Name
Purdue University Globle
NU566 NP I – Introduction to Primary Care for the Nurse Practitioner
Prof. Name
Date
Persistent fatigue in a 64-year-old woman with type 2 diabetes and hypertension should not be attributed to normal aging without further evaluation. In this case, the most likely explanation for the patient’s fatigue is poorly controlled type 2 diabetes mellitus associated with medication nonadherence, with nocturia, sleep disruption, blurred vision, and bilateral foot pain suggesting possible diabetes-related complications. Her elevated hemoglobin A1C of 8.5% supports inadequate glycemic control, while her blood pressure of 160/90 mmHg indicates uncontrolled hypertension. A comprehensive history, physical examination, laboratory evaluation, medication review, and assessment for diabetes complications are therefore essential.
The patient presents with the chief complaint:
“I am feeling a bit tired lately.”
She describes persistent fatigue that has progressively interfered with her normal activities and independence.
The patient is a 64-year-old African American woman who reports progressively worsening fatigue for approximately 4–6 months. She states that the symptoms began suddenly after cleaning her kitchen and have persisted since that time.
She describes the sensation as “dragging” throughout the day, with fatigue becoming particularly noticeable between 3:00 PM and 4:00 PM. Activities such as grocery shopping significantly worsen her symptoms. She increasingly relies on her daughter for assistance because she is no longer able to complete shopping independently.
Rest provides temporary improvement. Sitting quietly for approximately 30–40 minutes helps restore some energy, although the fatigue eventually returns. She rates the severity of her fatigue at 6–7 out of 10 and has not tried a specific treatment.
The patient also reports bilateral foot pain, occasional headaches, progressively blurred vision during the past year, frequent daytime urination, and nocturia approximately three times each night.
Her medical history includes type 2 diabetes mellitus and essential hypertension. However, medication adherence is inconsistent. She frequently forgets to take her medications and stopped taking metformin approximately six months ago because of persistent gastrointestinal adverse effects, including gas, diarrhea, and abdominal discomfort.
She currently uses extra-strength acetaminophen as needed for headaches.
The combination of fatigue, elevated A1C, medication nonadherence, urinary frequency, nocturia, blurred vision, and bilateral foot pain raises concern for inadequate diabetes control and possible early diabetes-related complications.
Medication | Dosage | Indication |
Atenolol | 25 mg orally once daily | Hypertension |
Hydrochlorothiazide | 25 mg orally once daily | Hypertension |
Metformin | 2,000 mg orally once daily; currently not taking | Type 2 diabetes |
Glyburide | 20 mg orally once daily | Type 2 diabetes |
Aspirin | 81 mg orally once daily | Cardiovascular protection |
Extra-strength acetaminophen | Two tablets every 4–6 hours as needed | Headache relief |
Medication adherence is a major concern in this case. The patient frequently forgets to take her prescribed medications and independently discontinued metformin because of gastrointestinal adverse effects.
Metformin commonly causes gastrointestinal symptoms, particularly when treatment is initiated or doses are increased. However, discontinuing diabetes medication without discussing alternatives with a healthcare professional can result in inadequate glycemic control.
Potential strategies for improving metformin tolerance include discussing an extended-release formulation, taking the medication with meals, or gradually adjusting the dose. If intolerance persists, the healthcare provider can consider an alternative glucose-lowering medication.
The patient denies allergies to prescription medications, foods, and environmental allergens.
The patient’s significant medical history includes:
Both conditions require consistent treatment, monitoring, lifestyle modification, and periodic evaluation for complications.
The patient reports:
The patient’s family history indicates substantial cardiovascular and diabetes risk.
Family Member | Medical History |
Father | Died from myocardial infarction at age 58 |
Mother | Died from complications of type 2 diabetes at age 81 |
Sister | Died from myocardial infarction at age 67 |
This family history further increases concern for cardiovascular complications in a patient who already has diabetes and uncontrolled hypertension.
The patient is a retired teacher who has been widowed for more than 25 years. She lives independently and reports feeling safe in her home. Her adult daughter assists with physically demanding activities, particularly grocery shopping, because of the patient’s increasing fatigue.
She reports that she:
Although she reports few traditional lifestyle-related risk factors, her declining energy and functional capacity are beginning to affect her independence.
The patient reports persistent fatigue that has gradually worsened over several months. She reports approximately five pounds of unintended weight gain during the past year and reduced participation in normal activities because of decreased energy.
She denies chest pain, palpitations, and peripheral edema.
She denies shortness of breath, cough, wheezing, and respiratory distress.
She denies rashes, skin lesions, nonhealing wounds, bruising, and changes in skin color.
The patient reports progressively worsening blurred vision during the past year and uses reading glasses.
She reports gas, diarrhea, and abdominal discomfort associated with metformin use. She denies constipation, nausea, vomiting, black or tarry stools, and eating disorders.
The patient reports urinating approximately 10–12 times during the day and waking approximately three times each night to urinate.
She denies dysuria, hematuria, foul-smelling urine, vaginal discharge, and sexual activity.
She also reports that her last Pap smear and mammogram were approximately seven years ago, indicating that preventive screening should be reviewed according to current age-appropriate recommendations.
The patient reports bilateral foot pain but denies joint stiffness, previous fractures, and muscle weakness.
She reports persistent fatigue but denies syncope, seizures, focal weakness, or balance problems.
