NU566 NP case 3

Student Name

Purdue University Globle 

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

Prof. Name

Date

Understanding Fatigue in an Older Adult With Type 2 Diabetes and Hypertension

Persistent fatigue in older adults should never be dismissed as a normal part of aging. In this case, a 64-year-old African American woman presents with worsening fatigue that has persisted for several months alongside uncontrolled type 2 diabetes, hypertension, medication nonadherence, nocturia, and bilateral foot pain. These symptoms warrant a comprehensive assessment to identify the underlying cause while evaluating chronic disease management, medication tolerance, endocrine disorders, and lifestyle factors. A systematic history and physical examination help differentiate between metabolic, cardiovascular, neurological, and endocrine conditions that may contribute to her symptoms.

Chief Complaint

The patient reports:

“I am feeling a bit tired lately.”

She describes persistent fatigue that has progressively interfered with her daily activities and independence.

History of Present Illness

The patient is a 64-year-old African American woman presenting with progressively worsening fatigue that began approximately 4–6 months ago. She recalls that the symptoms started suddenly after cleaning her kitchen and have continued since then.

She reports feeling tired throughout the day, describing the sensation as “dragging.” The fatigue becomes significantly worse during the afternoon, particularly between 3:00 PM and 4:00 PM. Physical activities, including grocery shopping, increase the severity of her symptoms, often requiring assistance from her daughter because she can no longer complete shopping independently.

Rest provides temporary relief. Sitting quietly for approximately 30–40 minutes improves her energy level, although the fatigue eventually returns. She rates the severity of her fatigue as 6–7 out of 10 and has not attempted any specific treatments to manage the symptom.

In addition to fatigue, the patient reports:

• Bilateral foot pain

• Occasional headaches

• Progressive blurry vision during the past year

• Increased urinary frequency during the day

• Nocturia occurring approximately three times each night

Her medical history includes type 2 diabetes mellitus and essential hypertension, both managed with prescribed medications. However, she admits to inconsistent medication adherence. She frequently forgets to take her medications and reports discontinuing metformin approximately six months ago because of persistent gastrointestinal side effects, including:

• Gas

• Diarrhea

• Abdominal discomfort

She currently manages headaches with over-the-counter extra-strength acetaminophen as needed.

The patient’s persistent fatigue, poor diabetic control, medication noncompliance, nocturia, and chronic foot pain suggest that several underlying medical conditions may be contributing to her current presentation and require further evaluation.

Current Medications

The patient currently uses the following medications:

Medication Adherence

Medication adherence is poor. The patient admits that she frequently forgets to take her prescribed medications and intentionally stopped taking metformin because of bothersome gastrointestinal adverse effects. This nonadherence likely contributes to poor glycemic control and increases the risk of diabetes-related complications.

Allergies

The patient denies allergies to:

• Prescription medications

• Foods

• Environmental allergens

Medication Intolerances

The patient reports intolerance to metformin, which causes:

• Excessive gas

• Diarrhea

• Abdominal discomfort

These adverse effects led her to discontinue the medication without consulting her healthcare provider.

Past Medical History

The patient’s significant medical conditions include:

• Type 2 diabetes mellitus

• Essential hypertension

Both chronic illnesses require ongoing monitoring and long-term management.

Past Surgical History

The patient reports the following surgical procedures:

• Tonsillectomy at three years of age

• Appendectomy at twelve years of age

She has also been hospitalized once for childbirth.

Family History

The patient’s family history demonstrates a significant risk for cardiovascular disease and diabetes.

This family history substantially increases the patient’s risk for cardiovascular complications associated with diabetes and hypertension.

Social History

The patient is a retired teacher who has been widowed for more than twenty-five years. She currently lives independently and reports feeling safe in her home. She has one adult daughter who assists her with physically demanding activities such as grocery shopping because of increasing fatigue.

She reports the following lifestyle habits:

• Does not smoke cigarettes

• Does not consume alcohol

• Does not use recreational or illicit drugs

• Is not currently sexually active

• Denies any history of sexually transmitted infections

Overall, her social history demonstrates minimal lifestyle-related risk factors; however, her declining functional capacity has begun affecting her independence.

