Case Study of Hispanic Female

Case Study of Hispanic Female

Patient Information

Initials: Mrs. G

Age: 50 years old

Sex: Female

Race: Hispanic

SUBJECTIVE

Chief Complaint

50-year-old Mrs. G reported to the hospital and complained of feeling tired and the desire to lose weight. Moreover, Mrs. G notes that her bladder could have fallen owing to the urinary frequency during the day and at night. Mrs. G further states that she frequently gets thirsty and hungry.

History of presenting Illness (HPI)

Onset:  She notes that the fatigue, the urinary frequency and increased hunger and thirst were a recent occurrence and did not state the actual timeline of the first onset. Moreover, the patient notes of a gradual weight gain for about a year

Location: Generalized fatigue and an overall weight gain reported

Duration: A recent history of fatigue with a gradual weight gain for about a year

Characteristics: Fatigue, general weight gain, frequent hunger pangs and persistent thirst, frequent urination- both day and night

Aggravating factors: Exercise makes her more hungry and thirsty.

Relieving factors: None mentioned.

Treatment: Not reported

Severity: Mrs. G feels more tired after exercising and gets more hungry and thirsty. Moreover, frequent urination disrupts her sleep at night.

 Current medication

 Mrs. G reports that she takes Tylenol daily for knee pain. Notably, the dosage and period she has been on Tylenol were not stated. She also takes multivitamin daily. From the patient history, she does not state the duration that she has been using multivitamin and the reason for using it.

Allergies 

Medication: There is No Known Drug Allergy (NKDA).

Food: There is no history of allergy to any food

Environmental: the patient is allergic to Latex and cats.

Past Medical History (PMHx)

 Mrs. G has left knee arthritis. Additionally, she had chick pox and mumps in her childhood. Her vaccinations are up to date. The patient does not report any history of surgeries. Notably, the patient is obese with no acute distress.

Social History

Mrs. G works from home as a telemarketer. She is married with one child who is living well just as Mrs. G’s parents. There are no reports on the use of illicit drugs; she is also not a smoker/ no tobacco consumption. She notes that she takes 1-2 glasses of wine on weekends. It would be imperative to find out if the family eats healthy and whether they are involved in any form of exercise. Since Mrs. G is obese, it would be imperative if she exercises regularly and if the family takes healthy diet as a means to encourage her to lose her weight. According to Clark (2015), diet and exercise are important in promoting weight loss. Interpretively, the unhealthy diet would promote weight gain in obesity.

Family History

Her parents are all alive and well. Also, no information about the siblings as Mrs. G is the only sibling in her family.

Review of Systems

Constitutional: Fatigue, weight gain, thirst, increased urinary frequency. Frequent hunger pangs

HEENT: Head is normocephalic, the hair thick and distribution throughout the skin of the head. The eyes are without exudates and sclera white thus the use of contact lenses. The tympanic membranes are gray and intact with light reflex noted. Pinna and tragus are non-tender. Nares patent without exudate while oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple; interior thyroid lymph nodes are non-tender to palpation, thyroid midline, small and firm without palpable masses

SKIN: no rashes on the skin

Cardiovascular: no cases of unclear blood vessels and problems of the heart or murmurs

Respiratory: Clear to auscultation bilaterally, respirations unlabored.

Musculoskeletal: Abdomen- soft, round, non-tender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT

Hematologic: WBC and RBC are within the normal range, HgB level is also normal. Leukocyte esterase negative

Lymphatics: cervical lymph non-tender to palpation

Psychiatric: No history of depression as well as anxiety

Endocrinologic: No lymphadenopathy. No endocrine disorders reported

Allergies: no allergies to drugs

Objective

Physical examination

  • The Vital signs: BP 130/82; pulse 80
  • Regular respiration 20
  • Physical height of 5.2 m
  • The weight of 192 pounds
  • Regarded obese
  • No acute stress
  • Hair properly distributed in the scalp
  • HEENT: head normocephalic
  • Eyes: without exudate, sclera white and Wears contacts
  • Neck supple:  Anterior cervical lymph non-tender to palpation.
  • Lungs: Clear to auscultation bilaterally, respirations unlabored
  • Abdomen- soft, round, non-tender with positive bowel sounds present; no organomegaly; no abdominal bruits

Diagnostic Result

In the previous years, Mrs. G was positively diagnosed with left knee arthritis and has been on medication. According to Heidari (2011), a positive diagnosis of arthritis is made by the presence of a high Erythrocyte sedimentation rate and the C-reactive protein in the lab results. The lab results denote a high protein and glucose level in urine, that is, +1 glucose and +1 protein. The patient shows a high Free Triglyceride (228mg/dl), The LDL value is above the normal range. Moreover, the patient has a high VLDL (36mg/dl). Notably, the lab results show a high hemoglobin A1c levels showing that the patient has diabetes that is the figure is 7.7%.

