NU566 NP case 3

Student Name

Purdue University Global

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

Prof. Name:

Date

Comprehensive Clinical Assessment

Persistent fatigue in older adults should not automatically be attributed to normal aging. In this case, a 64-year-old African American woman presents with months of worsening fatigue, uncontrolled type 2 diabetes mellitus, hypertension, inconsistent medication use, nocturia, blurred vision, and bilateral foot pain. The most likely contributor to her symptoms is poorly controlled type 2 diabetes caused by medication nonadherence, resulting in persistent hyperglycemia and possible early diabetic complications. A comprehensive assessment is essential to identify contributing factors, evaluate chronic disease management, and prevent further complications.

Fatigue in older adults may result from multiple conditions, including metabolic disorders, cardiovascular disease, endocrine abnormalities, medication effects, sleep disruption, and chronic illnesses. Therefore, a detailed history, physical examination, and diagnostic evaluation are necessary to determine the underlying cause and develop an effective treatment plan.

Chief Complaint

The patient presents with the primary concern:

“I am feeling a bit tired lately.”

She reports persistent fatigue that has gradually worsened and has begun interfering with daily activities and independence.

The fatigue has affected her ability to complete routine tasks, including grocery shopping, requiring occasional assistance from her adult daughter. The progressive decline in energy levels suggests that further evaluation is necessary to determine whether an underlying medical condition is contributing to her symptoms.

History of Present Illness

The patient is a 64-year-old African American woman who presents with progressively worsening fatigue that began approximately 4–6 months ago. She recalls that the symptoms initially developed suddenly after cleaning her kitchen and have continued despite rest and reduced activity.

She describes the fatigue as a constant feeling of being “dragging” throughout the day. Symptoms are most severe during the afternoon, particularly between 3:00 PM and 4:00 PM. Physical activities such as grocery shopping significantly worsen her fatigue, limiting her ability to complete errands independently.

Rest provides temporary improvement. Sitting quietly for approximately 30–40 minutes helps restore some energy; however, the fatigue returns after resuming normal activities. She rates the severity of fatigue as 6–7 out of 10 and has not attempted any specific interventions to relieve the symptoms.

NU566 NP case 3

Along with fatigue, the patient reports several additional symptoms that may indicate complications associated with poorly controlled diabetes:

• Bilateral foot pain

• Occasional headaches

• Progressive blurred vision over the past year

• Increased daytime urinary frequency

• Nocturia occurring approximately three times nightly

These symptoms are clinically significant because chronic hyperglycemia may contribute to neurological, ophthalmologic, and urinary complications.

Diabetes and Medication History

The patient has a history of type 2 diabetes mellitus and essential hypertension, both requiring ongoing pharmacologic management. However, she acknowledges inconsistent medication adherence.

She reports frequently forgetting to take her prescribed medications and discontinued metformin approximately six months ago due to gastrointestinal side effects, including:

• Excessive gas

• Diarrhea

• Abdominal discomfort

The patient stopped metformin independently without consulting her healthcare provider. Discontinuation of diabetes medication may have contributed to worsening glycemic control and increased risk of diabetes-related complications.

She currently uses extra-strength acetaminophen as needed for headaches but has not implemented additional strategies to manage her fatigue.

Current Medication List

Medication Adherence Concerns

Medication adherence is a major clinical concern in this patient. She reports difficulty remembering her medications and intentionally stopped metformin because of gastrointestinal intolerance.

Poor medication adherence increases the likelihood of:

• Persistent hyperglycemia

• Increased hemoglobin A1C levels

• Progression of diabetic complications

• Increased cardiovascular risk

• Reduced quality of life

A medication review and patient-centered approach are necessary to identify treatment options that improve adherence while minimizing adverse effects.

Allergies and Medication Intolerances

Allergies

The patient denies allergies to:

• Prescription medications

• Foods

• Environmental allergens

Medication Intolerance

The patient reports intolerance to metformin due to gastrointestinal symptoms, including:

• Diarrhea

• Excessive gas

• Abdominal discomfort

These adverse effects resulted in discontinuation of therapy without medical guidance.

Metformin intolerance is common among some patients and may be improved through medication adjustments, including dose modification, gradual titration, or switching to an extended-release formulation.

Past Medical History

The patient’s significant medical conditions include:

• Type 2 diabetes mellitus

• Essential hypertension

Both conditions require long-term monitoring because uncontrolled diabetes and hypertension significantly increase the risk of cardiovascular, neurological, renal, and ophthalmologic complications.

