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Patient Diagnoses and Treatment Case Study


Mr. W presents for his annual examination with complaints of lack of energy, thirst, and hunger during the last three months. The patient reports nocturia 2-3 times per night and gaining about 10 pounds over the last year. Mr. W’s family has a history of coronary artery disease (CAD). The patient goes to the gym, rejects smoking or drugs, and drinks 1-2 wine glasses on weekends. The purpose of this paper is to analyze the case, including laboratory and physical examination results, his past medical and social history, diagnose the patient, and develop a care management plan.


Primary Diagnosis

Type 2 diabetes mellitus without complications (ICD-10: E11.9) is a primary diagnosis. This common metabolic disorder has pathophysiological changes like pancreatic β-cells defective insulin secretion and the inability of the system to respond to insulin (Galicia-Garcia et al., 2020). Although the early stage of diabetes may stay asymptomatic, patients should be careful with such symptoms as excessive thirst or hunger, blurry vision, frequent urination, pain, and fatigue (Artasensi et al., 2020).

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Pertinent positive findings include fatigue, weight gain, nocturia, and the inability to get enough to drink or eat. The lipid panel shows high total cholesterol (230 mg/dl with 180-200 mg/dl normal limits), low-density lipoprotein (144 mg/dl with 100-130 mg/dl normal limits), and triglycerides (232 mg/dl with 150 mg/dl normal limits) (Artha et al., 2019). Pertinent negative findings are regular physical exercises, no diabetes family history, and negative lab results for ketones and nitrites (Abebe et al., 2019). Lab values from the lipid panel and subjective information about hunger, fatigue, and obesity contribute to type 2 diabetes as a primary diagnosis (American Diabetes Association [ADA], 2020). The presence of glucose 1+ and negative for ketones and nitrites tell about an early stage of the condition.

Secondary Diagnosis

Hyperlipidemia, unspecified (ICD-10: E78.5), is another metabolic disorder diagnosed in Mr. W. The pathophysiology of this disease includes the elevation of lipids or fats in the blood (Clebak & Dambro, 2020). Hyperlipidemia remains a strong risk factor for CAD, leading to increased cholesterol and triglyceride and resulting in obesity and fatty bumps on the skin as the main symptoms recognized in patients at an early stage.

The pertinent positive finding is his BMI (33.8), which tells about moderate obesity, despite regular physical experiences and an active style of life. Many patients with hyperlipidemia remain asymptomatic, and the presence of pathophysiology is proved after completing screening labs to check different lipid panel elements (Clebak & Dambro, 2020). The pertinent negative findings are normal blood pressure, no smoking history, and no family history (Clebak & Dambro, 2020). The patient does not have kidney or liver problems and has normal vital signs (129/80 blood pressure) and a comprehensive metabolic panel (Calcium 9.5, bilirubin 0.6, and sodium 139). The patient is a Cuban male, and hyperlipidemia is more frequent among the Hispanic male population compared to other races (Rivas-Gomez et al., 2018). Regarding the demographic factors, subjective complaints, and objective lab results, the patient is at risk of having hyperlipidemia that could lead to severe heart problems with time.



The first lab test is the glycated hemoglobin test, also known as HbA1c. It is defined as a specific approach to detecting a new case of diabetes in an undiagnosed patient (Kaur et al., 2020). HbA1c is taken once in three months to identify the warning limits of glycemic level. Diagnostic criteria include 5.7% (normal level), 5.7-6.4% (prediabetes condition), and more than 6.5% (diabetes) (ADA, 2020). It is allowed to eat and drink before the test, and there is no need to wait some time for Mr. W to check his results, with repetition in three months.

The second test to be repeated under specific conditions is lipid profile assessment. A patient has to be properly prepared for this test, including fasting (except for water) during the last 9-12 hours (Nordestgaard, 2018). Regularly, patients ask to take this test once per five years, but in this case, repetition is required to remove external factors. Normal limits for total cholesterol are between 100 and 199 mg/dl; high-density lipoprotein – more than 40 mg/dl, low-density lipoprotein – less than 100 mg/dl, and triglycerides – less than 150 mg/dl (ADA, 2020; Nordestgaard, 2018). As the patient shows borderline high results, it is important to check if there are any changes when no extra food or medications are taken directly before the test.


