A Study in Diabetes Management
This paper has been written by reviewing the subjective and objective data provided in the case study to diagnose Mrs. Wu and develop a treatment plan for her diagnosis. SOAP note will be provided and the rest of the paper will be created using the national guidelines for Diabetes.
Type 2 diabetes mellitus (E11.9).
Type 2 diabetes mellitus is a heterogenous disease that occurs when there is a progressive loss of b-cell function and/or mass, typically due to inflammation, metabolic stress, or genetics. This leads to decreased insulin secretion, which is compounded by decreased insulin resistance, all leading to hyperglycemia; clinically, this typically presents as polyuria and polydipsia, though not all will experience these (American Diabetes Association, 2018).
Pertinent positive and negative findings and rationale.
The patient has fatigue, no weight loss despite exercise, polyuria, and polydipsia, all of which are signs and symptoms of type 2 diabetes (Castonguay & Miquelon, 2018). She has glucose in her urine, her fasting glucose is 130 mg/dL, total cholesterol, LDL, VLDL, and triglycerides are all elevated, HDL is low, HgbA1C is 6.8%, and her BMI is 30.2, which are all found in type 2 diabetes mellitus (American Diabetes Association, 2018).
This diagnosis was chosen because of the patient’s symptoms and lab values, which all indicate a diagnosis of type 2 diabetes. Per the American Diabetes Association, her fasting plasma glucose of 130 mg/dL and A1C of 6.8% are both diagnostic of type 2 diabetes (2018).
Hyperlipidemia is a heterogenous disease, which can be genetic-related and/or due to poor diet and decreased physical activity. When the lipid levels are not in the correct range, blood vessel injury and plaque formation can form. Unfortunately, there are not many signs and symptoms of hyperlipidemia and it can go undetected unless the patient has lipid levels checked or if the patient presents with more severe cardiovascular symptoms (Dunphy, Winland-Brown, Porter, & Thomas, 2015).
Pertinent positive and negative findings and rationale.
All of the patients cholesterol values are abnormal, leading to a diagnosis of hyperlipidemia and putting her at very high risk of developing atherosclerotic cardiovascular disease (Jellinger et al., 2017).
Mrs. R has elevated total cholesterol level of 215 mg/dL, LDL 144 mg/dL, VLDL 36 mg/dL, triglycerides 229 mg/dL, and a low HDL of 32mg/d, which all indicate a diagnosis of hyperlipidemia (Jellinger et al., 2017). Hyperlipidemia and type 2 diabetes mellitus are very commonly found to co-exist (American Diabetes Association, 2018).
Obesity (E66.9). a body mass index (BMI) of 30kg/m2 or higher indicates obesity and is defined as an excess of body fat (Dunphy et al., 2015). According to the AACE/ACE (2017), a BMI of 30kg/m2 is classified as obese, where as a BMI = 25-29kg/m2 are identified as overweight. Obesity occurs when the consumption of calories far exceeds the metabolic needs of the body (Dunphy et al., 2015). Bullock-Palmer (2015) stated that the prevalence of obesity is greater among black and Hispanic females when compared to Caucasian females in the United States. CVD risk in females increases proportionately with the increase in BMI (Bullock-Palmer, 2015).
Rationale. Mrs. R’s calculated BMI=30, which identifies her as overweight for her given height. The most common presenting symptoms for obesity are shortness of breath, decreased energy, fatigue, weakness, joint pain, depression, and increased daytime sleepiness (Dunphy et al., 2015). Its treatment consists of lifestyle interventions and behavioral modifications (Cefalu et al., 2015). Some pertinent positives
for Mrs. R.’s obesity are fatigue, decreased energy, and weakness. Over the past 3 months, she has gained 3 pounds despite going to the gym and walking on the treadmill. Exercising makes her hungrier and therefore causing her to eat more. Pertinent negatives are daytime sleepiness, shortness of breath and depression
Type 1 diabetes mellitus.
Mrs. R needs a spot urinary albumin-to-creatinine ratio done in order to further assess for renal function; this should be done annually along with eGFR. She will need another HgbA1C done in three months, then quarterly until it is normal; at that point, it can be increased to twice annually. This is used to assess the average of Mrs. R’s blood glucose levels over the previous three months so that adjustments may be made to her management if necessary (American Diabetes Association, 2018).
