CASE STUDY

Primary Care of the Maturing and Aged Family Case Study

Chamberlain College of Nursing

NR 601

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CASE STUDY

Primary Care of the Maturing and Aged Family Case Study

The purpose of this paper is to analyze a case study provided with patient information,

lab work, subjective, and objective data. Diagnosis will be developed from reviewing the given

information, as well as a management plan will be implemented. Demonstrating skills, such as

writing a SOAP note, will be mastered, and this paper will help the FNP prepare for upcoming

patients and case studies in the future, by mastering this assignment.

Assessment

Primary Diagnosis: Type 2 diabetes mellitus (E11)

Pathophysiology: Type 2 diabetes mellitus is a metabolic disorder, which occurs when

the body does not utilize insulin properly (ADA, 2019). The pancreas will try to

overcompensate by making more insulin in efforts to get glucose into cells, but over time

the pancreas can not keep up, leading to an excess amount of sugar in the blood (ADA,

2019). Classic signs and symptoms include the following: polydipsia, polyuria, and

polyphagia (ADA, 2019).

Pertinent positive findings: Type 2 diabetes mellitus was chosen because of many

subjective and objective findings. The patient has risk factors such as his race (African

American), age of 57 years, and weight of 210 pounds (ADA, 2019). According to the

American Diabetes Association, people are at a higher risk of developing type 2 diabetes,

who are overweight, are of Hispanic or African American decent, and live a sedentary

lifestyle.

Pertinent negative findings: This patient does not live a sedentary lifestyle, as he has

mentioned working out at least 3-4 days a week, and walking for 30 minutes on the

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CASE STUDY

treadmill. Despite his efforts of living a more active lifestyle, he is still overweight, with

a BMI of 31 (obese), which puts him at risk for T2DM (ADA, 2019).

Rationale for the diagnosis: Lab values contributing to this diagnosis are the following:

glucose of 136, hemoglobin A1C 6.8%, and small amount of glucose (+1) found in urine.

According to the American Diabetes Association guidelines, patients with an A1C greater

than 6.5% puts you at the diabetes mark, along with a glucose over 126 mg/dl (2019).

Secondary Diagnosis: Hyperlipidemia (E78.5)

Pathophysiology: Hyperlipidemia occurs when there are high levels of fat or lipids due

to an overproduction of lipoproteins by the liver (Shattat, 2014). Patients will not

typically present with any symptoms, and it is diagnosed using lab values.

Pertinent positive findings: Patient’s total cholesterol is just a little bit over 200.

Pertinent negative findings: LDL, HDL, and tryglycerides are out of range, and much

higher than the norm.

Rationale for the diagnosis: His triglycerides are 225, LDL 134, HDL 32, TC 202; the

normal for triglycerides should be below 150, LDL should be less than 70 (for patients

with heart disease or diabetes), and HDL should be greater than 60, and the total

cholesterol should be less than 200, this would indicate hyperlipidemia (ACC, 2018).

Secondary Diagnosis: Obesity (E66.0)

Pathophysiology: Obesity is linked to the central circuit mechanisms of the brain

becoming impaired, and causing neuro-endocrinological dysfunctions of the hormones

(Zhang et al., 2014).

Pertinent positive findings: Patient does workout regularly, and is being mindful of

making lifestyle changes.

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