NU566 Unit 5 Journal

NU566 Unit 5 Journal

Student Name

Purdue University Global

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

Prof. Name:

Date

NU566 Unit 5 Journal: Evaluation and Management of Uncontrolled Type 2 Diabetes Mellitus

Persistent fatigue, excessive thirst, recent weight changes, and a hemoglobin A1C (HbA1C) level of 8.5% strongly suggest that this patient has uncontrolled Type 2 diabetes mellitus (T2DM). Although hypertension and hypothyroidism should be considered as possible causes of fatigue, the patient’s medical history, clinical presentation, physical examination, and laboratory findings most closely support uncontrolled diabetes as the primary diagnosis. Appropriate management should focus on improving glycemic control through medication optimization, lifestyle modifications, regular monitoring, patient education, and coordinated care to reduce the risk of long-term complications.

Patient Chief Complaint

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

During the visit, the patient states:

“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.”

Although fatigue is the primary reason for seeking care, the patient’s additional symptoms and medical history suggest that poor blood glucose control may be contributing to her condition.

History of Present Illness

The patient reports experiencing progressively worsening fatigue for approximately four to five months. The fatigue persists throughout the day and becomes more noticeable during the afternoon. A short rest lasting about 30 to 40 minutes temporarily improves her energy level, but the fatigue soon returns.

In addition to fatigue, the patient reports several symptoms that are commonly associated with poorly controlled Type 2 diabetes, including increased thirst over the past four months and an approximate five-pound weight change during the previous year. She also acknowledges missing her last scheduled medical appointment and confirms that she is currently receiving treatment for both hypertension and Type 2 diabetes mellitus.

The combination of persistent fatigue, excessive thirst (polydipsia), weight changes, and a known history of diabetes strongly indicates inadequate glycemic control. These findings warrant a comprehensive evaluation to determine the effectiveness of the current treatment plan and to reduce the risk of diabetes-related complications.

Current Medications

The patient currently takes the following medications to manage her chronic health conditions.

NU566 Unit 5 Journal

Despite receiving combination oral therapy for diabetes, the patient’s symptoms and elevated HbA1C indicate that her blood glucose levels remain inadequately controlled.

Medication Intolerances

The patient reports experiencing medication-related adverse effects that may interfere with treatment adherence and overall disease management.

Reported medication intolerances include:

• Diarrhea and gastrointestinal discomfort while taking metformin and glyburide.

• Frequent nighttime urination associated with hydrochlorothiazide.

Because these side effects can reduce medication adherence and negatively affect glycemic control, they should be discussed during follow-up. Alternative medications or dosage adjustments may improve tolerability and treatment outcomes.

Allergies

The patient reports no known drug allergies (NKDA).

Past Medical History

The patient’s medical history is significant for two chronic conditions that substantially increase her risk of cardiovascular disease and diabetes-related complications:

• Type 2 diabetes mellitus

• Essential hypertension

She denies a history of major trauma, chronic kidney disease, chronic respiratory illness, or other significant medical conditions.

Surgical History

The patient’s previous surgical history includes:

• Tonsillectomy at three years of age

• Appendectomy at 12 years of age

• One pregnancy approximately 34 years ago

No postoperative complications or long-term surgical issues were reported.

Family History

The patient’s family history reveals a strong genetic predisposition to both cardiovascular disease and Type 2 diabetes mellitus.

This family history significantly increases the patient’s risk of cardiovascular complications. Combined with her existing diabetes and hypertension, it highlights the importance of aggressive risk-factor management through blood glucose control, blood pressure management, and preventive care.

Social History

The patient is a retired teacher who earned a bachelor’s degree in education. She lives independently and reports feeling safe in her home. Since her daughter married, she has been living alone and remains capable of managing her daily activities without assistance.

The patient also reports the following lifestyle information:

• Does not smoke or use tobacco products.

• Does not consume alcohol.

• Denies recreational drug use.

• Is not currently in a relationship.

• Is not sexually active.

