Case Study: by Ashley Sweeney, Chamberlain College of Nursing, NR601-10901 Primary Care of the Maturing and Aged Family, Primary Diagnosis: Diabetes Mellitus Type 2 (E11.9)

Document Content and Description Below

Case Study: Ashley Sweeney Chamberlain College of Nursing NR601-10901 Primary Care of the Maturing and Aged Family The purpose of this assignment is to review a case study involving the patie... nt, Mrs. Wong, who is a 59 year-old female of Asian descent presenting to the clinic to follow up for her prior diagnosis of arthritis of the right knee. This extensive review includes multiple topics including primary, secondary, and differential diagnosis, management and treatment plans of each of these diagnosis, diagnostic testing, medication review and prescription, patient education, as well as consultations and referrals and follow up care for the patient. In addition, we will also discuss contributing factors such as medication cost for prescription as well as over the counter medications, possible barriers to treatment, and will also include a clinical chart SOAP note for this patient. Assessment As previously stated, miss Wong is a 59 year-old Asian female who was recently diagnosed with arthritis in her right knee. She has returned for a 3 month follow up and, though she states that she is having less knee pain an increased mobility with the previous treatment plan, she has developed some new symptoms which she wants to discuss today. Her concerns today include difficulty losing weight despite weight loss attempts, increased hunger, polydipsia, and recent 4-pound weight gain. She is also having increased fatigue over the last 2 months. Mrs. Wong is four years post menopause and utilizes is a gym membership to exercise multiple times weekly including cardio as well as light weightlifting. Despite her weight loss attempts she continues to have difficulty losing weight and has, in fact, recently gained weight. Although Mrs. Wong is returning for follow up on a previous diagnosis of arthritis in her right knee, range of motion in both knees is within normal limits, knees are non-tender, and gate is normal. Therefore, the previous diagnosis of right knee arthritis, other than possibly effecting any treatment plan exercises or activities, will likely not factor into the diagnosis and differential list for this case study review. Mrs. Wong is 5’1.5” and weighs 165 pounds which give her a body mass index (BMI) of 30.7. This BMI indicates that Mrs. Wong is obese (Calculate Your BMI, n.d.). She is also having difficulty losing weight despite weight loss attempts, is complaining of increased hunger and thirst, and has a blood glucose of 127 with an HgbA1C of 6.6%. Based on these subjective and objective findings, primary diagnosis for Mrs. Wong is Diabetes Mellitus type 2 (DM2), with secondary diagnosis of hyperlipidemia, and differential diagnosis of vitamin D deficiency, and metabolic syndrome. Primary Diagnosis: Diabetes Mellitus Type 2 (E11.9) Pathophysiology: DM2 is a metabolic disorder which affects the body's ability to use insulin properly resulting an insulin resistance and often leading to hyperglycemia (Goroll & Mulley, 2014). Individuals with this condition have a higher risk for developing vascular and neurologic deficits, especially if the disease is not managed, as well as multi-organ damage. Symptoms associated with DM2 include hyperglycemia, polyurea, polydipsia, polyphagia, fatigue, weight gain, slow healing wounds, blurred vision, and numbness or tingling in the hands/feet (Diabetes Symptoms, n.d.). Pertinent Positives: Mrs. Wong has several pertinent positives which indicate possible DM2. She is presenting with increased hunger and thirst, fatigue, obesity, and failure to lose weight despite weight loss attempts. Mrs. Wong is also of Asian descent which puts her at an increased risk for development of DM2 as this is common in people of this ethnicity (Kennedy-Malone, Plank, & Duffy, 2019). In addition, Mrs. Wong also has a fasting glucose of 127, and an HgbA1C of 6.6%. According to the American Diabetes Association, diagnosis of DM2 may be made based on fasting glucose of greater than 126, a random glucose of 200 or greater, and may also be indicated by HgbA1C greater than 6.5% (2018). Mrs. Wong also has a past history of smoking, current alcohol use, and 1+ glucose in her urine. Glycosuria is associated with DM2 but may also be caused by hyperthyroidism, liver cirrhosis, high sugar diet, renal insufficiency, or may even be benign (Hung et al., 2016). Whatever the cause, this reading warrants further investigation and, based on the other presenting symptoms, is most likely due to diabetes. Although Mrs. Wong’s lab values are only slightly above the threshold for diagnosis, they are still above normal and, along with her accompanying symptoms, warrant the need for intervention. [Show More]

Last updated: 1 year ago

Preview 1 out of 22 pages