Question

Mary is a 44-year-old African American female who is reporting to her primary care provider for a follow-up visit for evaluation of her diabetes, hypertension and dyslipidemia. During her last visit 3 months ago, her provider increased the dosage of one anti-hypertensive medication and added a second anti-hypertensive medication to her regimen due to her blood pressures hanging around 160/100. A second agent to assist with the management of her diabetes was also added to her plan of care at that time because her blood sugars were averaging 250-300, and her HA1C was 10.4%. She had lab work drawn two days ago so that it would be available for this visit.

Medical Diagnoses: Stage 2 hypertension, dyslipidemia, type 2 diabetes mellitus

Current Medications:

• Metformin (IR) 1000 mg by mouth twice daily
• Exenatide 10 mcg subcutaneous twice daily
• Captopril 25 mg by mouth three times daily
• Indapamide 5 mg by mouth daily
• Rosuvastatin 40 mg by mouth daily

Review of Systems Subjective Data

General: Denies excessive fatigue, fever or problems other than dizziness when getting out of bed in the morning or standing up too quickly

Skin: Denies rashes or lesions but does report having dry skin, especially her extremities

HEENT: Denies visual or hearing changes, allergies, dizziness, rhinorrhea, colds or respiratory changes

Cardiac: Denies chest pain, tightness or palpitations; blood pressure readings at home 130s/80s

Respiratory:   Denies shortness of breath or breathing difficulties; denies infections or cough

GI: Reports occasional bloating and GI upset

GU: Denies pain, burning, hesitancy, blood or urgency with urination   

MS: Denies issues other than frequent leg cramps/pain in the evening time most days for the past couple of weeks. The pain seems to be getting more severe.

Neuro: Denies weakness, paresthesias or changes in speech or memory

Psych: Denies feeling depressed or down

Physical Examination

Ht: 60 inches, Wt: 170 pounds

General: No acute distress

BP 138/86, T 98.1°F, P 78, R 20

Heart: RRR, S1 and S2, no murmurs

Lungs: Clear to auscultation bilaterally

Abdomen: Soft, non-tender, no bruits; Normoactive bowel sounds x 4

Lower Extremities: Pedal pulses 1+ bilaterally; skin warm and dry; capillary refill 3 seconds

Laboratory Results:

• Basic Chemistry Panel

Glucose: 188
Creatinine: 1.1 mg/dl

Carbon dioxide: 28 mEq/L

Chloride: 100 mEq/L

Potassium: 3.0 mEq/L

Sodium: 139 mg/dl

Calcium: 9 mg/dl

BUN 14 mg/dl

• Urine

Microalbumin 50 mg/24 hours

eGFR 58 mL/min

• HA1C: 8.2%

• Lipid Panel

TC: 200

TG: 150

HDL: 50

LDL: 120

• Vitamin B12:   180 pg/mL

Case Analysis Discussion Points

1. Discuss the relationship between the pathophysiology of type 2 diabetes to specific findings in Mary’s assessment data. Consider only the abnormal signs and symptoms that could be a direct result of diabetes. Include abnormal lab values, if applicable. When discussing lab values, relate Mary’s values to normal values and discuss their significance. Include references to support your discussion.
2. Discuss Mary’s prescribed drug therapy for her diabetes in relation to drug purpose, mechanism of action, metabolism and excretion, dosage and adverse effects. You only need to address the two drugs specific to the management of her diabetes in this section. Include references to support your discussion.
3. Are Mary’s pharmacological interventions congruent with recommendations outlined in the American Diabetes Association Standards of Medical Care in Diabetes – 2019? For this section, include an analysis of all of her prescribed medications - even those prescribed for her hypertension and dyslipidemia. Specific points to include in your analysis include first-line recommendations for treatment for type 2 DM as well as first-line recommendations for the management of hypertension and dyslipidemia in patients with diabetes. Provide rationale as to why. Lastly, determine if Mary’s plan of care is congruent with those recommendations. The standards are included in your learning module. Cite references.
4. Mary has been taking the prescribed medications for 3 months prior to this visit. Review her assessment data and discuss whether treatment is proving to be effective in treating her disorders. Support your analysis with information related to what the expected response would be if treatment were effective and pull in Mary’s data to support your analysis. Lastly, determine if Mary is experiencing any side effects associated with her medication regimen. If so, identify the side effect and briefly discuss what it is, which medication is causing it and how. Include references.

Answer 1

by PATHOPHYSIOLOGY OF Type 2 OLABETES IN Moreys Dam. HE = 60 inches Wba 10 pounds. Bm 1.-) 33.3 The patient is obese, the reason for mary developing diabetes. To Obesity > Smulin fail to Kansport glucose into tissue Insulin resistance develops Blood glucose rises. Eventually leads to increased cholesterol level - and causes hypertension. These are combinely called metabolic syndannae - Normal gluose range - 4140 - Patients reult = 188. 3 E - : Normal cholestewl - L200 Patients result = 200 (which indicate. borderline complication) eGFR normal value - 90 to 120 milmin. Patients result = 58 ml/min (Hypertension indication)

DRUGH THERAPY FOLLOWED By Patiews For Daletes * METFORMIN 2 Because * EXENATINE her Bloog sugas was 250-300 initially. | Merforminio - Oral hypoglycemic agent mechanism of action achivares Ampdependent Protein kinase Supress hepatic gluconeogenesis Enhances insulin mediated glucose uptake. I & NOT METABOLIZED + EXCRETED UNHANGES IN URINE AdverSE EFFECTS > Abdominal pain, Blogling - Anorexia Causes vit B12 deficiency I T CHOICE OF DRUG IN TREATING YPE 2 Diab. This mary is put on this drug Dose :) Haintenanu dose = 1500-2550 me day taken orally divided once every 8-12h

EXENATIVE - Preserve Bull function in - type 2 Diabetis. and always used in combination with metformin.. I Mechanism of action Exenatide. + Achirates GLP-1 receptors. • ' which induce Insulin selease Inhibit gleucagon. Slows gastic emptying. Supresses appetite. * Inactive orally, being a peptide & Excreted how ug kidney ADVERSE EFFECTS NAUSEA. VOMITTING fcute pancreatitis. Dose. Initially sug soe increased to loggs.c. Bl. if needed

According to ANA standards of Medical Care in Diabetes 2019 * METFORMIN. ĭs the ist choice of daug as it has a neutral effect on weight followed by. SULFONYL. UREAS "like glipizide In managing Hypertension *ACE INHIBITORS -) ist choice followed by Are's Cancio TENSIN RECEPTOR BLOCKER and STURENCS For treating dyslipidemia HSTBIINS -> Hma Co-B reefucteue inhibitor is the it choice of drug. followed by to fibrates ** niacin quid and bile acid binding en resine Mary's plans of care in conguent with the above given recomendations

Mary's Treatment is proving to be EFFECTWE. Her blood glucose has dapped from 250 10 188. HAIL droped from 10.4% to 8.2%. Hea pressure has also been reduced from - 160 (100 to 188 186. The above findings prove the effectiveness. hau due to the above Side effects Mary medications are Bloating & GI upsets which are mainly due to fetformin. due to their increased dose and oral absorption of the drug ALL Potassium level slightly decreased to 3:0 mEq/L when compared to normal 3.5 to smegle due to use of Indapamide...