She denies easy bruising, blood clots, swollen lymph nodes, excessive thirst, increased appetite, heat intolerance, cold intolerance, and previous blood transfusions.
The patient reports difficulty sleeping because nocturia repeatedly interrupts her sleep. She denies depression, anxiety, suicidal ideation, and previous suicide attempts.
Several findings are particularly important when evaluating this patient’s fatigue:
Together, these findings make poorly controlled diabetes a major clinical concern while also requiring assessment for cardiovascular, neurological, ophthalmic, endocrine, and sleep-related contributors to fatigue.
A comprehensive physical examination was performed to evaluate possible causes of fatigue and assess the patient’s chronic conditions. She appeared fatigued but clinically stable and was not in acute distress.
Parameter | Result |
Weight | 190 lb (86.2 kg) |
Height | 5 ft 7 in (170 cm) |
BMI | 29.8 kg/m² |
Temperature | 37.7°C |
Blood pressure | 160/90 mmHg |
Pulse | 80 beats/minute |
Respiratory rate | 20 breaths/minute |
The blood pressure reading is elevated and indicates inadequate hypertension control. Her BMI falls within the overweight range, which is an important consideration in diabetes and cardiovascular risk management.
The patient is a pleasant, cooperative 64-year-old woman who appears fatigued but is not in acute distress. She is alert and oriented to person, place, time, and situation. Her posture and gait are steady, and she answers questions appropriately. Hygiene and clothing are appropriate.
The skin is warm, dry, clean, and intact. No rashes, ulcers, lesions, bruising, or signs of infection are observed.
The head is normocephalic and atraumatic without visible deformities or lesions. Hair distribution is normal.
Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. There is no conjunctival injection or scleral icterus.
Despite the normal basic eye examination, the patient’s history of progressive blurred vision requires further ophthalmic evaluation because a routine examination does not rule out diabetic retinal disease.
The external auditory canals are patent. Tympanic membranes are pearly gray with visible landmarks and normal light reflexes.
Nasal mucosa is pink and moist. Turbinates appear normal.
The oral mucosa is pink and moist. The pharynx is nonerythematous and without exudate. Dentition is in good condition.
The neck is supple with full range of motion. No cervical lymphadenopathy, thyroid enlargement, thyroid nodules, carotid bruits, or jugular venous distention are noted.
Cardiovascular examination demonstrates a regular rate and rhythm with normal S1 and S2 heart sounds. No murmurs, gallops, rubs, or additional heart sounds are detected.
Peripheral pulses are strong and symmetrical, capillary refill is less than two seconds, and there is no peripheral edema.
Although the cardiovascular examination is otherwise unremarkable, the patient’s elevated blood pressure and strong family history warrant continued cardiovascular risk assessment.
The chest wall is symmetrical, and respiratory effort is normal. Lung sounds are clear bilaterally without wheezing, crackles, or rhonchi. Respirations are regular and unlabored.
The abdomen is mildly obese but soft and nontender. Bowel sounds are active in all four quadrants. There is no hepatosplenomegaly, palpable mass, guarding, rebound tenderness, or other significant abnormality.
No breast masses, tenderness, nipple discharge, skin dimpling, discoloration, or retraction are identified.
However, a normal clinical breast examination does not replace recommended screening mammography. The patient’s screening history should therefore be reviewed and updated.
The genitourinary examination is unremarkable. There is no erythema, edema, or tenderness. The bladder is nondistended, and there is no costovertebral angle tenderness or palpable mass.
The patient has full range of motion in all extremities with 5/5 muscle strength bilaterally. There is no joint swelling, deformity, or crepitus. Deep tendon reflexes are 2+ throughout, with normal muscle tone.
Dorsalis pedis and posterior tibial pulses are 2+ bilaterally. Nails appear healthy, and capillary refill is normal.
Despite these normal findings, the patient’s persistent bilateral foot pain warrants additional assessment for peripheral neuropathy and other diabetes-related foot complications.
The neurological examination is within normal limits. Cranial nerves II–XII are intact. Speech, coordination, balance, gait, and strength are normal, with no focal neurological deficits.
A normal basic neurological examination does not exclude diabetic peripheral neuropathy, so focused sensory testing remains important.
The patient is alert, cooperative, and appropriately groomed. Eye contact is maintained, and speech is soft but clear with normal rate and rhythm.
A depression screening score of 3/6 suggests mild depressive symptoms based on the information provided. However, the patient denies depression, anxiety, and suicidal ideation. Continued monitoring of mood and sleep is appropriate because psychological and sleep-related factors can contribute to fatigue.
Laboratory testing helps identify potential metabolic, endocrine, hematologic, renal, and nutritional contributors to fatigue.
Laboratory Test | Result | Clinical Interpretation |
Hemoglobin A1C | 8.5% | Above the usual treatment goal for many adults; indicates inadequate glycemic control |
CBC | Normal | No evidence of anemia or obvious hematologic abnormality |
CMP | Normal | Kidney and liver function are within the reported normal range |
Urinalysis | Normal | No reported glucose, protein, ketones, nitrites, or blood |
Lipid panel | HDL 45 mg/dL; LDL 52 mg/dL | LDL is well controlled based on the reported value |
TSH | 0.555 μIU/mL | Within the reported reference range |
Vitamin D | Normal | Vitamin D deficiency is unlikely to explain the fatigue |
The laboratory results help narrow the differential diagnosis.