Review of Systems

General

The patient reports persistent fatigue that has gradually worsened over the previous several months. She has experienced an unintended weight gain of approximately five pounds during the past year and acknowledges reduced participation in routine daily activities because of decreased energy.

Cardiovascular

She denies:

• Chest pain

• Palpitations

• Bilateral upper or lower extremity edema

Respiratory

The patient denies:

• Shortness of breath

• Cough

• Wheezing

• Respiratory distress

Skin

She denies:

• Skin lesions

• Rashes

• Non-healing wounds

• Changes in skin color

Eyes

The patient reports progressively worsening blurred vision over the previous year and uses reading glasses for near vision.

Gastrointestinal

She reports:

• Diarrhea

• Excessive gas

• Abdominal discomfort associated with metformin use

She denies:

• Constipation

• Nausea

• Vomiting

• Black or tarry stools

• Eating disorders

Genitourinary

The patient reports:

• Urinary frequency approximately 10–12 times daily

• Nocturia approximately three times each night

She denies:

• Dysuria

• Hematuria

• Foul-smelling urine

• Vaginal discharge

• Sexual activity

Her preventive screenings are overdue, with the last Pap smear and mammogram performed approximately seven years ago.

Musculoskeletal

The patient reports bilateral foot pain but denies:

• Joint stiffness

• Previous fractures

• Muscle weakness

Neurological

She reports persistent fatigue but denies:

• Syncope

• Seizures

• Focal weakness

• Loss of balance

Hematologic, Endocrine, and Lymphatic

The patient denies:

• Easy bruising

• Blood clots

• Swollen lymph nodes

• Excessive thirst

• Increased appetite

• Heat intolerance

• Cold intolerance

• Previous blood transfusions

Psychiatric

The patient reports difficulty sleeping because of frequent nighttime urination. She denies symptoms of depression, anxiety, suicidal ideation, or previous suicide attempts.

Key Clinical Findings

The patient’s history strongly suggests several clinically significant concerns requiring further evaluation, including:

• Persistent fatigue lasting more than four months

• Poorly controlled type 2 diabetes with medication nonadherence

• Hypertension with inconsistent medication compliance

• Gastrointestinal intolerance leading to discontinuation of metformin

• Bilateral foot pain that may indicate diabetic peripheral neuropathy

• Progressive blurred vision raising concern for diabetic eye disease

• Nocturia and urinary frequency affecting sleep quality and contributing to daytime fatigue

• Strong family history of cardiovascular disease and diabetes

• Overdue preventive screenings, including mammography and cervical cancer screening

These findings support the need for a comprehensive physical examination, laboratory evaluation, and differential diagnosis to determine the underlying cause of the patient’s fatigue while addressing chronic disease management and preventing long-term complications.

Objective Physical Examination

A comprehensive physical examination was performed to identify potential causes of the patient’s persistent fatigue and evaluate the status of her chronic conditions, including hypertension and type 2 diabetes mellitus. Overall, the patient appeared stable but demonstrated signs of fatigue without acute distress.

Vital Signs

The elevated blood pressure indicates uncontrolled hypertension, while the BMI places the patient in the overweight category, increasing her risk of cardiovascular disease and worsening insulin resistance.

General Appearance

The patient is a pleasant, cooperative, 64-year-old African American woman who appears fatigued but is in no acute distress. She is alert and oriented to person, place, time, and situation. Her posture and gait are steady, and she answers questions appropriately. Personal hygiene is well maintained, with clean clothing appropriate for the weather.

Skin Examination

The skin is warm, dry, clean, and intact with normal pigmentation. No rashes, ulcers, lesions, bruising, or signs of infection are present.

HEENT Examination

Head

The head is normocephalic and atraumatic without deformities or lesions. Hair distribution is normal.

Eyes

• Pupils are equal, round, and reactive to light and accommodation (PERRLA).

• Extraocular movements are intact.

• No conjunctival injection or scleral icterus is noted.

• The patient reports progressive blurred vision despite an otherwise normal examination.

Ears

External auditory canals are patent. Tympanic membranes are pearly gray with visible landmarks and normal light reflexes.

Nose

Nasal mucosa is pink and moist. Turbinates appear normal without septal deviation.

