Running head: CASE STUDY 1

NR601: Primary Care of the Maturing and

Aged Family

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CASE STUDY 2

Introduction

The purpose of this paper is to demonstrate the ability to analyze the subjective and

objective information from the case study to formulate a management plan using evidenced

based guidelines. It also demonstrates the student’s ability to write SOAP note in chronological

order. In this case study the assessment, treatment plan, medication and its cost, and SOAP note

will be discussed in detailed.

Assessment

Based on the chief complaints, subjective, and objective findings patient’s primary

diagnosis is type 2 diabetes mellitus (E11). The pathophysiologic mechanism of type 2 diabetes

involves insulin resistance and decreased insulin secretion by beta cells of pancreas (McCance,

Huether, Brashers, & Rote, 2013). The genetic, epigenetic, and environmental factors interfere

the ability to sense increased blood glucose, insulin synthesis, and insulin secretion, which

causes type 2 diabetes. The prevalence of type 2 diabetes increased with age, is higher among

African American female, but obesity, hypertension, physical inactivity, and family history

predominantly increased the risk of type 2 diabetes (McCance et al., 2013). Polyuria, polydipsia,

and polyphagia are the classis symptoms of diabetes, but patient may present with nonspecific

symptoms such as fatigue, pruritus, recurrent infection, visual change, paresthesia, or weakness

(McCance et al., 2013). Based on the information given, the pertinent positive findings include

very fatigued, no energy, weight gain, increased hunger and thrust, and increased frequency of

urination for past 3 month. The polydipsia, polyuria, and polyphagia also known as 3P are the

hallmark symptoms of diabetes (American Diabetes Association [ADA], 2017). The laboratory

finding indicates her hemoglobin A1C is 6.9%, total cholesterol is 230 mg/dl, LDL 144mg/dl,

VLDL 36 mg/dl, HDL 38mg/dl and triglycerides 232. The hemoglobin A1C of ≥ to 6.5% is one

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CASE STUDY 3

of the criteria that indicates diabetes (National Diabetes Education Initiative [NDEI], 2016). Mrs.

G. blood glucose level of 126 which is at the meets the criteria for diabetes but has limited

information on fasting status. The fasting plasma glucose of ≥ 126 is indicative to diabetes

(NDEI, 2016).Her history of delivering a baby who weigh 9lb 2 oz is another risk factor of type

2 diabetes according to the ADA guidelines (NDEI, 2016). In addition, she has 1+ glucose and

small protein on her UA. She weighs 185 pounds and her BMI based on her height and weight is

33.3 which is considered obese. Type 2 diabetes is most common in overweight or obese because

excess weight causes some degree of insulin resistance (ADA, 2017). Other pertinent positive

information that helps to diagnose type 2 diabetes includes obesity, dyslipidemia, and being

Hispanic age greater than 50 years because risk of type 2 increases with age, obesity, lack of

physical activity, dyslipidemia, and in certain racial or ethic groups such as Hispanic (ADA,

2017). The pertinent negative findings include no pruritus, recurrent infection, visual change,

paresthesia, or weakness (McCance et al., 2013). Type 2 diabetes has a strong genetic

predisposition, which Mrs. G is negative for this risk. The patient presenting symptoms such as

3P which are the hallmark symptoms of diabetes, her risk factors, and laboratory findings

strongly suggest type 2 diabetes, thus it is a primary diagnosis of Mrs. G.

Secondary Diagnosis

Mixed hyperlipidemia (E78.2) is a secondary diagnosis that needs to be addressed during

this visit. Hyperlipidemia is an acquired or genetic disorder that causes increased circulating

lipids such as cholesterol, triglycerides, and fats in the blood (Moneta, n.d.). It is most commonly

caused due to consumption of food high in saturated or trans fats, sedentary lifestyle, obesity,

smoking, and diabetes. The familial hyperlipidemia is result from mutation in gene in a form of

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