequent urination both at night and during the day. A symptom of not supporting the condition is the absence of blurred vision. Considering the lab test results, Mrs. R has a high haemoglobin A1C of 6.9%. Her cholesterol is also high which is 230 mg/dl while the triglycerides are 232 which is also abnormal. 

Selecting metabolic syndrome as the primary diagnosis is centred mainly on the patient’s symptoms. According to Chassaing et al. (2015), metabolic syndrome emanates from adipose function and deposition that is abnormally accompanied by insulin resistance. The condition comprises of various risk factors including diabetes, cancer, fatty livers, and coronary artery disease. Common symptoms for the condition include increased hunger, thirst, and urination, blurred vision and fatigue. Mrs. R demonstrates all these symptoms apart from blurred vision. Satoh-Asahara et al. (2015) argue that metabolic syndrome does not cause particular symptoms. However, a large waist circumference is a key sign. Essentially, the fatigue, thirst, and blurred vision are attributed to the high blood sugar level. Moreover, Esser, Legrand-Poels, Piette, Scheen, and Paquot (2014) espouse that an individual suffers from metabolic syndrome if three of the following disorders exist. High blood sugar level, glucose value higher than 100 mg/dL, high levels of triglyceride, abdominal obesity, and low high-density lipoprotein (HDL). Mrs. R has high triglyceride levels of 232, high glucose levels, increased weight, and low HDL cholesterol recorded as 35 mg/dL.

Secondary Diagnosis

Overweight. ICD 10: E66.3. Overweight is described as the increased normal adiposity which is the foundation of diabetes mellitus, hypertension, atherosclerosis, and insulin resistance pathophysiology (Esser et al., 2014). The condition is characterized by daily health challenges including increased sweating, inability to deal with rigorous physical activity, feeling tired most of the time, joint and back pains, feeling lonely and isolated, and dyspnea. Mrs. R presents with fatigue and low energy levels. In overweight, the BMI of the patient is between 25 and 29.9 after which the patient can be categorized as obese (Zeng et al., 2014). Mrs. R’s BMI is 29.7 based on her weight and height as provided in the subjective information. Besides, her cholesterol levels are 230 mg/dL which can be used to define the overweight conditions.

Choosing overweight as the secondary condition is based on Mrs. R complain that she has attempted to reduce her weight without success. Some of the self-management approaches have included going the gym and running on the treadmill for more than 30 minutes. Rather than loosing, Mrs. R. notes adding 5 pounds. Essentially, the normal weight of an individual is denoted by his or her BMI which should be between 18.5-24.9. Between 25.0-29.9, the patient is considered overweight after which he or she can be described as obese (Chukhraiev, Zukow, Chukhraieva, & Unichenko, 2017). Mrs. R is overweight and according to Weatherald et al. (2018), this may be the foundation of her increased hunger, thirst, and fatigue. Considering this condition is based on identifying the risk factor for cardiovascular conditions and diabetes. The high cholesterol levels aspect is described based on the 200 mg/dL threshold as the normal. Between 200 and 239 is considered high which is reflected in Mrs. R where her lab results demonstrate 230 mg/dL

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Differential Diagnosis 1

Diabetes Mellitus Type II without complications. ICD 10: E11.9. The condition is described by various dysfunctions and characterized mainly by hyperglycemia. It originates from the combination of insulin resistance action, insufficient insulin secretion, and high or inappropriate secretion of glucagon (Kahn, Cooper, & Del Prato, 2014). Key symptoms of the condition include frequent hunger, thirst, and urination, weight loss, fatigue, slow healing of sores, and areas with darkened skin. Mrs. R. presents with increased hunger, thirst, urination, and fatigue thus diabetes considered as the first priority as a differential diagnosis.

