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    Diabetes Case: Presentation

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    Kimberly Abellar Lato
    This 48-year-old man with type 2 diabetes and a history of obesity and hypertension presented for a routine medical checkup. Laboratory tests showed an A1C of 9.5%, elevated blood pressure of 158/95 mmHg, microalbuminuria, and dyslipidemia. The patient's obesity, poorly controlled diabetes, and hypertension place him at risk for related complications. Further testing and lifestyle management are needed to address his medical issues.

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    Diabetes Case: Presentation

    Uploaded by

    Kimberly Abellar Lato
    13 views2 pages
    This 48-year-old man with type 2 diabetes and a history of obesity and hypertension presented for a routine medical checkup. Laboratory tests showed an A1C of 9.5%, elevated blood pressure of 158/95 mmHg, microalbuminuria, and dyslipidemia. The patient's obesity, poorly controlled diabetes, and hypertension place him at risk for related complications. Further testing and lifestyle management are needed to address his medical issues.

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    This 48-year-old man with type 2 diabetes and a history of obesity and hypertension presented for a routine medical checkup. Laboratory tests showed an A1C of 9.5%, elevated blood pressure of 158/95 mmHg, microalbuminuria, and dyslipidemia. The patient's obesity, poorly controlled diabetes, and hypertension place him at risk for related complications. Further testing and lifestyle management are needed to address his medical issues.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    13 views2 pages

    Diabetes Case: Presentation

    Uploaded by

    Kimberly Abellar Lato
    This 48-year-old man with type 2 diabetes and a history of obesity and hypertension presented for a routine medical checkup. Laboratory tests showed an A1C of 9.5%, elevated blood pressure of 158/95 mmHg, microalbuminuria, and dyslipidemia. The patient's obesity, poorly controlled diabetes, and hypertension place him at risk for related complications. Further testing and lifestyle management are needed to address his medical issues.

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    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

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