This paper provides an in-depth examination of the chronic health problem known as type 2 diabetes mellitus. The foundation for this research is two peer-reviewed original research contributions. The paper examines major concepts and viewpoints on chronic health concerns using these resources. The objective is to provide the reader with a deep insight into type 2 diabetes mellitus with regard to clinikc evaluation, symptomatic presentation, evaluation, and management of clinical guidelines
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Write My Essay For MePatient ID: Mr. G.H DOB, 1/1/1957, age 65, is an American white man who has presented himself to the clinic and seems to be a reliable historian.
Subjective Data
Chief Complaint: “I am here for an annual checkup.”
History of Present Illness: The patient is a 65-year-old retired firefighter officer. Mr. G.H has a past medical illness of type 2 diabetes mellitus and Hyperlipidemia, and he is currently on medications. The patient’s prescriptions are a daily oral dose of Metformin 500mg and a daily oral dose of Simvastatin 10 mg. He claims he has no complaints and is only here for a checkup because he had blood work done two weeks ago. The laboratory test results reveal that his health has significantly improved regarding glucose and cholesterol levels. At this moment, he denies experiencing an increase in urination. He denies fever, vomiting, diarrhea, constipation, muscle numbness, or pain. He denies loss of appetite or weight loss. He also denies experiencing cardiovascular and respiratory disorders.
Past Medical History
Major illness:
Type 2 diabetes mellitus
Hyperlipidemia
Current Medication:
Takes Metformin 500mg PO daily for type 2 diabetes control
Takes Simvastatin 10 mg PO daily film-coated tablet for Hyperlipidemia
Allergies: No known allergies
Immunizations: Up to date
Surgery: None
Social History
Living situation: He lives with his wife and two grandchildren. Denies financial strains.
Occupation: Retired firefighter
Marital Status: Married
Tobacco/Street drugs: Denies
Alcohol: Stopped drinking 10 years ago
Diet: Vegan
Exercise: Occasionally, only once in two weeks
Ability to perform ADLs: Yes
Family History:
Father: Died, had diabetes
Mother: Alive, has diabetes and Osteoarthritis
Grandfather: Diseased, no known illness
Grandmother: Diseased, no known illness
Review of Systems
General: He denies experiencing fatigue, fever, breathing difficulties, chest pain, muscle pain, nausea, vomiting, or diarrhea, and he states to have a normal appetite. He states he is in good health.
Head: Denies loss of consciousness or head injuries.
Eyes: Denies color blindness, eye pain, dryness, or excessive tears. Uses corrective lenses.
Ears: Denies hearing loss, ringing in ears, discharge, or ear pain.
Nose: Denies nosebleed, loss of smell, nasal congestion, or pain.
Mouth: Denies mouth wounds, bleeding gums, or lesions. No tooth decay. He states Last dental checkup was approximately 6 years ago.
Throat: Denies sore throat, swallowing discomforts, altered taste, or hoarseness.
Skin: Denies skin color change, bruises, rashes, or lesions.
Respiratory: Denies coughing, wheezing, breathing difficulties, or dyspnea at the moment.
Cardiovascular: Denies chest pain, tachycardia or palpitations.
Gastrointestinal: Denies vomiting, odynophagia, constipation, dysphagia, nausea, abdominal discomforts, or diarrhea
Genitourinary: Denies penile abnormal discharge. Denies increase in urine frequency. No burning sensation.
Musculoskeletal: Denies muscle and joint pain, tenderness, swelling, or a reduction in range of motion in the joints.
Heme/Lymph/Endo: Denies swollen gland, history of blood transfusion. Denies excessive sweating.
Neurologic: Denies dizziness, headaches, seizures, transient paralysis, tremors, or syncope.
Psychological: Denies suicidal thoughts, depression, hallucinations, anxiety, or memory loss.
Objective Data
Vital Signs: Temperature: 98.4F, Blood Pressure: 118/77mmHg, Pulse rate: 62 beats per minute. Weight: 176.3 lbs. Height: 6ft, BMI: 23.9
Physical Examination
Head: normocephalic, atraumatic, symmetric
Ears: Hearing grossly intact, external auditory canals and tympanic membranes clear.