Past Surgical History

The patient reports the following surgical procedures:

• Tonsillectomy at three years of age

• Appendectomy at twelve years of age

She also reports one previous hospitalization related to childbirth.

Family History

The patient has a strong family history of cardiovascular disease and diabetes, increasing her risk for similar complications.

This family history demonstrates a significant genetic predisposition toward cardiovascular disease and metabolic disorders. Combined with uncontrolled diabetes and hypertension, these factors increase her long-term cardiovascular risk.

Social History

The patient is a retired teacher who has been widowed for more than 25 years. She currently lives independently and reports feeling safe in her home environment.

Her adult daughter provides occasional assistance with physically demanding activities, such as grocery shopping, because increasing fatigue has affected her ability to complete these tasks independently.

Lifestyle Factors

The patient reports:

• No cigarette smoking history

• No alcohol consumption

• No recreational drug use

• No current sexual activity

• No history of sexually transmitted infections

Although she has limited lifestyle-related risk factors, her declining energy levels and reduced physical ability are beginning to affect her functional independence.

Review of Systems

A comprehensive review of systems was completed to identify additional symptoms contributing to fatigue and evaluate possible complications of chronic disease.

General Health

The patient reports:

• Persistent fatigue worsening over several months

• Reduced participation in daily activities

• Approximately five-pound unintended weight gain over the past year

She denies significant changes in appetite.

Cardiovascular System

The patient denies:

• Chest pain

• Palpitations

• Swelling of the extremities

• Symptoms suggestive of acute cardiovascular distress

However, her history of hypertension, diabetes, and strong family history places her at increased cardiovascular risk.

Respiratory System

The patient denies:

• Shortness of breath

• Cough

• Wheezing

• Difficulty breathing

No respiratory symptoms are reported that would explain her fatigue.

Skin

The patient denies:

• Skin lesions

• Rashes

• Non-healing wounds

• Changes in skin color

Because diabetes increases the risk of impaired wound healing and infection, continued skin monitoring remains important.

Eyes and Vision

The patient reports progressively worsening blurred vision over the previous year.

She currently uses reading glasses for near vision but reports increasing difficulty with visual clarity.

This symptom requires further evaluation because uncontrolled diabetes may contribute to:

• Diabetic retinopathy

• Cataracts

• Other diabetes-related eye complications

Gastrointestinal System

The patient reports gastrointestinal symptoms associated with metformin use:

• Diarrhea

• Excessive gas

• Abdominal discomfort

She denies:

• Constipation

• Nausea

• Vomiting

• Black or tarry stools

• Eating disorders

Genitourinary System

The patient reports:

• Urinary frequency approximately 10–12 times daily

• Nocturia approximately three times each night

She denies:

• Painful urination

• Blood in urine

• Foul-smelling urine

• Vaginal discharge

Frequent nighttime urination contributes to disrupted sleep, which may worsen daytime fatigue.

Her preventive health screenings are overdue. She reports that her last Pap smear and mammogram were approximately seven years ago.

Musculoskeletal System

The patient reports bilateral foot pain but denies:

• Joint stiffness

• Previous fractures

• General muscle weakness

Bilateral foot pain in a patient with diabetes raises concern for possible peripheral neuropathy.

Neurological System

The patient reports persistent fatigue but denies:

• Loss of consciousness

• Seizures

• Focal weakness

• Balance problems

Further evaluation is needed to determine whether diabetic neuropathy is contributing to her foot symptoms.

Hematologic, Endocrine, and Lymphatic System

The patient denies:

• Easy bruising

• Blood clots

• Enlarged lymph nodes

• Excessive thirst

• Increased appetite

• Heat intolerance

• Cold intolerance

• Previous blood transfusions

Psychiatric System

The patient reports difficulty sleeping due to frequent nighttime urination.

She denies:

• Depression

• Anxiety

• Suicidal thoughts

• Previous suicide attempts

A depression screening score of 3/6 indicates mild depressive symptoms, but the patient does not meet criteria for a depressive disorder based on current information.

Key Clinical Findings

The patient’s history reveals multiple clinically significant findings that require further evaluation. Although fatigue can have numerous causes in older adults, the combination of uncontrolled diabetes, medication nonadherence, urinary symptoms, visual changes, and foot pain suggests that chronic disease complications may be contributing to her declining energy levels.