The patient gets the following prescription: “Rx: Metformin 500 mg tablets; Sig: Take one tablet by mouth up to two times per day; Disp: #30; Refill: Three times.” For a long period, metformin is the first-line treatment for diabetes patients to reduce the glucose level and promote insulin-sensitizing outcomes in tissues (Artasensi et al., 2020). If the chosen medication does not decrease HbA1C results after three months, it is recommended to add another medication like Glucotrol or other alpha-glucosidase inhibitors.

Rosuvastatin is another important medication to predict the complications of hyperlipidemia. Statins are prescribed for this condition, and Mr. W gets the following recipe: “Rx: Rosuvastatin 20 mg tablets; Sig: Take one tablet by mouth once per day; Disp: #30; Refill: Two times.” Statins aim to treat hyperlipidemia among patients who are older than 40 years and reduce the development of negative cardiovascular outcomes (Clebak & Dambro, 2020). The patient is a 63-year-old male, and his parents deceased due to CAD (family predisposition for cardiovascular problems), which meets the offered evidence-based criteria.

Finally, before this new plan, the patient took “Tylenol 500 mg tablets; Sig: Take two tablets by mouth daily; Disp: #90; Refill: Two times” and unknown multivitamins to keep his body healthy. Metformin, as well as the majority of statins, does not have unwanted drug-drug interactions, and the offered combinational therapies are appropriate (Artasensi et al., 2020). Regarding the possibility of controlling pain related to his left knee arthritis, there are no contradictions to stopping this line of medications.



Mr. W is diagnosed with two diseases – type 2 diabetes and hyperlipidemia – based on his lab results and subjective information. The most evident diabetes signs are Glucose 1+ and increased total cholesterol levels. The normal cholesterol levels are between 180 and 200 mg/dl, and the patient has 230 mg/dl (Artha et al., 2019). Despite the intention to control weight at the gym, it was not enough to predict obesity (the patient’s BMI level is 33.8, meaning moderate obesity). In addition, Mr. W’s race is a risk factor for diabetes-related complications (Rivas-Gomez et al., 2018). All these factors prove the offered diagnoses and need special care attention.


The patient is already aware of the importance of taking Tylenol for his arthritis pain and multivitamin for overall well-being. At this moment, the task is to reduce the level of sugar in the blood. Therefore, metformin is prescribed to treat diabetes, control weight, and manage dietary and drinking habits (Artasensi et al., 2020). This medication may have side effects like sweating, lactic acidosis, and hunger, but such monotherapy is effective for many patients (Artasensi et al., 2020). Regarding the possibility of cardiovascular complications (family history) and a high level of triglycerides, statin medication – Rosuvastatin – is prescribed to reduce hyperlipidemia outcomes in the heart (Clebak & Dambro, 2020). If no improvements in lab results are observed within the next three months, another pharmacological plan has to be developed. The patient should not change something without professional medical counseling.


There are many controversies about how to develop dietary habits in patients with diabetes. However, one simple rule is that the prevention of diabetes complications by means of properly chosen dietary patterns should be followed. No perfect percentage of calories is established for diabetic patients, and the consumption of proteins, carbohydrates, and fats is purely individual (ADA, 2020). Mr. W has to set a special meal plan to meet the required caloric goals with a dietitian nutritionist. Common recommendations at this moment include the consumption of food rich in fiber (vegetables, fruits, and dairy products) and avoidance of sugar drinks and food with high protein levels (ADA, 2020). The patient allows drinking alcohol as per the limits reported during his first examination (1-2 glasses of wine during weekends).


Regarding his obesity-related problems, it is important for Mr. W to pay attention to physical activity. It is advised to increase the duration of exercises from 60 minutes (two times per 30 minutes, as the patient reports) to 150 minutes of moderate-intensity physical activity like brisk walking (ADA, 2020). Prolonged sedentary time has to be broken up, as well as it contributes to the increase of glucose levels in the blood (Artasensi et al., 2020). Such recommendations as swimming, cycling, and walking cannot be ignored.

