NR 508 Week 5: Maria is a 46-year-old woman who presents for her yearly physical examination

Maria is a 46-year-old woman who presents for her yearly physical examination. Her medical history is notable for borderline hypertension and moderate obesity. Six months ago her fasting lipid profile was normal. Maria report that her mother and brother have diabetes and hypertension. She reports that she knows she should be on a low calorie, low fat diet and exercising but with her full time job and four children, she finds it difficult to exercise, and she eats out most of the time. She is 66″ tall and weighs 219lbs today, no current medication. She does report taking a multivitamin, biotin Vit-C when she remembers. She is a nonsmoker, only drinks sweet tea with each meal, 3-4 cups of coffee per day.

Today: BP 120/70 mm Hg, pulse 76, temperature 98.7, respirations 18, weight 219 pounds. Urine dip + glucose, fasting plasma glucose 179 mg/dl, HgbA1C is 7.4%. Physical Exam reveals notable for acanthosis nigricans at the neck but otherwise is normal.

What are your treatment goals for Maria?
What is your plan for drug therapy? What is the mechanism of action for each drug?
Please give five teaching points for each drug prescribed.
How would you change the plan if her initial HbgA1C was 10.2mg/dL and her fasting blood glucose was 305mg/dL? Provide a detailed alternative plan with the rationale

What are your treatment goals for Maria?

Maria presents to the clinic for her yearly physical examination. Observing that her history is positive for borderline hypertension and moderate obesity with fasting lipid profile being normal six months ago and a family history of diabetes and hypertension. Maria presents today with multiple complications that should be assessed and further evaluated. Fasting plasma glucose elevated at 179 mg/dL, HgbA1C elevated at 7.4%. Maria has a BMI of 36.4% which is grade 2 overweight (Edmunds & Mayhew, 2014). My treatment goals for today’s visit are to decrease blood glucose level. I would also want to check other labs of liver function and kidney function in the preparation of treatment for diabetes. Treating her Acanthosis Nigricans is also part of the plan of care. Acanthosis Nigricans is a skin condition that characterizes by brown to black, skin pigmentation, hyperkeratosis, and velvet hyperplasia, and it associated with insulin resistance, a hormonal disorder.

A thorough examination of Maria would be taken to include possible signs and symptoms within the past si

NR 508 Week 5 Maria is a 46 year old woman who presents for her yearly physical examination

x months to help diagnose and corroborate the lab values seen in Maria today.

According to NGSP (2010), with Maria’s HgbA1c, which is an average of her blood glucose levels over a 3-month period, of 7.4. In evaluating a HgbA1c level, anything above 6.5% would be considered Type 2 diabetes and would need confirmation with a second measurement unless there is a clear indication of symptoms. The second measurement of Maria’s blood sugar is her fasting plasma glucose of 179 mg/dL today (U.S. Department of Health and Human Services, 2018). Maria’s lifestyle is evidence of what you would probably find in your everyday person, this day and age. Although it is not a healthy lifestyle to lead, sometimes things cannot be helped in personal lives, but when it gets to this point, modifications must be made before severe complications persist. Maria is a mother of four children who has a full-time job, often finding herself eating out most of the time. Education needs to be provided to Maria about the risk factors that she is leading up to with her lifestyle choices including increased morbidity and mortality, diabetes, hypertension, coronary heart disease, etc. (Edmunds & Mayhew, 2014). Of these listed risk factors, Maria has some of them that need to be addressed to prevent further complications.

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What is your plan for drug therapy? What is the mechanism of action for each drug?

Maria has had borderline hypertension in the past, and her blood pressure is within a reasonable limit. However, she will need treatment to prevent further cardiovascular complications. For the first line treatment of hypertension, in Maria’s case, I would prescribe an angiotensin-converting enzyme inhibitor (ACEI), as these are recommended for first-line therapy for HTN in patients who diagnosed with diabetes (James, Ortiz, et al., 2014). The ACE inhibitor that I would choose to start Maria on is lisinopril 2.5mg one PO (by mouth) daily. The method of action of ACE inhibitors is they block angiotensin I from converting to angiotensin II, thereby stimulating the release of aldosterone from the renal glands. The reduced aldosterone causes less water absorption and sodium/potassium exchange increasing potassium. ACE inhibitors also inhibit bradykinin breakdown by blocking the kininase II enzyme, sometimes leading to a slightly dry, hacky cough (Edmunds & Mayhew, 2014).

