CASE STUDY TITLE 2
Week 5: Case Study
Name………..
Chamberlain College of Nursing
NR601: Primary Care of the Maturing and Aged Family
Week 5: Case Study
For this case study, we have Mr. Jones who 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
,CASE STUDY TITLE 3
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
, CASE STUDY 4
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)
Pathophysiology: Beta cells in the pancreas become weak, causing insulin to be
blocked, and insulin secretion to be impaired. This process leads to a rise in insulin
levels, which produces hyperinsulinemia causing fasting hyperglycemia (Dunphy,
Winland-Brown, Porter, & Thomas, 2019). Common signs and symptoms include
classic triad symptoms of polydipsia, polyphagia with weight loss, and polyuria
(Kennedy- Malone, Martin-Plank, & Duffy, 2019)
pertinent positive findings: This patient presents with increased thirst (polydipsia),
increased/frequent urination (polyuria), and increased hunger (polyphagia),
obesity, and fatigue. His hemoglobin A1C is 6.9%, 1+ glucose in the urine, and
fasting glucose of
135. Some pertinent subjective findings patients present, according to Dunphey et
al., 2019 are fatigue, nocturia, polydipsia, polyphagia, and polyuria. An objective
finding is many of these patients are obese (Dunphy et al., 2019).
pertinent negative findings: This patient has no family history of diabetes, he
exercises, triglycerides less than 250, no HTN, or history of cardiovascular disease
(Advanced Practice Education Associates, 2020).
CCK 4/19
Week 5: Case Study
Name………..
Chamberlain College of Nursing
NR601: Primary Care of the Maturing and Aged Family
Week 5: Case Study
For this case study, we have Mr. Jones who 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
,CASE STUDY TITLE 3
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
, CASE STUDY 4
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)
Pathophysiology: Beta cells in the pancreas become weak, causing insulin to be
blocked, and insulin secretion to be impaired. This process leads to a rise in insulin
levels, which produces hyperinsulinemia causing fasting hyperglycemia (Dunphy,
Winland-Brown, Porter, & Thomas, 2019). Common signs and symptoms include
classic triad symptoms of polydipsia, polyphagia with weight loss, and polyuria
(Kennedy- Malone, Martin-Plank, & Duffy, 2019)
pertinent positive findings: This patient presents with increased thirst (polydipsia),
increased/frequent urination (polyuria), and increased hunger (polyphagia),
obesity, and fatigue. His hemoglobin A1C is 6.9%, 1+ glucose in the urine, and
fasting glucose of
135. Some pertinent subjective findings patients present, according to Dunphey et
al., 2019 are fatigue, nocturia, polydipsia, polyphagia, and polyuria. An objective
finding is many of these patients are obese (Dunphy et al., 2019).
pertinent negative findings: This patient has no family history of diabetes, he
exercises, triglycerides less than 250, no HTN, or history of cardiovascular disease
(Advanced Practice Education Associates, 2020).
CCK 4/19
