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Metabolic Diseases Case Study

Dana Weisbrot

NR601 - Primary Care of the Maturing and Aged Family

Dr. Debra Jackson-Elwer

Metabolic Diseases Case Study

This paper will describe the case study of Mrs. G which begins with an assessment to include the pathophysiology, positive and negative pertinent findings, rationale for diagnosis, a secondary diagnosis, positive and negative pertinent findings, rationale for diagnosis. It will continue with the plan to include diagnostics, medications, education, referral and follow up. Next, it will describe an assessment of comorbidities, cost and finalize with a conclusion.

Assessment

Primary Diagnosis Type 2 diabetes mellitus E11.8

pathophysiology Diabetes mellitus is a complex metabolic disorder associated with an increased risk of microvascular and macrovascular disease; its main clinical characteristic is hyperglycemia. Signs and symptoms often include increased thirst, increased urination, always feeling hungry, fatigue or tiredness. More advanced symptoms are blurred vision, tingling or pain to extremities, acanthosis nigricans, yeast infections (Zaccardi, Webb, Yates & Davies, 2016).

pertinent positive findings Patient’s A1C: 6.9 The guidelines for the diagnosis and treatment of diabetes mellitus from the American Family Physician (2019) explains that the American Diabetic Association (ADA) revised in 2019 the diagnostic tests to make it clear that Diabetes may be diagnosed based on results A1C level of 6.5% or higher. The ADA is now recommending the screening for diabetes and prediabetes for every adult starting at age 45 regardless of weight (AAFP, 2019). Ms. G’s elevated BMI: 33. She also reports tiredness, excessive thirst, need to urinate frequently, and excessive hunger are some of her symptoms. The ADA describes these symptoms to be consistent with the positive findings of diabetes mellitus (ADA, 2019)

pertinent negative findings She denies unexplained weight loss, blurred vision, tingling or pain in extremities. The ADA describes the above symptoms as characteristic from diabetes which can develop slowly through the years. (ADA, 2020a). Her fasting plasma glucose is 95, per AAFP (2019) one way to diagnose diabetes mellitus is a fasting plasma glucose testing more than 126.

rationale for the diagnosisThe guidelines for the diagnosis and treatment of diabetes mellitus from the American Family Physician (2016) explains that the ADA revised in 2016 the diagnostic tests to make it clear that Diabetes may be diagnosed based on results A1C level of 6.5% or higher. Ms. G’s A1C of 6.9. In addition to this, supporting diagnosis include her symptoms of: increased hunger and thirst, daily tiredness, nocturia and BMI of 32 as shown above in negative and positive findings.

Secondary Diagnosis Hyperlipidemia E78.5

Pathophysiology Hyperlipidemia has high levels of LDL in the body, these lipids could potentially become hard deposits inside the arteries causing a restriction of blood flow or even breaking off and causing a stroke or death. Most adults with hyperlipidemia typically display no signs or symptoms (Hoover, 2019). However, Xanthelasma Palpebrarum (yellow plaques on eyelids) is sometimes present most commonly in females between ages 30-50. These deposits are correlated with high cholesterol. In addition, Arcus Senilis (yellow-bluish opacity around the cornea) is also correlated with hyperlipidemia in the older adult (Nair, Patel, Ganjiwale, Diwan, & Jivani, 2016)

pertinent positive findings Overweight. Father with a history of Hyperlipidemia. Cholesterol: Total Cholesterol 230 mg/dl, VLDL 36 mg/dl; LDL 144 mg/dl; Triglycerides 232, HDL 38mg/dl (Nair, et. al, 2016).

pertinent negative findings Negative for xanthelasma. Negative for bruits. Denied cramping or transient ischemic attacks (Nair, et. al, 2016)

rationale for the diagnosis - As explained by Hoover (2019) on his recent journal, the guidelines for the diagnosis and treatment of American College of Cardiology (ACC) and American Heart Association (AHA) explain that Total cholesterol levels normal range is 125mg/dl -200mg/dl, LDL should be less than 100mg/dl and HDL needs to be higher than 50mg/dl. In addition, triglycerides need to measure less than 150mg/dl. MS. G’s lipid panel revealed Cholesterol: Total Cholesterol 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 38mg/dl, Triglycerides 232. She is overweight and positive family history of Hyperlipidemia.

Plan

Diagnostics

Lab test (#1) Repeat A1C + GFR + Vitamin B12 in 3 months.

rationale: Re-assess A1C test every 3 months for those whose therapy has changed or who are not achieving blood glucose desired levels. Practitioners must monitor kidney function closely via GFR. In addition, the use of Metformin can cause Vitamin 12 deficiency, therefore it should be checked periodically as well (ADA, 2020a).

Lab test (#2) Repeat Lipid Panel in 3 months.

Hoover (2019) explains in his journal based on the ACC/AHA guidelines that high-quality evidence shows that repeating a fasting lipid panel to be done 8 to 12 weeks after initiating the statin.