The hemoglobin A1C of 8.5% is the most clinically significant abnormality because it demonstrates that the patient’s diabetes is not adequately controlled. Her history of inconsistent medication use provides a likely explanation.
The normal CBC makes anemia less likely as the primary cause of fatigue. Normal metabolic testing also makes significant renal or hepatic dysfunction less likely based on the available results. Similarly, the reported normal vitamin D level makes vitamin D deficiency an unlikely explanation.
The normal TSH reduces the likelihood that hypothyroidism is causing her fatigue and weight gain.
A normal urinalysis does not rule out diabetes or its chronic complications. Glycemic control should be assessed using appropriate measures such as A1C and, when indicated, blood glucose monitoring.
The patient’s presentation includes chronic fatigue, poorly controlled type 2 diabetes, uncontrolled hypertension, medication nonadherence, nocturia, blurred vision, and bilateral foot pain.
The available evidence makes inadequate diabetes control the leading clinical explanation for her symptoms. However, fatigue is often multifactorial, so sleep disruption, cardiovascular disease, medication effects, depression, deconditioning, and other conditions should remain part of the broader assessment.
Poorly controlled type 2 diabetes is the primary diagnosis because the patient’s symptoms and laboratory findings are consistent with inadequate glycemic control.
Supporting findings include:
Chronic hyperglycemia can contribute to fatigue and increase the risk of microvascular and macrovascular complications. The patient’s visual symptoms and foot pain make screening for diabetic retinopathy and neuropathy particularly important.
Hypertension is another significant diagnosis because the patient’s blood pressure is 160/90 mmHg despite prescribed antihypertensive therapy.
Potential contributing factors include medication nonadherence and excess cardiovascular risk associated with diabetes and overweight status.
Hypertension does not fully explain the patient’s symptom pattern, but uncontrolled blood pressure substantially increases her risk of cardiovascular disease, stroke, kidney disease, and other complications.
Hypothyroidism should initially be considered because fatigue, weight gain, and decreased activity can occur with thyroid hormone deficiency.
However, it is less likely in this case because the patient’s reported TSH is within the normal reference range. She also denies several common symptoms associated with hypothyroidism, including cold intolerance and constipation.
Therefore, hypothyroidism remains part of the differential diagnosis but is not the leading explanation for the patient’s symptoms.
Poorly Controlled Type 2 Diabetes Mellitus Associated With Medication Nonadherence, With Symptoms Concerning for Diabetes-Related Complications
The patient’s fatigue is most consistent with inadequate diabetes control in the setting of inconsistent medication use. Her A1C of 8.5%, urinary frequency, nocturia, progressive blurred vision, and bilateral foot pain collectively indicate the need for improved diabetes management and evaluation for complications.
Uncontrolled hypertension further increases her overall cardiovascular risk but does not adequately account for the complete symptom pattern. Hypothyroidism is less likely because the reported TSH is normal.
Type 2 diabetes mellitus involves insulin resistance combined with progressive impairment of pancreatic beta-cell function. As insulin becomes less effective, glucose regulation becomes impaired and blood glucose levels rise.
Persistent hyperglycemia can affect multiple organ systems. Excess glucose can contribute to osmotic diuresis, resulting in increased urination and nocturia. Chronic metabolic and vascular changes can damage peripheral nerves and retinal vessels, potentially contributing to foot symptoms and visual changes.
Poor glycemic control can also increase the risk of cardiovascular disease, kidney disease, neuropathy, retinopathy, and impaired wound healing.
In this patient, inconsistent medication use and discontinuation of metformin because of adverse effects likely contribute to inadequate diabetes control.
Management should address the patient’s diabetes, hypertension, medication adherence, fatigue, sleep disruption, foot pain, visual changes, and preventive healthcare needs.
The treatment plan should be individualized by the patient’s healthcare provider and should consider her medication tolerance, cardiovascular risk, kidney function, lifestyle, preferences, and ability to follow the treatment regimen.
The patient’s current medications should be reviewed by her healthcare provider rather than simply continued or discontinued without reassessment.
Her regimen includes atenolol and hydrochlorothiazide for hypertension, glyburide for diabetes, aspirin for cardiovascular protection, and acetaminophen for headaches.
Because medication adherence is inconsistent, medication reconciliation should determine what she is actually taking and identify barriers to adherence.
The patient stopped metformin because of gas, diarrhea, and abdominal discomfort. These symptoms should be discussed with her healthcare provider before restarting the medication.
Depending on clinical circumstances, strategies may include:
The goal is to achieve effective glycemic control without causing unacceptable adverse effects.
The underlying cause of diarrhea should be assessed rather than automatically treating the symptom with an antidiarrheal medication. If diarrhea is directly associated with metformin and continues after medication adjustment, the healthcare provider can determine whether symptomatic treatment or an alternative diabetes medication is appropriate.
Lifestyle interventions are important components of diabetes and hypertension management.
The patient should be encouraged to gradually increase physical activity according to her functional capacity and medical status. Nutrition should emphasize vegetables, high-fiber foods, whole grains, lean proteins, and minimally processed foods while limiting added sugars, refined carbohydrates, and excess sodium.
Because fatigue and nocturia interfere with sleep, improving nighttime urinary symptoms and establishing consistent sleep habits should also be part of the care plan.
Weight management may provide additional benefits for blood glucose control, blood pressure, and cardiovascular health.
