DM New Onset Case Study

Chief Complaint• The chief complaint is a brief statement of the reason why the

patient consulted the physician, stated in the patient’s own

words. In order to convey the patient’s symptoms accurately,

medical terms and diagnoses are generally not used. The

appropriate medical terminology is used after an appropriate

evaluation (i.e., medical history, physical examination,

laboratory and other testing) leads to a medical diagnosis.

Chief Complaint

• “My gynecologist said I should have a

check-up since I am tired all the time.”

HPI• The history of present illness is a more complete description of

the patient’s symptom(s). Usually included in the HPI are:• Date of onset• Precise location• Nature of onset, severity, and duration• Presence of exacerbations and remissions• Effect of any treatment given• Relationship to other symptoms, bodily functions, or activities (e.g., activity, meals)• Degree of interference with daily activities

HPI• Louise Jackson is a 49-year-old woman who presents to her

primary care physician after her gynecologist recently diagnosed her with polycystic ovarian syndrome (PCOS) during an evaluation for amenorrhea.

• She complains of increasing fatigue, which she attributes to being overweight. She states her last appointment with her PCP was over 2 years ago.

PMH

• The past medical history includes serious illnesses,

surgical procedures, and injuries the patient has

experienced previously. Minor complaints (e.g.,

influenza, colds) are usually omitted unless they might

have a bearing on the current medical situation.

PMH

• PCOS × 2 months

• Hyperlipidemia × 2 years (diet controlled)

• HTN × 4 years

FH

• The family history includes the age and health of parents,

siblings, and children. For deceased relatives, the age

and cause of death are recorded. In particular, heritable

diseases and those with a hereditary tendency are noted

(e.g., diabetes mellitus, cardiovascular disease,

malignancy, rheumatoid arthritis, obesity).

FH

• Diabetes present in both mother and maternal

grandmother. Father died suddenly of colon cancer at

age 59, mother alive age 76 with history positive for DM

Type 2, HTN, and hyperlipidemia; one younger sister with

PCOS and HTN.

SH

• The social history includes the social characteristics of

the patient as well as the environmental factors and

behaviors that may contribute to the development of

disease. Items that may be listed are the patient’s marital

status; number of children; educational background;

occupation; physical activity; hobbies; dietary habits; and

use of tobacco, alcohol, or other drugs.

SH

• Married × 23 years with two children. Works full-time as

insurance consultant which is telephone based from home. No

alcohol or tobacco use. Rarely exercises and admits to trying

fad diets for weight loss with little success. She reports

adherence to her medications.

Meds:• The medication history should include an accurate record of the

patient’s current use of prescription medications,

nonprescription products, and dietary supplements. Because

pharmacists possess extensive knowledge of the thousands of

prescription and nonprescription products available, they can

perform a valuable service to the health care team by obtaining

a complete medication history that includes the names, doses,

routes of administration, schedules, and duration of therapy for

all medications, including dietary supplements and other

alternative therapies.

Meds:

• Ortho-Novum 1/35 as directed

• Hydrochlorothiazide 50 mg po daily

ALL:

• Allergies to drugs, food, pets, and environmental factors

(e.g., grass, dust, pollen) are recorded. An accurate

description of the reaction that occurred should also be

included. Care should be taken to distinguish adverse

drug effects (“upset stomach”) from true allergies

(“hives”).

All

• Codeine

ROS• In the review of systems, the examiner questions the patient

about the presence of symptoms related to each body system.

In many cases, only the pertinent positive and negative findings

are recorded. In a complete ROS, body systems are generally

listed by starting from the head and working toward the feet

and may include the skin, head, eyes, ears, nose, mouth and

throat, neck, cardiovascular, respiratory, gastrointestinal,

genitourinary, endocrine, musculoskeletal, and neuropsychiatric

systems.

• The purpose of the ROS is to evaluate the status of each

body system and to prevent the omission of pertinent

information. Information that was included in the HPI is

generally not repeated in the ROS.

ROS

• Frequent fatigue. Occasional polydipsia, polyphagia,

weakness, and lightheadedness upon standing. Denies

blurred vision, chest pain, dyspnea, tachycardia, dizziness,

or tingling or numbness in extremities, leg cramps,

peripheral edema, changes in bowel movements, GI

bloating or pain, nausea or vomiting, urinary

incontinence, or presence of skin lesions.

Physical Examination

• The exact procedures performed during the physical

examination vary depending upon the chief complaint and the

patient’s medical history. In some practice settings, only a

limited and focused physical examination is performed. In

psychiatric practice, greater emphasis is usually placed on the

type and severity of the patient’s symptoms than on physical

findings. A suitable physical assessment textbook should be

consulted for the specific procedures that may be conducted for

each body system. The general sections for the PE are outlined

as follows:

• Gen (general appearance)

• VS (vital signs)—blood pressure, pulse, respiratory rate,

and temperature.

• In hospital settings, the presence and severity of pain is

included as “the fifth vital sign, weight and height are

included in the vital signs section here, but they are not

technically considered to be vital signs.