Mouth and Throat

Oral mucosa is pink and moist. The pharynx is nonerythematous without exudate. Dentition is in good condition.

Neck

The neck is supple with full range of motion. No cervical lymphadenopathy, thyroid enlargement, thyroid nodules, carotid bruits, or jugular venous distention are present.

Cardiovascular Examination

Cardiovascular assessment demonstrates:

• Regular heart rate and rhythm

• Normal S1 and S2 heart sounds

• No murmurs, gallops, rubs, or extra heart sounds

• Peripheral pulses are strong and symmetrical (3+)

• Capillary refill is less than two seconds

• No peripheral edema

Although the physical examination is unremarkable, the patient’s elevated blood pressure requires improved management.

Respiratory Examination

The chest wall is symmetrical with normal respiratory effort. Lung auscultation reveals clear breath sounds bilaterally without wheezing, crackles, or rhonchi. Respirations are regular and unlabored.

Gastrointestinal Examination

The abdomen is mildly obese but soft and nontender.

Clinical findings include:

• Active bowel sounds in all four quadrants

• No hepatosplenomegaly

• No palpable masses

• No abdominal tenderness

• No guarding or rebound tenderness

Breast Examination

Breast examination reveals:

• No palpable masses

• No tenderness

• No nipple discharge

• No skin dimpling, discoloration, or retraction

Although the examination is normal, the patient is overdue for routine mammography.

Genitourinary Examination

Genitourinary examination is unremarkable.

Findings include:

• No erythema

• No edema

• No tenderness

• Bladder is nondistended

• No costovertebral angle tenderness

• No palpable masses

Musculoskeletal Examination

Musculoskeletal assessment demonstrates:

• Full range of motion in all extremities

• Muscle strength 5/5 bilaterally

• No joint swelling or deformity

• No crepitus

• Deep tendon reflexes are 2+ throughout

• Normal muscle tone

• Dorsalis pedis and posterior tibial pulses are 2+ bilaterally

• Nails are healthy with normal capillary refill

Despite normal objective findings, the patient continues to report chronic bilateral foot pain, raising concern for diabetic peripheral neuropathy.

Neurological Examination

Neurological examination is normal.

Findings include:

• Cranial nerves II–XII intact

• Normal speech

• Stable balance

• Steady gait

• Intact coordination

• No focal neurological deficits

Psychiatric Examination

The patient is alert, cooperative, and appropriately groomed. Eye contact is maintained throughout the examination. Speech is soft but clear with normal rate and rhythm.

A depression screening score of 3/6 indicates mild depressive symptoms; however, the patient denies depression, anxiety, or suicidal ideation.

Laboratory Findings

Laboratory studies provide valuable information regarding the patient’s chronic disease management and possible causes of fatigue.

Interpretation of Diagnostic Findings

Several important clinical findings emerge from the laboratory evaluation:

• Hemoglobin A1C of 8.5% confirms inadequate glycemic control and supports poor adherence to diabetes treatment.

• A normal CBC makes anemia a less likely explanation for chronic fatigue.

• Normal thyroid function argues against hypothyroidism as the primary cause of symptoms.

• Normal metabolic panel reduces the likelihood of renal or hepatic dysfunction contributing to fatigue.

• Normal vitamin D levels make vitamin D deficiency an unlikely explanation.

• The absence of proteinuria or glucosuria does not exclude diabetes-related complications because chronic hyperglycemia remains evident from the elevated A1C.

Assessment

The patient’s clinical presentation is characterized by chronic fatigue, poorly controlled type 2 diabetes mellitus, uncontrolled hypertension, medication nonadherence, nocturia, blurred vision, and bilateral foot pain. Although several conditions may contribute to fatigue, the available evidence suggests that uncontrolled diabetes and its associated complications are the most likely explanation.

Differential Diagnosis 1: Poorly Controlled Type 2 Diabetes Mellitus (Primary Diagnosis)

Poorly controlled type 2 diabetes mellitus is the leading diagnosis because the patient’s history, laboratory findings, and clinical presentation strongly support inadequate glycemic control.