The most important clinical concerns include:

• Persistent fatigue lasting more than four months

• Poorly controlled type 2 diabetes mellitus with inconsistent medication use

• Discontinuation of metformin due to gastrointestinal intolerance

• Elevated risk for diabetes-related complications

• Uncontrolled hypertension

• Bilateral foot pain suggestive of possible diabetic peripheral neuropathy

• Progressive blurred vision requiring ophthalmologic evaluation

• Frequent urination and nocturia affecting sleep quality

• Strong family history of cardiovascular disease and diabetes

• Overdue preventive screenings, including mammography and cervical cancer screening

These findings indicate the need for a comprehensive diagnostic evaluation to identify the primary cause of fatigue while addressing chronic disease management and preventing long-term complications.

Objective Physical Examination

A complete physical examination was performed to evaluate potential causes of fatigue and assess the current status of the patient’s chronic conditions, including type 2 diabetes mellitus and hypertension.

The patient appeared clinically stable but demonstrated signs consistent with ongoing fatigue. No acute distress was observed.

Vital Signs

The patient’s blood pressure of 160/90 mmHg indicates inadequate hypertension control. Persistent elevation increases the risk of cardiovascular events, particularly in individuals with diabetes.

Her BMI of 29.8 kg/m² places her in the overweight category, which may worsen insulin resistance and complicate diabetes management.

General Appearance

The patient is a pleasant and cooperative 64-year-old African American woman who appears fatigued but is not in acute distress.

Assessment findings include:

• Alert and oriented to person, place, time, and situation

• Appropriate responses to questions

• Stable posture and gait

• Appropriate hygiene and grooming

• Clothing appropriate for environmental conditions

Her presentation suggests chronic fatigue rather than an acute medical emergency.

Skin Examination

Skin assessment reveals:

• Warm, dry, intact skin

• Normal pigmentation

• No rashes

• No ulcers

• No lesions

• No bruising

• No signs of infection

Although the examination is normal, individuals with poorly controlled diabetes remain at increased risk for impaired wound healing and skin infections. Continued monitoring is recommended.

HEENT Examination

Head

The head is:

• Normocephalic

• Atraumatic

• Without visible lesions or deformities

Hair distribution appears normal.

Eyes

Eye examination findings include:

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

• Extraocular movements intact

• No conjunctival injection

• No scleral icterus

Despite normal physical findings, the patient reports progressive blurred vision over the past year. Because diabetes can damage retinal blood vessels, further ophthalmologic evaluation is indicated.

Possible diabetes-related causes include:

• Diabetic retinopathy

• Cataracts

• Macular changes

Ears

Findings include:

• Patent external auditory canals

• Tympanic membranes intact

• Normal landmarks visible

• Normal light reflex

Nose

Assessment reveals:

• Pink, moist nasal mucosa

• Normal turbinates

• No septal deviation

Mouth and Throat

Findings include:

• Moist, pink oral mucosa

• No throat inflammation

• No exudate

• Good dental condition

Neck Examination

The neck examination demonstrates:

• Full range of motion

• Supple neck

• No cervical lymphadenopathy

• No thyroid enlargement

• No thyroid nodules

• No carotid bruits

• No jugular venous distention

The absence of thyroid abnormalities reduces the likelihood of significant thyroid disease contributing to fatigue.

Cardiovascular Examination

Cardiovascular assessment reveals:

• Regular heart rate and rhythm

• Normal S1 and S2 heart sounds

• No murmurs

• No gallops

• No abnormal heart sounds

• Strong symmetrical peripheral pulses (3+)

• Capillary refill less than two seconds

• No peripheral edema

Although the cardiovascular examination is normal, the patient’s elevated blood pressure and diabetes history indicate increased cardiovascular risk.

Risk factors include:

• Long-standing diabetes

• Uncontrolled hypertension

• Overweight BMI

• Family history of myocardial infarction

Respiratory Examination

Respiratory assessment reveals:

• Symmetrical chest movement

• Normal respiratory effort

• Clear bilateral breath sounds

• No wheezing

• No crackles

• No rhonchi

Respirations are regular and unlabored.

The absence of respiratory abnormalities makes pulmonary disease less likely as a contributor to fatigue.

Gastrointestinal Examination

The abdomen is mildly obese but soft and non-tender.