Warning Signs for Diagnoses and Mediations

It is usually hard for a healthy person to become a diabetic and follow a number of prescriptions. For example, the patient should know that not all signs can be identified soon after the diagnosis. Therefore, it is important to control all health changes and measure the glucose level in the blood regularly (Artasensi et al., 2020). Metformin is usually a good medication to treat diabetes, but it has negative outcomes on the system. Hyperlipidemia is even more asymptomatic than diabetes, and the task of the patient is to follow prescriptions and take medications (Clebak & Dambro, 2020). Dietary modifications and physical activities may prevent heart-related complications, but if the man feels chest discomfort, a 911 emergency is the only option.


An exercise specialist has to be referred to with the purpose of choosing an appropriate physical activity plan and setting the goals for weight management. The contractions of skeletal muscles lead to increased blood flow and improved glucose intake (Galicia-Garcia et al., 2020). Therefore, communication with an expert in this field predicts unwanted complications and physical disability at an old age. Cooperation with a dietitian is also important as it helps to understand what kind of food is preferred or dangerous for the patient with specific lab results. Medical nutrition therapy is a crucial part of this care treatment plan (ADA, 2020). Finally, a visit to an eye care professional is required once a year to check if there are some vision changes (ADA, 2020). Diabetes signs may emerge and disappear, and the task of the patient is not to miss a moment when a new therapeutic step is necessary.

Follow up

If no side effects are observed, the next follow-up for Mr. W is set for three months. During this period, it is possible to recognize the effectiveness of the chosen medications and take another HbA1C test to check the glucose level (Artasensi et al., 2020). Visits to a local ophthalmologist, a therapist, and a dietitian are recommended once per six months. However, if any change or complication is observed, an emergency visit should not be a problem.

Assessment of Comorbidities

Diabetes comorbidities are complications that affect diabetic patients more than other people due to their health condition. One of the potential threats to Mr. W is cancer of the liver, bladder, or pancreas. The relationship between cancer and diabetes may be explained by old age, negative family history, and obesity (ADA, 2020). The impact of this disease physiology and the necessity to take medications regularly is small, but it cannot be ignored. The patient should refer to an oncologist and take an age- and sex-appropriate cancer screenings every five years.

Medication Cost

It is possible to buy the necessary medications at Walmart and use a free coupon to save money (,, and The price of metformin is about $4-5 (60 tablets), the price for 30 tablets of Rosuvastatin is $15.83, and Tylenol costs $3.32 for 30 tablets. Per month, the total price for medications is $30.47 (including one pack of metformin, one pack of Rosuvastatin, and two packs of Tylenol).


The assessment of Mr. W’s subjective and objective data, including his labs, social and medical history, and current medications, proves that he has diabetes as his primary diagnosis. Regarding high lipid panel results, hyperlipidemia is also diagnosed. A pharmacological plan includes taking metformin and Rosuvastatin regularly during the next three months to treat diabetes and Tylenol to relieve arthritis pain. Non-pharmacological interventions like physical activity and dietary habits are necessary to predict body weight growth and possible obesity-related complications.


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American Diabetes Association (ADA). (2020). Standards of medical care in diabetes – 2020. Web.

Artasensi, A., Pedretti, A., Vistoli, G., & Fumagalli, L. (2020). Type 2 diabetes mellitus: A review of multi-target drugs. Molecules, 25(8). Web.

Artha, I. M. J. R., Bhargah, A., Dharmawan, N. K., Pande, U. W., Triyana, K. A., Mahariski, P. A., Yuwono, J., Bhargah, V., Prabawa, I. P. U., Manuaba, I. B. A. P., & Rina, I. K. (2019). High level of individual lipid profile and lipid ratio as a predictive marker of poor glycemic control in type-2 diabetes mellitus. Vascular Health and Risk Management, 15, 149-157. Web.