Mrs. R will need a fasting CMP done annually to assess electrolyte levels and fasting serum glucose. A vitamin B12 baseline level is needed since Metformin is associated with vitamin B12 deficiency with prolonged use, and a repeat level every 2-3 years is recommended. Assessing LFT levels annually are also recommended, since Metformin is contraindicated with decreased liver function (American Diabetes Association, 2018).
A comprehensive foot exam is needed, which includes a thorough skin inspection; assessment for foot deformities; neurological assessment with a 10-g monofilament and either a pinprick, temperature, or vibratory exam with a 128-Hz tuning fork; and a vascular assessment including pulses of the feet and legs. An annual 10-g monofilament will need to be done and at least a brief foot inspection must be done at every visit. This assesses for peripheral neuropathy that may develop and detect early skin issues (American Diabetes Association, 2018).
Mrs. R should have repeat lipid levels, especially LDL, three months after initiating statin therapy, then annually thereafter, unless circumstances require more frequent monitoring. This helps assess if her atorvastatin dosage is correct so that adjustments may be made as necessary (American Diabetes Association, 2018).
It should be determined if Mrs. R has ever had a mammogram; if she has not, it should be recommended to schedule one as soon as possible, since the current recommendation for women age 50-74 years is that a mammogram be performed every other year (USPSTF, 2016). It also should be determined if Mrs. R has ever had a colonoscopy; if she has not, it should be recommended to schedule one as soon as possible, since the current recommendation is that screening begin at age 45 for people who do not have risk factors, and again every 10 years minimum (Wolf et al., 2018). She also needs to make sure that her hepatitis B, influenza, and pneumococcal vaccinations are kept current, since diabetes makes her at higher risk of contracting hepatitis B and having greater chance of complications from influenza and pneumococcal diseases (American Diabetes Association, 2018).
Type 2 Diabetes Mellitus.
Metformin ER 500mg
Sig: Take 1 (one) tab every evening with food. Disp: #30. RF: 2
Glucagon Emergency Kit
Sig: Inject 1mg IM as directed. Disp: 1 kit. RF: 2
Onetouch Delica 33gauge Lancets
Sig: Test blood glucose BID, more frequently as needed. Disp: 200 (2 boxes). RF: 4
Onetouch Ultra2 glucometer
Sig: Test blood glucose BID, more frequently as needed. Disp: 1 kit. RF: 1
Onetouch Ultra Blue test strips
Sig: Test blood glucose BID, more frequently as needed. Disp: 100 (1 box). RF: 4
Women’s Daily Multivitamin over the counter
Sig: Take 1 (one) tab daily
Mrs. R will be prescribed Metformin, as it is a first-line medication for type 2 diabetes for symptomatic patients with an A1C <9% and eGFR >99 mL/min/1.73. It could help her with weight loss and has been shown to decrease total cholesterol and LDL levels (American Diabetes Association, 2018). She will be started on 500mg of extended release (ER), which can increase by 500mg per day every week as tolerated to a maximum dose of 2000mg per day until blood glucose goals are achieved (Epocrates, 2016).
Glucagon is important for diabetics to have if blood glucose readings are <54 mg/dL or if she is unconscious due to hypoglycemia. Mrs. R and her family must be taught how to administer glucagon in case of emergency (American Diabetes Association, 2018).
For Mrs. R to test her blood sugar, she will need lancets, test strips, and a glucometer. Once her blood glucose has stabilized, she may not need as many lancets and test strips (American Diabetes Association, 2018).
Mrs. R should continue her multivitamin, especially since her metformin can result in deficiency in vitamin B12 (American Diabetes Association, 2018).
Sig: Take 1 (one) tab daily. Disp: #30. RF: 2
Atorvastatin is a first-line medication for hyperlipidemia and is recommended by the American Diabetes Association in type 2 diabetic patients 40-75 years of age without known atherosclerotic cardiovascular disease, but with LDL levels >100 mg/dL (2018). At 10-20mg daily, it has been shown to decrease LDL levels by 30-50%, but can be increased to 40-80mg daily if needed to decrease LDL levels by 50% or more (American Diabetes Association, 2018).