Findings include:

• Active bowel sounds in all four quadrants

• No abdominal tenderness

• No guarding

• No rebound tenderness

• No palpable masses

• No hepatosplenomegaly

The examination does not indicate gastrointestinal pathology contributing to fatigue.

Breast Examination

Breast examination findings include:

• No palpable masses

• No tenderness

• No nipple discharge

• No skin dimpling

• No skin discoloration

• No nipple retraction

Although the examination is normal, the patient is overdue for recommended breast cancer screening.

A screening mammogram should be scheduled according to current preventive care recommendations.

Genitourinary Examination

The genitourinary examination is unremarkable.

Findings include:

• No erythema

• No swelling

• No tenderness

• No bladder distention

• No costovertebral angle tenderness

• No palpable abnormalities

The patient’s urinary frequency and nocturia are likely related to impaired glucose regulation rather than infection, as urinalysis results are normal.

Musculoskeletal Examination

Musculoskeletal assessment demonstrates:

• Full range of motion in all extremities

• Muscle strength 5/5 bilaterally

• No joint swelling

• No deformities

• No crepitus

• Normal muscle tone

• Deep tendon reflexes 2+ throughout

Peripheral circulation findings:

• Dorsalis pedis pulses 2+ bilaterally

• Posterior tibial pulses 2+ bilaterally

• Healthy toenails

• Normal capillary refill

Although objective findings are normal, persistent bilateral foot pain remains concerning for early diabetic peripheral neuropathy.

Additional evaluation should include:

• Monofilament testing

• Sensory examination

• Assessment for loss of protective sensation

Neurological Examination

Neurological evaluation demonstrates:

• Cranial nerves II–XII intact

• Normal speech

• Appropriate coordination

• Stable balance

• Steady gait

• No focal neurological deficits

The neurological examination does not reveal acute abnormalities; however, diabetic neuropathy may still be present despite normal gross neurological findings.

Psychiatric Examination

The patient is:

• Alert and cooperative

• Appropriately groomed

• Maintaining eye contact

• Communicating clearly

Speech characteristics:

• Soft volume

• Normal rate

• Appropriate rhythm

A depression screening score of 3/6 indicates mild depressive symptoms; however, the patient denies:

• Depression

• Anxiety

• Suicidal ideation

Her sleep disturbance appears primarily related to nocturia rather than a psychiatric condition.

Laboratory Findings

Laboratory testing was performed to evaluate diabetes control, identify possible causes of fatigue, and assess for complications.

Interpretation of Diagnostic Findings

The laboratory results provide important information regarding the cause of fatigue and the patient’s chronic disease control.

Poor Glycemic Control

The hemoglobin A1C level of 8.5% confirms inadequate diabetes management.

This finding is supported by:

• Medication nonadherence

• Discontinuation of metformin

• Increased urination

• Nocturia

• Blurred vision

• Fatigue

Persistent hyperglycemia reduces the body’s ability to efficiently use glucose for energy, contributing to fatigue.

Normal Blood Counts

The normal CBC reduces the likelihood that anemia or infection is causing fatigue.

Common causes of fatigue ruled out include:

• Iron deficiency anemia

• Acute infection

• Hematologic abnormalities

Normal Kidney and Liver Function

The normal comprehensive metabolic panel indicates:

• Preserved renal function

• Normal liver enzymes

• No evidence of metabolic dysfunction

This decreases the likelihood that kidney or liver disease is contributing to fatigue.

Normal Thyroid Function

The normal TSH level makes hypothyroidism less likely.

Although symptoms such as fatigue and weight gain may suggest thyroid dysfunction, supporting laboratory evidence is absent.

Normal Vitamin D Level

Vitamin D deficiency is unlikely to explain the patient’s symptoms because laboratory results are within normal limits.

Clinical Assessment

The patient presents with chronic fatigue associated with:

• Poorly controlled type 2 diabetes mellitus

• Medication nonadherence

• Uncontrolled hypertension

• Nocturia

• Progressive blurred vision

• Bilateral foot pain

Based on the clinical history, physical examination, and laboratory findings, uncontrolled type 2 diabetes mellitus is the most likely primary cause of her fatigue.

The patient’s symptoms suggest possible early diabetes-related complications, including:

• Peripheral neuropathy

• Diabetic eye disease

Differential Diagnosis

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

Poorly controlled type 2 diabetes mellitus is the most likely diagnosis explaining the patient’s symptoms.

