November 08, 2020 2:42 PM

Jean Kimberly A. Lato, BSN1A

Diabetes Case
Presentation
Mr. Reyes is a 48-year-old man with Type 2 diabetes first diagnosed 3 years ago. Other
medical problems include obesity and hypertension. He has a history of heavy alcohol use but
quit drinking about a year ago. He presents now for routine follow-up and is noted to have a
blood pressure of 158/95 mmHg. He is asymptomatic.
Physical exam reveals a height of 5’5” (165cm), weight of 246 pounds (112kg),
temperature of 37.9°C, and heart rate of 79 beats per minute. There is no sign f retinopathy or
aneurysm. There no clinical evidence of congestive heart failure or peripheral vascular disease.
Laboratory evaluation reveals trace protein on urinalysis, a low-density lipoprotein (LDL)
of cholesterol level of 131 mg/dL, a high-density lipoprotein (HDL) cholesterol level of 38
mg/dL, a triglyceride level of 460 mg/dL, and a total cholesterol level of 240 mg/dL, serum
creatinine of 1.2 mg/dL, random sermun glucose of 190 mg/dL, a glycosylated hemoglobin
level of 9.5%, and normal electrolytes. A 24-hour urine collection reveals a urinary albumin
excretion rate of 250mg daily.

Subjective Findings
Chief Complaint: Routine follow-up/ regular medical checkup
History of Patient Illness: 48-year-old male with Type 2 diabetes (diagnosed 3 years
ago) presents for his regular medical checkup and is asymptomatic
Past Medical History: Alcohol abuse (quit 1 year ago), obesity, and hypertension

Objective Findings
Vital Signs: BP 158/95 mmHg
BMI 41.18 kg/m²
Temp 37.9°C
HR 79 bpm
SC 1.2 mg/dL
Albumin Excretion Rate 250mg daily
LDL 131 mg/dL
Diagnostic Test: HgA1C 9.5%
General Survey: Alert, oriented adult man, in no apparent distress
Assessment
This is a 48-year-old male with Type 2 diabetes and history of hypertension and obesity
present for his regular medical checkup.
Related Complications
• High Blood Pressure
• Dyslipidemia
• Nephropathy manifested as proteinuria
Risk Factors
• Obesity (BMI greater than 25)
• A1C ≥ 5.7%
• Blood Pressure ≥ 140/90; Hypertension

Plan
Further tests and Work-Up
• Liver function tests
• Repeat blood pressure to confirm hypertension
• CBC to rule out and monitor for infections
• More detailed history needed
-List of medications (current and failed therapies)
-Family history
-Previous immunizations
-Medication regimen adherence and barriers to adhere