NU566 Unit 5 Journal

Student Name

Purdue University Globle 

NU566 NP I – Introduction to Primary Care for the Nurse Practitioner

Prof. Name

Date

NU566 Unit 5 Journal

Fatigue, excessive thirst, weight changes, and an elevated hemoglobin A1C of 8.5% strongly indicate uncontrolled Type 2 diabetes mellitus (T2DM) in this patient. Although hypertension and hypothyroidism should also be considered, the patient’s history, symptoms, physical examination, and laboratory findings most closely support uncontrolled diabetes as the primary diagnosis. Effective management requires improved glycemic control, lifestyle modification, medication adherence, specialist referrals, and close follow-up to reduce the risk of long-term complications.

Patient Chief Complaint (CC)

“To be honest, I did not really want to come here today, but my daughter insisted. She knows I missed my last appointment. But I have been really tired lately.”

The patient presents primarily with persistent fatigue that has progressively worsened over the past several months.

History of Present Illness (HPI)

The patient reports experiencing increasing fatigue for approximately 4–5 months. The tiredness persists throughout the day but becomes significantly worse during the afternoon. A brief rest lasting 30–40 minutes usually provides temporary relief.

The patient also reports:

• Increased thirst over the past four months

• Menopausal status

• Approximately five-pound weight change over the previous year

• Missed previous medical appointment

• Ongoing treatment for hypertension and Type 2 diabetes

These symptoms are highly suggestive of poor glycemic control and warrant further evaluation.

Current Medications

The patient currently takes the following medications:

• Atenolol 25 mg daily

• Hydrochlorothiazide 25 mg daily

• Metformin 2,000 mg daily

• Glyburide 20 mg daily

• Low-dose aspirin for cardiovascular prevention because of a strong family history of heart disease

Medication Intolerances

The patient reports several medication-related adverse effects, including:

• Diarrhea and gastrointestinal discomfort with metformin and glyburide

• Frequent nighttime urination associated with hydrochlorothiazide

Allergies

No known drug allergies.

Past Medical History

The patient’s medical history includes:

• Type 2 diabetes mellitus

• Essential hypertension

No history of major trauma or chronic illnesses beyond these conditions.

Surgical History

Previous surgeries include:

• Tonsillectomy at age 3

• Appendectomy at age 12

• One pregnancy approximately 34 years ago

Family History

The patient’s family history demonstrates multiple cardiovascular and metabolic risk factors.

This history significantly increases the patient’s cardiovascular risk.

Social History

The patient is a retired teacher with a bachelor’s degree in education. She lives independently and reports feeling safe in her home. She denies tobacco use, alcohol consumption, and recreational drug use.

Additional history includes:

• Lives alone after her daughter married

• Not currently in a relationship

• Not sexually active

Review of Systems

General

The patient reports:

• Persistent fatigue

• Approximately five-pound weight change over the past year

Eyes

Uses reading glasses (“cheaters”) for fine print.

Cardiovascular

No chest pain, palpitations, or edema.

Respiratory

No cough, dyspnea, or respiratory complaints.

Gastrointestinal

No abdominal pain, nausea, vomiting, or bowel changes.

Genitourinary

No urinary discomfort or incontinence reported.

Musculoskeletal

No muscle weakness or joint complaints.

Neurological

Normal sensation without numbness or weakness.

Psychiatric

Negative for:

• Depression

• Anxiety

• Sleep disturbances

• Suicidal ideation

Breast Examination

Normal inspection and palpation findings:

• Symmetrical breasts

• Everted nipples

• No masses

• No nipple discharge

Physical Examination

Vital Signs

The patient is overweight and demonstrates poorly controlled hypertension.

General Appearance

The patient appears fatigued but remains pleasant, cooperative, alert, and fully oriented. Personal hygiene is appropriate, and no acute distress is observed.

Skin Examination

Skin is:

• Warm

• Dry

• Intact

• Free of lesions or rashes

HEENT Examination

Findings include:

• No carotid bruits

• No jugular venous distention

• Trachea midline

• No cervical lymphadenopathy

• Extraocular movements intact

• Pupils equal and reactive

• Fundoscopic examination within normal limits

• No diabetic retinopathy

• Normal ears and tympanic membranes

• No sinus tenderness

Cardiovascular Examination

Cardiovascular findings include:

• Regular rate and rhythm

• Normal S1 and S2

• No murmurs, rubs, or gallops

• Capillary refill approximately two seconds

• Peripheral pulses 3+

• No peripheral edema

Respiratory Examination

Respiratory assessment is unremarkable with:

• Normal respiratory effort

• Clear breath sounds

• Resonant percussion

Gastrointestinal Examination

The abdomen is:

• Soft

• Symmetrical

• Nontender

• Without masses

• Free of guarding or visible abnormalities

Musculoskeletal Examination

The patient demonstrates:

• Full range of motion in all extremities

• Normal gait

• Stable balance

• Good posture

Neurological Examination

Neurological findings include:

• Clear speech

• Normal muscle tone

• Intact sensation

• Appropriate cognition

Psychiatric Examination

The patient is alert and oriented to person, place, time, and situation. Speech is soft but appropriate, with normal thought processes and eye contact.

Diagnostic Laboratory Findings

Most laboratory values are within normal limits, including:

• Complete Blood Count (CBC)

• Comprehensive Metabolic Panel (CMP)

• Lipid Profile

• Thyroid-Stimulating Hormone (TSH)

• Urinalysis

• Urine Microalbumin

• Vitamin D

The only abnormal laboratory result is:

An A1C of 8.5% indicates poor long-term glycemic control and confirms inadequately controlled diabetes.