Diabetes Mellitus type II is described by the way the body metabolizes glucose or sugar. For an individual with Diabetes, the body either fails to produce enough insulin or resists the work of the hormone to regulate the sugar moving into the individual’s lungs (Tangvarasittichai, 2015). Notably, the symptoms are described by the blood sugar levels and insulin action. For instance, the increased frequency of urination and thirst is related to sugar buildup in the bloodstream thus causing the fluid to be pulled from the tissues. According to DeFronzo et al. (2015), normal haemoglobin A1C should be 4%-5.6%. Between 5.6%-6.5% reflects on pre-diabetes while an individual with more than 5.6% has diabetes. Mrs. R has 6.9% which is a positive indication of diabetes. In hunger, organs and muscles become deprived of energy if the cells lack sufficient insulin to the cells. Fatigue, on the other hand, originates from the cells being deprived of sugar thus one becoming irritable and tired. Symptoms not present in Mrs. R diagnosis include blurred vision, poor healing of infections and darkened skin areas.

Differential Diagnosis 2

Hyperthyroidism. ICD 10: E03.90. The condition is described by an overactive thyroid where the thyroid gland produces more thyroxine hormone. It accelerates the body’s metabolism significantly resulting in irritability, nervousness, sweating, and irregular heartbeat (Biondi & Cooper, 2018). Common symptoms include weakness in muscles which is noted as fatigue, anxiety, insomnia, and weight loss. Mrs. R mainly presents with fatigue which is a positive indication of hyperthyroidism. She is also irritated by the hunger levels and frequency of urination. However, she does not demonstrate weight loss, insomnia, tachycardia, and anxiety.

Hyperthyroidism is selected as the second differential diagnosis mainly due to fatigue issue which is informed by muscle weakness. As a result of high body metabolism, Mrs. R also demonstrates nervousness and irritability. The condition can, on the other hand, be challenged as a possible diagnosis as it is not related to frequency in urination and weight gain which are present in Mrs. R condition (Ross et al., 2016).

Differential Diagnosis 3

Major Depressive Disorder that is recurrent and has no psychotic features. ICD 10: F 33.2. The condition is described by affective signs that are predominance including sadness, irritability, distress and impotence in facing life demands. The condition is an interaction of social, biological, and physiological factors and is characterized by various symptoms including lack of energy to perform simple tasks, agitation, restlessness, concentration difficulties, and loss of interest in daily pleasures such as hobbies and sports (Otte et al., 2016). Mrs. R is in no acute distress. She is also cooperative and oriented. However, her lack of energy for the last three months and being fatigued may describe depressive condition thus an important consideration. Mrs. R further mentions that she is being irritated by her frequent urination situation during the day which is more than at night.

The rationale of selecting major depression condition that is recurrent and without psychotic features is centred on the patient’s symptoms drawn from the information provided. According to Kaiser, Andrews-Hanna, Wagner, and Pizzagalli (2015), depressive symptoms can be ordered and assessed based on the operational diagnostic criteria. The most common approaches both in the research and clinic studies are DSM-IV classifications and ICD-10. According to the ICD-10 general diagnostic criteria, the depressive episodes should last for more than two weeks and should not be attributed to organic mental disorder or psychoactive substance (Vancampfort et al., 2015). Both DSM-IV and V use a list of symptoms to assess for depression which includes the condition lasting for more than two weeks, increased fatigue or reduced energy and inability to enjoy the daily pleasures. In Mrs. R situation, she has demonstrated four symptoms which inform the consideration of diagnosing depression. These include irritability, loss of energy, fatigue, and weight changes. The condition may, however, be refuted as the patient does not demonstrate psychomotor activity change with inhibition or agitation. In addition, she does not demonstrate recurrent thoughts of suicide or death.

Plan

A profound management plan considers a holistic approach that integrates pharmacological, non-pharmacological, patient education, and referral in case the diagnostics demonstrate adverse condition. Prior to developing the plan, diagnostics should be ordered which are informed by the patient’s symptoms. According to Reddy, Rose, Burgess, Charns, and Yano (2016), a comprehensive evaluation of the patient’s condition is imperative to develop a plan that will promote the individual’s health.