Progressive blurred vision in a patient with diabetes requires comprehensive eye evaluation. A dilated retinal examination can assess for diabetic retinopathy and other common causes of vision changes.
The patient should be referred for appropriate eye care rather than assuming that her normal basic eye examination excludes retinal disease.
Bilateral foot pain should prompt focused assessment for diabetic peripheral neuropathy and other foot complications.
Evaluation may include:
The patient reports that her last mammogram was approximately seven years ago. At age 64, she should discuss current breast cancer screening recommendations with her healthcare provider and obtain screening appropriate to her individual risk profile.
Her cervical cancer screening history is also overdue based on the information provided. Screening recommendations depend on age, previous results, screening history, and whether she has had a hysterectomy or other relevant procedures.
Patient education should focus on helping the patient understand why consistent chronic disease management is important.
The patient should be encouraged to discuss medication side effects rather than stopping medications independently.
Helpful adherence strategies include:
Home blood pressure monitoring can provide useful information about treatment response.
The patient should measure her blood pressure according to provider instructions, record the results, and bring the log to follow-up visits.
A persistent reading of 160/90 mmHg warrants clinical reassessment rather than being managed through lifestyle measures alone.
The need for home glucose monitoring depends on the patient’s diabetes treatment plan and clinical circumstances. If monitoring is recommended, she should receive instruction on proper meter use, timing of measurements, recording results, and recognizing symptoms of hypoglycemia and hyperglycemia.
Diabetes self-management education and support can help patients develop practical skills for managing their condition.
Important topics include:
Preventive care should be incorporated into the patient’s long-term management plan.
Important considerations include:
Referral for a comprehensive eye examination is appropriate because of the patient’s progressive blurred vision and diabetes history.
A certified diabetes care and education specialist can help address medication adherence, glucose monitoring, nutrition, lifestyle changes, and diabetes self-management.
A registered dietitian can provide individualized nutrition counseling to support glycemic control, weight management, and blood pressure reduction.
Follow-up should be arranged promptly to reassess the patient’s fatigue and chronic disease management.
At follow-up, clinicians should review:
Earlier assessment is appropriate if the patient develops chest pain, severe shortness of breath, sudden vision changes, confusion, severe weakness, or other concerning symptoms.
Persistent fatigue in an older adult should be evaluated rather than automatically attributed to aging. In this case, inadequate diabetes control is the leading concern because the patient has an A1C of 8.5%, inconsistent medication use, urinary frequency, nocturia, blurred vision, and bilateral foot pain.
Her uncontrolled hypertension and strong cardiovascular family history further increase her risk profile. A comprehensive approach should therefore combine diabetes and blood pressure management with medication reconciliation, evaluation for neuropathy and eye disease, lifestyle counseling, preventive screening, and close follow-up.
The most likely contributor is poorly controlled type 2 diabetes associated with medication nonadherence. Her elevated A1C and symptoms such as frequent urination, nocturia, blurred vision, and foot pain support inadequate diabetes control.
Hypothyroidism can cause fatigue and weight gain, but the patient’s reported TSH is within the normal reference range. She also lacks several classic hypothyroid symptoms, making thyroid dysfunction less likely as the primary cause.
An A1C of 8.5% indicates that average blood glucose has been above the usual treatment target for many adults with diabetes. Individual A1C goals should be determined based on factors such as age, comorbidities, treatment risks, and patient preferences.
Yes. Bilateral foot pain in a person with diabetes can be associated with peripheral neuropathy, although other causes must also be considered. A focused diabetic foot and neurological assessment is appropriate.
Diabetes can affect the retinal blood vessels and increase the risk of diabetic retinopathy. Progressive blurred vision can also have other causes, so a comprehensive eye examination is important.
Consistent use of prescribed diabetes therapy helps maintain blood glucose within the individualized target range and reduces the risk of long-term complications. Patients experiencing side effects should contact their healthcare provider rather than stopping medication independently.
Improving glycemic control, addressing medication barriers, following an individualized nutrition and activity plan, improving sleep, maintaining hydration, and attending regular follow-up appointments can help address fatigue and reduce diabetes-related health risks.
This case demonstrates why persistent fatigue in an older adult requires a systematic clinical assessment. The patient’s elevated A1C, medication nonadherence, urinary frequency, nocturia, blurred vision, bilateral foot pain, and uncontrolled blood pressure point toward inadequate management of chronic disease, with poorly controlled type 2 diabetes representing the leading clinical concern.
Management should focus on improving diabetes and hypertension control, addressing medication intolerance, evaluating possible neuropathy and diabetic eye disease, improving sleep and lifestyle habits, and updating preventive care. Patient education and close follow-up are essential for improving adherence, reducing complications, maintaining independence, and supporting long-term health.
