The primary diagnosis for this condition is poorly controlled type 2 diabetes. Type 2 diabetes is a medical condition that happens when a patient’s body produces less insulin as needed or resists produced insulin (American Diabetes Association, 2018). According to the association, some of the clinical symptoms of type two diabetes include blurred vision, unintended weight loss, increased thirst, tingling of the lower body and hands, and increased sores that hardly heal.
A person suffering from poorly controlled diabetes is a patient who does not follow clinical instructions to control diabetes. It is highly likely that the patient suffers poorly controlled diabetes because he experiences increased tingling to the lower extremities and is obese.
Differential Diagnosis
Multiple sclerosis is a medical condition that can damage a patient’s central nervous system. People with multiple sclerosis can experience the following symptoms. They include fatigue, blurred vision, tingling of one or multiple body parts, sexual problems, lack of coordination, Lhermitte sign, and prolonged double vision (Briggs et al., 2018). This disease has been included in the differential diagnosis because the patient complains of tingling of the lower parts of the body.
Latent autoimmune diabetes is an illness that happens when a patient’s body does not produce enough insulin as required. Low insulin level, increased thirst, tingling of hands and feet, fatigue, and vision problems are signs of the disease. The patient complains of tingling of the body parts, and that is why the disease has been included in the diagnosis.
Brachial plexus injury is a medical condition that affects one’s nerves. It occurs when a patient’s nerves are overstretched, ripped, and compressed. Glenn et al. (2016) note that the tingling of the body parts is among the symptoms of the disease, and that is why it has been included in the diagnosis.
Role of Patient History and Physical Examination
Patient history and physical examination were so significant during diagnosis. For instance, through the patient’s medical history, the nurse found that the patient was under Januvia 50mg QD, Lipitor 40mg QD, and Lisinopril 20mg prescriptions. This information would be vital when prescribing drugs for the patient to prevent drug interaction. The current patient’s medical history provided a symptom that was used to provide the primary diagnosis.
The patient’s history provided risk factors that were used to decide the actual diagnosis for the patient. It was found that the patient was obese through medical history, type 2 diabetes, HTN, and dyslipidemia. Physical examination also provided great insight into the patient’s condition. Through physical examination, the nurse found that the patient was obese and had HBP. The information would help the nurse provide better medications that can improve the patient’s health.
Potential Treatment Options
Both medical and non-medical approaches should treat this patient. The current medications should be adjusted accordingly because the patient does not show signs of improvement. Khan et al. (2017) note that Lipitor 40mg per day should be increased to 60mg per day, and the patient monitored for two weeks.
Januvia can also be increased to 100 mg once per day. Lisinopril 20mg can be increased to 30 mg per day. The patient should be checked after two weeks to monitor his progress. The patient should also be advised to observe a balanced diet and exercise often to improve the effects of the medication.
References
American Diabetes Association. (2018). 2. Classification and diagnosis of diabetes: standards of medical care in diabetes—2018. Diabetes care, 41(Supplement 1), S13-S27. https://doi.org/10.2337/dc18-S002
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