Supporting findings include:

• Hemoglobin A1C of 8.5%

• Discontinuation of metformin for six months

• Medication nonadherence

• Chronic fatigue

• Polyuria and nocturia

• Blurred vision

• Bilateral foot pain suggestive of diabetic peripheral neuropathy

• Overweight BMI (29.8 kg/m²)

• Family history of diabetes

• History of hypertension

Persistent hyperglycemia reduces cellular glucose utilization, resulting in decreased energy production and fatigue while increasing the risk of neuropathy, retinopathy, and cardiovascular disease.

Differential Diagnosis 2: Essential Hypertension

The patient has a well-established history of hypertension and currently demonstrates poor blood pressure control.

Evidence supporting this diagnosis includes:

• Blood pressure of 160/90 mmHg

• History of hypertension

• Intermittent medication noncompliance

• Elevated BMI

• Strong family history of cardiovascular disease

Although hypertension alone does not fully explain the patient’s fatigue, uncontrolled blood pressure increases cardiovascular risk and may contribute to decreased exercise tolerance and generalized weakness.

Differential Diagnosis 3: Hypothyroidism

Hypothyroidism should be considered because fatigue, weight gain, decreased activity, and sleep disturbances commonly occur in patients with thyroid hormone deficiency.

Symptoms supporting consideration include:

• Persistent fatigue

• Mild weight gain

• Reduced physical activity

• Sleep disturbance

However, this diagnosis is less likely because:

• Thyroid-stimulating hormone (TSH) is within the normal reference range.

• The patient does not report classic symptoms such as cold intolerance, constipation, dry skin, or bradycardia.

• Laboratory findings do not support thyroid dysfunction.

Therefore, hypothyroidism remains a differential diagnosis but is not the primary cause of the patient’s current presentation.

Final Diagnosis

Poorly Controlled Type 2 Diabetes Mellitus with Medication Nonadherence and Early Diabetic Complications

The patient’s persistent fatigue is most consistent with uncontrolled type 2 diabetes mellitus resulting from prolonged medication nonadherence. Elevated hemoglobin A1C, chronic hyperglycemia, nocturia, blurred vision, and bilateral foot pain collectively indicate inadequate glycemic control and suggest the development of early microvascular complications.

Although hypertension remains uncontrolled and contributes to overall cardiovascular risk, it does not adequately explain the patient’s constellation of symptoms. Likewise, hypothyroidism is unlikely because thyroid function testing is normal.

Pathophysiology of the Primary Diagnosis

Type 2 diabetes mellitus develops through a combination of insulin resistance and progressive pancreatic β-cell dysfunction. As insulin becomes less effective, glucose cannot efficiently enter muscle and adipose tissue, resulting in persistent hyperglycemia.

Chronic hyperglycemia leads to several physiological changes:

• Reduced cellular energy production, causing fatigue.

• Osmotic diuresis, leading to polyuria and nocturia.

• Peripheral nerve damage, contributing to bilateral foot pain.

• Retinal microvascular injury, resulting in blurred vision.

• Progressive vascular inflammation, increasing cardiovascular risk.

• Impaired wound healing and susceptibility to infection.

In this patient, discontinuation of metformin and inconsistent use of prescribed medications have likely accelerated these pathological changes, explaining both her worsening fatigue and evidence of diabetes-related complications.

Management Plan

The management plan focuses on improving glycemic control, optimizing blood pressure management, addressing medication intolerance, preventing diabetes-related complications, promoting healthy lifestyle modifications, and improving the patient’s overall quality of life. Because the patient’s fatigue is most likely related to uncontrolled type 2 diabetes mellitus and poor medication adherence, interventions should prioritize long-term disease management while addressing her current symptoms.

Pharmacologic Management

Continue Current Medications

The patient should continue taking her prescribed medications as directed unless changes are recommended after reassessment.

Current medications include:

• Atenolol 25 mg orally once daily for hypertension

• Hydrochlorothiazide 25 mg orally once daily for hypertension

• Glyburide 20 mg orally once daily for type 2 diabetes mellitus

• Aspirin 81 mg orally once daily for cardiovascular protection

• Extra-strength acetaminophen as needed for headaches

Address Metformin Intolerance

The patient discontinued metformin because of gastrointestinal side effects, including diarrhea, abdominal discomfort, and excessive gas. Rather than permanently stopping therapy, alternative management strategies should be discussed.