American Diabetes Association Professional Practice Committee. (2025). 1. Improving care and promoting health in populations: Standards of care in diabetes—2025. Diabetes Care, 48(Supplement_1), S10–S18. https://doi.org/10.2337/dc25-S001
American Diabetes Association Professional Practice Committee. (2025). 6. Glycemic goals and hypoglycemia: Standards of care in diabetes—2025. Diabetes Care, 48(Supplement_1). https://diabetesjournals.org/care/issue/48/Supplement_1
American Diabetes Association Professional Practice Committee. (2025). 10. Cardiovascular disease and risk management: Standards of care in diabetes—2025. Diabetes Care, 48(Supplement_1). https://diabetesjournals.org/care/issue/48/Supplement_1
American Diabetes Association Professional Practice Committee. (2025). 12. Retinopathy, neuropathy, and foot care: Standards of care in diabetes—2025. Diabetes Care, 48(Supplement_1). https://diabetesjournals.org/care/issue/48/Supplement_1
Centers for Disease Control and Prevention. (2024). Diabetes basics. https://www.cdc.gov/diabetes/about/index.html
Centers for Disease Control and Prevention. (2024). Diabetes and your eyes. https://www.cdc.gov/diabetes/about/diabetes-and-your-eyes.html
U.S. Preventive Services Task Force. (2024). Breast cancer: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening
U.S. Preventive Services Task Force. (2018). Screening for prediabetes and type 2 diabetes. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes
Mayo Clinic. (2024). Hypothyroidism: Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20350284
Persistent fatigue in a 64-year-old woman with type 2 diabetes and hypertension should not be attributed to normal aging without further evaluation. In this case, the most likely explanation for the patient’s fatigue is poorly controlled type 2 diabetes mellitus associated with medication nonadherence, with nocturia, sleep disruption, blurred vision, and bilateral foot pain suggesting possible diabetes-related complications. Her elevated hemoglobin A1C of 8.5% supports inadequate glycemic control, while her blood pressure of 160/90 mmHg indicates uncontrolled hypertension. A comprehensive history, physical examination, laboratory evaluation, medication review, and assessment for diabetes complications are therefore essential.
The patient presents with the chief complaint:
“I am feeling a bit tired lately.”
She describes persistent fatigue that has progressively interfered with her normal activities and independence.
The patient is a 64-year-old African American woman who reports progressively worsening fatigue for approximately 4–6 months. She states that the symptoms began suddenly after cleaning her kitchen and have persisted since that time.
She describes the sensation as “dragging” throughout the day, with fatigue becoming particularly noticeable between 3:00 PM and 4:00 PM. Activities such as grocery shopping significantly worsen her symptoms. She increasingly relies on her daughter for assistance because she is no longer able to complete shopping independently.
Rest provides temporary improvement. Sitting quietly for approximately 30–40 minutes helps restore some energy, although the fatigue eventually returns. She rates the severity of her fatigue at 6–7 out of 10 and has not tried a specific treatment.
The patient also reports bilateral foot pain, occasional headaches, progressively blurred vision during the past year, frequent daytime urination, and nocturia approximately three times each night.
Her medical history includes type 2 diabetes mellitus and essential hypertension. However, medication adherence is inconsistent. She frequently forgets to take her medications and stopped taking metformin approximately six months ago because of persistent gastrointestinal adverse effects, including gas, diarrhea, and abdominal discomfort.
She currently uses extra-strength acetaminophen as needed for headaches.
The combination of fatigue, elevated A1C, medication nonadherence, urinary frequency, nocturia, blurred vision, and bilateral foot pain raises concern for inadequate diabetes control and possible early diabetes-related complications.
Medication | Dosage | Indication |
Atenolol | 25 mg orally once daily | Hypertension |
Hydrochlorothiazide | 25 mg orally once daily | Hypertension |
Metformin | 2,000 mg orally once daily; currently not taking | Type 2 diabetes |
Glyburide | 20 mg orally once daily | Type 2 diabetes |
Aspirin | 81 mg orally once daily | Cardiovascular protection |
Extra-strength acetaminophen | Two tablets every 4–6 hours as needed | Headache relief |
Medication adherence is a major concern in this case. The patient frequently forgets to take her prescribed medications and independently discontinued metformin because of gastrointestinal adverse effects.
Metformin commonly causes gastrointestinal symptoms, particularly when treatment is initiated or doses are increased. However, discontinuing diabetes medication without discussing alternatives with a healthcare professional can result in inadequate glycemic control.
Potential strategies for improving metformin tolerance include discussing an extended-release formulation, taking the medication with meals, or gradually adjusting the dose. If intolerance persists, the healthcare provider can consider an alternative glucose-lowering medication.
The patient denies allergies to prescription medications, foods, and environmental allergens.
The patient’s significant medical history includes:
Both conditions require consistent treatment, monitoring, lifestyle modification, and periodic evaluation for complications.
The patient reports:
The patient’s family history indicates substantial cardiovascular and diabetes risk.
Family Member | Medical History |
Father | Died from myocardial infarction at age 58 |
Mother | Died from complications of type 2 diabetes at age 81 |
Sister | Died from myocardial infarction at age 67 |
This family history further increases concern for cardiovascular complications in a patient who already has diabetes and uncontrolled hypertension.
The patient is a retired teacher who has been widowed for more than 25 years. She lives independently and reports feeling safe in her home. Her adult daughter assists with physically demanding activities, particularly grocery shopping, because of the patient’s increasing fatigue.
She reports that she:
Although she reports few traditional lifestyle-related risk factors, her declining energy and functional capacity are beginning to affect her independence.
The patient reports persistent fatigue that has gradually worsened over several months. She reports approximately five pounds of unintended weight gain during the past year and reduced participation in normal activities because of decreased energy.
She denies chest pain, palpitations, and peripheral edema.
She denies shortness of breath, cough, wheezing, and respiratory distress.
She denies rashes, skin lesions, nonhealing wounds, bruising, and changes in skin color.
The patient reports progressively worsening blurred vision during the past year and uses reading glasses.