Evidence Supporting This Diagnosis

Clinical findings include:

• Hemoglobin A1C of 8.5%

• Six months without metformin therapy

• Medication nonadherence

• Chronic fatigue

• Polyuria

• Nocturia

• Blurred vision

• Bilateral foot pain

• BMI of 29.8 kg/m²

• Family history of diabetes

• History of hypertension

Chronic hyperglycemia contributes to reduced cellular energy production and increases the risk of microvascular complications.

Potential complications include:

• Diabetic peripheral neuropathy

• Diabetic retinopathy

• Cardiovascular disease

• Chronic kidney disease

Differential Diagnosis 2: Essential Hypertension

The patient has established hypertension with evidence of inadequate control.

Supporting findings include:

• Blood pressure of 160/90 mmHg

• Medication inconsistency

• Elevated BMI

• Diabetes diagnosis

• Strong cardiovascular family history

Although hypertension may contribute to reduced physical endurance, it does not fully explain the patient’s fatigue, urinary symptoms, blurred vision, and foot pain.

Differential Diagnosis 3: Hypothyroidism

Hypothyroidism was considered because it commonly presents with:

• Fatigue

• Weight gain

• Reduced activity tolerance

• Sleep disturbances

However, it is less likely because:

• TSH levels are normal

• No cold intolerance is reported

• No constipation is reported

• No dry skin is reported

• No bradycardia is present

Therefore, hypothyroidism remains a possible but unlikely explanation.

Final Diagnosis and Management Plan for Persistent Fatigue Associated With Poorly Controlled Type 2 Diabetes Mellitus

Final Diagnosis

The most likely diagnosis for this patient is:

Poorly controlled type 2 diabetes mellitus with medication nonadherence and early diabetes-related complications contributing to persistent fatigue

The patient’s fatigue is most consistent with inadequate glycemic control caused by inconsistent medication use and discontinuation of metformin due to gastrointestinal intolerance.

Several clinical findings support this diagnosis:

• Elevated hemoglobin A1C of 8.5%

• Discontinuation of metformin for approximately six months

• Frequent missed medication doses

• Daytime fatigue and reduced activity tolerance

• Increased urinary frequency and nocturia

• Progressive blurred vision

• Bilateral foot pain suggestive of diabetic peripheral neuropathy

• Overweight BMI of 29.8 kg/m²

• History of hypertension

• Strong family history of diabetes and cardiovascular disease

Although uncontrolled hypertension contributes to cardiovascular risk, it does not adequately explain the patient’s complete symptom pattern. Similarly, hypothyroidism is unlikely because thyroid function testing is within normal limits.

The combination of hyperglycemia, urinary symptoms, visual changes, and neurological complaints indicates that diabetes-related complications should be evaluated promptly.

Pathophysiology of the Primary Diagnosis

Type 2 Diabetes Mellitus and Development of Fatigue

Type 2 diabetes mellitus is a chronic metabolic disorder characterized by insulin resistance and progressive pancreatic beta-cell dysfunction. In individuals with insulin resistance, body tissues become less responsive to insulin, reducing glucose uptake into muscle and adipose tissue.

As a result, glucose remains elevated in the bloodstream, causing persistent hyperglycemia.

When glucose cannot effectively enter cells for energy production, the body experiences reduced energy availability, which may contribute to chronic fatigue.

In this patient, inconsistent medication use and discontinuation of metformin likely contributed to worsening hyperglycemia and progression of symptoms.

Effects of Chronic Hyperglycemia

Long-term elevated blood glucose levels can lead to multiple physiological changes, including:

Reduced Cellular Energy Production

When glucose cannot enter cells efficiently, tissues receive less available energy. This may result in:

• Persistent tiredness

• Reduced physical endurance

• Difficulty completing daily activities

Osmotic Diuresis and Nocturia

Excess glucose in the bloodstream increases kidney filtration demands.

This can result in:

• Increased urine production

• Frequent daytime urination

• Nighttime urination

• Sleep disruption

In this patient, nocturia occurring approximately three times nightly may contribute significantly to daytime fatigue.

Peripheral Nerve Damage

Chronic hyperglycemia can damage peripheral nerves through metabolic and vascular changes.

Possible symptoms include:

• Burning foot pain

• Tingling

• Numbness

• Reduced sensation

The patient’s bilateral foot pain may represent early diabetic peripheral neuropathy.