Acetaminophen 500mg over the counter
Sig: Take 1 (one) tab every 4-6 hrs prn. Do not exceed 4000mg in 24 hrs.
Acetaminophen is a recommended first-line medication in the pharmacologic management of osteoarthritis of the knee. NSAIDs are also first-line, but the gastric side effects can be more harmful, especially since she is already taking metformin, which can have gastric side effects as well; so acetaminophen will be recommended until it no longer provides relief (Hochberg et al., 2012).
Type 2 diabetes mellitus.
The treatment for type 2 diabetes mellitus is multifactorial, meaning that it should be a combination of medication, dietary changes, and increased physical activity. She will need to check her blood glucose levels regularly, though for non-insulin dependent diabetics, there is no set guideline for how often to check or whether they should or not. Initially, it will be recommended for Mrs. R to check her blood sugar once in the morning and once before bedtime, and more often if needed until her blood sugar is stable. Her goals are an A1C of <7% (can be increased to <7.5% or even <8% if necessary), preprandial blood glucose of 80-130 mg/dL, postprandial <180 mg/dL, and bedtime level 90-150 mg/dL. Mrs. R must know that stress, illness, surgery, and dehydration are a few of the conditions that may increase her blood sugar, so she should check it more often during those times (American Diabetes Association, 2018).
Mrs. R needs to know signs and symptoms of hypoglycemia, since that is a commonly seen condition in new diabetics. Shakiness, irritability, confusion, tachycardia, and hunger are all signs and symptoms of hypoglycemia. If she feels any of these, she should take her blood sugar reading and eat or drink 15-20g of glucose, which is recommended for a reading of 70 mg/dL or less; if the reading is less than 54 mg/dL or if she is unconscious, she should use her emergency glucagon. She should recheck her blood glucose level 15 minutes after either oral glucose or glucagon injection and, based on her repeat level, take the appropriate action as detailed above. After her glucose is stable, she should eat a meal or snack to prevent another episode of hypoglycemia. She should be aware of situations where potential episodes of hypoglycemia may occur, including but not limited to fasting for tests, exercise, during sleep, or delayed meals, and it is recommended that she keep small snacks with her in case of a hypoglycemic episode (American Diabetes Association, 2018).
Foot care should be thoroughly explained, since diabetics have a high risk of peripheral neuropathy, leading to injuries to the bottoms of their feet without their realization. This can lead to infection which could eventually lead to amputation or even death if it is not caught and treated quickly. Mrs. R needs to examine her feet every day for signs of injury or skin breakdown, including toenails. If she notices injuries or ulcers, she shoul
d notify the office so it can be examined and treated if necessary. She also needs to make sure that she is seeing her podiatrist regularly (American Diabetes Association, 2018).
Since diabetic retinopathy is another major complication of diabetes, Mrs. R needs to see an eye doctor regularly and report any changes in vision immediately (American Diabetes Association, 2018).
She also needs to monitor her blood pressure, since hypertension can negatively affect the cardiovascular system, for which her diabetes and hyperlipidemia already put her at risk. Even though her blood pressure today was normal, she should be aware that it needs to stay <140/90 to keep her risk of cardiovascular or renal injury lower (American Diabetes Association, 2018).
Since hyperlipidemia and diabetes commonly coexist, Mrs. R needs to understand the importance of doing what she can to lower her cholesterol levels and maintain them at appropriate levels. Diabetes and hyperlipidemia both put her at high risk of developing atherosclerotic cardiovascular disease, so it is extremely important for her to ensure that they are both controlled. Lipid control can be attained in much the same way that diabetes can be, by a combination of medications, diet, and increased physical activity. These conditions should not be controlled by medication alone; lifestyle changes should be the most important factor in managing them. Lipid goals are mostly based on LDL, which should be <70 mg/dL; these will be checked 3 months after initiating atorvastatin, every 6-12 months until normal, then every 1-2 years, unless more frequent monitoring is necessary (American Diabetes Association, 2018).
Mrs. R should be screened annually at minimum for depression, but should also be aware that signs of depression, including but not limited to worsening fatigue, appetite changes, overwhelming sadness, decreased interest in social activities, feelings of hopelessness, and sleep disturbances, should be reported to the office immediately. Since she is now having to make major lifestyle changes, she is at risk for depression, so being aware and cognizant of this can help her control it sooner (American Diabetes Association, 2018).
