Type 2 Diabetes Management and Polycystic Ovarian Syndrome

Introduction

My Adult Case Study involved a 25-year-old Hispanic female who was seen on February 6, 2019, at one of my clinical sites, Texas Tech Physicians of the Permian Basin in Odessa, Texas. This clinical site primarily sees OBGYN patients from prenatal, post-partum, and women’s health. This particular female came in seeking a primary care provider. She recently moved to Odessa from El Paso, Texas, where she was newly diagnosed with Type 2 Diabetes and Cystic Ovarian Syndrome and needed to establish care with a new provider. The Patient is unfunded and applied for the grant program offered by the Texas Tech Clinic.

“I just moved to the Permian Basin, and I need a primary care provider. I moved here from El Paso, and the doctor I saw there told me I had high blood sugar and something was wrong with my ovaries. I didn’t bring my ultrasound report, but I do have my labs. I’ve been in Odessa for over one month, trying to get settled in my new job and apartment.

History of Present Illness

A 25-year-old female Hispanic patient presents today accompanied by her mother, who is here to establish care with the clinic. Recently moved to the Permian Basin from El Paso. The Patient states she was newly diagnosed with Type 2 Diabetes and “something wrong with her ovaries.” The Patient reports having polyuria, polydipsia, and abnormal weight gain since she was 21. The mother reports taking her to the ER years ago due to excessive nausea and vomiting and was told she had high blood sugar but failed to follow up with a provider.

The Patient has not seen a doctor since then due to insurance issues. He was originally seen for a work physical and was requesting oral contraceptives. During the initial work-up, the Patient was found to have a fasting blood glucose of 186 and a hemoglobin A1C of 8.1. Before she left El Paso, she was given a prescription to start Metformin 500 mg 1-tab BID but did not pick up the prescription from CVS. The Patient reports that she gets really thirsty at times, has excessive hunger, and has been gaining weight for the last three years. Other associated symptoms include irregular menstrual cycles and bilateral pelvic pain that has been an issue for one year. Prior treatment includes taking Tylenol and Motrin PRN for pain relief, and was requesting oral contraceptives back in El Paso.

No alleviating factors or radiation in pain. Aggravating factors include pain with intercourse. The Patient was told she had something wrong with her ovaries while she was over there. Had an ultrasound due to the pelvic pain and remembers the terminology “Polycystic Ovarian Syndrome” (PCOS), but did not bring her ultrasound report. Denies having chest pain, shortness of breath, nausea or vomiting. No numbness or tingling was reported. Reports an abnormal menstrual period, with menses lasting about 7-10 days with a moderate flow. The Patient is willing to re-do lab work and a possible ultrasound of the pelvis to re-evaluate her issues.

Past Medical History (PMH)

Allergies: NKDA

Current medications: No daily medications. The Patient denies the use of over-the-counter or herbal medications. No home remedies.

Age/Health status: 25-year-old obese female. Unmanaged Type 2 Diabetes and PCOS.

Immunization status: The Patient is up-to-date (UTD) on current immunizations for her age, including (Varicella et al., MCV4, IPV, and Tdap). Received influenza vaccine in December 2018. Gardasil was given at age 11.

Dates of illness during childhood: History of strep throat at age 10. He was seen in the ER in November 2016 for nausea/vomiting and hyperglycemia. No other illness was reported.

Injuries: None reported by the Patient.

Hospitalizations: None reported by the Patient.

Surgeries: Tonsillectomy and Adenoidectomy at age 11.

Current Health Maintenance

• Last well exam was at age 19.
• Dental visit in 2017. She has had three cavities and fillings. Brushes teeth twice a day.
• Patient reports good hygiene and showers twice a day.
• Unhealthy diet consisting of high carbohydrates and sugar. Rarely eats vegetables during her meals. Drink about 2-3 soft drinks per day. The Patient reports she has gained an abnormal amount of weight since age 21.
• Obtained a driver’s license when she was 18 and always wore a seatbelt when driving.
• Sexually active with one partner, uses condoms. No pregnancies were reported. No prior STD/STI’s. The last PAP Smear was in 2016 and was normal. Prefers to use tampons. No oral contraceptives were used.
• Oligomenorrhea reported for two consecutive years.
• Reports issues with abnormal hair growth on the upper lip and her nipples. Also has issues with acne on her back.
• Performs self-breast exams once a month.
• Does not take any daily multivitamins.
• Patient does not exercise or play sports. No extracurricular activities. Watches about 7-8 hours of television per day. The Patient graduated high school at age 19 and attended one year of college courses. Stopped going to college due to my job.
• Patient is fluent in both English and Spanish.