She reports gas, diarrhea, and abdominal discomfort associated with metformin use. She denies constipation, nausea, vomiting, black or tarry stools, and eating disorders.
The patient reports urinating approximately 10–12 times during the day and waking approximately three times each night to urinate.
She denies dysuria, hematuria, foul-smelling urine, vaginal discharge, and sexual activity.
She also reports that her last Pap smear and mammogram were approximately seven years ago, indicating that preventive screening should be reviewed according to current age-appropriate recommendations.
The patient reports bilateral foot pain but denies joint stiffness, previous fractures, and muscle weakness.
She reports persistent fatigue but denies syncope, seizures, focal weakness, or balance problems.
She denies easy bruising, blood clots, swollen lymph nodes, excessive thirst, increased appetite, heat intolerance, cold intolerance, and previous blood transfusions.
The patient reports difficulty sleeping because nocturia repeatedly interrupts her sleep. She denies depression, anxiety, suicidal ideation, and previous suicide attempts.
Several findings are particularly important when evaluating this patient’s fatigue:
Together, these findings make poorly controlled diabetes a major clinical concern while also requiring assessment for cardiovascular, neurological, ophthalmic, endocrine, and sleep-related contributors to fatigue.
A comprehensive physical examination was performed to evaluate possible causes of fatigue and assess the patient’s chronic conditions. She appeared fatigued but clinically stable and was not in acute distress.
Parameter | Result |
Weight | 190 lb (86.2 kg) |
Height | 5 ft 7 in (170 cm) |
BMI | 29.8 kg/m² |
Temperature | 37.7°C |
Blood pressure | 160/90 mmHg |
Pulse | 80 beats/minute |
Respiratory rate | 20 breaths/minute |
The blood pressure reading is elevated and indicates inadequate hypertension control. Her BMI falls within the overweight range, which is an important consideration in diabetes and cardiovascular risk management.
The patient is a pleasant, cooperative 64-year-old woman who appears fatigued but is not in acute distress. She is alert and oriented to person, place, time, and situation. Her posture and gait are steady, and she answers questions appropriately. Hygiene and clothing are appropriate.
The skin is warm, dry, clean, and intact. No rashes, ulcers, lesions, bruising, or signs of infection are observed.
The head is normocephalic and atraumatic without visible deformities or lesions. Hair distribution is normal.
Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. There is no conjunctival injection or scleral icterus.
Despite the normal basic eye examination, the patient’s history of progressive blurred vision requires further ophthalmic evaluation because a routine examination does not rule out diabetic retinal disease.
The external auditory canals are patent. Tympanic membranes are pearly gray with visible landmarks and normal light reflexes.
Nasal mucosa is pink and moist. Turbinates appear normal.
The oral mucosa is pink and moist. The pharynx is nonerythematous and without exudate. Dentition is in good condition.
The neck is supple with full range of motion. No cervical lymphadenopathy, thyroid enlargement, thyroid nodules, carotid bruits, or jugular venous distention are noted.
Cardiovascular examination demonstrates a regular rate and rhythm with normal S1 and S2 heart sounds. No murmurs, gallops, rubs, or additional heart sounds are detected.
Peripheral pulses are strong and symmetrical, capillary refill is less than two seconds, and there is no peripheral edema.
Although the cardiovascular examination is otherwise unremarkable, the patient’s elevated blood pressure and strong family history warrant continued cardiovascular risk assessment.
The chest wall is symmetrical, and respiratory effort is normal. Lung sounds are clear bilaterally without wheezing, crackles, or rhonchi. Respirations are regular and unlabored.
The abdomen is mildly obese but soft and nontender. Bowel sounds are active in all four quadrants. There is no hepatosplenomegaly, palpable mass, guarding, rebound tenderness, or other significant abnormality.
No breast masses, tenderness, nipple discharge, skin dimpling, discoloration, or retraction are identified.
However, a normal clinical breast examination does not replace recommended screening mammography. The patient’s screening history should therefore be reviewed and updated.
The genitourinary examination is unremarkable. There is no erythema, edema, or tenderness. The bladder is nondistended, and there is no costovertebral angle tenderness or palpable mass.
The patient has full range of motion in all extremities with 5/5 muscle strength bilaterally. There is no joint swelling, deformity, or crepitus. Deep tendon reflexes are 2+ throughout, with normal muscle tone.
Dorsalis pedis and posterior tibial pulses are 2+ bilaterally. Nails appear healthy, and capillary refill is normal.
Despite these normal findings, the patient’s persistent bilateral foot pain warrants additional assessment for peripheral neuropathy and other diabetes-related foot complications.
The neurological examination is within normal limits. Cranial nerves II–XII are intact. Speech, coordination, balance, gait, and strength are normal, with no focal neurological deficits.
A normal basic neurological examination does not exclude diabetic peripheral neuropathy, so focused sensory testing remains important.
The patient is alert, cooperative, and appropriately groomed. Eye contact is maintained, and speech is soft but clear with normal rate and rhythm.
A depression screening score of 3/6 suggests mild depressive symptoms based on the information provided. However, the patient denies depression, anxiety, and suicidal ideation. Continued monitoring of mood and sleep is appropriate because psychological and sleep-related factors can contribute to fatigue.
Laboratory testing helps identify potential metabolic, endocrine, hematologic, renal, and nutritional contributors to fatigue.
