Type 2 DM: New Onset

PATIENT PRESENTATIONENT

Chief Complaint
“My gynecologist said I should have a check-up since I am tired all the time.”

HPI
Louise Jackson is a 49-year-old woman who presents to her primary care physician after her
gynecologist recently diagnosed her with polycystic ovarian syndrome (PCOS) during an
evaluation for amenorrhea. She complains of increasing fatigue, which she attributes to
being overweight. She states her last appointment with her PCP was over 2 years ago.

PMH
PCOS × 2 months
Hyperlipidemia × 2 years (diet controlled)
HTN × 4 years

FH
Diabetes present in both mother and maternal grandmother. Father died suddenly of colon
cancer at age 59, mother alive age 76 with history positive for DM Type 2, HTN, and
hyperlipidemia; one younger sister with PCOS and HTN.

SH
Married × 23 years with two children. Works full-time as insurance consultant which is
telephone based from home. No alcohol or tobacco use. Rarely exercises and admits to
trying fad diets for weight loss with little success. She reports adherence to her medications.

Meds
Ortho-Novum 1/35 as directed
Hydrochlorothiazide 50 mg po daily

Allergy
Codeine

ROS
Frequent fatigue. Occasional polydipsia, polyphagia, weakness, and lightheadedness upon
standing. Denies blurred vision, chest pain, dyspnea, tachycardia, dizziness, or tingling or
numbness in extremities, leg cramps, peripheral edema, changes in bowel movements, GI
bloating or pain, nausea or vomiting, urinary incontinence, or presence of skin lesions.

Physical Examination
Gen
Patient is an African-American woman with central obesity in no apparent distress

VS
BP 152/88 sitting R arm, BP 130/70 standing R arm, P 82, RR 18, T 37.2°C; Wt 95.5 kg, Ht
5'6''

Skin
Dry with poor skin turgor; no ulcers or rash
HEENT
PERRLA; EOMI; TMs intact; no hemorrhages or exudates on funduscopic examination;
mucous membranes normal; nose and throat clear w/o exudates or lesions

Neck/Lymph Nodes
Supple; without lymphadenopathy, thyromegaly, or JVD

Lungs
CTA

CV
RRR; normal S1 and S2; no S3, S4, rubs, murmurs, or bruits
Abd
Soft, NT, central obesity; normal BS; no organomegaly, or distention

GU/Rect
Deferred

Ext
Normal ROM and sensation; peripheral pulses 2+ throughout; no lesions, ulcers, or edema

Neuro
A & O × 3, CN II–XII intact; DTRs 2+ throughout; feet with normal vibratory and pinprick
sensation (5.07/10 g monofilament)

UA
(–) ketones, (–) protein, (–) microalbuminuria

Labs

Assessment
1. Elevated random glucose; presumed newly diagnosed Type 2 diabetes mellitus; will
obtain a fasting blood glucose level to confirm the diagnosis and also check A1C
2. Elevated total cholesterol; will obtain fasting lipid profile to evaluate LDL, HDL, and
triglycerides
3. Hypertension with suboptimal treatment and possible side effects due to diuretic
4. Obesity
5. PCOS

Clinical Course
The patient returned to clinic 3 days later for lab work, which revealed: FBG 189 mg/dL;
A1C 9.4%; FLP: T. chol 263 mg/dL, HDL 31 mg/dL, LDL 152 mg/dL, Trig 260 mg/dL.

Problem Identification
1.a. What risk factors for Type 2 DM are present in this patient?
1.b. What information (signs, symptoms, laboratory values) supports the diagnosis of Type
2 DM?
1.c. What information indicates the presence of insulin resistance?
1.d. Create a list of this patient’s drug therapy problems.

Desired Outcome
2.a. What are the desired goals for the treatment of this patient’s diabetes?
2.b. Considering her other medical problems, what other treatment goals should be
established?

Therapeutic Alternatives
3.a. What nonpharmacologic therapies might be useful in the management of this patient?
3.b. What feasible pharmacotherapeutic alternatives are available for the treatment of this
patient’s DM? Identify the factors that will influence your choice of initial therapy.

Optimal Plan
4.a. Outline a complete pharmacotherapeutic plan to manage this patient’s current
problems, including drug, dosage form, dose, schedule, and rationale for your selections.
4.b. What changes in therapy would you recommend if your initial plan fails to achieve
adequate glycemic control?

Note: These are just guide questions but your required output is only the
Pharmacotherapeutic Plan. This can be asked during the presentation of your case.