Recommended options include:

• Restarting metformin using an extended-release formulation

• Gradually increasing the dosage to improve tolerance

• Taking the medication with meals

• Considering an alternative antihyperglycemic medication if symptoms persist

Improving medication tolerance is essential for achieving adequate glycemic control.

Management of Diarrhea

If diarrhea continues while restarting metformin, short-term use of loperamide (Imodium) 2 mg orally as needed may be considered under provider supervision. The medication should be discontinued once symptoms resolve.

Non-Pharmacologic Management

Lifestyle modification remains one of the most effective interventions for improving diabetes and hypertension.

The patient should be encouraged to:

• Balance activity with adequate periods of rest.

• Gradually increase physical activity as tolerated.

• Follow a diabetic meal plan emphasizing vegetables, whole grains, lean protein, and high-fiber foods.

• Limit processed foods, refined carbohydrates, and sugary beverages.

• Reduce dietary sodium to improve blood pressure control.

• Maintain adequate hydration.

• Aim for gradual weight reduction to improve insulin sensitivity.

• Establish consistent sleep habits to improve daytime fatigue.

Recommended Diagnostic Tests

Additional diagnostic testing is recommended to evaluate complications and ensure appropriate preventive care.

Mammography

The patient reports that her last mammogram was performed approximately seven years ago. Current preventive care recommendations support routine breast cancer screening for women in her age group.

A screening mammogram should be ordered promptly.

Diabetic Eye Examination

Because the patient reports progressive blurred vision and has poorly controlled diabetes, a comprehensive dilated retinal examination is indicated to evaluate for:

• Diabetic retinopathy

• Cataracts

• Glaucoma

• Age-related macular degeneration

Diabetic Foot Examination

Persistent bilateral foot pain warrants a comprehensive diabetic foot assessment to evaluate:

• Peripheral neuropathy

• Peripheral arterial disease

• Loss of protective sensation

• Foot ulcer risk

Patient Education

Patient education is essential for improving treatment adherence and preventing long-term complications.

Medication Adherence

The patient should understand that stopping prescribed medications without consulting her healthcare provider can result in worsening diabetes control and increased risk of complications.

Education should emphasize:

• Taking medications exactly as prescribed.

• Reporting medication side effects promptly.

• Never discontinuing medications without medical advice.

• Using medication reminders such as pill organizers or smartphone alarms.

Blood Pressure Monitoring

The patient should begin monitoring blood pressure at home.

Instructions include:

• Measure blood pressure at approximately the same time each day.

• Record readings in a blood pressure log.

• Bring the log to each follow-up appointment.

• Seek medical attention if blood pressure remains consistently elevated.

Blood Glucose Monitoring

Self-monitoring of blood glucose should become part of the patient’s daily routine.

Education includes:

• Purchasing a home glucometer.

• Recording fasting and postprandial glucose readings.

• Recognizing symptoms of hyperglycemia and hypoglycemia.

• Understanding target blood glucose goals.

Diabetes Self-Management Education

Effective diabetes management extends beyond medication alone.

Key teaching points include:

• Following a balanced diabetic diet.

• Maintaining regular physical activity.

• Performing daily foot inspections.

• Wearing properly fitting footwear.

• Reporting numbness, tingling, wounds, or infections immediately.

• Scheduling routine eye examinations.

• Keeping regular medical appointments.

Health Promotion

Preventive care should be incorporated into the patient’s long-term healthcare plan.

Recommended health promotion strategies include:

• Annual comprehensive physical examinations

• Routine diabetes follow-up visits

• Healthy weight management

• Regular aerobic exercise

• Heart-healthy nutrition

• Annual influenza vaccination

• COVID-19 vaccination as recommended

• Age-appropriate cancer screenings

• Annual diabetic eye examinations

• Routine diabetic foot examinations

• Cervical cancer screening based on current clinical guidelines

Referrals

Ophthalmology

Referral to an ophthalmologist is recommended because of:

• Progressive blurred vision

• Long-standing diabetes

• Elevated hemoglobin A1C

• Increased risk of diabetic retinopathy

A comprehensive dilated eye examination can identify vision-threatening complications before permanent vision loss occurs.

