Case Study
Rita Lewis
Chamberlain College of Nursing
NR601: Primary Care of the Maturing and Aged Family
For this case study, we have Mr. Jones wh
... [Show More] o is a 60-year-old African American coming to the clinic for his six-month follow-up for his hyperlipidemia and weight problems. In diagnosing this patient’s condition, I will gather a thorough history of present illness, physical, laboratory, and diagnostic studies to assist me with implementing a management and treatment plan for this patient. The reason for this paper is to provide evidence-based guidelines to help with clinical reasoning for the treatment decisions made to provide an effective and safe treatment for Mr. Jones.
Assessment
Mr. Jones is presenting to the clinic with complaints of weight gain of seven pounds in spite of exercising 4-5 times a week, fatigue, increased urination, hunger, and thirst. He also states that he has been urinating more frequently during the day and waking to urinate at night. This patient has a history of hyperlipidemia and osteoarthritis. He is up to date on his immunizations and has completed his colonoscopy and will need a repeat in 10 years. His family history is not significant for any chronic health conditions. He quit smoking cigarettes five years ago and drinks 1-2 beers per day. He denies illicit drug use. He has allergies to Bactrim, strawberries, cats, and pollen. He denies latex allergy. His current medications include Simvastatin 10 mg daily for his hyperlipidemia, Tylenol 500 mg two tabs every morning for his knee pain related to osteoarthritis, daily multivitamin, and turmeric. On exam, his vitals are BP 119/77; pulse 80 regular, respirations 16, weight 210 pounds (95.2 kg), Calculated BMI 31. He is alert and oriented. His physical assessment is unremarkable; however, his fasting laboratory values
are significant for 1+ glucose in the urine, hemoglobin A1C of 6.9%, fasting glucose of 135, total cholesterol of 202 mg/dl, LDL 134 mg/dl, HDL 32 mg/dl and Triglycerides of
225. This information will be used to diagnose and implement an effective treatment plan for Mr. Jones.
Primary Diagnosis: Type 2 diabetes mellitus (E11.9) [Show Less]