With regards to other treatment for Maria’s other problems this visit, I would start Maria on an anti-diabetic medication due to her HgbA1C being at 7.4% with a fasting glucose of 179, which is consisting of 2 different tests that can be used to diagnose Maria with Type 2 diabetes (American Diabetes Association, 2018). The first line treatment of choice for Type 2 DM is metformin, as it is safe and effective in reducing the risk of cardiovascular events, weight, and death. Before prescribing metformin, I would check Maria’s GFR as metformin contraindicated in patients with a GFR of <30 mL/min/1.73 m2 (2018). The mechanism of action of metformin is that it decreases glucose production and has a minimal effect of insulin sensitivity in the liver and peripheral tissues. Metformin has also been known to be effective in reducing triglycerides and low-density lipoproteins and increasing high-density lipoproteins (Edmunds & Mayhew, 2014). Metformin would be prescribed at the lowest dose possible to see how Maria responds to this medication and how she can tolerate this medication. The medication regimen for treatment of diabetes would be, metformin 500mg PO (by mouth) twice daily (metformin, 2018). Diet and exercise can use in conjunction with treatment of HTN and diabetes. In treating Maria’s diabetes, in combination with her lifestyle changes, and with extensive education on lifestyle modifications of diet, exercise, improving sleep patterns, decreasing the amount of caffeine intake in a day (as evidenced by Maria only drinking tea and coffee). In addition to the new medication of lisinopril to help decrease her blood pressure and metformin to control her blood sugars; a follow-up visit for Maria would be scheduled in 2-3 months for follow up lab work to reevaluate Maria’s blood pressure, diabetes. For the treatment of the skin condition Acanthosis Nigricans, I would prescribe Melatonin 5 mg PO at bedtime. According to Sun et al., 2018, Melatonin is a hormone secreted by the pineal gland. The synthesis and secretion of melatonin regulated by light intensity. Investigations found that melatonin has multiple effects and acts as an antioxidant, has anti-inflammatory properties, regulates circadian rhythms, regulates immunity and has antineoplastic effects. Research also found that melatonin can control lipid metabolism, increase insulin sensitivity, regulate glucose metabolism, and reduce body weight.

Please give five teaching points for each drug prescribed:

Teaching for the prescribed medication of lisinopril for Maria’s control of hypertension would include:

Educating on monitoring blood pressures at home to prevent hypotension.
Signs and symptoms to watch for when taking an ACEI are a nonproductive cough and lightheadedness, although rare education about signs and symptoms of angioedema need to discuss with Maria, and signs and symptoms of hyperkalemia including irregular heartbeat, numbness, and tingling of the hands and feet, or weakness.
Education will provide about missing a dose of this medication including taking medication as soon as she realizes she lost it, but if it is too close to the next treatment then skip that dose, do not take two doses at the same time.
Compliance with medication including setting a reminder on her phone to ensure that she remembers to make this and all other drugs every day is imminent.
Education to avoid the use of potassium-containing medications or salt substitutes while taking an ACEI to prevent hyperkalemia (Edmunds & Mayhew, 2014).