Diagnostics

Mrs. R’s condition diagnosis is dependent on five key symptoms. These include increased hunger, thirst, frequent urination, fatigue and loss of energy, and irritability. Moreover, the diagnostics are informed by the primary diagnosis of metabolic syndrome, secondary diagnosis as overweight, and the three differential diagnosis including diabetes mellitus type II, hyperthyroidism, and depression. Presently, the vital signs have already been recorded to include a blood pressure of 118/80 which is ideal, a pulse of 76 which is regular and respiration of 16 which is also regular. Considering the BMI, Mrs. R is overweight. This is based on the 5’2.5’’ height and 165 pounds weight. Her BMI is calculated as 29.7.

The metabolic syndrome, overweight, diabetes mellitus type II informs the main diagnoses. The first diagnosis is the fasting blood sugar level. According to Caburnay et al. (2015) the blood sugar level should be less than 5.6 mmol/L or 100 mg/dL. Higher than this is the cause of increased thirst and hunger. The blood sugar test is for diagnosing both the metabolic syndrome and diabetes mellitus type II. The glycated haemoglobin (A1C) is used in this regard where beyond 6.5% demonstrates diabetic condition. Mrs. R haemoglobin A1C is 6.9% thus diabetes management should be initiated. The next diagnostic is the triglyceride level which according to Scorletti et al. (2015) is the fat found in the blood. According to Jakobsson et al. (2017), the normal level should be below 1.7 mmol/L or 150 mg/dL. For Mrs. R, the figure is 232 which is extremely high. The reduced HDL cholesterol of below 1.04 mmol/L or 40 mg/dL for men and 50 mg/dl for women is considered good. For Mrs. R, the HDL is 38mg/dL which is not good since for women the value should be between 40 and 50. The HDL and triglyceride diagnostics are essential in prescribing medication for lowering the blood fats.

Another essential lab result is the total cholesterol (TC) which Stellaard, von Bergmann, Sudhop, and Lutjohann (2017) notes should be less than 200 mg/dL. TC between 200 and 239 is described as borderline high which is the case for Mrs. R. A complete blood count (CBC) should also be ordered to determine the patient’s overall health. To diagnose for hyperthyroidism, the TSH and thyroxine levels should be tested. Normal TSH levels should be 0.4-4.0 mU/L (Cohen, Sommer, and Vuckovic, 2018). Also, the radio iodine uptake test may be considered as well as the thyroid scan. For the overweight, the circumference level is important where more than 35 inches reflects on poor health. It is also essential to examine the depressive condition. In this regard, a PHQ-9 questionnaire is employed (Manea, Gilbody, and McMillan, 2015). The scores should be interpreted as minimal depression (1-4), mild depression (5-9), moderate depression (10-14), moderately severe depression (15-19), and severe depression (20-37).

Medications

The pharmacological management of Mrs. R’s condition is informed by the lab test results and the diverse symptoms. Key elements are the 230 mg/dL TC, 6.9% haemoglobin A1C, a triglyceride level of 232, and the 126-glucose level although this is dependent on whether the figures were taken after eating or during fasting. The urgent issue is to lower the blood sugar level. This can be achieved by use of Biguanides which in this case is Glucophage (Metformin). This medicine works by reducing the glucose amount secreted by the liver (Brandmaster et al., 2015). Also, Metformin enhances the body tissues’ sensitivity to insulin which makes the glucose absorption more effective. The drug is prescribed at a strength of 500mg taken orally twice daily with meals. Metformin should be taken with Glipizide which is an oral sulfonylurea taken to reduce the blood sugar through stimulation of insulin production from the pancreas (Sri Lakshmi, Jacob, Srinivas, & Satyanarayana, 2015). Glipizide dosage should be 5mg taken once a day 30 minutes before breakfast. The next medication is for lowering the cholesterol level and high blood fat. In this regard, Statins are considered more effective, and according to Stone et al. (2014), they are essential in lowering the LDL and triglycerides, and mildly increasing the good HDL cholesterol. Fluvastatin (Lescol) is in this regard ordered at a dose of 20 mg PO qDay. Although the dosage is between 20 and 40, the lower value is chosen since it has a number of side effects including damaging the liver, muscle inflammation, and diabetes type II.