Laboratory Test | Result | Clinical Interpretation |
Hemoglobin A1C | 8.5% | Above the usual treatment goal for many adults; indicates inadequate glycemic control |
CBC | Normal | No evidence of anemia or obvious hematologic abnormality |
CMP | Normal | Kidney and liver function are within the reported normal range |
Urinalysis | Normal | No reported glucose, protein, ketones, nitrites, or blood |
Lipid panel | HDL 45 mg/dL; LDL 52 mg/dL | LDL is well controlled based on the reported value |
TSH | 0.555 μIU/mL | Within the reported reference range |
Vitamin D | Normal | Vitamin D deficiency is unlikely to explain the fatigue |
The laboratory results help narrow the differential diagnosis.
The hemoglobin A1C of 8.5% is the most clinically significant abnormality because it demonstrates that the patient’s diabetes is not adequately controlled. Her history of inconsistent medication use provides a likely explanation.
The normal CBC makes anemia less likely as the primary cause of fatigue. Normal metabolic testing also makes significant renal or hepatic dysfunction less likely based on the available results. Similarly, the reported normal vitamin D level makes vitamin D deficiency an unlikely explanation.
The normal TSH reduces the likelihood that hypothyroidism is causing her fatigue and weight gain.
A normal urinalysis does not rule out diabetes or its chronic complications. Glycemic control should be assessed using appropriate measures such as A1C and, when indicated, blood glucose monitoring.
The patient’s presentation includes chronic fatigue, poorly controlled type 2 diabetes, uncontrolled hypertension, medication nonadherence, nocturia, blurred vision, and bilateral foot pain.
The available evidence makes inadequate diabetes control the leading clinical explanation for her symptoms. However, fatigue is often multifactorial, so sleep disruption, cardiovascular disease, medication effects, depression, deconditioning, and other conditions should remain part of the broader assessment.
Poorly controlled type 2 diabetes is the primary diagnosis because the patient’s symptoms and laboratory findings are consistent with inadequate glycemic control.
Supporting findings include:
Chronic hyperglycemia can contribute to fatigue and increase the risk of microvascular and macrovascular complications. The patient’s visual symptoms and foot pain make screening for diabetic retinopathy and neuropathy particularly important.
Hypertension is another significant diagnosis because the patient’s blood pressure is 160/90 mmHg despite prescribed antihypertensive therapy.
Potential contributing factors include medication nonadherence and excess cardiovascular risk associated with diabetes and overweight status.
Hypertension does not fully explain the patient’s symptom pattern, but uncontrolled blood pressure substantially increases her risk of cardiovascular disease, stroke, kidney disease, and other complications.
Hypothyroidism should initially be considered because fatigue, weight gain, and decreased activity can occur with thyroid hormone deficiency.
However, it is less likely in this case because the patient’s reported TSH is within the normal reference range. She also denies several common symptoms associated with hypothyroidism, including cold intolerance and constipation.
Therefore, hypothyroidism remains part of the differential diagnosis but is not the leading explanation for the patient’s symptoms.
Poorly Controlled Type 2 Diabetes Mellitus Associated With Medication Nonadherence, With Symptoms Concerning for Diabetes-Related Complications
The patient’s fatigue is most consistent with inadequate diabetes control in the setting of inconsistent medication use. Her A1C of 8.5%, urinary frequency, nocturia, progressive blurred vision, and bilateral foot pain collectively indicate the need for improved diabetes management and evaluation for complications.
Uncontrolled hypertension further increases her overall cardiovascular risk but does not adequately account for the complete symptom pattern. Hypothyroidism is less likely because the reported TSH is normal.
Type 2 diabetes mellitus involves insulin resistance combined with progressive impairment of pancreatic beta-cell function. As insulin becomes less effective, glucose regulation becomes impaired and blood glucose levels rise.
Persistent hyperglycemia can affect multiple organ systems. Excess glucose can contribute to osmotic diuresis, resulting in increased urination and nocturia. Chronic metabolic and vascular changes can damage peripheral nerves and retinal vessels, potentially contributing to foot symptoms and visual changes.
Poor glycemic control can also increase the risk of cardiovascular disease, kidney disease, neuropathy, retinopathy, and impaired wound healing.
In this patient, inconsistent medication use and discontinuation of metformin because of adverse effects likely contribute to inadequate diabetes control.
Management should address the patient’s diabetes, hypertension, medication adherence, fatigue, sleep disruption, foot pain, visual changes, and preventive healthcare needs.
The treatment plan should be individualized by the patient’s healthcare provider and should consider her medication tolerance, cardiovascular risk, kidney function, lifestyle, preferences, and ability to follow the treatment regimen.
The patient’s current medications should be reviewed by her healthcare provider rather than simply continued or discontinued without reassessment.
Her regimen includes atenolol and hydrochlorothiazide for hypertension, glyburide for diabetes, aspirin for cardiovascular protection, and acetaminophen for headaches.
Because medication adherence is inconsistent, medication reconciliation should determine what she is actually taking and identify barriers to adherence.
The patient stopped metformin because of gas, diarrhea, and abdominal discomfort. These symptoms should be discussed with her healthcare provider before restarting the medication.
Depending on clinical circumstances, strategies may include:
The goal is to achieve effective glycemic control without causing unacceptable adverse effects.
The underlying cause of diarrhea should be assessed rather than automatically treating the symptom with an antidiarrheal medication. If diarrhea is directly associated with metformin and continues after medication adjustment, the healthcare provider can determine whether symptomatic treatment or an alternative diabetes medication is appropriate.