Family History (F.H.)

The Patient comes from a good-sized Hispanic family. Currently resides in Odessa, TX. I was born and raised in El Paso, Texas. Has one sister, age 15, and 2 younger brothers, ages 20 and 21. The parents are divorced and are both still alive. Mother is 51 years old, and father is 53 years old. The mother reports a history of Type 2 Diabetes and takes two oral medications to treat that. Mother had PCOS when she was 23 and then had a hysterectomy at age 46 due to abnormal uterine bleeding. The father has a history of HTN and Hyperlipemia.

The father is also morbidly obese. He is currently on medications for both medical problems. Maternal grandmother had HTN and passed away at age 86 from a CVA. Maternal grandfather had no chronic medical problems and passed away at age 88. Paternal grandmother has a history of Type 2 Diabetes, deceased. Paternal grandfather had a history of Type 2 DMD.M. complications and passed away at age 78. The mother had no complications during her pregnancy or delivery. The Patient was born full-term at 38 weeks gestation and weighed about 8 pounds.

OB/GYN History

Reports Oligomenorrhea for two consecutive years. Menses started at age 13 with irregular menstrual cycles. Admits to being sexually active and does not take oral contraceptives. Reports 1 sexual partner. Heterosexual. LMP was on January 5, 2019, and menstruated for nine days with a moderate flow. Uses tampons. The last PAP Smear was in 2016, with no abnormal findings reported. Has never been on oral contraceptives but uses condoms regularly. Has never been pregnant, nor does she plan on it. No family history of breast cancer, uterine cancer, or cervical cancer. Mother had normal PAP Smears. No dyspareunia was reported.

Social History (S.H.)

The Patient is currently residing in Odessa, Texas, and is originally from El Paso, Texas. Completed high school at age 19 and attended one year of a community college. The Patient does not exercise and does not participate in sports. The Patient does not smoke, drinks occasionally, and tried marijuana when she was 18 at a party. No other illicit drug use was reported. Mother and father do not smoke. There is no other exposure to second-hand smoke. Both parents drink on special occasions. The Patient drinks about 2-3 soft drinks per day. Averages about 7-8 hours of television. The Patient does own a cell phone. Currently employed as a bank teller. Works 8 hours per day, with 40 hours weekly. Averages about 6-7 hours of sleep. The Patient is in a monogamous relationship with a male.

Review of Systems

General – Denies any fever, chills, or weakness. Reports unexplained weight gain.

Skin – Denies lesions, petechiae, or rashes. No skin discoloration or bruises. Reports abnormal hair growth on upper lips and around her nipples. Reports acne on her back.

Eyes – Denies redness, swelling, and problems with vision. No contacts or glasses.

Head – Denies any headaches, dizziness, and light-headedness.

ENT/Mouth – Denies any hearing loss, ear pain, nasal congestion, cough, dry mouth, or sore throat.

Neck – Denies any swollen glands, lumps, pain, or stiffness.

Breast – Denies nipple discharge, lumps, or pain.

Respiratory – Denies cough, shortness of breath, sputum, asthma. No exposure to second-hand smoke.

Cardiovascular – Denies chest pain, palpitations, and heart problems. No varicose veins or edema.

Gastrointestinal – Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. No changes in bowel habits. The Patient reports an unhealthy diet.

Genitourinary – Denies painful urination, elimination, or frequent urination.

Female genitals – Positive for Oligomenorrhea for two consecutive years. Reports bilateral pelvic pain. No discharge or abnormal vaginal bleeding. LMP was January 5, 2019. Sexually active with one partner. Monogamous relationship.

Musculoskeletal – Denies any joint pain, swelling, tenderness, stiffness, or limited ROM. Denies exercise or engaged activities.

Psychiatric – Denies any nervousness, nightmares, insomnia, depression, mood changes, or suicidal thoughts. No exposure to violence or excessive anger.

Neurological – Denies speech problems, gait problems, memory loss, vertigo, seizures, tremors, or numbness.

Hematologic – Denies any unusual bleeding or bruising, anemia, or recent blood transfusion. Denies fatigue.

