Running head: CASE STUDY
Week 5: Case Study
NR601: Primary Care of the Maturing and Aged Family
,CASE STUDY TITLE 2
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
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 3
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
NR601: Primary Care of the Maturing and Aged Family
,CASE STUDY TITLE 2
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
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 3
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