Diabetes Education Program

Referral to a certified diabetes educator can improve:

• Medication adherence

• Blood glucose monitoring

• Meal planning

• Lifestyle modification

• Long-term diabetes self-management

Nutrition Services

Referral to a registered dietitian is recommended for individualized nutritional counseling and weight management.

Follow-Up Care

The patient should return for follow-up within two weeks to reassess:

• Fatigue

• Medication adherence

• Blood pressure

• Blood glucose control

• Response to treatment

• Gastrointestinal symptoms

• Need for medication adjustments

Earlier evaluation is warranted if symptoms worsen or new symptoms develop.

Key Clinical Takeaways

Older adults presenting with persistent fatigue require a comprehensive assessment because fatigue may indicate uncontrolled chronic disease rather than normal aging. In this case, poorly controlled type 2 diabetes mellitus, medication nonadherence, hypertension, nocturia, and early diabetic complications collectively explain the patient’s symptoms.

Early recognition and treatment can reduce the risk of neuropathy, retinopathy, cardiovascular disease, kidney disease, and other long-term diabetes-related complications.

Frequently Asked Questions

What is the most likely cause of this patient’s fatigue?

The patient’s fatigue is most likely caused by poorly controlled type 2 diabetes mellitus resulting from prolonged medication nonadherence. Elevated hemoglobin A1C, nocturia, blurred vision, and bilateral foot pain strongly support inadequate glycemic control.

Why was hypothyroidism not selected as the final diagnosis?

Although fatigue and weight gain are common symptoms of hypothyroidism, the patient’s thyroid-stimulating hormone (TSH) level is within the normal reference range, making thyroid dysfunction less likely.

Why is medication adherence important in diabetes management?

Consistent medication use helps maintain blood glucose within the target range, reducing the risk of complications such as diabetic neuropathy, retinopathy, kidney disease, and cardiovascular events.

What complications are suggested by the patient’s symptoms?

The patient’s bilateral foot pain may indicate diabetic peripheral neuropathy, while blurred vision raises concern for diabetic retinopathy. Poor glycemic control also increases the risk of cardiovascular disease and chronic kidney disease.

Why is an ophthalmology referral necessary?

Patients with poorly controlled diabetes are at increased risk for diabetic retinopathy and other vision-threatening conditions. A comprehensive dilated eye examination allows early detection and treatment of eye disease before irreversible vision loss occurs.

How can fatigue related to diabetes be improved?

Improving blood glucose control through medication adherence, healthy nutrition, regular physical activity, adequate sleep, hydration, and routine follow-up often reduces fatigue while lowering the risk of long-term complications.

Conclusion

This case highlights the importance of conducting a comprehensive assessment in older adults presenting with persistent fatigue. Although fatigue has many potential causes, the patient’s elevated hemoglobin A1C, medication nonadherence, nocturia, blurred vision, bilateral foot pain, and uncontrolled hypertension strongly support poorly controlled type 2 diabetes mellitus as the primary diagnosis. Early recognition, evidence-based treatment, patient education, and consistent follow-up are essential to improve glycemic control, reduce symptoms, prevent diabetes-related complications, and enhance the patient’s overall quality of life.

References 

American Academy of Ophthalmology. (2023). Reasons to see an ophthalmologist. https://www.aao.org/eye-health/tips-prevention/why-ophthalmologist-eye-exam-2020-vision

American Diabetes Association. (2025). Standards of care in diabetes—2025. Diabetes Care, 48(Supplement 1). https://diabetesjournals.org/care/issue/48/Supplement_1

Carretero, O. A., & Oparil, S. (2000). Essential hypertension: Part I: Definition and etiology. Circulation, 101(3), 329–335. https://doi.org/10.1161/01.CIR.101.3.329

Centers for Disease Control and Prevention. (2024). Breast cancer screening guidelines. https://www.cdc.gov/breast-cancer/screening/index.html

Goyal, R., & Jialal, I. (2024). Type 2 diabetes mellitus. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513253/

Mayo Clinic. (2024). Hypothyroidism (underactive thyroid): Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20350284

National Center for Biotechnology Information. (2023). Pathophysiology and diagnosis of thyroid disease. https://www.ncbi.nlm.nih.gov/books/NBK221541/

U.S. Preventive Services Task Force. (2024). Breast cancer: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening