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Diabetes Case Study
Kelly Keller- James
Chamberlain College of Nursing
NR 601 Primary Care of the Maturing
and Aged Family
Professor Charles
November 2021
, General Overview
Ms. TC is an 87-year-old Asian American female presenting to the clinic with an allergy to
cantaloupe- reaction hives. In clinic seeking guidance in weight management. Reports gaining
weight particularly in the abdomen. Endorsed to not following a diet plan and eating an
unhealthy diet that consist of sugary soft drinks 3-4 days per week, cookies and yogurt in the
morning, fried chicken, 2 string cheese, crackers, fried tortillas with butter for lunch,
occasionally will cook dinner, otherwise will have chips and dip and reports eating a cobb salad
once a week while at the golf club. She states she doesn’t drink enough water and states her
tongue is dry especially after partaking in golf. Ms. TC also reports frequent urination 8-10 per
day.
Differential Diagnoses: Primary Diagnoses
Based on data collected briefly discuss 3 Differential Diagnoses for your patient for the Primary
Diagnosis. Include ICD10 Codes (cite ICD10data.com):
Primary Diagnosis:
Primary Dx: Type 2 Diabetes Mellitus without complications (ICD E11.9) (2022 ICD-10-CM
codes. 10. (n.d.)- Type 2 Diabetes Mellitus (T2DM) characterized by decreased insulin resistance
due to a dysfunction of pancreatic beta cells. Common clinical presentation of T2DM includes
polydipsia, Polyphagia, and polyuria. TIDM is most common among older adults (American
Diabetes Association, 2021).
Differential Dx#1: Type 1 Diabetes Mellitus (E10) (2022 ICD-10-CM codes. 10. (n.d.) - Type I
Diabetes Mellitus is a chronic autoimmune disease resulting in insulin deficiency due to
destruction of pancreatic beta cells. Clinical presentation of TIDM is polydipsia, polyuria, and
polyphagia plus weight loss and fatigue (American
, Diabetes Association, 2021
Differential Dx #2: Cushing’s syndrome ICD- E24.8 (2022 ICD-10-CM codes. 10. (n.d.). - An
endocrine syndrome characterized by the pituitary glands excessive production of
Adrenocorticotropic hormone (ACTH) and inability to regulate cortisol (2 key components in
regulating glucose, protein, and lipid metabolism, and help maintain blood pressure ().
Differential Dx #3:
Hyperlipidemia (E78.5) (2022 ICD-10-CM codes. 10. (n.d.) - Hyperlipidemia is a disease that
occurs because of elevated concentrations of fat substances (particularly low-density lipoprotein
LDL) in the blood (Epidemiology and management of Hyperlipidemia. AJMC. (n.d.). However,
the main culprit of hyperlipidemia includes lifestyle habits such as diets high in saturated fats
that exceed 40% of total calories, obesity, and a sedentary lifestyle, and thyroid dysfunction
(Epidemiology and management of Hyperlipidemia. AJMC. (n.d.). A Diagnosis is based on lab
values ().
Diagnosing Your Clinical Patient
Based on your findings, (physical exam, lab values, diagnostics) what is the primary
diagnosis for your patient today? What information in the CPG let you to this primary
diagnosis?
Type 2 Diabetes Mellitus (E 11.9)
A diagnosis of diabetes is contingent on a plasma glucose criterion, which requires two
abnormal test results from the same sample or two separate test- day samples of either the fasting
plasma glucose > / = 126mg/dl or Hgb A1C > / = 6.5% or by a random plasma glucose & Oral
Glucose Tolerance Test (OGTT) result >/= 200 & symptomatic or 2-hour plasma glucose 200/=
Diabetes Case Study
Kelly Keller- James
Chamberlain College of Nursing
NR 601 Primary Care of the Maturing
and Aged Family
Professor Charles
November 2021
, General Overview
Ms. TC is an 87-year-old Asian American female presenting to the clinic with an allergy to
cantaloupe- reaction hives. In clinic seeking guidance in weight management. Reports gaining
weight particularly in the abdomen. Endorsed to not following a diet plan and eating an
unhealthy diet that consist of sugary soft drinks 3-4 days per week, cookies and yogurt in the
morning, fried chicken, 2 string cheese, crackers, fried tortillas with butter for lunch,
occasionally will cook dinner, otherwise will have chips and dip and reports eating a cobb salad
once a week while at the golf club. She states she doesn’t drink enough water and states her
tongue is dry especially after partaking in golf. Ms. TC also reports frequent urination 8-10 per
day.
Differential Diagnoses: Primary Diagnoses
Based on data collected briefly discuss 3 Differential Diagnoses for your patient for the Primary
Diagnosis. Include ICD10 Codes (cite ICD10data.com):
Primary Diagnosis:
Primary Dx: Type 2 Diabetes Mellitus without complications (ICD E11.9) (2022 ICD-10-CM
codes. 10. (n.d.)- Type 2 Diabetes Mellitus (T2DM) characterized by decreased insulin resistance
due to a dysfunction of pancreatic beta cells. Common clinical presentation of T2DM includes
polydipsia, Polyphagia, and polyuria. TIDM is most common among older adults (American
Diabetes Association, 2021).
Differential Dx#1: Type 1 Diabetes Mellitus (E10) (2022 ICD-10-CM codes. 10. (n.d.) - Type I
Diabetes Mellitus is a chronic autoimmune disease resulting in insulin deficiency due to
destruction of pancreatic beta cells. Clinical presentation of TIDM is polydipsia, polyuria, and
polyphagia plus weight loss and fatigue (American
, Diabetes Association, 2021
Differential Dx #2: Cushing’s syndrome ICD- E24.8 (2022 ICD-10-CM codes. 10. (n.d.). - An
endocrine syndrome characterized by the pituitary glands excessive production of
Adrenocorticotropic hormone (ACTH) and inability to regulate cortisol (2 key components in
regulating glucose, protein, and lipid metabolism, and help maintain blood pressure ().
Differential Dx #3:
Hyperlipidemia (E78.5) (2022 ICD-10-CM codes. 10. (n.d.) - Hyperlipidemia is a disease that
occurs because of elevated concentrations of fat substances (particularly low-density lipoprotein
LDL) in the blood (Epidemiology and management of Hyperlipidemia. AJMC. (n.d.). However,
the main culprit of hyperlipidemia includes lifestyle habits such as diets high in saturated fats
that exceed 40% of total calories, obesity, and a sedentary lifestyle, and thyroid dysfunction
(Epidemiology and management of Hyperlipidemia. AJMC. (n.d.). A Diagnosis is based on lab
values ().
Diagnosing Your Clinical Patient
Based on your findings, (physical exam, lab values, diagnostics) what is the primary
diagnosis for your patient today? What information in the CPG let you to this primary
diagnosis?
Type 2 Diabetes Mellitus (E 11.9)
A diagnosis of diabetes is contingent on a plasma glucose criterion, which requires two
abnormal test results from the same sample or two separate test- day samples of either the fasting
plasma glucose > / = 126mg/dl or Hgb A1C > / = 6.5% or by a random plasma glucose & Oral
Glucose Tolerance Test (OGTT) result >/= 200 & symptomatic or 2-hour plasma glucose 200/=