The absence of tobacco, alcohol, and recreational drug use reduces several modifiable cardiovascular risk factors. However, living alone and missing previous medical appointments may affect long-term medication adherence and diabetes self-management. Assessing the patient’s social support system and reinforcing the importance of routine follow-up visits may improve treatment adherence and overall health outcomes.

Review of Systems

A comprehensive review of systems was performed to identify symptoms associated with uncontrolled Type 2 diabetes mellitus and to assess for other underlying conditions. The findings primarily support poor glycemic control, while most other body systems remain unremarkable.

General

The patient reports persistent fatigue that has progressively worsened over the past several months. She also notes an approximate five-pound weight change during the previous year. No fever, chills, or unexplained night sweats are reported.

Eyes

The patient wears reading glasses for near vision but denies blurred vision, double vision, eye pain, or recent changes in eyesight. She has no history of diabetic retinopathy.

Cardiovascular

The patient denies chest pain, palpitations, shortness of breath with exertion, dizziness, or lower-extremity swelling. However, her history of hypertension and a significant family history of cardiovascular disease increase her overall cardiovascular risk.

Respiratory

The patient denies cough, wheezing, dyspnea, chest tightness, or other respiratory concerns. No respiratory abnormalities are reported.

Gastrointestinal

The patient denies abdominal pain, nausea, vomiting, constipation, diarrhea, or changes in bowel habits. Although she experiences gastrointestinal discomfort related to diabetes medications, no current gastrointestinal complaints are noted during the review of systems.

Genitourinary

The patient denies dysuria, urinary urgency, urinary incontinence, or hematuria. She reports increased nighttime urination, which is likely associated with hydrochlorothiazide therapy rather than an underlying urinary disorder.

Musculoskeletal

The patient reports no joint pain, muscle weakness, stiffness, or limitations in mobility. She remains independent in performing daily activities.

Neurological

The patient denies headaches, dizziness, numbness, tingling, weakness, or loss of sensation. She reports no symptoms suggestive of diabetic peripheral neuropathy.

Psychiatric

The patient denies symptoms of depression, anxiety, mood changes, sleep disturbances, or suicidal ideation. She remains alert, cooperative, and demonstrates appropriate emotional responses throughout the examination.

Breast Examination

Breast examination findings are normal. Inspection and palpation reveal symmetrical breasts with everted nipples. No masses, skin changes, tenderness, or nipple discharge are identified.

Physical Examination

The physical examination demonstrates findings consistent with uncontrolled diabetes and hypertension while showing no evidence of acute illness or diabetes-related complications.

Vital Signs

The patient’s body mass index places her in the overweight category, while her blood pressure remains above the recommended treatment target. Both obesity and hypertension increase the risk of cardiovascular complications in patients with Type 2 diabetes.

General Appearance

The patient appears mildly fatigued but is pleasant, cooperative, and fully oriented to person, place, time, and situation. She maintains appropriate hygiene and shows no signs of acute distress.

Skin Examination

Skin assessment reveals warm, dry, and intact skin without rashes, ulcers, lesions, or signs of infection. No evidence of diabetic skin complications is observed.

HEENT Examination

Head, eyes, ears, nose, and throat examination is unremarkable.

Clinical findings include:

• Pupils equal, round, and reactive to light

• Extraocular movements intact

• Normal fundoscopic examination

• No evidence of diabetic retinopathy

• Tympanic membranes intact

• No sinus tenderness

• Trachea midline

• No cervical lymphadenopathy

• No carotid bruits

• No jugular venous distention

These findings indicate no current ophthalmic or vascular complications related to diabetes.

Cardiovascular Examination

Cardiovascular assessment demonstrates:

• Regular heart rate and rhythm

• Normal S1 and S2 heart sounds

• No murmurs, rubs, or gallops

• Peripheral pulses graded 3+

• Capillary refill of approximately two seconds

• No peripheral edema

Although the examination is normal, the patient’s hypertension and family history warrant continued cardiovascular monitoring.

Respiratory Examination

Respiratory assessment is within normal limits.

Findings include:

• Normal respiratory effort

• Clear breath sounds bilaterally

• No wheezing, crackles, or rhonchi

• Resonant percussion throughout the lung fields

No evidence of respiratory disease is identified.