Eyes: Positive PERRLA. EOMI. Anicteric.
Nose: Moist mucous membranes. Nasal mucosa pink. No bleeding, lesions, or maxillary sinuses.
Throat: No exudate, lesions, inflammation. Pharynx normal. Teeth and gingiva in excellent general condition.
Skin: Smooth, warm, smooth, and dry. No rashes, bruises, or change in skin color.
Cardiovascular: Regular heart rhythm. Normal S1 and S2 sounds.
Gastrointestinal: Soft, non-tender, and non-distended abdomen. No palpable masses.
Respiratory: Auscultation of the lungs reveals no abnormalities.
Genitourinary: Prostate assessed with the digital examination, which reveals no abnormalities.
Musculoskeletal: No swollen, stiff, or tender joints or muscles.
Extremities: No edema.
Neurological: Normal gait and Stable balance. Clear speech and clear voice tone.
Psychiatric: Perfect memory. Cooperative, alert, good mood and behavior. Clear response.
Lab tests:
HbA1c test – 8.0%
LDL cholesterol – 186 mg/dL
Assessment
Type 2 Diabetes mellitus (E11. 9) – this is a disorder in which the body’s ability to control and utilize glucose as energy is impaired (Madhu et al., 2020). This long-lasting illness results in an abnormally high blood sugar level. Without control, it is possible to develop immune system diseases as a result of excessive blood sugar levels (Madhu et al., 2020). According to the lab test results, the diagnosis is ruled in
Hyperlipidemia (E78.5) – this is a condition whereby the blood contains an excessive amount of lipid particles (Saraogi et al., 2022). Hyperlipidemia is an asymptomatic disorder that can be detected with a blood test (Saraogi et al., 2022). In this case, the patient patients LDL cholesterol level is at 186 mg/dL; as a result, we rule in the diagnosis.
Dental complications (K08. 9) – Without proper care for diabetes, a person is more likely to have oral complications (Poudel et al., 2018). The blood sugar could become more difficult to control as a result of gum disease. Occasionally, individuals may start noticing that their gums seem inflamed and bleed during brushing and flossing (Poudel et al., 2018). Others report oral dryness, discomfort, white spots, or having a bad taste (Poudel et al., 2018). Even though the patient did not mention any symptoms in regard to oral complications, visiting a dentist is a good idea for any of these reasons.
DX: Type 2 Diabetes mellitus
Plan
Diagnostic Plan
Hemoglobin A1C test – The hemoglobin A1C test assesses whether the blood sugar level is too high or too low. HbA1c is also referred to as glycosylated hemoglobin (Madhu et al., 2020). The findings of one-day testing will not give a realistic assessment of how effective the treatment is working; therefore, individuals with diabetes must undergo this test on a frequent basis in order to check their blood sugar levels (Madhu et al., 2020). This also will help to evaluate if the diabetic medications should be modified. In this case, the HbA1c test result is 8.0%. These findings indicate that the medication is effective.
Lipid test – Due to the absence of symptoms, detecting Hyperlipidemia is challenging (Saraogi et al., 2022). But diagnosing Hyperlipidemia can be identified with a lipid profile blood test (Saraogi et al., 2022). As a result of this test, it is found that the patient has a high level of fats in the blood, but there has been a positive improvement.
Treatment Plan: In this case, we will not modify the medications. Therefore the patient will continue taking a daily oral dose of Metformin 500mg for type 2 diabetes and a daily oral dose of Simvastatin 10 mg film-coated tablet for Hyperlipidemia
Patient Education:
· To strictly take medication as prescribed
· To schedule daily exercises in order to keep fit
· To schedule a dental checkup at least twice a year
· To do a routine self-glucose assessment
Referral: Even though the patient did not show any symptoms related to dental disorders, he is recommended to check a dentist for a further dental examination.
Follow-up: The next visit will be in three months, but he is also recommended to visit the clinic as soon as possible if any symptoms arise.
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