Endocrine – Denies any heat or cold intolerance. Reports polydipsia, polyuria, polyphagia. No excessive sweating. No changes in hair or nail texture. Reports an increase in weight.

Physical Exam (P.E.) – Weight: 190 lbs. (86.1 kg) Height: 5’4″ (64 inches) BMI: 32.6

VS: (B.P.) 137/86 (H.R.) 76 (R.R.) 18 (SpO2) 98% on RA (Temp) 98.5 oral

General appearance: Well-appearing 25-year-old obese Hispanic female. Clean, well-groomed, and well-nourished. No distress.

Skin: Warm and dry. No lesions, masses, or rashes were noted. No clubbing or cyanosis. Moderate Acanthosis Nigricans noted to the posterior neck. Hirsutism to the upper lip and bilateral nipples. Mild acne noted to back.

HEENT: Head- Normocephalic, symmetrical. Hair is evenly distributed, no hair loss. Eyes- Conjunctiva/sclera clear bilaterally, PERRL, red light reflex present bilaterally. Ears- external canal normal; clear, auditory canal; tympanic membrane intact; light reflex present. Nose- Nares patent, the septum is mid-line and intact, turbinates’ are clear, and no maxillary or frontal sinus pressure was noted upon palpation. Throat- no erythema, no exudate, tonsils normal, uvula midline, pharynx normal.

Neck/Lymphatic: Neck is supple, full ROM with no pain. No cervical lymphadenopathy. No thyroidmegaly.

Cardiovascular: No murmurs, regular rate, and rhythm, S1, S2 normal. No palpitations. Peripheral and central pulses were palpated.

Respiratory: Clear to auscultation bilaterally anterior and posterior, no wheezes, rales, rhonchi.

Breast: Symmetrical. No lumps or fixed masses were appreciated on the breast, and no nipple discharge or skin discoloration was noted. (Female chaperone present during breast exam).

Gastrointestinal: Obese, bowel sounds present, soft, non-tender, non-distended; no suprapubic tenderness. No masses, organomegaly, or tenderness was detected.

Genitourinary/GYN: External genitalia normal. Vagina and cervix without lesions or masses. No lesions on labia, bilaterally. Cervical Os closed with no bleeding or discharge. No odor. The uterus is normal. Bilateral adnexa tenderness on bimanual. Negative for masses. The urethral meatus is normal. Perineum and anus are normal. (Female chaperone present during pelvic exam).

Musculoskeletal: Steady gait. Equal strengths in all four extremities with full ROM noted. No crepitus was palpated.

Neurological: Alert and oriented x 3. Pleasant and cooperative. CN II-XII is intact. Motor and sensory function, reflexes, gait, and coordination are within normal limits.

Psychological: Interacts cooperatively during exams. Calm and pleasant affect.

Family Assessment

Looking back at the information provided in Module 1 in regard to Family Theory for Assessment, the Resiliency Model of Family Stress, Adjustment, and Adaptation definitely pertains to this Patient. This particular theory model explains different variations in how families respond to stressful situations and crises. I also learned that this theory model will help healthcare providers like Advanced Practice Registered Nurses (APRNs) handle situations and help the Patient’s family by guiding them through a crisis. According to McCubbin (1993), “the outcome of the family’s efforts over time fit at two levels: the individual to family and the family to the community.”

Reading through the research, I have learned that families, over the course of life, face hardships and changes as a natural and predictable family life. In my adult case study for this Patient, she comes from a large Hispanic family, along with a strong family history of Type 2 diabetes and obesity. She has three other siblings and is trying to adjust to living on her own in a new city. With the brand-new Diagnosis of Type 2 Diabetes, she is very resilient and has a hard time accepting her Diagnosis. Both of her parents are divorced. Her father stayed back in El Paso and is employed as a car dealer. Her mother is not employed and speaks no English.

Coming from a big family myself, I can understand how stress can play a huge role in how you’re raised as a child. My Patient is very motivated and seems like she is ready to make some lifestyle changes to improve her overall health. Her weight gain has played a huge in motivation and self-perseverance. Her father is morbidly obese himself, and she has very little interaction with him, staying back home in El Paso. Her mother has D.M. and manages her diabetes without issues. Her brothers both work and have had issues with weight gain.