Gastrointestinal Examination

Abdominal examination reveals:

• Soft and symmetrical abdomen

• No tenderness on palpation

• No guarding or rebound tenderness

• No palpable masses

• Normal abdominal contour

These findings suggest no acute gastrointestinal pathology.

Musculoskeletal Examination

Musculoskeletal assessment demonstrates:

• Full range of motion in all extremities

• Normal gait

• Stable balance

• Appropriate posture

• No joint swelling or muscle weakness

The patient remains functionally independent.

Neurological Examination

Neurological findings are normal.

Assessment reveals:

• Clear and appropriate speech

• Normal muscle tone

• Intact sensation

• Normal coordination

• Appropriate cognitive function

No neurological deficits or signs of diabetic neuropathy are identified during this examination.

Psychiatric Examination

The patient is alert, cooperative, and demonstrates normal mood, affect, speech, thought processes, and eye contact. Judgment and insight appear intact.

Diagnostic Laboratory Findings

Laboratory testing supports the diagnosis of uncontrolled Type 2 diabetes mellitus while showing no evidence of significant dysfunction in other organ systems.

Most laboratory values fall within normal reference ranges, including:

• Complete Blood Count (CBC)

• Comprehensive Metabolic Panel (CMP)

• Lipid Profile

• Thyroid-Stimulating Hormone (TSH)

• Urinalysis

• Urine Microalbumin

• Vitamin D level

The only abnormal laboratory finding is the patient’s hemoglobin A1C.

A hemoglobin A1C of 8.5% reflects an average blood glucose level above the recommended treatment goal during the previous two to three months. According to current diabetes management guidelines, this level significantly increases the patient’s risk of developing microvascular complications, including diabetic nephropathy, retinopathy, and neuropathy, as well as macrovascular complications such as myocardial infarction and stroke.

Assessment

The patient’s history, physical examination, and laboratory findings strongly support a diagnosis of uncontrolled Type 2 diabetes mellitus.

Several clinical findings indicate inadequate glycemic control, including persistent fatigue, excessive thirst, weight changes, and an elevated hemoglobin A1C level of 8.5%. Although the patient is currently receiving combination oral antidiabetic therapy, her symptoms suggest that the existing treatment regimen is no longer achieving adequate blood glucose control.

Additionally, her blood pressure of 160/90 mmHg represents poorly controlled hypertension, further increasing her risk of cardiovascular disease. Combined with obesity and a strong family history of myocardial infarction, these findings place the patient at high risk for future diabetes-related complications.

Differential Diagnosis

Uncontrolled Type 2 Diabetes Mellitus (Primary Diagnosis)

Uncontrolled Type 2 diabetes mellitus is the most likely diagnosis based on the patient’s clinical presentation and laboratory findings.

Supporting evidence includes:

• Hemoglobin A1C of 8.5%

• Persistent fatigue

• Excessive thirst (polydipsia)

• Established history of Type 2 diabetes mellitus

• Inadequate symptom control despite current medication therapy

These findings clearly indicate chronic hyperglycemia requiring treatment optimization.

Essential Hypertension

The patient’s blood pressure remains elevated at 160/90 mmHg, suggesting suboptimal hypertension management. Although hypertension contributes to cardiovascular risk and may worsen fatigue, it does not fully explain the patient’s increased thirst or elevated A1C level.

Hypothyroidism

Hypothyroidism is considered because fatigue is a common presenting symptom. However, the patient’s normal TSH level makes thyroid dysfunction unlikely, effectively ruling it out as the primary cause of her symptoms.

Final Diagnosis

The final diagnosis is uncontrolled Type 2 diabetes mellitus with inadequate glycemic control.

This diagnosis is supported by persistent hyperglycemic symptoms, an elevated hemoglobin A1C level of 8.5%, ongoing fatigue, excessive thirst, and insufficient response to the current oral diabetes treatment regimen. Prompt intervention through medication optimization, lifestyle modification, routine monitoring, and multidisciplinary care is essential to reduce the risk of long-term diabetic complications.

