This project will discuss the overall wellbeing of a patient who is a 55-year-old Hispanic
woman, who came to the health center for her yearly examination with several health concerns.
The patient’s objective and subjective findings are reviewed to suitably formulate diagnoses and
create an individualized care plan grounded on evidence-based strategies. Also, this document
will recognize relevant primary and secondary diagnoses and utilize the standards from the
American Diabetes Association (ADA). Furthermore, the development of a management plan
will comprise reasonable medications, referrals, suitable diagnostics, follow-up, and education.
Assessment
Primary Diagnosis Type 2 diabetes with unspecified complications (E11.8)
Pathophysiology: type 2 diabetes mellitus (T2DM) is described as elevated plasma glucose
levels due to the reduction of the function of pancreatic beta cells, which can also impair insulin
secretion and cause insulin resistance (ADA, 2019). The most common indications of T2DM
involve fatigue, increased urination, increased thirst, and increased appetite but weight loss
(ADA, 2019).
Pertinent positive findings: in the past three months, the patient has been experiencing
decreased energy and fatigue, increased thirst and hunger with activities, and increased urination.
The patient also reported a recent three pounds of weight gain. Furthermore, Mrs. G is a
calculated BMI of 33.3, which is considered obese. The test results include high hemoglobin
A1C of 6.9%, urinalysis is 1+ glucose and some protein, and an abnormal lipid panel (ADA,
2019).
Pertinent negative findings: the patient does not have any family history of diabetes and reports
she exercises at least twice a week for 30 minutes. The blood glucose is 95 and urinalysis is
negative for ketones (ADA, 2019).
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