Metformin decreases the production of glucose from the liver. It should be taken with food in the evening and can cause nausea, diarrhea, and weight loss. While GI symptoms are common, they typically resolve with time, so Mrs. R should continue taking the medication as directed unless severe symptoms occur, such as vomiting, dehydration, or extreme weight loss. If she develops symptoms such as malaise, respiratory distress, somnolence, or severe abdominal pain, she should go to the nearest emergency department, as these can be signs of lactic acidosis, a severe adverse effect of metformin (American Diabetes Association, 2018).
As mentioned earlier, glucagon should be administered if Mrs. R’s blood glucose drops below 54 mg/dL or if she is unconscious. Her close friends and family need to be taught how to reconstitute and administer it. She should have it with her at all times and if it expires, she should throw it away in a sharps container or a puncture-proof plastic container that is labeled to indicate that it contains sharps, and obtain a new kit. The kit should be kept at room temperature, never frozen or heated, and should be administered immediately after reconstituting. When obtaining her glucagon kit from the pharmacy, she should ask for a kit that has the furthest expiration date available, so as to not have to buy one more often than necessary (American Diabetes Association, 2018).
While there is a slight risk of statin therapy increasing blood glucose levels, studies show that the benefit of lipid-lowering abilities, and ultimately the decreased risk of severe cardiovascular diseases, far outweigh the slight glucose elevations. There is a small chance that Mrs. R will experience myalgias and muscle weakness and she needs to report it if it becomes severe, as the medication may need to be temporarily stopped and a CK level obtained (Jellinger et al., 2017).
Mrs. R should be very careful and cognizant of how much acetaminophen she is taking in 24 hours and make sure that she does not take any other medications that has acetaminophen in it, such as over-the-counter cold and flu relievers (Hochberg et al., 2012). This can cause liver toxicity, which is dangerous in itself, but can also cause her to not be able to take her metformin (American Diabetes Association, 2018).
Mrs. R is obese, which can contribute to her diabetes, so she should decrease her caloric intake by at least 500cal/day to facilitate weight loss. Dietary changes are important to accomplish this and should include decreased carbohydrates, saturated and trans fats, and cholesterol; and increased n-3 fatty acids, viscous fiber, and plant stanols and sterols. This will help control her glucose levels and improve her cholesterol levels. The recommended diet for her diabetes and hyperlipidemia is the Mediterranean diet (American Diabetes Association, 2018).
As mentioned in previous sections, exercise is a large part of managing both diabetes and hyperlipidemia, and can contribute to weight loss as well, which also has a positive effect on diabetes and hyperlipidemia. It is recommended that at least 30 minutes of moderate-intensity exercise be done 4-6 times weekly, but may need to be increased to 60 minutes in order to lose weight. Depending on Mrs. R’s knee condition, she may need to make some adjustments to her exercise activities, and may need to include activities that are more gentle such as swimming or using an elliptical machine. She can also break up the activity into smaller sessions, such as 10-minute sessions spread throughout the day (Jellinger et al., 2017).
Mrs. R needs to be referred to a dietitian in order to learn exactly what types of foods she should be eating and to get an individualized diet plan that she will be more likely to adhere to (American Diabetes Association, 2018). She needs a referral to a podiatrist so she can have a specialist examining and caring for her feet, in addition to her self-exams and the exams at her primary care visits (American Diabetes Association, 2018). If she does not already have a dentist, she will need to be referred to one to ensure that her teeth are in good repair and that she is seen for regular exams, since periodontal disease is a risk of diabetes (American Diabetes Association, 2018). It is important that Mrs. R be referred to a diabetic educator so that she has someone to walk her through all the details of being diabetic and how to manage the disease. The diabetic educator can also be a great resource and contact for Mrs. R should she have any questions or issues come up, in the event that she cannot get in touch with the primary care office (American Diabetes Association, 2018). Another major risk of diabetes is diabetic retinopathy, so Mrs. R needs to be referred to an ophthalmologist if she does not already have one, so that regular exams can be done in order to detect any retinal or vision changes (American Diabetes Association, 2018).
