The purpose of this paper is to analyze the provided subjective and objective information to diagnose and develop a management plan for the patient in the case study. The paper intends to apply national diabetes guidelines to the management plan. The mastery of SOAP note writing will also be demonstrated.
Primary Diagnosis
Type 2 diabetes mellitus (E11.9). Pathophysiology
Type 2 diabetes is an endocrine and metabolic disorder that arises due to acquired resistance to insulin action or loss of function of pancreatic beta cells that produce insulin, which is responsible for the metabolism of glucose. Inadequate regulation of blood sugar levels causes hyperglycemia that often leads to the manifestation of the classical symptoms of diabetes mellitus, including include polyphagia, polyuria, and polydipsia (American Diabetes Association [ADA], 2018).
Pertinent positive findings
The patient reports that she has experienced increased fatigue for the last 12 weeks, frequent urination and weight gained despite her efforts to exercise. She also experiences extreme thirst and hunger after exercise, which complicates her weight loss process. Therefore, the patient presents with the classical symptoms of diabetes mellitus: polyphagia, polyuria, and polydipsia, which confirms this diagnosis (Acuna, Labinson, & McDermott, 2017).
Additionally, the laboratory tests are indicative of type 2 diabetes. The urinalysis shows glycosuria, whereas the blood glucose level is elevated at 130mg/dl, which is a symptom of hyperglycemia. Hemoglobin A1C level is 6.8 %, which is a symptom of type 2 diabetes (Chatterjee, Khunti, & Davies, 2017). Normal levels of glycated hemoglobin should be 5.7% and below, whereas hemoglobin A1C between 5.7% and 6.4% show prediabetes (American Diabetes Association [ADA], 2018).
Pertinent negative findings
Urine tests are the most reliable way of detecting ketones and microalbumin. The urinalysis did not indicate the presence of ketones or protein, which are usually present in severe hyperglycemia (Fayfman, Pasquel, & Umpierrez, 2017).
Rationale for the diagnosis
ADA (2018) recommends that type 2 diabetes should be diagnosed based on the three classical symptoms of diabetes with additional backing from laboratory tests. The diagnosis was made based on the presenting symptoms (polydipsia, polyphagia, and polyuria), high fasting blood glucose levels, the presence of glucose in urine, fatigue, and unexplained weight gain despite exercise. BMI of 31.17 is an indication of obesity, which is a known risk factor for type 2 diabetes mellitus. These findings confirmed the diagnosis of type 2 diabetes.
Secondary Diagnosis
Hyperlipidemia (E78.5). Pathophysiology
Hyperlipidemia refers to the presence of high levels of lipids in the blood, which arises from the consumption of food items that are rich in fats thereby increasing the amount of lipids that are circulating in the blood (Navar Boggan et al., 2015). Hyperlipidemia does not have any distinctive symptoms and can only be diagnosed by conducting a lipid panel.
Pertinent positive findings
Total cholesterol of 215 mg/dl (less than 200 ng/dl is desirable), LDL of 144 mg/dl (less than 100 mg/dl is optimal); VLDL 36 mg/dl (normal range is 2 to 30 mg/dl); HDL 32mg/dl (levels of 40 mg/dl is desirable), and triglycerides 229 (200 mg/dl and above is considered high) (ADA, 2018).
Pertinent negative findings
The patient had normal blood pressure values despite having elevated lipid levels. Cholesterol could accumulate in the inner walls of the blood vessels thus elevating blood pressure in the affected individuals (Rafieian Kopaei, Setorki, Doudi, Baradaran, & Nasri, 2014). However, in the case study, the patient had normal blood pressure values. In addition, hyperlipidemia could occur due to the consumption of a high-fat diet and hypothyroidism. However, the thyroid function test as indicated by the TSH and free T4 values were within the normal range. TSH was 2.31 (normal range is 0.35 to 5), whereas the free T4 was 0.9 ng/dl (normal range 0.7 to 1.9 ng/dl).
Rationale for the diagnosis
The lipid profile showed elevated levels of cholesterol, LDL, VLDL, triglycerides, and low levels of HDL, which are the main indicators in hyperlipidemia diagnosis (Rafieian-Kopaei et al., 2014).
Differential Diagnosis
Metabolic syndrome (E88.81). Pathophysiology
Metabolic syndrome is an array of risk factors attributed to insulin resistance. The typical symptoms include abdominal obesity, elevated fasting blood glucose, high triglyceride levels, high blood pressure, and low levels of LDL (Furukawa et al., 2017).
Rationale for the diagnosis
The
Quality Work
Unlimited Revisions
Affordable Pricing
24/7 Support
Fast Delivery