Week 5 Case Study Assignment

  Mrs. Wong is 59 years old Asian female presents to the office for follow up after three months, and complaints of increasing fatigue over the last 12 weeks. She also reported after her menopause 4 years ago she had experiencing a gradual weight gain. She has been exercise at least twice a week, but unsuccessful.

 The purpose of this paper is to use subjective and objective data that is provided to develop an appropriate diagnosis and plan for Mrs. Wong. This assignment will discuss the assessment of the primary diagnosis, secondary diagnosis, and the differential diagnoses for Mrs. Wong, and the management plan for treatment of the above diagnosis. It will consist of diagnostics, medications, education, referrals, and follow-up care.  This paper also includes a discussion on medication costs of all prescribed and over the counter (OTC) medications.

Assessment

Mrs. Wong came to the office complains of fatigue. Despite exercising twice a week, she is unable to lose weight. She also reported an increase of hunger for past two months.  Per morning lab result, urine analysis is positive for glucose, total cholesterol is elevated, a decreased in low-high density lipoprotein, and HbA1c is 6.6%. According to Cash and Glass (2017), fasting blood glucose greater than 126 and HbA1c of 6.5% is considered diabetic.

 Primary Diagnosis Diabetes Mellitus Type 2 (DM2) (E11.9).

Pathophysiology: The primary diagnostic for Mrs. Wong is diabetes mellitus type two. Diabetes Mellitus is a chronic disease, which is due to a decrease or lack of insulin secretion, or/and inability of cells to utilize insulin (Ramachandran, 2014). According to Goroll (2014), diabetes type two occurs when pancreas is unable to produce enough insulin to meet the metabolic needs of the body.  Common signs and symptoms include polydipsia, polyuria, polyphagia and extreme fatigue (Dunphy, 2015).

Pertinent Positive findings: Weight gain, polyuria, polydipsia, fatigue, fasting blood glucose of 127, HbA1c of 6.6, positive glucose in urine, and elevated CO2 of 29.  According to the ADA, 2019 guidelines, Asian American population age of 45 or greater with a BMI more than 23 kg/m2, and HbA1c equal or greater to 6.5% on initial testing is considered diabetes (ADA, 2018.p 29).

Pertinent Negative Findings: Patient exercise regularly, former smoker, normal BUN, creatinine and GFR, skin dry and intact, negative ketones in urine analysis, (ADA, 2018).

Rationale for the diagnosis: Diabetes mellitus type two is the chosen primary diagnosis for Mrs. Wong is based on her laboratory results of fasting plasma glucose of 127, and hemoglobin A1C level above 6.5 percent, and clinical presentation of fatigue, hunger and thirst. Also Mrs. Wong’s BMI put her at greater risk to develop diabetes because data has shown that in Asian Americans a BMI greater than 23 kg/m² puts an individual at increased risk of diabetes mellitus (ADA, 2019).