Retinal Microvascular Injury

Diabetes can damage small blood vessels supplying the retina, increasing the risk of:

• Diabetic retinopathy

• Vision changes

• Blurred vision

The patient’s progressive visual changes require comprehensive ophthalmologic evaluation.

Increased Cardiovascular Risk

Diabetes combined with hypertension accelerates vascular damage and increases the likelihood of:

• Coronary artery disease

• Stroke

• Peripheral arterial disease

The patient’s family history further increases cardiovascular risk.

Comprehensive Management Plan

The primary goals of treatment are to:

• Improve blood glucose control

• Increase medication adherence

• Reduce diabetes-related complications

• Improve fatigue and functional ability

• Optimize blood pressure management

• Promote preventive healthcare practices

Management should include pharmacologic treatment, lifestyle modification, patient education, monitoring, and specialty referrals.

Pharmacologic Management

Diabetes Medication Management

The patient should undergo medication reassessment because current diabetes management is inadequate.

Addressing Metformin Intolerance

The patient discontinued metformin because of gastrointestinal adverse effects, including:

• Diarrhea

• Gas

• Abdominal discomfort

Rather than permanently discontinuing therapy, alternative strategies should be considered.

Possible approaches include:

• Restarting metformin at a lower dose

• Using extended-release metformin to improve gastrointestinal tolerance

• Gradually increasing dosage as tolerated

• Taking medication with meals

• Considering alternative glucose-lowering medications if symptoms persist

Medication decisions should be individualized based on:

• Glycemic goals

• Kidney function

• Cardiovascular risk

• Medication tolerance

• Patient preferences

Continue Antihypertensive Therapy

The patient should continue prescribed antihypertensive medications unless adjustments are recommended after reassessment.

Current medications include:

Because her blood pressure remains elevated at 160/90 mmHg, medication effectiveness and adherence should be reviewed.

Potential management considerations include:

• Confirming daily medication use

• Reviewing home blood pressure readings

• Assessing need for medication adjustment

• Evaluating cardiovascular risk factors

Cardiovascular Risk Reduction

The patient currently takes:

• Aspirin 81 mg daily

Continued cardiovascular risk assessment is recommended because she has multiple risk factors, including:

• Diabetes

• Hypertension

• Overweight BMI

• Family history of myocardial infarction

Management of Gastrointestinal Symptoms

If metformin is restarted and diarrhea continues, management options should focus on improving medication tolerance.

Approaches may include:

• Dose adjustment

• Switching to extended-release formulation

• Dietary modification

• Monitoring symptoms closely

Medication changes should occur under healthcare provider supervision.

Non-Pharmacologic Management

Lifestyle interventions are essential components of diabetes and hypertension management.

Nutrition Recommendations

The patient should follow a diabetes-focused eating pattern emphasizing:

• Vegetables

• Whole grains

• Lean protein sources

• High-fiber foods

• Healthy fats

She should limit:

• Refined carbohydrates

• Sugary beverages

• Processed foods

• Excess sodium intake

A registered dietitian can provide individualized meal planning based on:

• Weight goals

• Blood glucose patterns

• Food preferences

• Cultural considerations

Physical Activity Recommendations

Because fatigue currently limits activity, exercise should increase gradually.

Recommended strategies include:

• Short periods of walking

• Increasing activity duration as tolerated

• Incorporating strength exercises when appropriate

• Balancing activity with adequate rest periods

Regular physical activity can improve:

• Insulin sensitivity

• Blood pressure control

• Energy levels

• Cardiovascular health

Weight Management

The patient’s BMI of 29.8 kg/m² places her in the overweight category.

Gradual weight reduction may improve:

• Glycemic control

• Insulin sensitivity

• Blood pressure

• Physical functioning

Weight management goals should focus on sustainable lifestyle changes rather than rapid weight loss.

Sleep Improvement

Sleep disruption is likely contributing to daytime fatigue.

Interventions include:

• Addressing nocturia through improved glucose control

• Establishing consistent sleep routines

• Limiting caffeine before bedtime

• Maintaining regular sleep and wake times

Recommended Diagnostic Evaluations

Additional testing is recommended to assess diabetes complications and update preventive care.

Comprehensive Diabetic Eye Examination

The patient should be referred for a dilated retinal examination because of:

• Long-standing diabetes

• Elevated A1C

• Progressive blurred vision

The examination should evaluate for:

• Diabetic retinopathy

• Cataracts

• Glaucoma

• Other vision-threatening conditions

Early detection allows timely treatment and reduces the risk of permanent vision loss.