Education

In person-centered care, patient education is central to promoting the individual’s awareness regarding the condition, its management, risk factors, and emergency situations. Some of the important aspects to include in the education are the side effects of the medications, exercises, diagnosis warning signs, and diet (Stenberg, Haaland-Overby, Fredriksen, Westermann, & Kvisvik, 2016). Mrs. R metabolic syndrome is addressed using drugs and non-pharmacological approaches. Three medications have been prescribed for Mrs. R. These are Metformin, Glipizide, and Fluvastatin. It is therefore imperative to educate Mrs. R on the medication schedule which is two times per day with meals for Metformin and once per day 30 minutes before breakfast for Glipizide. Side effects that the patient should be aware of include diarrhoea, flatulence, muscle pain, asthenia, and low blood sugar for metformin and headache, dizziness, hunger, diarrhoea, and skin rashes for Glipizide (Brandmaster et al., 2015; Sri Lakshmi et al., 2015). For the Fluvastatin, the patient should be aware of muscle inflammation, damage of the liver which is rare, and intestinal related problems.

Educating the patient on the medication warning signs assists in reducing the risks and taking an urgent intervention in case the signs present. For Metformin, such signs are low blood sugar and lactic acidosis. For Fluvastatin, some people may present with confusion and memory loss (Stone et al., 2014). Diet should also be included in the education. This entails taking healthy meals that have low fats and those rich in fiber. Mrs. R should also be educated on the importance of taking plenty of fluids, limiting the intake of processed foods, and increasing fruits and vegetables portion (Weatherald et al., 2018). However, grapes should be avoided as they limit the effectiveness of the body using Fluvastatin. On the issue of exercises, Mrs. R should be referred to a gym specialist and advised on improving the cardio exercises. This is aimed at reducing the blood fat and increasing the utilization of blood sugar.

Referral

In patient referral, it entails directing the individual to a specialist for a particular issue or condition. For Mrs. R who presents with Metabolic Syndrome, three key referrals for managing the condition are essential. These include a nutritionist, gym specialist, and psychotherapist incase the PHQ-9 results demonstrates the possibility of depression. The nutritionist and gym specialists are essential to developing a diet and exercise plan to lower the blood sugar and fat levels. The psychotherapist, on the other hand, is important in assessing Mrs. R mental health to establish if the resent separation has an impact and how it can be addressed. Another key referral is for a comprehensive patient assessment of any cardiovascular condition based on the high weight and increased blood fat. This aids in developing a management plan that suits the particular condition or reduces the risk factors (Heijnen, Wilmer, Blockmans, & Henckaerts, 2016). According to the American Diabetes Association (2018), a combination of drug and non-pharmacological interventions increases the recovery time and promotes the overall patient’s health.

Follow-up

In patient follow-up, it involves examining if the patient is responding to treatment which is reflected in the reduction or increase in the symptoms. For Mrs. R, the follow-up should be after one month although she is advised to report to the clinic in case the symptoms do not reduce. Core elements to examine after 30 days of medication, diet, and exercise therapy are the reduction in blood sugar level, decreased blood fat, improvement of HDL, reduced thirst and hunger, and less frequent urination. Besides, the patient should have energy in handling her activities as well as reduced fatigue. After one month, in case the symptoms do not improve, advanced and specialized treatment should be considered to prevent the patient’s conditions from transforming to disorders such as CAD and hypertension.

Medication Costs

           Calculating the medication costs for the given drugs, Glucophage cost for one month is $10.59, $12.73 for Glipizide, and $81.17 for Fluvastatin. The drug prices are calculated from (https://www.rxpricequotes.com/). The total medication cost is $104.49. Notably, the calculations are based on 30 days. Reflecting on the costs, they are expensive. However, in case the patient is medically insured, this cost may decrease significantly. The overall management cost of the condition may further increase based on the gym and diet referrals related charges. The use of the pricing resources is therefore centred on the patient’s insurance cover and affordability. This information may be obtained from the interactions.

