Case Study Assignment
Susan Brown
NR-601- Primary Care of the Maturing and Aged Family Chamberlain College of Nursing
This paper will develop an accu
... [Show More] rate primary and secondary diagnosis for Mr. Jones utilizing the subjective and objective data provided and will also include a brief discussion of the pathophysiology of the chosen diagnoses. It will include common signs and symptoms; pertinent positives and negatives as they relate to the patient and the disease processes. Additionally, it will include evidenced-based rationales to support the chosen diagnoses and a detailed management plan that is individualized; consisting of diagnostics, medications, education, referrals, as well as follow-up-care. This paper will include assessment and identification of one comorbidity; with a discussion on the significance and impact that comorbidity has on health outcomes. Anticipated monthly medication costs will be included for all prescription and over the counter (OTC)medications, as well as, where the patient can obtain medications for the best price, and end with a discussion of how this future nurse practitioner will utilize medication pricing resource in future practice.
Assessment
Mr. Jones is a 60-year-old African American male that presents to the clinic for a 6 month follow up for hyperlipidemia and weight loss. Although he reports that he has been going to the gym 3 to 4 times a week, walking on the treadmill, and lifting weights as recommended, and adhering to dietary modifications “as good as he could remember” he has not lost any weight and has gained 7 pounds. He reports increased fatigue for approximately 10 weeks, with increased hunger and thirst. Over the past 2 months he has been experiencing an increase of urinary frequency during the day, as well as having to get up during the night. He is concerned about his increase in fatigue and his inability to lose weight.
His vital signs are: BP: 119/77; P: 80 & regular; R: 16 & regular; Ht.: 5’9.5”, Wt.: 210 lbs., BMI: 30.6 [ CITATION USDnd \l 1033 ]. Pertinent laboratory findings include urinalysis with 1+ glucose; fasting blood glucose (FBG) 135, HgA1C of 6.9%, as well as total cholesterol of 202 mg/dl, LDL 134 mg/dl, HDL 32 mg/dl, and triglycerides of 225. He has a PMH significant for hyperlipidemia and osteoarthritis of the right knee. Based on the HPI, ROS, and objective findings an appropriate primary and secondary diagnosis can be determined.
Primary Diagnosis: new onset Type 2 Diabetes Mellitus (T2DM), ICD-10 (E11.9) [Show Less]