Diabetic Foot Examination

Because the patient reports bilateral foot pain, a comprehensive foot evaluation should be performed.

Assessment should include:

• Monofilament sensation testing

• Peripheral circulation assessment

• Skin inspection

• Evaluation for ulcers or pressure areas

The purpose is to identify:

• Peripheral neuropathy

• Loss of protective sensation

• Foot ulcer risk

Breast Cancer Screening

The patient reports that her last mammogram occurred approximately seven years ago.

A screening mammogram should be scheduled because preventive screening is overdue.

Cervical Cancer Screening

Her cervical cancer screening history should be reviewed, and screening should be updated according to current recommendations.

Patient Education Plan

Patient education is essential because medication adherence and self-management strongly influence diabetes outcomes.

Medication Adherence Education

The patient should understand that inconsistent medication use can lead to:

• Increased blood glucose levels

• Diabetes complications

• Increased cardiovascular risk

Education should include:

• Taking medications exactly as prescribed

• Discussing side effects before stopping medications

• Using reminders such as:

  • Pill organizers

  • Smartphone alerts

  • Medication calendars

Blood Glucose Monitoring Education

The patient should begin routine glucose monitoring.

Education should include:

• Obtaining a home glucose meter

• Recording glucose readings

• Monitoring fasting glucose levels

• Recognizing symptoms of high and low blood sugar

Symptoms of hyperglycemia may include:

• Increased urination

• Increased thirst

• Fatigue

• Blurred vision

Symptoms of hypoglycemia may include:

• Sweating

• Shakiness

• Confusion

• Dizziness

Blood Pressure Monitoring Education

The patient should monitor blood pressure at home.

Recommendations include:

• Checking blood pressure at consistent times

• Maintaining a written record

• Bringing readings to healthcare visits

She should seek medical advice if readings remain consistently elevated.

Diabetes Self-Management Education

Important diabetes self-care behaviors include:

• Following a balanced meal plan

• Performing regular physical activity

• Inspecting feet daily

• Wearing appropriate footwear

• Scheduling routine medical appointments

• Completing annual eye examinations

Referrals

Ophthalmology Referral

Referral to an ophthalmologist is recommended because of:

• Progressive blurred vision

• Poor diabetes control

• Increased risk of diabetic retinopathy

A comprehensive eye examination can detect early retinal changes before severe vision impairment occurs.

Certified Diabetes Educator Referral

A diabetes educator can assist with:

• Medication adherence strategies

• Blood glucose monitoring

• Lifestyle modification

• Diabetes self-management skills

Registered Dietitian Referral

Nutrition counseling can help improve:

• Meal planning

• Weight management

• Blood glucose regulation

• Cardiovascular health

Follow-Up Care

The patient should return for follow-up within approximately two weeks to evaluate response to interventions.

Follow-up assessment should include:

• Fatigue severity

• Medication adherence

• Blood pressure control

• Blood glucose readings

• Medication side effects

• Need for treatment adjustments

Earlier evaluation should occur if the patient develops:

• Worsening fatigue

• Chest pain

• Shortness of breath

• Severe weakness

• Vision deterioration

• Signs of infection

Key Clinical Takeaways

Persistent fatigue in older adults requires careful evaluation because it may indicate uncontrolled chronic disease rather than normal aging.

In this patient, the strongest contributing factors include:

• Poorly controlled type 2 diabetes mellitus

• Medication nonadherence

• Hyperglycemia-related symptoms

• Sleep disruption from nocturia

• Possible diabetic neuropathy

• Possible diabetic eye complications

Early recognition, evidence-based treatment, and patient-centered education can improve diabetes control, reduce complications, and enhance quality of life.

Frequently Asked Questions

What is the most likely cause of fatigue in this patient?

The most likely cause of fatigue is poorly controlled type 2 diabetes mellitus resulting from medication nonadherence. The patient’s elevated hemoglobin A1C (8.5%), frequent urination, nocturia, blurred vision, and bilateral foot pain indicate chronic hyperglycemia and suggest early diabetes-related complications. Poor glucose control reduces the body’s ability to use glucose efficiently for energy, leading to persistent fatigue.

Can uncontrolled diabetes cause chronic fatigue?

Yes. Uncontrolled diabetes is a common cause of chronic fatigue. Persistent hyperglycemia prevents glucose from entering cells effectively, reducing energy production. Diabetes can also cause dehydration through frequent urination, sleep disruption from nocturia, and complications such as neuropathy, all of which contribute to ongoing fatigue.