• Skin (integumentary)

• HEENT (head, eyes, ears, nose, and throat)

• Lungs/Thorax (pulmonary)

• Cor or CV (cardiovascular)

• Abd (abdomen)

• Genit/Rect (genitalia/rectal)

• MS/Ext (musculoskeletal and extremities)

• Neuro (neurologic)

Gen:

• Patient is an African-American woman with

central obesity in no apparent distress

VS• BP 152/88 sitting R arm, BP 130/70 standing R arm, P 82, RR

18, T 37.2°C; Wt 95.5 kg, Ht 5'6'‘

• BP = Blood Pressure.• HR = Heart rate.• Bpm = beat per minute.• RR = Respiratory rate.• T = Temperature. • Wt = Weigt• Ht= Hight

Skin

• Dry with poor skin turgor; no ulcers or rash

HEENT

• PERRLA; EOMI; TMs intact; no hemorrhages or exudates on

funduscopic examination; mucous membranes normal; nose and

throat clear w/o exudates or lesions

• PERRLA = Pupils equal, round, and reactive to light and

accommodation

• EOMI = Extraocular movements (or muscles) intact

• TM = Tympanic membrane.

Neck/Lymph Nodes

• Supple; without lymphadenopathy, thyromegaly, or JVD

Lungs:• CTA = Clear To Auscultation

CV:

• RRR; normal S1 and S2; no S3, S4, rubs, murmurs, or bruits

• RRR = Regular rate and rhythm.• S = Sound.

Abd:

• Soft, NT, central obesity; normal BS; no organomegaly, or distention.

• NT / ND = Non-tender/non-distended.

• BS = Bowel sounds; breath sounds or blood sugar

Genit/Rect:• Deferred

Ext:• Normal ROM and sensation; peripheral pulses 2+ throughout;

no lesions, ulcers, or edema• ROM = Range of motion

Neuro:

• A & O × 3, CN II–XII intact; DTRs 2+ throughout; feet with

normal vibratory and pinprick sensation (5.07/10 g

monofilament)

• CN II–XII = Cranial Nerves 2 to 12.

• A & O × 3 = Awake and oriented to person, place, and time.

• DTR = Deep-tendon reflex

LABS:

UA:

• (–) ketones, (–) protein, (–) microalbuminuria

Assessment:

1. Elevated random glucose; presumed newly diagnosed Type 2

diabetes mellitus; will obtain a fasting blood glucose level to

confirm the diagnosis and also check A1C

2. Elevated total cholesterol; will obtain fasting lipid profile to

evaluate LDL, HDL, and triglycerides

3. Hypertension with suboptimal treatment and possible side effects

due to diuretic

4. Obesity

5. PCOS

Clinical Course

• The patient returned to clinic 3 days later for lab work, which

revealed: FBG 189 mg/dL; A1C 9.4%; FLP: T. chol 263 mg/dL,

HDL 31 mg/dL, LDL 152 mg/dL, Trig 260 mg/dL.

Problem Identification

• 1.a. What risk factors for Type 2 DM are present in this patient?

Problem Identification

• 1.b. What information (signs, symptoms, laboratory values) supports the diagnosis of Type 2 DM?

Problem Identification

• 1.c. What information indicates the presence of

insulin resistance?

Problem Identification

• 1.d. Create a list of this patient’s drug

therapy problems.

Desired Outcome

• 2.a. What are the desired goals for the treatment of this patient’s diabetes?

Desired Outcome

• 2.b. Considering her other medical problems, what other treatment goals should be established?

Therapeutic Alternatives

• 3.a. What nonpharmacologic therapies

might be useful in the management of this

patient?

Therapeutic Alternatives

• 3.b. What feasible pharmacotherapeutic alternatives are

available for the treatment of this patient’s DM? Identify

the factors that will influence your choice of initial

therapy.

Optimal Plan

• 4.a. Outline a complete pharmacotherapeutic plan to

manage this patient’s current problems, including drug,

dosage form, dose, schedule, and rationale for your

selections.

• 4.b. What changes in therapy would you recommend if your

initial plan fails to achieve adequate glycemic control?

Outcome Evaluation

• 5.a. What clinical and laboratory parameters will you

monitor to evaluate glycemic efficacy and to detect or

prevent adverse effects?

Outcome Evaluation

• 5.b. The patient’s physician suggested that she obtain a blood

glucose meter for self-testing. What are the health care provider’s

responsibilities with respect to patients and self-monitoring of blood

glucose (SMBG)?

Outcome Evaluation

• 5.c. Identify at least four potential situations in which the

information provided by SMBG would be useful to

patients and health care providers.

Outcome Evaluation

• 5.d. What factors should be considered in the selection

of an appropriate blood glucose meter?

Patient Education

• 6.a. What information should be provided to the

patient about diabetes and its treatment to

enhance compliance, ensure successful therapy,

minimize adverse effects, and prevent future

complications?

Patient Education

• 6.b. How would you educate the patient

regarding how and when to check her blood

glucose?

Follow-up Questions

• 1. Which over-the-counter products could be

recommended for patients to use in treating

hypoglycemic episodes?

• 2. List several potential sources of error in SMBG.

Follow-up Questions

• 3. When starting patients on insulin, the use of combination oral

antihyperglycemic agents and insulin offers several advantages over

switching entirely to insulin:

• a. What are the advantages of adding insulin to existing therapies

with oral agents?

• b. List an appropriate method of starting insulin therapy to

adequately control fasting hyperglycemia in patients on

combination oral agents.

Questions?