Conclusion

Promoting the patient’s health is based on conducting a comprehensive evaluation of the condition and developing a management plan that addresses the signs and symptoms. Notably, the intervention strategy should be patient-centred and holistic to include pharmacological and non-pharmacological, education, referrals and patient follow-up. In the above case study, Mrs. R presents with several symptoms including frequent urination, thirst, and hunger, fatigue, and loss of energy. Drawing from the lab test results, the primary diagnosis is metabolic syndrome while the secondary diagnosis is overweight. The differential diagnoses are three including diabetes mellitus type II, hyperthyroidism, and depression. To narrow down on the diagnosis, lab tests ordered include blood sugar level, CBC, and thyroxine and TSH levels. The management plan, therefore, entails the use of metformin, glipizide, and Fluvastatin to reduce the blood sugar and fat levels. In addition, the patient should be advised on the drugs’ side effects, diet, physical exercise and medication schedule. Referrals, on the other hand, include a nutritionist and physical exercises specialist to develop a diet and work out plan. Follow-up of the patient’s condition should be after 30 days to examine the drugs’ effectiveness and refer her for further treatment.

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SOAP Note

Patient Information

Mrs. R, 56-year-old Hispanic Female

Subjective Data

Chief Complaint: Frequent hunger, thirst, urination, fatigue, and loss of energy.

History of Present Illness (HPI)

Mrs. R is a 56-year old Hispanic female who presents to the office for evaluation. She complains of fatigue and loss of energy. She further notes frequent urination during the day and at night for the last three months. She is concerned of increased weight since menopause last year and although she has joined the gym to reduce this, she has gained 3 pounds. Mrs. R, therefore, requests for evaluation of her symptoms which are irritating to her. Her perception is a fallen bladder which for the fallen bladder. At night, she mentions waking up to urinate, but she falls asleep immediately.

Current Medication

1.     Tylenol: 500 mg. 2 tables in AM for the knee pain.

2.     Daily multivitamin.

Allergies: NKDA. Allergic to pollen and cats. Denies latex allergy

Past Medical History:

Currently has left knee arthritis. Had mumps during childhood.

Vaccination: Current

Family History: Both parents alive. Father has high cholesterol while mother suffers from hypertension. Mrs. R does not have any siblings. She has one child who is alive and well. 

Social History: Works from home and on a part-time basis, she is a wedding coordinator. She separated recently. Mrs. R denies history of tobacco use. She confirms taking 1-2 glasses of wine on weekends. She does not use illicit drugs.

Review of Systems (ROS)

General: Weight gain of 3 pounds. Fatigue and lack of energy. Patient is corporative and alert.

Skin: Patient denies acne, bruising, or rashes.

Eyes: Patient uses contacts. Denies eye reddening.

Ears: Patient denies pain and hearing difficulties.

Nose/Mouth/Throat: Patient denies pain or sore throat. 

Breast: Patient denies lesions and lumps.

Endo/Lymph/Heme: Patient denies bruising or swollen glands. Notes increased hunger and thirst.

Cardiovascular: Patient denies edema, murmurs, grit, and chest pains.

Respiratory: Patient denies wheezing, cough, and dyspnea. Also denies tuberculosis history

Gastrointestinal/Gynecological: G2 P1. 1 SAB, 1 child, full term. LMP 15 months ago Weight 9 pounds 2 oz. Patient denies an abnormal Pap smear.

Musculoskeletal: Knee arthritis managed using medicine. 

Neurological: Patient denies weakness or seizures

Psychiatric: Patient notes irritation from the frequent urination. Denies stress

OBJECTIVE DATA

Vital Signs: Blood pressure 118/80, respirations 16, pulse 76, height 5’ 2.5’’, weight 165 lbs. and BMI 29.7.

General Appearance: Patient is an overweight female who is alert, corporative, and oriented to the surrounding.

Skin: Skin is dry, intact and warm. No lesions.

HEENT: Head is normocephalic. Hair is distributed evenly and thick. Sclera is while and no exudate in the eyes. Mrs. R uses contacts. Tympanic membranes are intact and grey. Light reflex noted. No exudate in the nose. Moist oropharynx without erythema. No tooth cavity. Neck is supple, and anterior cervical lymph is nontender to palpation. Thyroid midline is firm, small, and without palpable masses. 

Cardiovascular: S1 and S2 RRR without grit, murmurs, or rubs.

