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Running head: WEEK 5 CASE STUDY 2

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Week 5 Case Study Assignment

Chamberlain University

NR601: Primary Care of the Maturing and Aged Family

April 2019











Week 5 Case Study Assignment

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 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).

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).

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).

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).

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).

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).

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).



Lab test. Repeat A1C in 3 months (ADA, 2019).

Rationale. According to the ADA (2019), to properly evaluate and manage a patient with T2DM, an A1C test can be completed every 3 months to assess whether the patient’s glycemic goal has been accomplished and is being managed effectively. When evaluating the effectiveness of the T2DM treatment plan, it is the provider’s decision to determine how frequently an A1C needs to be completed based on the overall clinical picture of the patient and the current treatment plan in place (ADA, 2019).

Lab test. Spot urinary albumin-to-creatinine ratio (UACR) (ADA, 2019).

Rationale. A UACR test should be performed annually on all patients with T2DM to assess for urinary albumin or microalbuminuria, which is an indication of kidney damage (ADA, 2019). The UACR test is appropriate for Mrs. G due to the results of her urinalysis indicating small protein and her primary diagnosis of T2DM. Normal UACR results are <30 mg/g Cr and increased levels of urinary albumin are results ≥30 mg/g Cr (ADA, 2019). Additionally, due to the inconsistency in the excretion of urinary albumin and the possibility of false positive results, two positive UACR results out of 3 in a 3-6-month timeframe would be required to diagnosis a patient with microalbuminuria (ADA, 2019).

Lab test. Repeat complete metabolic panel (CMP) in 6 weeks (Hollier, 2018).

Rationale. A baseline CMP and CBC were performed initially. Therefore, a repeat CMP should be performed at least annually to monitor kidney and liver functions in diabetic patients; however, patients started on statin therapy for the management of hyperlipidemia, it is recommended to evaluate liver function tests at 4-6 weeks from initiation of treatment (Hollier, 2018). A CBC at least yearly is recommended for patients with T2DM who are being treated with metformin, because of the potential for vitamin B12 deficiency (megaloblastic anemia) caused by long-term use of metformin (ADA, 2019).

Lab test. Repeat fasting lipid panel (FLP) in 6 weeks.

Rationale. A baseline FLP was performed initially. Following the initiation of a statin medication or change in therapy, it is recommended to perform a FLP within 6-8 weeks to evaluate whether or not lipid level goals have been achieved with the current treatment regimen (Hollier, 2018). The recommended levels for lipids include a LDL <100 mg/dL, triglycerides <150 mg/dL, and HDL >50 mg/dL in women (ADA, 2019).

Screening test. Patient Health Questionnaire-9 (PHQ-9).

Rationale. The PHQ-9 is a self-report questionnaire based on symptoms experienced over the past 2 weeks that comprises of 9 items, and is one of the most commonly used screening instruments for depression in the adult population (Hirschtritt & Kroenke, 2017). Due to Mrs. G.’s change in medical status related to the diagnoses of T2DM and hyperlipidemia; this puts her at an increased risk for developing depression (ADA, 2019). Also, to rule out the differential diagnosis of depression, utilizing a screening instrument such as the PHQ-9 is key to diagnosing and managing this condition (Hirschtritt & Kroenke, 2017). According to Hirschtritt & Kroenke (2017), screening for depression should occur during each patient encounter.


Medication. Rx: Metformin 500 mg tablets

Sig: Take one (1) tablet by mouth twice daily

Disp: #60 (Sixty). RF: 2 (ADA, 2019).

Rationale. Metformin was the medication selected for the treatment of T2DM because it is first-line treatment, and should be prescribed at the time of the diagnosis unless contraindicated (ADA, 2019). According to the ADA (2019), metformin is effective in lowering A1C and weight, is safe and cheap, and can possibly lower an individual’s risk of having a cardiovascular incident or death (ADA, 2019).

Medication. Rx: Atorvastatin 20 mg tablets

Sig: Take one (1) tablet by mouth once daily

Disp: #30 (Thirty). RF: 2 (Stone et al., 2014).