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Teaching for the prescribed medication of metformin for Maria’s control of diabetes would include:

Diet to include a DASH diet. The DASH diet is rich in fruits, vegetables, whole grains, and low-fat dairy foods; includes meat, fish, poultry, nuts, and beans; and is limited in sugar-sweetened foods and beverages, red meat, and added fat or one that can be modified to meet the patients’ needs and glycemic control. Referral to a dietitian for an appropriate diet to meet the patient’s needs may be beneficial.
Exercise (moderate to vigorous aerobic activity) at least three days per week to help reduce weight to assist with the better glycemic control and decrease BMI. A weight loss of >5% is necessary to facilitate better glycemic control. (American Diabetes Association, 2018).
Educate that if any nausea, vomiting, or dehydration occurs that the patient should stop the medication and contact the office.
Educate about the possible side effects of Metformin including gastrointestinal discomfort of diarrhea, flatulence, and nausea, a bad taste in her mouth, and a server-side impact that she would want to notify the office of is signs and symptoms of lactic acidosis. Symptoms of lactic acidosis include nausea, abdominal pain, tachycardia, and hypotension and if patient is ever to have a surgical procedure or IV contrast dye that metformin must discontinue on the day of treatment/surgery and may be resumed 48 hours after the treatment/surgery (if renal function has returned to reasonable limits) (Edmunds & Mayhew, 2013).
Educate patient on monitor glucose levels at home and when to seek medical attention if blood sugar drops below 40 or is greater than 400 (Edmunds & Mayhew, 2014).
Side effects of melatonin is Dizziness, headache, tiredness, unusual dreams or nightmares, upset stomach. Educating Maria on standing up slowly to prevent dizziness and take medication at night as prescribe.

How would you change the plan if her initial HbgA1C was 10.2mg/dL and her fasting blood glucose was 305mg/dL? Provide a detailed alternative method with the rationale.

I’m not sure that I would change anything in my plan if Maria’s HbgA1C was 10.2 mg/dL and her fasting blood glucose was 305 mg/dL. It doesn’t matter how high her glucose is, she has diabetes regardless and must start medication to control blood sugars and modify her lifestyle that is contributing to these high blood sugars. Treatment with the initial metformin to see how the patient is going to react and follow up lab values to monitor the effectiveness of medication, lifestyle modifications, and patient’s compliance with each, is necessary. I do not want to overload the patient with too much medication or too many changes, as this is may not be effective and may lead to noncompliance issues.

Maria’s situation is an extensive and severe matter that needs to be addressed with her so that further complications to do not arise from her choices in lifestyle. Massive education with Maria and the seriousness of her compliance to the prescribed medication and adhering to a modified diet, increasing exercise to decrease obesity, and educating about possible complications relating to her choices in her current lifestyle and her family history is of utmost importance.

Reference

American Diabetes Association. (2018). Comprehensive medical evaluation and assessment of comorbidities: Standards of Medical Care in Diabetes 2018. Diabetes Care 2018, 41(1). S28–S37. Retrieved from http://care.diabetesjournals.org/content/diacare/suppl/2017/12/08/41.Supplement_1.DC1/DC_41_S1_Combined.pdf (Links to an external site.)

Armstrong, C. (2014). JNC 8 guidelines for the management of hypertension in adults. American Family Physician, 90(7). 503-504. Retrieved from https://www.aafp.org/afp/2014/1001/p503.html (Links to an external site.)

James PA, Ortiz E, et al. (2014). Evidence-based guideline for the management of high blood pressure in adults: (JNC8). JAMA, 311(5). 507-520

Metformin. (2018). In Epocrates Plus for Apple IOS. (Version 11.3.1). Retrieved from www.epocrates.com/mobile/iphone/essentials (Links to an external site.)

NGSP. (2010). HbA1 (NGSP, 2010) (Stone, et al., 2013) (U.S. Department of Health and Human Services, 2018) (Edmunds & Mayhew, 2014)c and estimated average glucose (eAG). National Institutes of Diabetes and Digestive and Kidney Diseases. Retrieved from http://www.ngsp.org/A1ceAG.asp (Links to an external site.)

Sun, H., Wang, X., Chen, J., Gusdon, A. M., Song, K., Li, L., & Qu, S. (2018). Melatonin Treatment Improves Insulin Resistance and Pigmentation in Obese Patients with Acanthosis Nigricans. International Journal of Endocrinology, 1–7. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1155/2018/2304746

U.S Department of Health and Human Services. (2018). The A1C test & Diabetes. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved from https://www.niddk.nih.gov/health-information/diabetes/overview/tests-diagnosis/a1c-test