Lungs: Clear to auscultation bilaterally. Unlabored respirations.

Abdomen: No CVAT. Nontender, soft, and round. Positive bowel sounds. No abdominal bruits.

Lab work (Fasting Labs).

CBC: WBC 6,000/mm3 Hgb 12.5 gm/dl Hct 41% RBC 4.6 million MCV 89 fl MCHC 34 g/dl RDW 13.8%

UA: pH 5, SpGr 1.012, Leukocyte esterase negative, nitrites negative, 1+ glucose; small protein; negative for ketones

CMP:

Sodium 139, Potassium 4.3, Chloride 100, CO2 29, Glucose 126, BUN 12, Creatinine 0.7, GFR est non-AA 99 mL/min/1.73, GFR est AA 101 mL/min/1.73, Calcium 9.7, Total protein 7.6, Bilirubin, total 0.6, Alkaline phosphatase 72, AST 25, ALT 29, Anion gap 8.10, Bun/Creat 17.7, Hemoglobin A1C: 6.9 %, TSH: 2.35, Free T 4 0.9 ng/dL, Cholesterol: TC 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 38mg/dl, Triglycerides 232

EKG: Normal sinus rhythm

ASSESSMENT

Primary Diagnosis:

Metabolic Syndrome (E88.81).

Secondary Diagnosis:

Overweight (E66.3)

Differential Diagnoses

Diabetes Mellitus Type II (E11.9)

Hyperthyroidism (E03.90)

Major Depressive Disorder (F33.2)

PLAN

Diagnostics:

Total cholesterol levels, haemoglobin A1C, CBC, triglyceride and HDL levels, TSH and thyroxine levels, waistline circumference, and PHQ-9.

Medication

Metformin (500 mg) orally twice a day with meals to reduce blood sugar levels.

Glipizide (5 mg) once per day 30 minutes before breakfast to reduce blood sugar levels.

Fluvastatin (20 mg PO qDay) to lower cholesterol levels.

Education:

Importance of medication adherence, their side effects, and schedule. Side effects of Metformin include flatulence, muscle pain, asthenia, low blood sugar, and diarrhoea. Side effects of Glipizide include diarrhoea, hunger, skin rashes, dizziness, and headache. Also included in the education is the importance of dieting and frequent exercising. Patient advised to take reduced processed foods and increase vegetables and fruits intake. Also advised to take more fluids.

Referrals:

Nutritionist and physical exercises instructor for developing eating and exercising plan. A psychotherapist for possible depression and large medical facility for advanced patient assessment. 

Follow-up:

Return to the clinic after 30 days to check for improvement in the condition. Patient to note any new symptoms and signs. Patient advised to call emergency care in case of adverse symptoms.

References

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Brandmaier, S., Xu, T., Illig, T., Suhre, K., Adamski, J., & Wang-Sattler, R. (2015). Response to Comment on Xu et al. Effects of Metformin on Metabolite Profiles and LDL Cholesterol in Patients With Type 2 Diabetes. Diabetes Care 2015; 38: 1858–1867. Diabetes care, 38(12), e216-e217.

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Hack, S. M., Muralidharan, A., Brown, C. H., Lucksted, A. A., & Patterson, J. (2017). Provider behaviors or consumer participation: How should we measure person-centered care?. International Journal of Person Centered Medicine, 7(1), 14-20.

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Kahn, S. E., Cooper, M. E., & Del Prato, S. (2014). Pathophysiology and treatment of type 2 diabetes: perspectives on the past, present, and future. The Lancet, 383(9922), 1068-1083.

Kaiser, R. H., Andrews-Hanna, J. R., Wager, T. D., & Pizzagalli, D. A. (2015). Large-scale network dysfunction in major depressive disorder: a meta-analysis of resting-state functional connectivity. JAMA psychiatry, 72(6), 603-611.

Manea, L., Gilbody, S., & McMillan, D. (2015). A diagnostic meta-analysis of the Patient Health Questionnaire-9 (PHQ-9) algorithm scoring method as a screen for depression. General hospital psychiatry, 37(1), 67-75.

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