Rationale. Atorvastatin was the medication selected for the treatment of hyperlipidemia. According to Stone et al. (2014), a moderate-intensity statin should be started on adults 40-75 years old who have diabetes and LDL 70-189 mg/dL as a primary prevention strategy. The recommended ACC/AHA Pooled Cohort Equation was utilized to calculate Mrs. G.’s 10-year ASCVD risk of 6.3%; therefore, guideline recommendations state that a moderate-intensity statin should be started on patients with a 10-year ASCVD risk of 5.0% to <7.5% (Stone et al., 2014). On average, atorvastatin lowers LDL levels by about 30% to <50% (Stone et al., 2014).


Diagnosis. Mrs. G, according to your A1C result of 6.9%, which measures your average blood sugars for the past 3 months, is higher than the recommended value 6.5% or lower (ADA, 2019). Along with your symptoms of feeling tired, hungry, thirsty, and urinating more frequently, I am going to say that you most likely have T2DM (ADA, 2019). In order to help you better understand what T2DM is and how it develops, I will explain in greater detail. T2DM is the most common type of diabetes, which causes hyperglycemia or higher than normal blood sugar levels (ADA, 2019). T2DM occurs when your body cannot correctly use the insulin secreted from your pancreas, which is also referred to as insulin resistance (ADA, 2019). What happens initially is that your pancreas will produce extra insulin, but over time the pancreas cannot keep up with the demands expected to keep your blood sugars normal; decreasing the amount of insulin produced, and ultimately resulting in higher than normal blood sugars or diabetes (ADA, 2019). There are risk factors associated with the development of T2DM, such as family history, being overweight, certain ethnicities, having high blood pressure, being over 45 years of age, lack of physical activity, and having low HDL (good) cholesterol or high triglyceride levels (ADA, 2019). Additionally, I want to mention that your glucose level on your lab work was 95 mg/dL, which is normal according to recommendations of less than 126 mg/dL; but because your A1C was higher than recommended and the symptoms you are experiencing, both are indicative of diabetes (ADA, 2019). Your blood sugar levels may be rising above the recommended value of 180 mg/dL after eating a meal, which is called postprandial hyperglycemia; a contributing factor for the elevated A1C and diabetes (ADA, 2019). T2DM can be effectively managed by eating a well-balanced diet, increasing your physical activity as tolerated, lowering your weight, and adhering to a prescribed medication regimen (ADA, 2019).

Medication. In order to properly manage your T2DM, I will be prescribing you a medication called metformin that you will be taking twice a day with breakfast and dinner. This medication will improve your blood sugar levels, help with weight loss, and improve your cholesterol levels by lowering your triglycerides and bad cholesterol while raising your good cholesterol (Dunphy et al., 2015).

Diet. Meal planning and understanding nutritional therapy will be a key component to properly managing your T2DM, elevated cholesterol levels, and helping you with weight loss. An effective method to managing your blood sugar levels is by watching your food portions and making healthier food choices (ADA, 2019). For weight loss management, the recommended caloric intake for a woman is 1,200-1,500 per day (ADA, 2019). There is no established dietary distribution of calories among carbohydrates, fats, and proteins; therefore, keeping track of your total caloric intake is important to successfully managing your T2DM (ADA, 2019). Knowing what encompasses a healthy meal plan is pertinent, such as fruits and vegetables, lean protein foods, no added sugar, and no trans-fat (ADA, 2019). To give you a better idea of how your plate should be divided; vegetables should take up half your plate, ¼ of the plate for a protein, and ¼ for a carbohydrate (ADA, 2019). The ADA (2019) recommends to fill your plate with non-starchy vegetables, such as broccoli, cabbage, carrots, and celery; substitute with fruit that is fresh, frozen or canned without added sugars if you are craving something sweet; eat foods high in fiber, such as legumes, nuts, and whole grains; include fish in your meal plan at least twice a week; and consume less saturated fat and cholesterol. Also, to address your alcohol consumption of 1-2 glasses of wine on the weekends; the ADA (2019) recommends no more than one 5 oz glass of wine per day, and not to forget to eat, because drinking alcohol on an empty stomach can put you at risk for low blood sugar.

Exercise. Exercise or physical activity is another essential component for managing your T2DM, lowering your cholesterol levels, and assisting you with weight loss. In order for an exercise regimen to be effective, it is important that it is tailored towards your interests and physical condition, such aerobic exercises, strength training, and stretching exercises (ADA, 2019). The ADA (2019) recommends aerobic exercise and strength training, because it allows your body to become more sensitive to insulin and is better utilized, thus lowering your blood sugars. In addition to lowering your blood sugar, these exercises help to lower your blood pressure, improve your cholesterol levels, and help with losing weight (ADA, 2019). For example, aerobic exercise is 30 minutes of moderate intensity exercise at least 5 days per week or 45-60 minutes is more beneficial for weight loss, which includes brisk walking, bicycling, swimming, or climbing stairs (ADA, 2019). In addition to aerobic exercise, the ADA (2019) also recommends participating in some sort of strength training, such as using resistance bands and/or lifting light weights or objects (canned goods) at least twice a week.