Mrs. R needs to come in to be seen again in three months in order to re-evaluate her current condition and symptoms, A1C, lipids, and evaluate a spot urinary albumin-to-creatinine ratio. She will need to follow up again in three months after that to be re-evaluated again and then to determine if her condition is controlled well enough that the visits can be spread further apart or if she needs to be seen more often. Once her A1C, blood glucose levels, and lipids are well-controlled and there is no sign of organ damage, she needs to be seen annually (American Diabetes Association, 2018).
For 30 pills of metformin ER 500mg, which is what Mrs. R is initially starting on, the cost is $4.00 at Walmart with no coupon required. If the dose has to be increased to the maximum of 2000mg, 120 500mg pills can be obtained at Walmart for $10.00 (GoodRx, 2018).
Glucagon kits are very expensive without insurance that covers them, ranging from about $250-$300 for one kit. If Mrs. R does not have insurance that will cover the majority of the cost, there is a coupon that can be used at multiple pharmacies that will discount it by 75%. It can be printed out, emailed, or sent via text message from www.helprx.com (2018).
Mrs. R can get 30 10mg atorvastatin pills at Walmart for $9.00 with no coupon required. If the dose needs to be increased to the maximum of 80 mg, she can get 30 pills at Walmart for $4.00 with no coupon required (GoodRx, 2018).
For her diabetic supplies, Mrs. R can get 2 boxes of lancets, totaling 200 lancets, at Walmart for $18.38 with a GoodRx coupon (2018). She can get her glucometer at Walmart for $15.78 with no coupon required. Her test strips will be the most expensive one at $132.62 if she gets them at Walmart with a GoodRx coupon (2018). Depending on her insurance, they might cover some of these costs, but she should be prepared if it does not.
Acetaminophen can be purchased over the counter relatively inexpensively, costing approximately $7.00 for two bottles of 250 pills each (Walmart, 2018). This should last her two months, even if she is using the maximum dosage of 4000mg per day.
If Mrs. R purchases the One A Day Women’s Menopause Formula Multivitamin at Walmart, it will cost $9.58 for a count of 50, which would last her almost 2 months (Walmart, 2018).
If she goes to Walmart and pays cash for her acetaminophen, multivitamin, metformin, atorvastatin and glucometer; uses the HelpRx coupon at CVS where she can get an additional $5.00 off (2018); and uses GoodRx (2018) coupons for her test strips and lancets at Walmart, for the lowest dosages she is starting with, she would pay at the most a total of $271.36 for her first month. If she makes sure that her glucagon kit has the furthest expiration date possible, she could potentially only have to pay for it once a year. Her glucometer would only have to purchased once, unless it breaks or malfunctions, which would mean that for 11 months out of the year, she would only have to pay for the acetaminophen, multivitamin, metformin, atorvastatin, test strips, and lancets, which would average about $172.50 for one month. If her blood sugar remains stable, she could potentially not have to test her blood sugar twice a day, which would mean she would not have to buy strips and lancets as often, which will save her money.
Depending on what Mrs. R’s insurance (if she has any) will pay, her medication plan may need to be adjusted if she cannot afford what is pr
escribed above. Her glucagon is not absolutely required, but is strongly recommended; so if it is too much for her to pay, she does not have to pick up the prescription, as long as she understands that she absolutely must keep snacks with her at all times to combat hypoglycemia, and she must be extremely careful and cognizant of the signs and symptoms so that she will not become so hypoglycemic that she loses consciousness (American Diabetes Association, 2018). Again, if insurance will not pay or if she does not have insurance and cannot afford all of the above, she does not have to check her blood glucose twice daily, since her fasting glucose was minimally elevated as was her A1C; so she would not have to get her prescriptions filled for the glucometer, test strips, and lancets. It is not required that she test her blood glucose levels at home; she simply will feel more in control and her medications can be adjusted better if she is aware of what her blood glucose levels are doing on a day-to-day basis (American Diabetes Association, 2018). I use GoodRx on a daily basis, not only in clinical, but in my job in the emergency department. I definitely plan to continue using it, as it is a great resource and patients are always extremely grateful for the assistance for sometimes otherwise impossibly expensive medications.