Lifestyle interventions are important components of diabetes and hypertension management.
The patient should be encouraged to gradually increase physical activity according to her functional capacity and medical status. Nutrition should emphasize vegetables, high-fiber foods, whole grains, lean proteins, and minimally processed foods while limiting added sugars, refined carbohydrates, and excess sodium.
Because fatigue and nocturia interfere with sleep, improving nighttime urinary symptoms and establishing consistent sleep habits should also be part of the care plan.
Weight management may provide additional benefits for blood glucose control, blood pressure, and cardiovascular health.
Progressive blurred vision in a patient with diabetes requires comprehensive eye evaluation. A dilated retinal examination can assess for diabetic retinopathy and other common causes of vision changes.
The patient should be referred for appropriate eye care rather than assuming that her normal basic eye examination excludes retinal disease.
Bilateral foot pain should prompt focused assessment for diabetic peripheral neuropathy and other foot complications.
Evaluation may include:
The patient reports that her last mammogram was approximately seven years ago. At age 64, she should discuss current breast cancer screening recommendations with her healthcare provider and obtain screening appropriate to her individual risk profile.
Her cervical cancer screening history is also overdue based on the information provided. Screening recommendations depend on age, previous results, screening history, and whether she has had a hysterectomy or other relevant procedures.
Patient education should focus on helping the patient understand why consistent chronic disease management is important.
The patient should be encouraged to discuss medication side effects rather than stopping medications independently.
Helpful adherence strategies include:
Home blood pressure monitoring can provide useful information about treatment response.
The patient should measure her blood pressure according to provider instructions, record the results, and bring the log to follow-up visits.
A persistent reading of 160/90 mmHg warrants clinical reassessment rather than being managed through lifestyle measures alone.
The need for home glucose monitoring depends on the patient’s diabetes treatment plan and clinical circumstances. If monitoring is recommended, she should receive instruction on proper meter use, timing of measurements, recording results, and recognizing symptoms of hypoglycemia and hyperglycemia.
Diabetes self-management education and support can help patients develop practical skills for managing their condition.
Important topics include:
Preventive care should be incorporated into the patient’s long-term management plan.
Important considerations include:
Referral for a comprehensive eye examination is appropriate because of the patient’s progressive blurred vision and diabetes history.
A certified diabetes care and education specialist can help address medication adherence, glucose monitoring, nutrition, lifestyle changes, and diabetes self-management.
A registered dietitian can provide individualized nutrition counseling to support glycemic control, weight management, and blood pressure reduction.
Follow-up should be arranged promptly to reassess the patient’s fatigue and chronic disease management.
At follow-up, clinicians should review:
Earlier assessment is appropriate if the patient develops chest pain, severe shortness of breath, sudden vision changes, confusion, severe weakness, or other concerning symptoms.
Persistent fatigue in an older adult should be evaluated rather than automatically attributed to aging. In this case, inadequate diabetes control is the leading concern because the patient has an A1C of 8.5%, inconsistent medication use, urinary frequency, nocturia, blurred vision, and bilateral foot pain.
Her uncontrolled hypertension and strong cardiovascular family history further increase her risk profile. A comprehensive approach should therefore combine diabetes and blood pressure management with medication reconciliation, evaluation for neuropathy and eye disease, lifestyle counseling, preventive screening, and close follow-up.
The most likely contributor is poorly controlled type 2 diabetes associated with medication nonadherence. Her elevated A1C and symptoms such as frequent urination, nocturia, blurred vision, and foot pain support inadequate diabetes control.
Hypothyroidism can cause fatigue and weight gain, but the patient’s reported TSH is within the normal reference range. She also lacks several classic hypothyroid symptoms, making thyroid dysfunction less likely as the primary cause.
An A1C of 8.5% indicates that average blood glucose has been above the usual treatment target for many adults with diabetes. Individual A1C goals should be determined based on factors such as age, comorbidities, treatment risks, and patient preferences.
Yes. Bilateral foot pain in a person with diabetes can be associated with peripheral neuropathy, although other causes must also be considered. A focused diabetic foot and neurological assessment is appropriate.
Diabetes can affect the retinal blood vessels and increase the risk of diabetic retinopathy. Progressive blurred vision can also have other causes, so a comprehensive eye examination is important.
Consistent use of prescribed diabetes therapy helps maintain blood glucose within the individualized target range and reduces the risk of long-term complications. Patients experiencing side effects should contact their healthcare provider rather than stopping medication independently.
Improving glycemic control, addressing medication barriers, following an individualized nutrition and activity plan, improving sleep, maintaining hydration, and attending regular follow-up appointments can help address fatigue and reduce diabetes-related health risks.
This case demonstrates why persistent fatigue in an older adult requires a systematic clinical assessment. The patient’s elevated A1C, medication nonadherence, urinary frequency, nocturia, blurred vision, bilateral foot pain, and uncontrolled blood pressure point toward inadequate management of chronic disease, with poorly controlled type 2 diabetes representing the leading clinical concern.
Management should focus on improving diabetes and hypertension control, addressing medication intolerance, evaluating possible neuropathy and diabetic eye disease, improving sleep and lifestyle habits, and updating preventive care. Patient education and close follow-up are essential for improving adherence, reducing complications, maintaining independence, and supporting long-term health.
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