Warning signs for diagnosis and mediation. Now, I want to discuss with you the warnings signs associated with T2DM. It is important that you know the signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar); along with the causes, appropriate treatments, and how to prevent this these problems from happening. Hypoglycemia can occur due to various reasons, such as taking too many of your metformin pills, missing meals or not eating enough, excessive exercising, and alcohol consumption (Dunphy et al., 2015). The signs and symptoms that you and your family need to be aware of, include sweating, hunger, feeling shaky, dizziness, confusion, or feeling anxious (Dunphy et al., 2015). To treat hypoglycemia, you will need to drink 6 to 12 ounces of orange juice or another fruit juice without adding sugar, or substitute an 8-ounce glass of milk if the other options are not available (Dunphy et al., 2015). Signs and symptoms of hyperglycemia include extreme thirst, frequent urination, fatigue, listlessness, nausea, dizziness; which are some of the symptoms you are experiencing now (Dunphy et al., 2015). Therefore, to avoid high blood sugars it is important for you to follow the diet and exercise recommendations previously discussed, and take your metformin as prescribed.

Important complications that can arise from T2DM, include diabetic neuropathy, which is a decreased sensation in your hands and feet due to nerve damage; and retinopathy, damage to the blood vessels in the back of the eye that can cause you to go blind (Dunphy et al., 2015). It is important for you to know the signs and symptoms of neuropathy, which includes pain, loss of sensation, and muscle weakness that occurs most commonly in the feet (Dunphy et al., 2015). Therefore, it is imperative for you to wash and inspect your feet daily for open sores, avoid walking barefoot, test the temperature of your bath water before getting in, and trim your toenails to the shape of your toes and avoid cutting the cuticles (Dunphy et al., 2015). You stated that you wear contacts, so hopefully you see an eye doctor yearly; and if you don’t, it is imperative that you do, so that you can be evaluated for any damaged blood vessels in your eyes (ADA, 2019). The most common side effects associated with metformin are stomach discomfort, nausea, vomiting, and diarrhea; which usually goes away within a couple of weeks (Dunphy et al., 2015). Also, metformin has a low risk for causing low blood sugars (Dunphy et al., 2015; ADA, 2019).

Diagnosis. According to your fasting lipid panel it indicates that your cholesterol levels are higher than recommended, which is also referred to as hyperlipidemia or dyslipidemia (Dunphy et al., 2015). Cholesterol is a waxy substance that has both pros and cons to maintaining a healthy lifestyle, but having high levels of bad cholesterol (LDL) and triglycerides, and low levels of good cholesterol (HDL) circulating in your blood will cause a buildup on the walls of your arteries making them narrow and hardened; increasing your risk for heart attack and/or stroke (Dunphy et al., 2015). Cholesterol is produced naturally by your liver, and comes from the foods you eat, such as meat, poultry, and dairy products (Dunphy et al., 2015). Animal products contain high saturated fats and trans fats, which causes your liver to produce extra cholesterol; therefore, consuming large amounts of these types of foods will raise your bad (LDL) cholesterol levels (Dunphy et al., 2015). There are risk factors that make people more prone to having high cholesterol, such as genetics, family history, T2DM, being overweight, lack of physical activity, and not following a healthy diet (Dunphy et al., 2015).

Medication. In order to properly manage your cholesterol levels and to lower your risk for heart attack or stroke, I will be prescribing you a medication called atorvastatin that you will be taking once a day (Stone et al., 2014). In addition to eating a healthy diet and exercising, this medication will help with lowering your triglycerides and bad cholesterol, while increasing your good cholesterol (Stone et al., 2014).

Diet and exercise. In addition to what was discussed regarding T2DM, restricting your intake of cholesterol to less than 200 mg/day is recommended (Dunphy et al., 2015). Other recommendations for improving your cholesterol is to eat red meat only a couple times a month; increase your intake of fruits and vegetables, whole grains, legumes and nuts; and use olive oil and/or canola oil instead of butter (Dunphy et al., 2014). Exercise recommendations for hyperlipidemia stated above.