Assessment

The patient’s symptoms, physical findings, and laboratory results strongly support uncontrolled Type 2 diabetes mellitus.

Poor glycemic control explains:

• Persistent fatigue

• Excessive thirst (polydipsia)

• Weight fluctuations

• Elevated A1C

The elevated blood pressure further increases cardiovascular risk, particularly given the patient’s strong family history of myocardial infarction.

Differential Diagnosis

Uncontrolled Type 2 Diabetes Mellitus (Primary Diagnosis)

This diagnosis is supported by:

• Hemoglobin A1C of 8.5%

• Persistent fatigue

• Increased thirst

• History of Type 2 diabetes

• Inadequate symptom control despite current medications

Essential Hypertension

Blood pressure remains elevated at 160/90 mmHg, suggesting suboptimal blood pressure control despite antihypertensive therapy.

Hypothyroidism

Although fatigue may occur with hypothyroidism, the patient’s normal TSH makes this diagnosis considerably less likely.

Final Diagnosis

Uncontrolled Type 2 Diabetes Mellitus with inadequate glycemic control

Evidence-Based Management Plan

Lifestyle and Non-Pharmacologic Recommendations

The patient should receive counseling regarding lifestyle interventions aimed at improving glucose control and reducing cardiovascular risk.

Recommended interventions include:

• Weight reduction

• Balanced diabetic meal planning

• Regular aerobic exercise

• Increased physical activity

• Blood glucose self-monitoring

• Stress management

• Adequate sleep

Diagnostic Screening

Recommended screening includes:

• PHQ-2 depression screening

• Continued monitoring of A1C every three months

• Routine blood pressure monitoring

• Annual diabetic foot examination

• Annual urine microalbumin testing

• Routine lipid monitoring

Medication Education

Patient education should emphasize:

• Importance of medication adherence

• Recognition of medication side effects

• Blood glucose monitoring techniques

• Recognition of hypoglycemia and hyperglycemia symptoms

• Appropriate timing of medications

• Lifestyle modifications to improve treatment outcomes

Medication intolerance should also be discussed with the endocrinologist to determine whether alternative diabetes therapies may improve adherence and glycemic control.

Health Promotion Strategies

Preventive healthcare recommendations include:

• Annual wellness examination

• Well-woman visit

• Breast cancer screening

• Age-appropriate immunizations

• Stroke prevention counseling

• Cardiovascular risk reduction

• Nutrition counseling

• Diabetes self-management education

Specialist Referrals

The patient should be referred to:

• Endocrinology for optimization of diabetes treatment

• Ophthalmology for annual diabetic retinal examination

Follow-Up Plan

The patient should return for follow-up in two weeks to evaluate:

• Blood glucose control

• Blood pressure response

• Medication tolerance

• Lifestyle modification progress

• Need for medication adjustments

Key Clinical Takeaways

• Persistent fatigue and excessive thirst are classic symptoms of uncontrolled diabetes.

• An A1C of 8.5% confirms inadequate long-term glycemic control.

• Hypertension and obesity significantly increase cardiovascular risk.

• Medication intolerance may contribute to poor diabetes management and should be addressed promptly.

• Early specialist referral and patient education can reduce diabetes-related complications.

Frequently Asked Questions (FAQs)

What is the patient’s primary diagnosis?

The patient’s primary diagnosis is uncontrolled Type 2 diabetes mellitus, supported by an elevated hemoglobin A1C of 8.5%, excessive thirst, fatigue, and a known history of diabetes.

Why is an A1C of 8.5% concerning?

An A1C of 8.5% indicates that average blood glucose levels have remained above the recommended target over the previous two to three months, increasing the risk of cardiovascular disease, neuropathy, nephropathy, and retinopathy.

Why is fatigue common in uncontrolled diabetes?

Poor glucose regulation prevents cells from efficiently using glucose for energy. This energy deficit often causes persistent fatigue despite adequate rest.

What additional complications should be monitored?

Patients with poorly controlled diabetes should be routinely monitored for diabetic nephropathy, retinopathy, neuropathy, cardiovascular disease, and peripheral vascular disease.

Why is referral to an ophthalmologist necessary?

Annual dilated eye examinations help detect diabetic retinopathy early, allowing treatment before permanent vision loss occurs.

What lifestyle changes can improve diabetes control?

Evidence-based lifestyle interventions include regular physical activity, weight management, a balanced diabetic diet, medication adherence, smoking avoidance, and routine blood glucose monitoring.

Early identification and aggressive management of uncontrolled Type 2 diabetes can significantly reduce the risk of long-term complications. Combining pharmacologic therapy, lifestyle modification, routine monitoring, preventive screenings, and multidisciplinary care provides the best opportunity for achieving optimal glycemic control and improving overall health outcomes.

References

American Diabetes Association Professional Practice Committee. (2024). Standards of care in diabetes—2024. Diabetes Care, 47(Supplement_1), S1–S350. https://diabetesjournals.org/care/issue/47/Supplement_1

American Association of Clinical Endocrinology. (2022). Clinical practice guideline: Developing a diabetes mellitus comprehensive care plan—2022 update. Endocrine Practice, 28(10), 923–1049. https://www.endocrinepractice.org/article/S1530-891X(22)00595-7/fulltext

James, P. A., Oparil, S., Carter, B. L., et al. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA, 311(5), 507–520. https://jamanetwork.com/journals/jama/fullarticle/1791497

U.S. Preventive Services Task Force. (2021). Screening for prediabetes and Type 2 diabetes: US Preventive Services Task Force recommendation statement. JAMA, 326(8), 736–743. https://jamanetwork.com/journals/jama/fullarticle/2783414

World Health Organization. (2023). Diabetes. https://www.who.int/news-room/fact-sheets/detail/diabetes