Running head: CASE STUDY 1
Case Study
Dipa Adhikari
Chamberlain College of Nursing
NR601: Primary Care of the Maturing and Aged
Family May, 2018
,CASE 2
Introduction
The purpose of this paper is to demonstrate the ability to analyze the subjective and
objective information from the case study to formulate a management plan using evidenced
based guidelines. It also demonstrates the student’s ability to write SOAP note in chronological
order. In this case study the assessment, treatment plan, medication and its cost, and SOAP note
will be discussed in detailed.
Assessment
Based on the chief complaints, subjective, and objective findings patient’s primary
diagnosis is type 2 diabetes mellitus (E11). The pathophysiologic mechanism of type 2 diabetes
involves insulin resistance and decreased insulin secretion by beta cells of pancreas (McCance,
Huether, Brashers, & Rote, 2013). The genetic, epigenetic, and environmental factors interfere
the ability to sense increased blood glucose, insulin synthesis, and insulin secretion, which
causes type 2 diabetes. The prevalence of type 2 diabetes increased with age, is higher among
African American female, but obesity, hypertension, physical inactivity, and family history
predominantly increased the risk of type 2 diabetes (McCance et al., 2013). Polyuria, polydipsia,
and polyphagia are the classis symptoms of diabetes, but patient may present with nonspecific
symptoms such as fatigue, pruritus, recurrent infection, visual change, paresthesia, or weakness
(McCance et al., 2013). Based on the information given, the pertinent positive findings include
very fatigued, no energy, weight gain, increased hunger and thrust, and increased frequency of
urination for past 3 month. The polydipsia, polyuria, and polyphagia also known as 3P are the
hallmark symptoms of diabetes (American Diabetes Association [ADA], 2017). The laboratory
finding indicates her hemoglobin A1C is 6.9%, total cholesterol is 230 mg/dl, LDL 144mg/dl,
VLDL 36 mg/dl, HDL 38mg/dl and triglycerides 232. The hemoglobin A1C of ≥ to 6.5% is one
, CASE 3
of the criteria that indicates diabetes (National Diabetes Education Initiative [NDEI], 2016). Mrs.
G. blood glucose level of 126 which is at the meets the criteria for diabetes but has limited
information on fasting status. The fasting plasma glucose of ≥ 126 is indicative to diabetes
(NDEI, 2016).Her history of delivering a baby who weigh 9lb 2 oz is another risk factor of type
2 diabetes according to the ADA guidelines (NDEI, 2016). In addition, she has 1+ glucose and
small protein on her UA. She weighs 185 pounds and her BMI based on her height and weight is
33.3 which is considered obese. Type 2 diabetes is most common in overweight or obese
because excess weight causes some degree of insulin resistance (ADA, 2017). Other pertinent
positive information that helps to diagnose type 2 diabetes includes obesity, dyslipidemia, and
being Hispanic age greater than 50 years because risk of type 2 increases with age, obesity, lack
of physical activity, dyslipidemia, and in certain racial or ethic groups such as Hispanic (ADA,
2017). The pertinent negative findings include no pruritus, recurrent infection, visual change,
paresthesia, or weakness (McCance et al., 2013). Type 2 diabetes has a strong genetic
predisposition, which Mrs. G is negative for this risk. The patient presenting symptoms such as
3P which are the hallmark symptoms of diabetes, her risk factors, and laboratory findings
strongly suggest type 2 diabetes, thus it is a primary diagnosis of Mrs. G.
