Case Study: Diabetes Type 2 Mellitus

Requirements:
The assignment is a paper, which is to be written in APA format using the provided assignment
template. The paper shall not exceed 10 pages, excluding title page and references.  
NR601 _week 5 case study paper template_Nov 19.docx
Case Study Patient - March 2020
Review the provided patient visit information. You are provided with the subjective and objective exam
findings. As the provider, you are to diagnose the case study patient and develop the management plan
for this case study patient. Keep in mind this is a complex patient who has more than one diagnosis,
which is common in primary care.  
Use the provided case study template for your paper. Review the APA Manual to adhere to APA
formatting.
Introduction: briefly discuss the purpose of this paper. (no more than 5 sentences)  
Assessment:  review the provided case study information.
Identify the primary and secondary diagnosis for the patient. Each diagnosis will include the following
information:
1. ICD 10 code.
2. A brief pathophysiology statement which is no longer that two sentences, paraphrased and
includes common signs and symptoms of the diagnosis and proper citation.
3. The patient’s pertinent positive and negative findings, including a brief 1-2 sentence statement,
which links the subjective and objective findings (including lab data and interpretation).
4. An evidence-based rationale statement, which summarizes why the diagnosis was chosen.
5. Do not include quotes, paraphrase all scholarly information and provide an in-text citation to
your scholarly reference. Use the Reference Guidelines document for information on scholarly
references.
Plan: (there are five (5) sections to the management plan)
1. Diagnostics. List all labs and diagnostic test you would like to order. Each test includes a
rationale statement following the listed lab, which includes the diagnosis requiring the test, the
purpose of the test and how the test results will contribute to your management plan. Each
rationale statement is cited. Include all future follow up labs for each listed diagnosis.
2. Medications: Each medication is listed in prescription format. Each prescribed and OTC
medication is linked to a specific diagnosis and includes a paraphrased EBP rationale for
prescribing.
3. Education: section includes personalized detailed education on all five (5) subcategories:
diagnosis, each medication purpose and side effects, diet, personalized appropriate exercise
recommendations and warning sign for diagnosis and medications if applicable. All education

steps are linked to a diagnosis, paraphrased, and include a paraphrased EBP rationale. Review
the NR601 Clinical SOAP note guideline for more detailed information.
4. Referrals: any recommended referrals are appropriate to the patient diagnosis and current
condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale with in text
citation. Review the ADA guidelines for specific follow up recommendations.
5. Follow up: Follow up includes a specific time, not a time range, to return to PCP office for next
scheduled appointment. Includes EBP rationale with in text citation.
Assessment of Comorbidities: in this section students will review the ADA Standards of Medical Care in
Diabetes (the guidelines) Assessment of Comorbidities section on comorbidities subsection and choose
one listed comorbidity. Students will discuss the significance of and the relationship between the
patient’s primary diagnosis and the chosen comorbidity, explaining how one diagnosis affects the other
diagnosis. Any recommended screening, diagnostic testing, and referrals are also included.
Medication costs: in this section students will research the costs of all prescribed and OTC monthly
medications that you have prescribed and that the patient is currently taking that you would like to
continue. Students may use Good Rx, Epocrates or another resource (students may use local pharmacy
websites) which provides medication costs. Students will list each medication, the monthly cost of the
medication and the reference source. Students will calculate the monthly cost of the case study
patient’s prescribed and OTC medications and provide the total costs of the month’s medications.
Reflect on the monthly cost of the medications prescribed. Discuss if prescriptions were adjusted due to
cost. Discuss if will you use medication pricing resources in future practice.

Mrs. G, a 55 year old Hispanic female, presents to the office for her annual exam. She
reports that lately she has been very fatigued and just does not seem to have any
energy. This has been occurring for 3 months. She is also gaining weight since
menopause last year. She joined a gym and forces herself to go twice a week, where
she walks on the treadmill at least 30 minutes but she has not lost any weight, in fact
she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states
that exercise seems to make her even more hungry and thirsty, which is not helping her
weight loss. She wants get a complete physical and to discuss why she is so tired and
get some weight loss advice. She also states she thinks her bladder has fallen because
she has to go to the bathroom more often, recently she is waking up twice a night to
urinate and seems to be urinating more frequently during the day. This has been
occurring for about 3 months too. This is irritating to her, but she is able to fall
immediately back to sleep.
Current medications: Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin
PMH: Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to
date.
GYN hx: G2 P1. 1 SAB, 1 living child, full term, wt 9lbs 2 oz. LMP 15months ago. No
history of abnormal Pap smear.
FH: parents alive, well, child alive, well. No siblings. Mother has HTN and father has
high cholesterol.
SH: works from home part time as a planning coordinator. Married. No tobacco history,
1-2 glasses wine on weekends. No illicit drug use
Allergies: NKDA, allergic to cats and pollen. No latex allergy
Vital signs: BP 129/80; pulse 76, regular; respiration 16, regular
Height 5’2.5”, weight 185 pounds
General: obese female in no acute distress. Alert, oriented and cooperative.
Skin: warm dry and intact. No lesions noted
HEENT: head normocephalic. Hair thick and distribution throughout scalp. Eyes without
exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light
reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx
moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior
cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small
and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs
Lungs: Clear to auscultation bilaterally, respirations unlabored.

Abdomen- soft, round, nontender with positive bowel sounds present; no
organomegaly; no abdominal bruits. No CVAT.
Labwork:
CBC: WBC 6,000/mm3 Hgb 12.5 gm/dl Hct 41% RBC 4.6 million MCV 88 fl MCHC
34 g/dl RDW 13.8%
UA: pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites negative, 1+ glucose; small
protein; negative for ketones
CMP:
Sodium 139
Potassium 4.3
Chloride 100
CO2 29
Glucose 95
BUN 12
Creatinine 0.7
GFR est non-AA 92 mL/min/1.73
GFR est AA 101 mL/min/1.73
Calcium 9.5
Total protein 7.6
Bilirubin, total 0.6
Alkaline phosphatase 72
AST 25
ALT 29
Anion gap 8.10
Bun/Creat 17.7
Hemoglobin A1C: 6.9 %
TSH: 2.35, Free T 4 0.7
Cholesterol: TC 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 38mg/dl, Triglycerides
232
EKG: normal sinus rhythm