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Robertson Case Study week 5
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CASE STUDY 1 Case Study: Diabetes Courtney Robertson Chamberlain College of Nursing NR601: Primary Care of the Maturing and Aged Family March 2019 CASE STUDY 2 Case Study: Diabetes The purpose of this paper is to analyze the objective and subjective data provided by a case study on Mrs. G...

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  • April 30, 2022
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  • 2021/2022
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CASE STUDY 1




Case Study: Diabetes

Courtney Robertson

Chamberlain College of Nursing

NR601: Primary Care of the Maturing and Aged Family

March 2019

,CASE STUDY 2


Case Study: Diabetes

The purpose of this paper is to analyze the objective and subjective data provided by a

case study on Mrs. G from her annual exam. After evaluation an appropriate diagnosis,

treatment, and management plan per the latest national guidelines will be developed including

cost of medications. The information collected through out the exam will be placed into a SOAP

note format with and individualized plan made and presented per Mrs. G’s findings.



Assessment

In the reviewed case study of Mrs. G’s annual exam we find a Hispanic 56 year old

female who has presented with increased fatigue, weight gain, increased hunger and thirst, and

increased urination. She has no history of which would be significant of the above-mentioned

symptoms. Objective data collected and presented in this case study together with the above-

mentioned symptoms are used in decision to diagnose the patient appropriately.

Primary Diagnosis

Type 2 Diabetes Mellitus (E11) was chosen as the primary diagnosis based on the

national diabetes guidelines from the American Diabetes Association [ADA] (2019). According

to the recommended criteria a Hgb A1C > 6.5%, a fasting plasma glucose (FPG) > 126, a 2-h

plasma glucose > 200, or the presence of symptoms of hyperglycemia such as polyuria,

polydipsia, polyphagia plus a random PG > 200 can be used to diagnose (ADA, 2019). If using

an A1C, 2-H plasma glucose, or FPG alone a repeated test should be done without delay with a

second blood sample to confirm the diagnosis of T2DM (ADA, 2019). Signs and symptoms

related to T2DM are polyuria, polydipsia, increased hunger, blurred vision, numbness or tingling

in hands or feet, slow healing wounds, or increase of infections (ADA, 2019). Risk factors are

, CASE STUDY 3


related to family history of T2DM, age >45, ethnicity of Hispanic, African American, American

Indian, or Alaskan, history of gestational diabetes, obesity, and a sedentary lifestyle (ADA,

2019). The American Diabetes Association recommends screening for those >45 and overweight

or obesity with at least one other risk factor (ADA, 2019).

Pathophysiology. Type 2 Diabetes Mellitus is caused by a decrease in insulin secretion

due to abnormal B-cell function (ADA, 2019). Signs and symptoms of T2DM are fatigue,

frequent urination, increased hunger, increased thirst, pain or tingling in hands and feet,

and slow healing wounds (ADA, 2019).


pertinent positive findings. The rationale for this diagnoses is based on her pertinent

positive objective findings of Hgb A1C of 6.9%, glucose in her urine, protein in urine,

total cholesterol 230mg/dl; LDL 144 mg/dl; VLDL 36; HDL 38 mg/dl; Triglycerides;

232, height 5’2”, weight 185 pounds, and elevated blood pressure 129/80 (ADA, 2019).

Signs and symptoms of fatigue, polyuria, polydipsia, increased hunger, obesity, and birth

weight of her child 9lbs 2 oz. which is indicative of gestational diabetes and also puts her

at a higher risk for developing T2DM (ADA, 2019).


pertinent negative findings. Pertinent negative findings would be blood glucose of 95,

blurred vision, slow healing wounds, or known family history as indicated by the

American Diabetic Association (2019).


rationale for the diagnosis. The subjective and objective findings with in this case study

that were used to diagnose Mrs. G with T2DM are a Hgb A1C of 6.9%, abnormal lipid

panel, glucose and protein in urine, fatigue, obesity, polyuria, polydipsia, and increased

hunger (ADA, 2019). The risk for development are greatly increased with age, elevated

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