NR 601 Week 5 Case Study Assignment -Diabetes

The purpose of this paper is to review the patient’s subjective and objective information from the visit, and analyze the information to formulate an appropriate diagnosis; then develop an evidence based plan of care for the patient, by applying the National Diabetes Guidelines to the care for mature and aging families…………….. I will demonstrate comprehensive knowledge and proficiency on my ability to correctly write a SOAP note.

Primary Diagnosis: Diabetes (E10.9) Pathophysiology of diabetes type I is insulin dependent, this is the inability of the pancreatic beta cells to produce insulin due to autoimmune destruction; type II, the pancreas does not produce enough insulin needed by the body, or the body is unable to use insulin properly (American Diabetes Association, 2017). Symptoms: fatigue, excessive thirst, hunger, and frequent urination.

Secondary Diagnosis: Hyperlipidemia (E78.5) Pathophysiology of hyperlipidemia is the increase in the plasma lipid levels by the over production of TG-rich lipoproteins in the liver (Shattat, 2014). Symptoms: Typically does not have any symptoms

Hypertension (I15.2) Pathophysiology of hypertension is the increase in the vascular resistance, stiffness, and the vascular system to respond to stimuli (Delacroix, Chokka & Worthley, 2014). Symptoms: Typically have no symptoms………………………., back and joint aches, and overweight.

Left knee arthritis (M19.072) Pathophysiology of osteoarthritis-cartilage loss and the thickening of the subchondral plate, and production of new bone in the joint spaces (Ashkavand, Malekinejad & Vishwanath, 2013). Symptoms: Joint pain, stiffness, swelling, and tenderness.

Differential Diagnosis: Proteinuria (R80.9) Pathophysiology of proteinuria is structural damage to the kidneys, glomerular membrane, and tubulointerstitial tissue from an alteration in of metabolic changes such as hyperglycemia, hyperlipidemia, and hypertension, causing an increase in the urinary albumin (Shen, Fang, Xing & Wang, 2017). Symptoms: Protein in urine, hypertension, and increase need to urinate, fatigue, weight gain from fluid retention, foamy urine, and swelling in the face and extremity.

I chose each diagnosis based of the CC and labs that were both subjective and objective findings. The patient has an Hgb A1C of 7.7 and glucose in her urine which indicate diabetes, according to the (American Diabetes Association, 2016) an A1C of 6.5 or greater meets the criteria for diabetes, to confirm the patient’s diagnosis she will need to repeat the A1C. She also has symptom of diabetes such as fatigue, excessive thirst, hunger, and frequent urination. Mrs. G blood pressure is 130/82, which is considered stage I hypertension according to the (American College of Cardiology, 2017); systolic pressure 130-139 or diastolic 80-89. Her triglycerides are 232, LDL 143, HDL 37, TC 228; the normal for triglycerides should be between 50-150, LDL should be less than 100, and HDL should be greater than 40, and the TC should be less than 200, this would indicate hyperlipidemia (American Diabetes Association, 2017).

The patient is 5’2 and weighs 190 pounds which gives her a BMI of 34.8, a BMI of 30-35 or greater is classified as Obesity (Nuttall, 2015). The patient has protein in her urine which could be an indicator of proteinuria or kidney disease; she also has symptoms of proteinuria which includes protein in urine, hypertension, and increase need to urinate, fatigue, weight gain (Shen, Fang, Xing & Wang, 2017). The patient has a history of arthritis, as well as obesity; some contributing factors to osteoarthritis are obesity, age, women are more at risk, and a sedentary lifestyle (Ashkavand, Malekinejad & Vishwanath, 2013)

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