Assessment

Primary Diagnosis:

Diabetes Mellitus (2014 ICD-9-CM 250.00). Based on the subjective and objective information, the patient is likely to be suffering from Diabetes mellitus. Based on some studies, HbA1c has been confirmed as the diagnostic indicator for diabetes mellitus (Florkowski, 2013). According to Florkowski (2013), HbA1c values of between 5.7-6.4% shows that a patient is at increased risk for diabetes and cardiovascular disease. Mrs. G value of 7.7% is a clear indicator that she has diabetes and has a risk for cardiovascular disease.

Secondary Diagnosis:

Obesity (2012 ICD-9-CM 278.00); Mrs. G is obese and has been having a continuous weight gain and has not been doing any physical exercise till recently (Wiklund, 2016). Additionally, there will be the need to talk to her on her hyperlipidemia (2013 ICD-9-CM 272.4), for example, she has a high VLDL that can predispose her to atherosclerosis and cardiac arrest (Nojiri & Daida, 2017). There is the need to review Mrs. G and establish the therapeutic outcome for the left knee arthritis treatment to determine the efficacy of the medication she is using.

Differential diagnosis- metabolic syndrome, hyperthyroidism

Plan

Diagnostics

  • Random blood sugar test
  • Thyroid function tests
  • Check for autoantibodies to rule out hyperthyroidism
  • Lipid profile test

Intervention

Early intervention will help improve the quality and quantity of life. For Mrs. G, the first intervention would be to initiate diabetic treatment to control her blood sugar level and relieve her of the symptoms. A good therapeutic outcome would combine both pharmacological regimen and lifestyle modification (Marín-Peñalver, Martín-Timón, Sevillano-Collantes, & del Cañizo-Gómez, 2016). The patient will first be put on medications to control both diabetes and hyperlipidemia. The following medications will be of benefit to the patient:

  1. Use Metformin 500mg Once Daily at night for one week. Should be taken with the evening meal as the first line drug for type 2 diabetes
  2. Use Acarbose 25 mg three times daily for one week taken before meals. The rationale for combining metformin and Acarbose ensures better control of the blood sugar (Liu, et al., 2017). Acarbose prevents carbohydrate breakdown by inhibiting the alpha-glucosidase enzyme. Moreover, metformin suppresses appetite hence ideal for promoting weight loss. The combined therapy of metformin and Acarbose will be given for a week and a follow up done to note the efficacy in blood sugar control. If there is no adequate control in blood sugar levels, then the dose will be titrated upwards, or we can institute insulin.
  3. Use Atorvastatin 10mg at night for two weeks. This is given for hyperlipidemia, as it will blocks cholesterol synthesis hence increasing the level of HDL cholesterol and decreases levels of triglycerides. The lipid profile should be reviewed after 2-4 weeks.
  4. Continue on Tylenol for pain management for arthritis- to be reviewed in a week. Multivitamin to be used for only 28 days then stopped.

Education:

  1. Regular exercise to promote weight loss. Regular exercise helps in controlling obesity (Montesi, et al., 2016). The range of motion exercise will help boost the ability of the joints to move within their range.
  2. Mrs. G needs to be put on a healthy diet- consult the nutritionist for this.

Referral/Consults– the nutritionist for dietary planning.

Follow up

The patient will be reviewed in a week. The review will assess the response to medications, and a random and fasting blood sugar test will be done. For hyperlipidemia, scheduled lipid profile test will be done to check the lipid profile and gauge the efficacy of atorvastatin dose.

References

Clark, J. (2015). Diet, exercise or diet with exercise: comparing the effectiveness of treatment options for weight-loss and changes in fitness for adults (18–65 years old) who are overfat, or obese; systematic review and meta-analysis. J Diabetes Metab Disord, 14(31).

Florkowski, C. (2013). HbA1c as a Diagnostic Test for Diabetes Mellitus – Reviewing the Evidence. Clin Biochem Rev, 34(2), 75-83.

Heidari, B. (2011). Rheumatoid Arthritis: Early diagnosis and treatment outcomes. Caspian J Intern Med, 2(1), 161-170.

Liu, Z., Zhao, X., Sun, W., Wang, Y., Liu, S., Kang, L., et al. (2017). Metformin combined with acarbose vs. single medicine in the treatment of type 2 diabetes: A meta-analysis. Experimental and Therapeutic Medicine, 13(6), 3137-3145.

Marín-Peñalver, J. J., Martín-Timón, I., Sevillano-Collantes, C., & del Cañizo-Gómez, F. J. (2016). Update on the treatment of type 2 diabetes mellitus. World Journal of Diabetes, 7(17), 354-395.

Montesi, L., El Ghoch, M., Brodosi, L., Calugi, S., Marchesini, G., Dalle, R. G., et al. (2016). Long-term weight loss maintenance for obesity: a multidisciplinary approach. Diabetes, Metabolic Syndrome Obesity, 9, 37-46.

Nojiri, S., & Daida, H. (2017). Atherosclerotic Cardiovascular Risk in Japan. Japanese Clinical Medicine, 8, 1-7.

Wiklund, P. (2016). The role of physical activity and exercise in obesity and weight management: Time for critical appraisal. Journal of Sport and Health Science, 5(2), 151-154.

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