Warning signs for diagnosis and medications. There are no true warning signs for your elevated cholesterol except for the increased risk of having a heart attack or stroke. If you develop symptoms of chest pain, shortness of breath, weakness to one side of your body, or slurred speech, then you need to seek emergency care immediately. Atorvastatin is usually well tolerated; however, there are side effects to this medication such as muscle symptoms, which include pain, tenderness, stiffness, cramping, weakness, or fatigue (Stone et al., 2014). If you experience any of these symptoms it is important for you to call the office immediately to avoid any serious muscle damage that could be occurring from taking this medication; and it is also recommended to avoid drinking grapefruit juice due to the potential for a drug interaction (Last et al., 2017).

Diagnosis. According to your BMI of 33.3 kg/m2, which is calculated from your height and weight, indicates obesity. Obesity is characterized by having too much body fat and is determined by a BMI greater than or equal to 30 kg/m2 (Dunphy et al., 2015; ADA, 2019). What contributes to excessive weight gain is when people eat too much food or consume too many calories, and do not get enough exercise to burn off or balance out the calories consumed (Dunphy et al., 2015). Obesity can cause many health issues, such as T2DM, hyperlipidemia, strokes, and coronary heart disease (Dunphy et al., 2015).

Diet, exercise, and medication. Diet and exercise recommendations for weight loss were explained during the discussion of your T2DM and elevated cholesterol levels, but I strongly encourage you to follow a calorie restricted diet to facilitate weight loss (Jones et al., 2015). No medications will be prescribed specifically for the diagnosis of obesity.


Diabetes Educator. A referral to a diabetes educator will be completed for Mrs. G based on her new diagnosis of T2DM. According to the ADA (2019), every patient with diabetes should take part in diabetes self-management education and support because it provides patients with the necessary education, skills, and support that is needed to effectively self-manage and maintain their diabetes.

Registered Dietitian. A referral to a registered dietitian will be completed as this is also recommended for the diagnosis of T2DM (ADA, 2019). According to the ADA (2019), a personalized medical nutrition therapy program; which is provided under the direction of registered dieticians, is pertinent for all diabetic patients in order for them to adequately achieve their recommended treatment goals (ADA, 2019).

Ophthalmologist or Optometrist. Referral to an ophthalmologist or optometrist is recommended by the ADA for patients to have a dilated and comprehensive eye exam initially for the diagnosis of T2DM, then annually thereafter (ADA, 2019). It cannot be assumed that Mrs. G visits an eye doctor on an annual basis just because she wears contacts; therefore, it is imperative to ascertain whether or not a referral is still needed and to stress the importance of this particular recommendation.

Follow up

Mrs. G will be scheduled for a 4-week follow up visit, which at this time an evaluation for medication compliance, intolerances or side effects from metformin and/or atorvastatin can be evaluated; along with her psychosocial status, adherence to recommended lifestyle modifications, such as diet and exercise; and address any other questions or concerns that Mrs. G may have in regards to the self-management of her diabetes, hyperlipidemia, and obesity (ADA, 2019). Additionally, the 4-week follow-up visit will assess her height, weight, BMI, and blood pressure.

Medication Cost

At Walmart pharmacy, the retail price for sixty metformin 500 mg tablets is $4.00 and $9.00 for thirty atorvastatin 10 mg tablets (GoodRx, 2019). The estimated monthly cost for Mrs. G’s new prescriptions would be $13.00 per month. When prescribing Mrs. G’s medications, I took into account the cost of the medications and decided to prescribe generic formulations (cheapest). The cost of prescription medications should be taken into consideration when developing a treatment plan for all patients. Diabetes can negatively impact a patient’s financial status; therefore, as a future nurse practitioner I will strive to facilitate improved patient care and outcomes by utilizing cost containment resources and strategies. The utilization of GoodRx.com allows providers to compare prices of generic and brand name medications among various pharmacies to reduce the financial burden that many patients experience with the healthcare industry. The ADA recommends providers to evaluate the patient’s social situation for financial barriers; which may lead to non-adherence of the prescribed management plan, thus resulting in suboptimal patient outcomes (ADA, 2019).