Why was hypothyroidism ruled out?

Although hypothyroidism can cause fatigue, weight gain, and decreased activity tolerance, it is unlikely in this case because the patient’s thyroid-stimulating hormone (TSH) level is within the normal reference range. Additionally, she does not exhibit classic symptoms such as cold intolerance, constipation, dry skin, or bradycardia.

How does medication nonadherence affect diabetes management?

Medication nonadherence significantly increases the risk of poor glycemic control and long-term complications. Missing or discontinuing diabetes medications can lead to persistent hyperglycemia, increasing the likelihood of diabetic neuropathy, retinopathy, kidney disease, cardiovascular disease, and worsening fatigue.

Why is the patient’s blurred vision concerning?

Blurred vision in a patient with poorly controlled diabetes raises concern for diabetic retinopathy or other diabetes-related eye diseases. Early ophthalmologic evaluation is essential because diabetic eye disease can progress without noticeable symptoms and may eventually cause permanent vision loss if left untreated.

What does bilateral foot pain suggest in diabetes?

Bilateral foot pain may indicate diabetic peripheral neuropathy, a common complication of prolonged hyperglycemia. Symptoms often include burning, tingling, numbness, or pain in the feet. Early diagnosis and management help reduce the risk of foot ulcers, infections, and lower-extremity complications.

What additional diagnostic tests are recommended?

Based on the patient’s presentation, recommended evaluations include:

• Comprehensive dilated eye examination

• Diabetic foot examination with monofilament testing

• Updated mammography

• Cervical cancer screening according to current guidelines

• Home blood glucose monitoring

• Home blood pressure monitoring

These assessments help identify diabetes-related complications and support preventive healthcare.

How can fatigue caused by poorly controlled diabetes be improved?

Improving fatigue requires better diabetes management through:

• Taking medications consistently as prescribed

• Following a balanced diabetic meal plan

• Increasing physical activity gradually

• Maintaining healthy sleep habits

• Staying adequately hydrated

• Monitoring blood glucose regularly

• Attending routine follow-up appointments

Improved glycemic control often leads to increased energy levels and reduces the risk of long-term complications.

Key Evidence Summary

The clinical evidence in this case strongly supports poorly controlled type 2 diabetes mellitus as the primary diagnosis.

Supporting findings include:

• Hemoglobin A1C: 8.5%

• Medication nonadherence

• Six-month discontinuation of metformin

• Persistent fatigue lasting more than four months

• Polyuria and nocturia

• Progressive blurred vision

• Bilateral foot pain

• Hypertension (160/90 mmHg)

• BMI: 29.8 kg/m²

• Strong family history of diabetes and cardiovascular disease

Conversely, several laboratory findings reduce the likelihood of alternative causes of fatigue:

• Normal complete blood count (CBC), making anemia less likely

• Normal thyroid-stimulating hormone (TSH), making hypothyroidism unlikely

• Normal comprehensive metabolic panel (CMP), reducing the likelihood of renal or hepatic dysfunction

• Normal vitamin D level, making vitamin D deficiency an unlikely cause

Conclusion

Persistent fatigue in older adults should always prompt a comprehensive clinical evaluation rather than being attributed solely to aging. In this case, the patient’s history, physical examination, and laboratory findings demonstrate that poorly controlled type 2 diabetes mellitus, primarily driven by medication nonadherence, is the most likely cause of her symptoms. Elevated hemoglobin A1C, nocturia, blurred vision, bilateral foot pain, and uncontrolled hypertension collectively indicate inadequate glycemic control and suggest the development of early microvascular complications.

A patient-centered management plan should focus on optimizing diabetes treatment, improving medication adherence, controlling blood pressure, promoting healthy lifestyle modifications, and screening for diabetes-related complications. Referral to ophthalmology, diabetes education services, and nutritional counseling can further support long-term disease management and reduce the risk of progression.

Early recognition and evidence-based intervention are essential for improving glycemic control, relieving fatigue, preventing complications such as diabetic neuropathy and retinopathy, and enhancing the patient’s overall quality of life. Regular follow-up and ongoing patient education remain critical components of successful diabetes care.

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/

NU566 NP case 3

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

World Health Organization. (2024). Diabetes. https://www.who.int/news-room/fact-sheets/detail/diabetes