Medication (#1): Glucophage 500 mg tab once daily with breakfast. Disp: 30, refills:2 (ADA, 2018).

The ADA recommends the biguanide metformin (Glucophage) at 500mg-850mg daily as first-line medication for type 2 diabetes to be titrated weekly to decrease GI symptoms (Steinberg & Carlson, 2019).

Medication (#2) Atorvastatin 10mg tab daily. Disp: 30, refills 2.

Rationale. Hoover (2019) explain in their journal based on the ACC/AHA guidelines that high-quality evidence recommends the initiation of moderate-intensity statin for the prevention of cardiovascular disease for all patients 40 to 75 years of age with diabetes mellitus.

Medication (#3) Aspirin 81mg tab once daily. OTC

Strong evidence from the U.S. Preventive Services Task Force (USPSTF) is to start patients 50-59 years of age who are at high risk for cardiovascular disease and have low bleeding risk on a daily low dose aspirin for a period of 10 years (Lin & Middleton, 2019).

Education

Diagnoses.

Diabetes Mellitus Type 2: Did you know Diabetes type 2 can be reversed? What you need to do in order to reverse it is lower your A1C levels to at least 6.5. The way to achieve this is basically to reach a healthy weight through lifestyle modifications and medication. We will schedule frequent follow up appointments to track your progress (ADA, 2020a).

Hyperlipidemia:

Your father had a history of high cholesterol, now your cholesterol levels appear to be high as well. Blood cholesterol is made by the liver and it is important to maintain their level within normal limits. Following a healthy eating pattern has shown to help lower hypercholesterolemia (CDC, 2020).

Medications.

Metformin: It used to help lower your blood sugar levels. Some patients may experience GI upset symptoms such as vomiting, diarrhea, or nausea. That’s why it’s important to take it with meals at the same time every day. (Corcoran & Jacobs, 2018).

Atorvastatin: It is used to help lower LDL cholesterol, bad cholesterol, and increase your HDL, good cholesterol, along with a proper diet (Medscape, 2020).

Aspirin: it is used to prevent the development of cardiovascular disease in those at risk, such as diabetics (Peters & Mutharasan, 2020).

Diet.

Diabetes type 2/Hyperlipidemia: There is no fixed amount of carbohydrates to suit every individuals’ needs. This is why the ADA (2020a) recommends an individualized plan to be taylored with a nutritionist. Overall, DASH or mediterranean diet, accompanied by lowering saturated fat consumption as well as increased intake of n3 fatty acids and fiber. These recommendations are for diabetic patients to lower weight and reduce the risk of cardiovascular disease (ADA, 2020a).

Exercise.

Diabetes type 2/Hyperlipidemia: Start resistance exercises such as pushup, chin-up, sit-up, and body squat 2-3 times a week on non consecutive days. In addition, start aerobic exercises 2-3 times a week on non-consecutive days. These exercises are associated with lower risk of cardiovascular events on diabetic individuals. (ADA, 2020a)

Warning Signs for diagnoses and mediations

Metformin: An overdose can cause hypoglycemia. This means that blood sugar level in the blood can get too low. Symptoms of hypoglycemia are: hunger, sweats, feeling shaky, rapid heart rate or even feeling anxious. In this case, drink orange juice or eat crackers. Metformin can rarely cause lactic acidosis (Corcoran & Jacobs, 2018) If you do not feel well while taking Metformin, call your doctor.

Atorvastatin: Risk of rhabdomyolysis. If you experience muscle weakness, low urine output or dark urine and fatigue stop taking Atorvastatin and call the office (Medscape, 2020).

Aspirin: With long term use, it could cause gastrointestinal bleeding. If you experience abdominal pain or discomfort, call the office (Peters & Mutharasan, 2020).

Referral

Registered Dietician Nutritionist - Diabetes Type 2.

rationale: According to the ADA (2020a) guidelines, a consultation with a dietician is key to achieve dietary control of blood sugars. Patient and dietician need to plan together to achieve glycemic control through proper nutrition.

Follow up

Follow up in 3 months to re-check blood levels of A1C, renal function, lipid levels. We will discuss progress towards glycemic control, lipid levels, weight, exercise, diet will be discussed as well as medication adjustment and refills (ADA, 2020a).

Assessment of comorbidities

Nonalcoholic Fatty Liver Disease (NAFLD) is a comorbidity of Diabetes type 2. Ms. G’s ALT: 29 suggests that she may be at risk for Non Alcoholic hepatic Liver Disease. The relationship between Diabetes type 2 and NAFLD is that they share some of the same metabolic abnormalities. In fact, measures that enhance metabolic abnormalities in individuals with diabetes such as blood sugar control, weight loss, medications, are favorable for fatty liver disease as well (ADA, 2020b).

Mrs. G should be evaluated for NAFLD with an ultrasound of the liver. If the diagnosis is confirmed, she should then be further evaluated for liver fibrosis and nonalcoholic steatohepatitis (ADA, 2020b).

