Running head: WEEK 5 CASE STUDY ASSIGNMENT 1
Week 5 Case Study Assignment
Kelsey R. Gunter
Chamberlain College of Nursing
NR 601: Primary Care of the
... [Show More] Maturing and Aged Family
August 2019
WEEK 5 CASE STUDY ASSIGNMENT 2
Week 5 Case Study Assignment
The purpose of this paper is to review and analyze a case study involving a patient named Mrs.
Wong with the end goal of diagnosing her and developing a management plan of care for her with the
incorporation of the national diabetes guidelines. The subsequent sections of this paper are: Assessment,
Plan, Medication Costs, SOAP Note, and Conclusion. The assessment will include a primary, secondary
and differential diagnosis, the rationale for selecting each diagnosis, the pathophysiology of each
diagnosis, and pertinent positive and negative subjective and objective findings for each diagnosis. The
plan will include diagnostics, medications, education, referrals and follow-up for each diagnosis. The
medication costs section will review individual and total costs for a one-month supply of the prescribed
and OTC medications for the patient. The SOAP note will include subjective data, objective data,
assessment and plan information.
Assessment
Mrs. Wong is a 59-year-old Asian woman who presents to the clinic for a planned follow-up
appointment for right knee arthritis. Mrs. Wong reports less knee pain and increased mobility with her
current treatment plan; however, she reports having new concerns unrelated to her arthritis. Her new
concerns consist of increased fatigue over the past two months, increased hunger, increased thirst, and
weight gain of four pounds since menopause 4 years ago even though she exercises regularly at a health
club that includes walking on a treadmill for a minimum of 30 minutes and lifting light weights at least
twice a week. Even though Mrs. Wong initially came to the clinic for a follow-up appointment for her
previously diagnosed arthritis in her right knee, her assessment revealed full range of motion in both
knees, knees were both nontender to palpation and her gait was normal; therefore, I excluded her original
diagnosis of arthritis for this case study review.
Primary Diagnosis Diabetes Mellitus Type 2 (E11.9)
Pathophysiology Diabetes mellitus type 2 is linked to a genetic susceptibility and risk factors of
age, obesity, hypertension, physical inactivity and family history (McCance et al., 2013). Diabetes
mellitus type 2 is caused by insulin resistance and/or decreased insulin secretion by beta cells which
WEEK 5 CASE STUDY ASSIGNMENT 3
means there is a lack of insulin being produced by the pancreas or the circulating insulin in the body is
unable to move glucose into the cells resulting in hyperglycemia (American Diabetes Association, 2018;
McCance et al., 2013).
Pertinent Positive Findings According to the U.S. Preventive Task Force and the American
Diabetes Association, there are four different ways to diagnose a patient with diabetes which are: a fasting
plasma glucose of 126 mg/dL or greater, a Hgb A1C of 6.5% or greater, the presence of acute symptoms
of diabetes plus a random plasma glucose concentration of 200mg/dL or greater, and a 2-hour oral
glucose tolerance test of 200mg/dL or greater (ADA, 2018; U.S. Department of Health and Human
Services, 2014). Based off these guidelines, Mrs. Wong’s Hgb A1C of 6.6% and fasting plasma glucose of
127 is indicative of diabetes type 2 (ADA, 2019). Other pertinent positive findings indicative of diabetes
type 2 are: 1+ glucose present in urine, increased thirst, increased hunger, fatigue, obesity/BMI of 30.7,
and inability to lose weight despite weight loss attempts. In addition, Mrs. Wong’s ethnicity of Asian
descent increases her risk of diabetes (ADA, 2018; Kennedy-Malone, Plank, & Duffy, 2019).
Pertinent Negative Findings No known family history of diabetes. There is no mentioning of
polyuria in the case study which is a common complaint/symptom of diabetes (ADA, 2018). There is also
no evidence of previous diagnosis of hyperglycemia or previous lab work that would be indicative of
hyperglycemia. Also, Mrs. Wong does not live a sedentary lifestyle as evidence by her reports of walking
two times a week for 30 minutes and light weight lifting, in which a sedentary lifestyle is normally
present in diabetes type 2 cases (Dunphy et al., 2015).
Rationale for Diagnosis The selection of diabetes type 2 was made based off the patient’s
subjective and objective information in the case study which consisted of fatigue for 2 months, weight
gain despite weight loss measures, increased thirst, increased hunger, fasting plasma glucose level of 127
mg/dL, A1C of 6.6%, 1+ glucose in urine, and a BMI of 30.7. Mrs. Wong’s symptoms along with her lab
work results which are consistent with the guidelines for diabetes, it is clear that Mrs. Wong meets the
criteria for diabetes mellitus type 2 (ADA, 2019).
Secondary Diagnosis Hyperlipidemia (E78.5)
WEEK 5 CASE STUDY ASSIGNMENT 4
Pathophysiology Hyperlipidemia is often referred to as dyslipidemia and is a result of increased
level of lipids or fats in the body (Dunphy et al., 2015). Hyperlipidemia can lead to plaque build up in the
arteries which can increase one’s chances of a cardiovascular complication such as a heart attack or stroke
as well as development of coronary artery disease and peripheral arterial disease (Jellinger, 2018).
Patients with hyperlipidemia are typically asymptomatic and risk factors that are associated with
hyperlipidemia are: diabetes, obesity, history of stroke or heart attack, cardiovascular disease, an elevated
LDL, low HDL, elevated triglyceride level and elevated total cholesterol level (Dunphy et al., 2015).
Pertinent Positive Findings Mrs. Wong’s lab work is indicative of hyperlipidemia. Her LDL was
elevated at 144 mg/dL and an LDL of 130-159 mg/dL is indicative of coronary artery disease (Dunphy et
al., 2015). Other lab work that is indicative of hyperlipidemia is her triglycerides that were elevated at
229 mg/dL, total cholesterol level was elevated at 215 mg/dL, and her HDL was low at 32 mg/dL. Normal
total cholesterol level is <200 mg/dL, normal HDL is >40 mg/dL and more specifically is >50 mg/dL for
females, normal LDL is <100 mg/dL, and normal triglyceride level is <250 mg/dL (Dunphy et al., 2015;
Hollier, 2018). In addition to Mrs. Wong’s lab work, she also has an elevated blood glucose level, obesity,
history of smoking and weekly intake of alcohol which increases her risk for a cardiovascular event (Woo
& Robinson, 2016).
Pertinent Negative Findings Mrs. Wong’s medical history and family history were negative for
cardiac disease and dyslipidemia. Mrs. Wong’s blood pressure was 112/76 which is a normal blood
pressure result and the fact that she does not have a sedentary lifestyle are both negative findings since
they are typically associated with hyperlipidemia (Jellinger, 2018).
Rationale for Diagnosis The diagnosis of hyperlipidemia was selected because of Mrs. Wong’s
obvious abnormal lipid panel results. Also, hyperlipidemia increases the risk of cardiovascular events and
can contribute or exacerbate symptoms of diabetes, obesity and fatigue (Woo & Robinson, 2016).
Secondary Diagnosis: Obesity with BMI 30.7 (E66.9; Z68.30) [Show Less]