Sarah, a 55-year-old woman, presents to her primary care nurse practitioner with complaints of increased thirst, frequent urination, and fatigue over the past few weeks. She has

Case Study 3: Holistic Management of Type 2 Diabetes with Comorbidities Patient Profile: Sarah, a 55-year-old woman, presents to her primary care nurse practitioner with complaints of increased thirst, frequent urination, and fatigue over the past few weeks. She has a family history of type 2 diabetes mellitus (T2DM), with her father and two siblings diagnosed with the same condition. She has a BMI of 30.9 and a sedentary lifestyle. Laboratory tests reveal elevated fasting blood glucose levels of 140 mg/dL, an HbA1c of 8.5%, and a total cholesterol level of 207 mg/dL, and triglycerides of 158 mg/dL Her blood pressure measures is 135/78 mmHg, Case Scenario: Sarah is your patient now, and you have just diagnosed her with type 2 diabetes. You (as her PCP) initiate a comprehensive treatment plan according to the latest guidelines to mitigate long-term complications. Questions:

1. According to the latest guidelines, what would be the initial pharmacologic and non- pharmacological treatment for Sarah's type 2 diabetes?

2. According to the latest guidelines, what additional preventive (pharmacological and non- pharmacological) measures would need to be taken to mitigate Sarah's risk of cardiac consequences, considering her lipids and hypertension state?

3. Which referrals, if any, would be necessary for Sarah's comprehensive management, and what specific assessments or interventions would these referrals entail?

4. When would you recommend scheduling Sarah for a follow-up appointment to assess her response to treatment ?

Case Study: Acute Gastroesophageal Reflux Disease (GERD) Patient Information:

• Name: Laura Martinez • Age: 35 years • Gender: Female • Occupation: Teacher • Medical History: Laura has a history of occasional heartburn and GERD symptoms,

managed with antacids as needed. She has no known allergies.

Presenting Complaint: Laura presents to the clinic with complaints of severe chest pain and burning sensation behind the sternum for the past two days. She describes the pain as a sharp, burning sensation that worsens after meals and when lying down. She reports regurgitation of sour-tasting fluid into her mouth and occasional difficulty swallowing. She denies any associated symptoms such as fever, cough, or abdominal pain. Physical Examination:

• Vital Signs: BP 120/80 mmHg, HR 70 bpm, RR 16/min, Temp 98.4°F (36.9°C) • Chest Examination: No abnormal findings on auscultation, no signs of respiratory

distress • Abdominal Examination: Soft and non-tender, no organomegaly • Other Findings: No signs of anemia or jaundice

Investigations:

1. Upper Endoscopy: Shows evidence of esophageal mucosal injury (erosive esophagitis) with mucosal breaks and inflammation, indicative of GERD.

2. Esophageal pH Monitoring: Confirms increased acid exposure in the distal esophagus, consistent with GERD.

Diagnosis: Acute Gastroesophageal Reflux Disease (GERD) with erosive esophagitis Management: Laura is advised on lifestyle modifications, including avoiding trigger foods (e.g., spicy, fatty foods), eating smaller meals, and avoiding lying down after meals. She is prescribed a proton pump inhibitor (PPI) for 4-8 weeks to suppress gastric acid secretion and promote healing of esophageal mucosa. Antacids are provided for immediate relief of symptoms as needed. Questions for Medical Students:

1. What are the typical symptoms of GERD, and how is it differentiated from other causes of chest pain?

2. Describe the endoscopic findings seen in erosive esophagitis. 3. Discuss the pathophysiology of GERD and factors contributing to its development. 4. Outline the pharmacological and non-pharmacological management strategies for GERD,

including the role of PPIs, antacids, and lifestyle modifications.