Evidence-Based Management Plan

Effective management of uncontrolled Type 2 diabetes mellitus requires a patient-centered approach that combines medication optimization, lifestyle modifications, regular monitoring, preventive care, and multidisciplinary collaboration. The primary goals are to achieve individualized glycemic targets, reduce cardiovascular risk, improve medication adherence, and prevent both microvascular and macrovascular complications.

Lifestyle and Non-Pharmacologic Recommendations

Lifestyle modification remains a cornerstone of diabetes management and should accompany pharmacologic therapy. The patient should receive individualized counseling to support sustainable behavioral changes that improve blood glucose control and overall health.

Recommended lifestyle interventions include:

• Achieving gradual and sustainable weight loss through a balanced calorie-controlled diet.

• Following a diabetes-friendly meal plan that emphasizes whole grains, lean proteins, vegetables, fruits, and healthy fats while limiting refined carbohydrates and added sugars.

• Engaging in at least 150 minutes of moderate-intensity aerobic exercise each week, along with resistance training on two or more days per week, as tolerated.

• Increasing daily physical activity by incorporating walking, stretching, and other low-impact exercises.

• Monitoring blood glucose levels as recommended to evaluate treatment effectiveness.

• Practicing stress-management techniques, such as mindfulness, relaxation exercises, or yoga.

• Maintaining consistent sleep habits and obtaining adequate nightly sleep to support metabolic health.

These lifestyle interventions have been shown to improve glycemic control, reduce cardiovascular risk, and enhance overall quality of life in individuals with Type 2 diabetes.

Diagnostic Screening and Ongoing Monitoring

Routine monitoring is essential for evaluating disease progression, identifying complications early, and guiding treatment adjustments.

Recommended follow-up screenings include:

• Hemoglobin A1C testing every three months until glycemic targets are achieved.

• Routine blood pressure monitoring at each healthcare visit.

• Annual diabetic foot examination to assess for neuropathy and peripheral vascular disease.

• Annual urine microalbumin testing to detect early diabetic kidney disease.

• Regular lipid profile assessments to evaluate cardiovascular risk.

• PHQ-2 depression screening to identify symptoms of depression that may affect diabetes self-management.

Consistent monitoring allows healthcare providers to intervene early and reduce the likelihood of long-term complications.

Medication Education

Patient education plays a vital role in improving medication adherence and treatment success. The patient should receive clear instructions regarding medication use, expected outcomes, and potential adverse effects.

Education should focus on the following topics:

• The importance of taking medications exactly as prescribed.

• Proper techniques for home blood glucose monitoring.

• Recognizing the signs and symptoms of hypoglycemia and hyperglycemia.

• Understanding the appropriate timing of diabetes medications.

• Reporting persistent medication side effects to healthcare providers rather than discontinuing therapy independently.

• The role of healthy eating and physical activity in enhancing medication effectiveness.

Because the patient reports gastrointestinal discomfort with metformin and glyburide, as well as nocturia related to hydrochlorothiazide, referral to an endocrinologist is appropriate to evaluate alternative treatment options that may improve medication tolerance and glycemic control.

Health Promotion Strategies

Preventive healthcare is essential for reducing the long-term complications associated with diabetes and hypertension. The patient should receive comprehensive preventive care tailored to her age, medical history, and risk factors.

Recommended health promotion strategies include:

• Scheduling annual wellness examinations.

• Attending routine well-woman visits.

• Completing age-appropriate breast cancer screening.

• Receiving recommended adult immunizations, including influenza, pneumococcal, COVID-19, and shingles vaccines, when appropriate.

• Participating in cardiovascular disease prevention programs.

• Receiving individualized nutrition counseling from a registered dietitian.

• Enrolling in a diabetes self-management education and support (DSMES) program.

Preventive care not only improves health outcomes but also empowers patients to actively participate in managing their chronic conditions.

Specialist Referrals

Coordinated multidisciplinary care can significantly improve outcomes for patients with uncontrolled diabetes.

The patient should be referred to the following specialists:

• Endocrinologist: To evaluate the current diabetes treatment regimen, optimize medication therapy, and improve glycemic control.

