Running Head: CASE STUDY 1

Week 5 Case Study

Student’s Name:

Chamberlain University College of Nursing

NR 601: Primary Care of the Maturing and Aged Family Dr.

Robert Lewis

2021

CASE STUDY 2

Week 5 Case Study

The purpose of this paper is to evaluate patient information, subjective data, and objective data to

devise a clinical diagnosis. The evidence supporting the diagnosis will be presented and the

pathophysiology will be discussed. A treatment plan will be developed and presented including what

diagnostic tests are appropriate, what medications will be prescribed, potential lifestyle changes, and

possible referrals. A timeframe for follow up will be explored and an assessment of comorbidities will be

discussed. The assessment and treatment plan will be based upon American Diabetes Association’s

(ADA) 2020 Standards of Medical Care in Diabetes.

Assessment

Primary Diagnosis: Type 2 diabetes mellitus (E11)

pathophysiology Type 2 diabetes is a disorder of glucose metabolism in which the body cannot

produce enough insulin, due to a dysfunction of pancreatic ß-cells, or is resistant to the

utilization of insulin in the body. The resistance to insulin or lack thereof, creates increased

plasma glucose concentrations which results in the associated symptoms of polyuria, polydipsia,

and polyphagia (Chamberlain et al., 2016).

pertinent positive findings AJS has a family history of diabetes (mother, brother), BMI 39.5

(obese), and he is a Pacific Islander (2.5 times more likely to develop diabetes than non-Hispanic

white person) (Bellou et al., 2018). 24-h urine collection = urinary albumin excretion rate

250mg/day which is indicative of diabetic kidney disease. His lab results of TC 242 mg/dl, LDL

199 mg/dl; VLDL 38 mg/dl; HDL 48mg/dl, Triglycerides 228 are indicative of diabetic

dyslipidemia (Schofield et al., 2016). He has +1 glucose in his U/A and his hemoglobin A1C is

11.9% (ADA, 2020). He complains of symptoms of numbness and tingling in feet for 6 weeks

(neuropathy) and delayed wound healing (Chamberlain et al., 2016).

CASE STUDY 3

pertinent negative findings His fasting glucose 94, below the 126 cutoff and the U/A is

negative for ketones (Reusch, & Manson, 2017). No signs/symptoms of peripheral vascular

disease or CHF.

rationale for the diagnosis AJs has an A1C of 11.9% and according to the ADA’s 2020

guidelines an A1C above 6.5% is indicative of a diabetes diagnosis (ADA, 2020). He is obese,

has a family history of diabetes, is a Pacific Islander, and has hypertension, all of which increase

his risk of developing diabetes (Bellou et al., 2018). The patient complains of delayed wound

healing, neuropathy, and symptoms of gastroparesis all of which are associated with diabetes

(Reusch, & Manson, 2017).

Secondary Diagnosis Hyperlipidemia (E78.5)

Pathophysiology Abnormal accumulation of lipids in the blood stream because of abnormal lipid

or lipoprotein metabolism which can lead to plaque deposits and atherosclerosis (Schofield et al., 2016).

pertinent positive findings TC 242 mg/dl, LDL 199 mg/dl; VLDL 38 mg/dl; HDL 48mg/dl,

Triglycerides 228, BP 170/100, A1C 11.9%, history of alcohol abuse, family history of coronary artery

disease (CAD), BMI 39.5, thyroid dysfunction, central obesity, sedentary lifestyle (Schofield et al., 2016).

pertinent negative findings No signs/symptoms of peripheral vascular disease or CHF. HR 90.

rationale for the diagnosis Patient’s lipid profile is in the abnormal range (TC 242 mg/dl, LDL

199 mg/dl; VLDL 38 mg/dl; HDL 48mg/dl, Triglycerides 228), which is indicative of hyperlipidemia.

Patient has multiple risk factors for hyperlipidemia such as an A1C of 11.9% which is diagnostic of

diabetes, BMI 39.5 (obese), BP 170/100 (hypertension), previous ETOH abuse, and a family history of

CAD (Schofield et al., 2016).

Secondary Diagnosis Hypertension (I10)

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