Primary Care of the Maturing and Aged Family

Primary Care of the Maturing and Aged Family

The intent of this paper is to examine subjective and objective findings of a case study patient to appropriately diagnose and formulate an individualized management plan that utilizes evidence-based practice guidelines. The case study patient is a 55-year-old Hispanic female who presents to the office for her annual exam complaining of fatigue, weight gain, polyuria, polydipsia, and polyphagia for the past 3 months. This paper will identify applicable primary, secondary, and differential diagnoses; and apply national guidelines from the American Diabetes Association’s (ADA) 2019 Standards of Medical Care in Diabetes to develop a management plan that will include the appropriate diagnostics, affordable medications, education, referrals, and follow-up. Primary Care of the Maturing and Aged Family


Primary Diagnosis

Type 2 diabetes mellitus without complications (E11.9).

Pathophysiology. Type 2 diabetes mellitus (T2DM) is characterized by high levels of plasma glucose due to a decreased function of pancreatic beta cells, which causes insulin resistance and impaired insulin secretion (Dunphy, Winland-Brown, Porter, & Thomas, 2015). The most common manifestations of T2DM include the following: fatigue, polyuria (increased urination), polydipsia (increased thirst), polyphagia (increased appetite) with weight loss (Dunphy et al., 2015). Primary Care of the Maturing and Aged Family

Pertinent positive findings. Very fatigued and low energy, increased hunger and thirst with exercise, increased urination at night and more frequently during the day; which all have been occurring for the past 3 months and a weight gain of 3 pounds (subjective). Mrs. G is 55 years old, Hispanic, and obese according to the calculated BMI of 33.3 kg/m2; elevated hemoglobin A1C of 6.9%, urinalysis showed 1+ glucose and small protein, and dyslipidemia according to lipid panel (objective) (Dunphy et al., 2015).

Pertinent negative findings. No family history of diabetes and exercising twice a week for at least 30 minutes (subjective). Glucose 95 and urinalysis negative for ketones (objective) (Dunphy et al., 2015).

Rationale for the diagnosis. T2DM was selected as the primary diagnosis based on the aforementioned pertinent positive findings, which include the following: fatigue, polyuria, polyphagia, and polydipsia; along with several risk factors for T2DM, such as age, Hispanic ethnicity, obesity (BMI ≥25), and lack of physical activity (ADA, 2019). Additionally, the laboratory results showed conflicting results, a normal FPG of 95 and an elevated A1C of 6.9%. Therefore, according to the criteria for diagnosing diabetes, an A1C ≥6.5% with obvious signs and symptoms of hyperglycemia can confirm the diagnosis of T2DM without repeat testing (ADA, 2019). Lastly, the urinalysis showed 1+ glucose and small protein (albumin), which is an indication of diabetes and/or early sign of kidney disease; as well as, an indication for dyslipidemia, a common condition associated with T2DM (Dunphy et al., 2015; ADA, 2019). Primary Care of the Maturing and Aged Family

Secondary Diagnosis.

Hyperlipidemia, unspecified (E78.5).

Pathophysiology. Hyperlipidemia is an acquired or genetic metabolic condition comprising of various lipids and lipoproteins that increase the risk of atherosclerosis, or plaque sticking to the inner walls of arteries (Dunphy et al., 2015). Lipoproteins are molecules that carry cholesterol in the bloodstream and are separated by the following groups: VLDL, LDL, and HDL; and triglycerides are large lipid molecules from dietary fats (Dunphy et al., 2015). Characteristically, patients do not exhibit manifestations of hyperlipidemia, but often this condition occurs concurrently with hypertension, T2DM, and coronary artery disease (Dunphy et al., 2015). A carotid bruit, corneal arcus, xanthomas (yellowish skin deposits of cholesterol), or xanthelasma (deposits around the eyelids) may be found on physical examination (Dunphy et al., 2015). Primary Care of the Maturing and Aged Family

Pertinent positive findings. T2DM, obesity, family history of hypercholesterolemia (father), elevated blood pressure of 129/80, and lipid profile showing the following results: TC 230 mg/dL (borderline high), LDL 144 mg/dL (high), VLDL 36 mg/dL (high), HDL 38 mg/dL (low), and TG 232 mg/dL (high) (Dunphy et al., 2015; Bibbins-Domingo et al., 2016).