• Ophthalmologist: To perform an annual dilated retinal examination for early detection of diabetic retinopathy.

Additional referrals to a certified diabetes educator or registered dietitian may also support long-term disease management and lifestyle modification.

Follow-Up Plan

The patient should return for follow-up within two weeks to evaluate her response to the revised management plan.

During the follow-up visit, the healthcare provider should assess:

• Blood glucose control.

• Blood pressure response.

• Medication adherence and tolerance.

• Progress toward lifestyle modification goals.

• Need for medication adjustments or additional interventions.

Regular follow-up visits are critical for monitoring treatment effectiveness and preventing disease progression.

Key Clinical Takeaways

Several important clinical findings support the diagnosis and management of uncontrolled Type 2 diabetes mellitus:

• Persistent fatigue and excessive thirst are common symptoms of chronic hyperglycemia.

• A hemoglobin A1C level of 8.5% indicates inadequate long-term glycemic control.

• Poorly controlled hypertension and excess body weight substantially increase cardiovascular risk.

• Medication-related adverse effects may reduce adherence and contribute to poor diabetes management.

• Early intervention, patient education, lifestyle modification, and specialist referrals can significantly reduce diabetes-related complications and improve long-term outcomes.

Frequently Asked Questions (FAQs)

What is the patient’s primary diagnosis?

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

Why is a hemoglobin A1C level of 8.5% concerning?

An HbA1C level of 8.5% indicates that average blood glucose levels have remained above the recommended target during the previous two to three months. Poor glycemic control increases the risk of diabetic nephropathy, retinopathy, neuropathy, cardiovascular disease, and stroke.

Why does uncontrolled diabetes cause fatigue?

When blood glucose levels remain elevated, the body’s cells cannot efficiently utilize glucose for energy. This reduced cellular energy production often leads to persistent fatigue despite adequate rest.

What diabetes-related complications should be monitored?

Patients with poorly controlled Type 2 diabetes should be routinely evaluated for:

• Diabetic retinopathy

• Diabetic nephropathy

• Peripheral neuropathy

• Cardiovascular disease

• Peripheral arterial disease

• Diabetic foot complications

Early detection allows timely intervention and improves long-term outcomes.

NU566 Unit 5 Journal

Why is an annual eye examination recommended?

People with diabetes are at increased risk of developing diabetic retinopathy. Annual dilated eye examinations help detect retinal damage before vision loss occurs, allowing for early treatment and preservation of vision.

What lifestyle changes can improve blood glucose control?

Evidence-based lifestyle changes include:

• Following a balanced diabetes-friendly diet.

• Participating in regular physical activity.

• Achieving and maintaining a healthy body weight.

• Monitoring blood glucose as recommended.

• Taking medications consistently.

• Managing stress effectively.

• Attending routine medical appointments.

These interventions improve glycemic control and reduce the risk of diabetes-related complications.

How often should hemoglobin A1C be monitored?

For patients with uncontrolled diabetes or recent treatment changes, current clinical guidelines recommend measuring HbA1C approximately every three months until individualized treatment goals are achieved.

Conclusion

The patient’s clinical presentation, medical history, physical examination, and laboratory findings strongly support a diagnosis of uncontrolled Type 2 diabetes mellitus. Persistent fatigue, excessive thirst, recent weight changes, and an elevated hemoglobin A1C level of 8.5% indicate inadequate glycemic control despite current oral antidiabetic therapy. Additionally, poorly controlled hypertension and a significant family history of cardiovascular disease further increase the patient’s risk of adverse health outcomes.

A comprehensive, evidence-based management plan should emphasize medication optimization, lifestyle modification, regular monitoring, preventive screenings, patient education, and coordinated multidisciplinary care. Addressing medication intolerance, improving adherence, and promoting self-management are essential steps toward achieving optimal glycemic control and reducing the likelihood of long-term complications. Early intervention and consistent follow-up can significantly improve clinical outcomes and enhance the patient’s overall quality of life.

References

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

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

NU566 Unit 5 Journal

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: U.S. 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