Mrs. G was evaluated based on the collected subjective and objective information; and was provided with a management plan that was developed from evidence-based practice guidelines for the diagnoses of T2DM, hyperlipidemia, and obesity. Lastly, the cost of the prescription medications was taken into consideration, and only generic formulations were prescribed to help facilitate patient adherence and to optimize outcomes.


Clinical Chart SOAP Note

Patient Information:

Mrs. G., 55, Female, Hispanic


Chief Complaint: 



Mrs. G., a 55-year-old Hispanic female, presents to the office for her annual exam. She reports that lately she has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. She is also gaining weight since menopause last year. She joined a gym and forces herself to go twice a week, where she walks on the treadmill at least 30 minutes but she has not lost any weight, in fact she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She wants get a complete physical and to discuss why she is so tired and get some weight loss advice. She also states she thinks her bladder has fallen because she has to go to the bathroom more often, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 3 months too. This is irritating to her, but she is able to fall immediately back to sleep.


Current Medications: Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin.

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

PMHx: Left knee arthritis. Had chicken pox and mumps as a child. Vaccinations up to date.

GYN Hx: G2 P1. 1 SAB, 1 living child, full term, wt. 9 lbs. 2 oz. LMP 15 months ago.


Health Screening: No history of abnormal pap smear

Soc Hx: Works from home as a part time planning coordinator. Married. No tobacco history, 1-2 glasses wine on weekends. No illicit drug uses.


Fam Hx: Parents alive, well, child alive, well. No siblings. Mother has HTN and father has high cholesterol.


Constitutional: Reports fatigue, low energy, and weight gain of 3 lbs.

Genitourinary: Reports frequent urination and nocturia.

Endocrine: Reports increased hunger, thirst, and urination.


Physical Exam:

BP: 129/80; HR: 76; RR: 16; Height: 5′ 2.5″; Weight: 185 lbs.; BMI: 33.3

General: obese female in no acute distress. Alert, oriented and cooperative.

Skin: warm dry and intact. No lesions noted.

HEENT: head normocephalic. Hair thick and distribution throughout scalp. 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 cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.


CV: S1 and S2, RRR without murmurs no rubs.

Lungs: clear to auscultation bilaterally, respirations regular, unlabored

Abdomen: soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.


Diagnostic or Lab results:

CBC: WBC 6,000/mm3 Hgb 12.5 gm/dl Hct 41% RBC 4.6 million MCV 88 fl MCHC 34 g/dl RDW 13.8%


UA:  pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites negative, 1+ glucose; small protein; negative for ketones



Sodium 139, Potassium 4.3, Chloride 100, CO2 29, Glucose 95, BUN 12, Creatinine 0.7, GFR est non-AA 92 mL/min/1.73, GFR est AA 101 mL/min/1.73, Calcium 9.5, Total protein 7.6, Bilirubin, total 0.6, Alkaline phosphatase 72, AST 25, ALT 29, Anion gap 8.10, Bun/Creat 17.7


Hemoglobin A1C: 6.9 %

TSH: 2.35, Free T4: 0.7

Cholesterol: TC 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 38mg/dl, Triglycerides 232

EKG: normal sinus rhythm


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


Secondary Diagnosis: Hyperlipidemia (E78.5); Obesity (E66.9); Body mass index (BMI) 33.0-33.9, adult (Z68.33)


Differential Diagnosis: Major depressive disorder, unspecified (F32.9)



Spot urinary albumin-to-creatinine ratio

PHQ-9 screening

CMP in 6 weeks

FLP in 6 weeks

Repeat A1C in 3 months


· Rx: Metformin 500 mg tablets

Sig: Take one (1) tablet by mouth twice daily. Disp: #60 (Sixty). RF: 2

· Rx: Atorvastatin 20 mg tablets

Sig: Take one (1) tablet by mouth once daily. Disp: #30 (Thirty). RF: 2


Discussed T2DM, hyperlipidemia, and obesity diagnoses.

Diabetes education.

Discussed foot care.

Education provided about hypoglycemia and hyperglycemia.

Reviewed medications.

Discussed the need for repeat lab work.

Discussed lifestyle modifications with diet and exercise.

Referrals: Diabetic Educator, Registered Dietician for medical nutrition therapy, Optometrist or Ophthalmologist for dilated and comprehensive eye examination


Follow up: Return to office in 4 weeks to evaluate for adherence to prescribed medications and management plan.



















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