The Resiliency Model of Family Stress, Adjustment, and Adaptation, according to McCubbin (1993), compares two distinct parts: The Adjustment Phase and the Adaptation Phase. Both of these describe the family’s ability to cope with illness or stressors, looking at each family’s strengths and helping through the coping phase. If my Patient had had the opportunity for diet modification, exercise encouragement, diet counseling, and primary care follow-up, the Patient’s BMI would not be so worrisome.

Cultural Assessment

In the Hispanic population and ethnicity, family planning is very important. According to an article published by Rodriguez & Fehring (2012), “Hispanic women (U.S. born and non-U.S. born) have higher pregnancy rates, desire more children, and have fewer lifetime sex partners and more unplanned pregnancies compared to non-Hispanic white women.” Many Hispanic women are interested in natural family planning (NFP) when presented and consider it in a positive manner (Rodriguez & Fehring, 2012, pp. 192-193). My Patient did not have a desire to become pregnant any time soon but did voice a desire before she turned 30.

She is in a monogamous relationship with her significant other but uses condoms. She is aware that her having Type 2 D.M. and Polycystic Ovarian Syndrome, confirmed by ultrasound, will make it difficult for her to conceive someday. Teede, Misso, Costello, et al. (2018) also say “that information and education resources for women with PCOS should be culturally appropriate, tailored and high-quality, should use a respectful and empathetic approach, and promote self-care and highlight peer support groups” (Teede et al. & et al., 2018, p. 1605).

According to McCartney & Marshall (2016), the Diagnosis of “PCOS has life-long implications, with increased risk for infertility, metabolic syndrome, and type 2 diabetes mellitus, and possibly for cardiovascular disease and endometrial carcinoma. PCOS is diagnosed in adolescents with otherwise unexplained, persistent hyperandrogenic anovulatory symptoms that are inappropriate for age and stage of adolescence” (McCartney & Marshall, 2016, p. 58).

I learned that it should be considered in any adolescent girl with hirsutism, treatment-resistant acne, menstrual irregularity, or acanthosis nigricans, and evidence of these signs and symptoms should be especially sought in patients being evaluated for obesity. She wants to change her lifestyle and has a positive attitude about weight loss and the management of diabetes. Research shows that both physical health consequences and the emotional impact of PCOS have been ignored. PCOS and its influence on quality of life is an issue that needs to be taken seriously, as this syndrome affects many women across the world. As APRNs, it is our duty to help the Patient through any lifestyle change to ensure a great quality of life. Respecting the Patient’s culture is important and should be taken into account.

Differential Diagnosis

1. Type 1 Diabetes: Strong family history of diabetes on both sides of her family (maternal and paternal). Her excessive caloric intake and consumption make her a high risk. Initial labs will rule in and rule out this Diagnosis based on fasting glucose level and Hemoglobin A1C.
2. Hypothyroidism: Rule in and rule out this Diagnosis based on the TSH, Free T3/T4, and Cortisol level.
3. Depression: This can be ruled out by the excess amount of reported sleep, insomnia, anger outbursts, withdrawal from family, and low self-esteem. Poor hygiene.
4. Genetic Obesity: The Father is obese, and the Patient’s two brothers also have weight gain issues.
5. Polycystic Ovarian Syndrome: My Patient started her menstrual cycles at age 13 and has a high BMI for her age, height, and weight. Reported Oligomenorrhea and abnormal hair growth along with acne.
6. Pregnancy: This will be ruled out by performing an HCG (serum or urine).

Concluding Diagnosis:

1. Encounter for routine adult health examination with abnormal findings (Z00.01):

Increased BMI during the well-adult exam

2. Type 2 diabetes mellitus with other specified complications

This diagnosis was confirmed from previous labs. Fasting blood glucose of 186 and a Hemoglobin A1C of 8.1.

3. Acanthosis Nigricans (L83):

Dark discoloration on the back of the neck appears to be a case of Acanthosis Nigricans.

4. Body mass index (BMI) 32.0-32.9, adult (Z68.32):

Provided in the Patient’s objective data, according to the calculated BMI based on her weight of 190 lbs., height of 5’4″, her BMI is 32.6.

5. Family history of Diabetes Mellitus (Z83.3):

During my data collection for the Patient’s SOAP note, she has a strong family history of Type 2 Diabetes. Father and paternal grandmother are on medication regimens for their Type 2 Diabetes, putting my Patient at risk of inheriting this now.

