Type II Diabetes Mellitus - Essay Example

"Type II Diabetes Mellitus" is a great example of a paper on diabetes mellitus.
Patient ID: Mr GY

Source: All the information is collected from the patient who in sound mind.

Chief complaint: Hip pain and irregular menses

History of Present Illness: Mr GY, 47-year old Caucasian male has been admitted with a wound on the right foot that is getting worse. The patient is a known diabetic who was diagnosed five years ago. He has been using self-administered insulin injections since then. The patient is currently using insulin to control his blood glucose levels, antibiotics and painkillers for the wound and ACE inhibitors. The wound is also cleaned and dressed every day by the hospital staff.

A review of the systems indicates that apart from the wound, the patient is not experiencing any negative health symptoms.

Past medical history: high blood pressure and obesity

Hospitalizations: three years ago due to the past medical history of high blood pressure and obesity

Surgeries/procedures: none

Medications: insulin, Cefazolin and beta-lactamase inhibitor agents, Pentoxifylline, aspirin 300 mg daily

Allergies: no known drug allergies

Family history:  His father died of cardiovascular disease and his mother is receiving treatment for acute ischemia.

Social and substance use history: Mr GY reports that he takes at least three bottles of beer most days of the week as well as smoking a packet of cigarettes each day.

Physical examination: A physical examination of the patient does not indicate any significant health symptoms apart from pain from the wound area.

Laboratory tests: His blood glucose level was significantly high at 270mg/dl; blood pressure was 140/90, and he had a BMI of 31.

Differential diagnosis: Type II Diabetes mellitus – ICD-9-CM 250

Obesity – ICD-9-CM 278.00

High blood pressure – ICD-9-CM 401.9

Pharmacologic intervention: The patient will continue with self-administration of insulin and ACE inhibitors unless he develops a heart condition. He will also be put on antibiotics to prevent the infection on his leg from becoming worse.

Non-pharmacologic intervention: The patient will have to adhere to a diet that is suitable for his conditions. The diet should be low in energy, high in fibre and whole grains, vitamins and consist of plenty of fruits and vegetables to help him control his blood glucose and promote wound healing (American Diabetes Association, 2014). He should also ensure that his intake of salt is minimal to alleviate the symptoms of high blood pressure. The patient will also be required to engage in as much physical activity as he can while in the hospital and also after being discharged.

Patient education: The patient will be educated on how to maintain a healthy diet by making healthy food choices, calorie counting and ensuring that he does not have an irregular meal pattern. He will also be educated on behaviour change, specifically on ways to stop smoking and alcohol intake since they increase his risk of worsening his cardiovascular condition (Nakanishi et al., 2015). He will also be educated on the benefits of regular physical exercise such as weight control, muscle strength, and better blood glucose level control among others (Vina e al., 2012). He will also be educated on the appropriate clothing to wear to minimize the risk of injury since it may result in a recurrence of the same situation he is in presently.

Referrals: The patient will be referred to a nutritionist/dietitian for help in meal planning and nutritional counselling to manage his chronic conditions (Wukich et al., 2013). He will also be referred to a drug addiction support group in the local area where he can get support and help on how to quit smoking and his excessive alcohol intake. He will continue seeing his regular physician for pharmacological care on his various conditions.

Follow-up: The patient will be required to report to the clinic every two weeks to monitor the progress of treatment and also check if he is adhering to professional advice. His blood glucose levels, blood pressure, and A1c levels will be measured as necessary to determine if he is responding well to the interventions.