Case Study:

Mr Jones, a 60 year old African American male, presents to the office for a planned 6 month follow up visit for hyperlipidemia and weight loss. At the previous visit, Mr Jones was educated on lifestyle recommendations. He reports he has been following dietary recommendations “as good as he could remember” and exercising as

recommended. He reports some new concerns today. He reports that he has been experiencing increased fatigue for about the last 10 weeks. He has a health club membership and attends 3-4 times a week. He walks on the treadmill at least 30 minutes as you directed and lifts weights but he has not lost any weight, in fact he has gained 7 pounds. He doesn’t understand what he is doing wrong and is requesting more education and suggestions for weight loss. He reports that exercise makes him even more hungry and thirsty. He requests further evaluation for his fatigue. He reports he has to go to the bathroom more often- he is waking up during the night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 2 months. No other GU symptoms such as painful urination, dribbling or changes in sexual functionhave been noted.

Current medications: Simvastatin, 10 mg daily, Tylenol 500 mg 2 tabs in AM for knee pain. Daily multivitamin and turmeric.

PMH: Hyperlipidemia. Right knee OA (for 2 years) Had chicken pox as a child. Vaccinations up to date. Colonoscopy WNL 7 years- to repeat at 10 years

FH: parents deceased, child alive, well. No siblings.

SH: Divorced. Business executive, job requires frequent travel. Drinks 1-2 beers daily. Former smoker, quit 5 years ago. No reports illicit drug use. No CBD use.

Allergies: allergic to Bactrim, strawberries, cats and pollen. No latex allergy

Vital signs: BP 119/77; pulse 80, regular; respiration 16, regular Height 5’9.5”, weight 210 pounds

General: AA male in no acute distress. Alert, oriented and cooperative.

Skin: warm dry and intact. No lesions noted.

HEENT: head normocephalic. Hair thinning distribution across crown. Eyes without exudate, sclera white. Wears 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 and posterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.

CV: 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.

Musculoskeletal: full ROM both knees. Nontender to palpation bilaterally. Gait normal.

GU: bladder nontender upon palpation.

Rectal: DRE: prostate not enlarged, rubbery texture, no nodules noted. Guaic negative

Labwork: (fasting labs drawn this morning)

CBC: WBC 6,300/mm3 Hgb 13.8 gm/dl Hct 42% RBC 4.6 million MCV 93 fl MCHC 34 g/dl RDW 13.8%

UA: pH 5, SpGr 1.006, Leukocyte esterase negative, nitrites negative, 1+ glucose; negative protein; negative ketones

CMP:

Sodium 138

Potassium 4.2

Chloride 100

CO2 29

Glucose 135

BUN 12

Creatinine 0.7

GFR est non-AA 99 mL/min/1.73 GFR est AA                          101 mL/min/1.73 Calcium 9.0

Total protein 7.6

Bilirubin, total 0.5

Alkaline phosphatase 72

AST 25

ALT 29

Anion gap 8.10

Bun/Creat 17.7 Hemoglobin A1C: 6.9 %

TSH: 2.30, Free T 4 0.9 ng/dL

Cholesterol: TC 202 mg/dl, LDL 134 mg/dl; VLDL 36 mg/dl; HDL 32mg/dl, Triglycerides 225

EKG: normal sinus rhythm

SOLUTION  

Assessment

Primary Diagnosis: Diabetes Type 2 with diabetic neuropathy (E11.40)

Pathophysiology: B-Cells produce insulin in the body and increased glucose levels triggers the insulin to be released. There are two factors involved in DM II; the inability of body to respond to insulin and decreased B-Cells secreted in the body. Insulin release and activity are needed for glucose homeostasis as is the synthesis & release of insulin and are tightly regulated. (Galicia- Garcia et al., 2020) Some common signs & symptoms of DM Type II are increased thirst, slow healing wounds, tingling or numbness in the hands or feet, fatigue, blurred vision, etc. (American Diabetes Association, 2021)

Pertinent positive findings: C/O numbness & tingling in his feet for the past six weeks, delayed wound healing, HgbA1c 11.9, Urinary albumin excretion rate on 250 (suggest microalbuminuria and early kidney disease), Glucose in urine and trace of protein, BMI 39.5 (American Diabetes Association, 2021)

Pertinent negative findings: Glucose of 94(American Diabetes Association, 2021)

Rationale for the diagnosis: 2.11 Diabetes can be diagnosed using A1C criteria (>6.5%), a fasting plasma glucose (FPG) or using the OGTT (oral glucose tolerance test) and all are equally appropriate. (American Diabetes Association, 2020) This said patient has a HgbA1c of 11.9% & he has common symptoms including numbness/tingling in feet, microalbuminuria, glucose & protein in the urine, and slow healing wound.

Secondary Diagnosis: Metabolic Syndrome (E88.81)

Pathophysiology: The pathophysiology of Metabolic syndrome (MetS), is very complex and is yet to be fully understood. High caloric intake seems to be the primary trigger, and insulin resistance along with chronic inflammation seem to play a role in the initiation and progression to cardiovascular disease.….please click the purchase button below to access the entire solution at $15