Secondary Diagnosis
Mixed hyperlipidemia (E78.2) is a secondary diagnosis that needs to be addressed during
this visit. Hyperlipidemia is an acquired or genetic disorder that causes increased circulating
lipids such as cholesterol, triglycerides, and fats in the blood (Moneta, n.d.). It is most commonly
caused due to consumption of food high in saturated or trans fats, sedentary lifestyle, obesity,
smoking, and diabetes. The familial hyperlipidemia is result from mutation in gene in a form of
Case Study
Dipa Adhikari
Chamberlain College of Nursing
NR601: Primary Care of the Maturing and Aged
Family May, 2018
,CASE 2
Introduction
The purpose of this paper is to demonstrate the ability to analyze the subjective and
objective information from the case study to formulate a management plan using evidenced
based guidelines. It also demonstrates the student’s ability to write SOAP note in chronological
order. In this case study the assessment, treatment plan, medication and its cost, and SOAP note
will be discussed in detailed.
Assessment
Based on the chief complaints, subjective, and objective findings patient’s primary
diagnosis is type 2 diabetes mellitus (E11). The pathophysiologic mechanism of type 2 diabetes
involves insulin resistance and decreased insulin secretion by beta cells of pancreas (McCance,
Huether, Brashers, & Rote, 2013). The genetic, epigenetic, and environmental factors interfere
the ability to sense increased blood glucose, insulin synthesis, and insulin secretion, which
causes type 2 diabetes. The prevalence of type 2 diabetes increased with age, is higher among
African American female, but obesity, hypertension, physical inactivity, and family history
predominantly increased the risk of type 2 diabetes (McCance et al., 2013). Polyuria, polydipsia,
and polyphagia are the classis symptoms of diabetes, but patient may present with nonspecific
symptoms such as fatigue, pruritus, recurrent infection, visual change, paresthesia, or weakness
(McCance et al., 2013). Based on the information given, the pertinent positive findings include
very fatigued, no energy, weight gain, increased hunger and thrust, and increased frequency of
urination for past 3 month. The polydipsia, polyuria, and polyphagia also known as 3P are the
hallmark symptoms of diabetes (American Diabetes Association [ADA], 2017). The laboratory
finding indicates her hemoglobin A1C is 6.9%, total cholesterol is 230 mg/dl, LDL 144mg/dl,
VLDL 36 mg/dl, HDL 38mg/dl and triglycerides 232. The hemoglobin A1C of ≥ to 6.5% is one
, CASE 3
of the criteria that indicates diabetes (National Diabetes Education Initiative [NDEI], 2016). Mrs.
G. blood glucose level of 126 which is at the meets the criteria for diabetes but has limited
information on fasting status. The fasting plasma glucose of ≥ 126 is indicative to diabetes
(NDEI, 2016).Her history of delivering a baby who weigh 9lb 2 oz is another risk factor of type
2 diabetes according to the ADA guidelines (NDEI, 2016). In addition, she has 1+ glucose and
small protein on her UA. She weighs 185 pounds and her BMI based on her height and weight is
33.3 which is considered obese. Type 2 diabetes is most common in overweight or obese
because excess weight causes some degree of insulin resistance (ADA, 2017). Other pertinent
positive information that helps to diagnose type 2 diabetes includes obesity, dyslipidemia, and
being Hispanic age greater than 50 years because risk of type 2 increases with age, obesity, lack
of physical activity, dyslipidemia, and in certain racial or ethic groups such as Hispanic (ADA,
2017). The pertinent negative findings include no pruritus, recurrent infection, visual change,
paresthesia, or weakness (McCance et al., 2013). Type 2 diabetes has a strong genetic
predisposition, which Mrs. G is negative for this risk. The patient presenting symptoms such as
3P which are the hallmark symptoms of diabetes, her risk factors, and laboratory findings
strongly suggest type 2 diabetes, thus it is a primary diagnosis of Mrs. G.
Secondary Diagnosis
Mixed hyperlipidemia (E78.2) is a secondary diagnosis that needs to be addressed during
this visit. Hyperlipidemia is an acquired or genetic disorder that causes increased circulating
lipids such as cholesterol, triglycerides, and fats in the blood (Moneta, n.d.). It is most commonly
caused due to consumption of food high in saturated or trans fats, sedentary lifestyle, obesity,
smoking, and diabetes. The familial hyperlipidemia is result from mutation in gene in a form of