6. Polycystic Ovarian Syndrome (E28.2):

Diagnosis obtained by ultrasound of the pelvis confirming polycystic ovaries, bilaterally. Confirmed by radiologist. The Patient also had a previous U.S. of the pelvis in another city.

7. Encounter for initial prescription of injectable contraceptive (Z30.013):

Will trial Patient on Depo-Provera 150 mg (using 150 mg/mL depot contraceptive injection suspension) I.M. every three months. 

Plan

1. Will provide sufficient education on the management and treatment of Type 2 Diabetes
2. Will start the Patient on Metformin 500 mg 1 tab PO BID. 30-day supply with two refills.
3. Set a baseline target for Hemoglobin A1C with the Patient.
4. Set a weight loss goal.
5. Will trial Patient on Phentermine 37.5 mg 1 tab P.O. daily.
6. The Patient will start an exercise plan and diet modification changes. This will include a healthy diet consisting of fruits, vegetables, and proteins. Will cut back on soft drinks and excessive caloric intake and eliminate sugars from her diet.
7. The Patient will check blood sugars at least 3 times per day and will keep a log and bring it to her next appointment.
8. Initial labs were ordered: CBC, CMP, U.A., HCG, TSH, Lipid profile, Follicle stimulating hormone, luteinizing hormone, androstenedione level, insulin levels, and add testosterone level.
9. The Patient will schedule her PAP smear for next month.
10. Will monitor the Patient’s weight and blood pressure.

Safety/Risk Assessment

Safety and risk assessment should include appropriate management and surveillance of diabetes. A well-controlled diet and exercise are crucial for the well-being of my Patient. According to McCartney & Marshall (2016), “anxiety and depressive symptoms should be routinely screened in all adolescents and women with PCOS at diagnosis.” If the screen for these symptoms and/or other aspects of emotional well-being is positive, further assessment and/or referral for assessment and treatment should be completed by suitably qualified health professionals, informed by regional guidelines (McCartney & Marshall, 2016, pp. 63-64).

Guidelines: Comparisons/Contrasts

There are many types of guidelines and comparisons shared by the American Diabetes Association (2013) for PCOS. The ADA 2013 states that “Doctors most commonly prescribe birth control pills for this purpose. Birth control pills regulate menstruation, reduce androgen levels, and help to clear acne. Providers will talk to the Patient about whether a birth control pill is right for them. There also are drugs available to control blood pressure and cholesterol. Progestins and insulin-sensitizing medications can be taken to induce a menstrual period and restore normal cycles. Eating a balanced diet low in carbohydrates and maintaining a healthy weight can help lessen the symptoms of PCOS. Regular exercise helps weight loss and also aids the body in reducing blood glucose levels and using insulin more efficiently” (ADA, 2013).

Conclusion

Another guideline researched was provided by The Androgen Excess and PCOS Society (AE-PCOS, formerly the Androgen Excess Society), which is an international organization dedicated to promoting knowledge. They state that a “variety of balanced dietary approaches could be recommended to reduce dietary energy intake and induce weight loss in women with PCOS and overweight and obesity, as per general population recommendations” (Teede et al. et al., 2018; p. 16011-1612).

References

1. American Diabetes Association (2013). Polycystic Ovarian Syndrome (PCOS). Retrieved on February 7, 2018 from http://www.diabetes.org/living-with-diabetes/treatment-and care/women/polycystic-ovarian-syndrome.html
2. McCartney, C. R., & Marshall, J. C. (2016). Polycystic ovary syndrome. The New England Journal of Medicine,375(1), 54–64. doi:10.1056/NEJMcp1514916
3. McCubbin, M.A. (1993). Family stress theory and the development of nursing knowledge about family adaptation. In S.L. Feetham, S.B. Meister, J.M. Bell, & C.L. Gillis (Eds.) The Nursing Family. New Bury Park: Sage Publications, pp. 46–58.
4. Rodriguez, D., & Fehring, R. J. (2012). Family Planning, natural family planning, and abortion use among U.S. Hispanic women: Analysis of data from cycle 7 of the National Survey of Family Growth. The Linacre Quarterly,79(2), 192-207. doi:10.1179/002436312803571429
5. Teede, H. J., Misso, M. L., Costello, M. F. et al. (2018). Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Human Reproduction,33(1), 1602–1618. doi: https://doi.org/10.1093/humrep/dey256