Medication Cost

Metformin 500mg 30 tab supply. Winn Dixie: $4 (GoodRx, 2020a)

Atorvastatin 10mg 30 tab supply. Winn Dixie: $7.88 (GoodRx, 2020b)

Aspirin 81mg 30 tab supply. Winn Dixie: $1.13 (GoodRx, 2020c)

Tylenol 500mg 60 tab supply. Walmart $3.42 (GoodRx, 2020d)

Women Multivitamin 80 tab supply $9.96 ($3.73 monthly supply) (Walmart, 2020)

Total dollar amount of Mrs. G’s medication for 1 month supply: $20.16

All new medications prescribed are available in affordable generic versions. Her existing Tylenol and Multivitamin cost are affordable as well. The total monthly cost of Mrs. G’s medications are barely above $20. I would not make any changes.

Conclusion

Trying to manage diabetes type 2 and hyperlipidemia, both metabolic diseases, is a difficult challenge. They require a profound commitment from the individual in order to achieve the lifestyle changes necessary to reach the desired therapy goals. These include diet, exercise, medications, tests, compliance with primary care follow ups, and other consultations. However, if the individual is able to reach these goals the quality of life can be much highly improved and disease progression can be avoided.

References

American Diabetes Association (2019). Diabetes: Symptoms. https://ada.com/conditions/diabetes/#symptoms

American Diabetes Association (2020a). Standards of Medical Care in Diabetes: 2020 Abridged for Primary Care Providers https://clinical.diabetesjournals.org/content/38/1/10

American Diabetes Association (2020b). Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes—2020.https://care.diabetesjournals.org/content/43/Supplement_1/S37

American Diabetes Association. (2018) 8. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2018. Diabetes Care. Jan;41(Suppl 1):S73-S85. https://pubmed.ncbi.nlm.nih.gov/29222379/

Armstrong, C. (2019). ADA updates standards of medical care for patients with diabetes mellitus. American family physician, 95(1), 40-43.https://www.aafp.org/afp/2017/0101/p40.html

CDC (2020). Hyperlipidemia: About Cholesterol.https://www.cdc.gov/cholesterol/about.htm

Corcoran, C., & Jacobs, T. F. (2018). Metformin. In StatPearls. StatPearls Publishing.https://www.ncbi.nlm.nih.gov/books/NBK518983/

GoodRx - Metformin. (2020a). Prescription Prices, Coupons & Pharmacy Information.https://www.goodrx.com/metformin

GoodRx - Atorvastatin. (2020b). Prescription Prices, Coupons & Pharmacy Information.https://www.goodrx.com/atorvastatin?dosage=10mg&form=tablet&label_override=atorvastatin&quantity=30

GoodRx - Aspirin. (2020c). Prescription Prices, Coupons & Pharmacy Information.https://www.goodrx.com/aspirin

GoodRx - Tylenol Extra Strength. (2020d). Prescription Prices, Coupons & Pharmacy Information.https://www.goodrx.com/tylenol-extra-strength?dosage=500mg&form=tablet&label_override=acetaminophen+extra+strength&quantity=60

Hoover, L. E. (2019). Cholesterol Management: ACC/AHA Updates Guideline. American family physician, 99(9), 589-591.https://www.aafp.org/afp/2019/0501/p589.html

Lin, K. W., & Middleton, J. L. (2019). Rethinking Aspirin for the Primary Prevention of Cardiovascular Disease. American family physician, 99(11), 670-671. https://www.aafp.org/afp/2019/0601/p670.html

Medscape (2020). Hyperlipidemia: AtorvastatinRx https://reference.medscape.com/drug/lipitor-atorvastatin-342446

Nair, P. A., Patel, C. R., Ganjiwale, J. D., Diwan, N. G., & Jivani, N. B. (2016). Xanthelasma palpebrarum with arcus cornea: A clinical and biochemical study. Indian journal of dermatology, 61(3), 295.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4885182/

Peters, A. T., & Mutharasan, R. K. (2020). Aspirin for Prevention of Cardiovascular Disease. Jama, 323(7), 676-676.https://jamanetwork.com/journals/jama/article-abstract/2761090

Steinberg, J., Carlson, L. (2019). Type 2 Diabetes Therapies: A STEPS Approach. American family physician, 99(4), 237-243.https://www.aafp.org/afp/2019/0215/p237.html

Walmart (2020). One A Day Women's 50+ Mini Gels, Multivitamins for Women. https://www.walmart.com/ip/One-A-Day-Women-s-50-Mini-Gels-Multivitamins-for-Women-80-Ct/323900826?findingMethod=wpa

Zaccardi, F., Webb, D. R., Yates, T., & Davies, M. J. (2016). Pathophysiology of type 1 and type 2 diabetes mellitus: a 90-year perspective. Postgraduate medical journal, 92(1084), 63-69. https://pmj.bmj.com/content/92/1084/63.short

METABOLIC DISEASES CASE STUDY

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Running head: METABOLIC DISEASES CASE STUDY

METABOLIC DISEASES CASE STUDY

METABOLIC DISEASES CASE STUDY

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