Pertinent negative findings. No tobacco history, no past medical history of atherosclerotic cardiovascular disease, and has been exercising twice a week for at least 30 minutes (Bibbins-Domingo et al., 2016).

Rationale for the diagnosis. Hyperlipidemia was selected as a secondary diagnosis based on the laboratory results of the lipid profile and the primary diagnosis of T2DM. According to Stone et al. (2014), hyperlipidemia is very prevalent among Hispanics, and is characterized by a low HDL level, an elevated LDL, and high triglyceride levels; most likely as a result of insulin resistance within this ethnic group. Based on Mrs. G’s LDL 144 mg/dL and HDL 38 mg/dL, she is at risk of developing cardiovascular disease as a result of her dyslipidemia (LDL > 130 mg/dL and HDL < 40 mg/dL), T2DM, obesity, and elevated blood pressure (Stone et al., 2014). The USPSTF recommends using the ACC/AHA Pooled Cohort Equations to calculate 10-year risk of cardiovascular disease events, which Mrs. G’s calculated 10-year risk is 6.3% (Stone et al., 2014; Last, Ference, & Menzel, 2017). Primary Care of the Maturing and Aged Family


Secondary Diagnosis.

Obesity, unspecified (E66.9) & Body mass index (BMI) 33.0-33.9, adult (Z68.33)

Pathophysiology. Obesity is a multifaceted condition that is characterized as a dysfunction of the body’s normal metabolism and control of one’s appetite (Dunphy et al., 2015). Obesity results from an inequality among a high caloric intake and a decreased number of calories burned; which can be caused by various factors, such as sedentary lifestyles, dietary choices, and environmental and genetic components (Dunphy et al., 2015). The most common manifestations of obesity include the following: fatigue, low energy levels, generalized weakness, joint pain, shortness of breath, daytime sleepiness, and depression; and a BMI ≥30 kg/m2 (Dunphy et al., 2015).

Pertinent positive findings. Fatigue, low energy, increased tiredness during the day, polyphagia, an attempt to lose weight, a weight gain of 3 pounds, (subjective). General appearance is obese, weight is 185 pounds, BMI 33.3 kg/m2, left knee arthritis, and elevated blood pressure of 129/80 (objective) (Dunphy et al., 2015). Primary Care of the Maturing and Aged Family

Pertinent negative findings. Exercising twice a week for at least 30 minutes on the treadmill (subjective); normal thyroid studies TSH 2.35 and Free T4 0.7 (objective) (Dunphy et al., 2015).

Rationale for the diagnosis. Obesity was selected as a secondary diagnosis based on the patient’s aforementioned subjective findings and BMI of 33.3 kg/m2. According to Dunphy et al. (2015), in order to diagnosis obesity, one has to have a BMI ≥30 kg/m2.

Differential Diagnosis

Major depressive disorder, unspecified (F32.9).

Pathophysiology. Depression still remains not well understood, but there are several theories on the pathophysiology; the most appropriate theory suggesting an altered regulation or reduction of the neurotransmitters serotonin, norepinephrine or dopamine in the central nervous system (McCance, Huether, Brashers, & Rote, 2014). Other theories suggest an impaired regulatory mechanism involving the hypothalamus, which plays an essential role in an individual’s ability to cope with stress; thyroid hormone involvement with the variation of mood and behavior, as well as genetics and psychosocial factors contributing to depression (McCance et al., 2014; Dunphy et al., 2015). The most common manifestations of depression include the following: continuous feelings of sadness and despair, appetite changes, weight loss or gain, sleep disturbances, irritability, fatigue or loss of energy, anhedonia (loss of interest or pleasure), and thoughts of self-harm or suicide (Dunphy et al., 2015). Primary Care of the Maturing and Aged Family

Rationale for the diagnosis. Depression was selected as a differential diagnosis based on Mrs. G’s pertinent positive subjective data, including: fatigue, loss of energy, weight gain, and increased appetite (Dunphy et al., 2015). Even though Mrs. G does not express thoughts of self-harm or suicide, helplessness, and worthlessness (pertinent negatives); the differential diagnosis of depression should still be considered and appropriately evaluated with a screening assessment tool based on the collected information (Dunphy et al., 2015) Primary Care of the Maturing and Aged Family