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NR 507 Week 6 Case Study- Diabetes
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- Chamberlain College Of Nursing
Chamberlain NR 507 Week 6 Case Study- Diabetes
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Week 6 Case Study - DiabetesCase Study Scenario
Chief Complaint
J.T. is a 48-year old male who presents to the primary care clinic with fatigue, weight loss, and
extreme thirst and increased appetite.
History of Present Illness
J.T. has been in his usual state of health until three weeks ago when he began experiencing
symptoms of fatigue, weight loss, and extreme thirst. He reports that he would like to begin a
walking program, but he feels too fatigued to walk at any point during the day. Now he is very
concerned about gaining more weight since he is eating more. He reports insomnia due to having
to get up and urinate greater than 4 times per night.
Past Medical History
Hypertension
Hyperlipidemia
Obesity
Family History
Both parents deceased
Brother: Type 2 diabetes
Social History
Denies smoking
Denies alcohol or recreational drug use
Landscaper
Allergies
No Known Drug Allergies
Medications
Lisinopril 20 mg once daily by mouth
Atorvastatin 20 mg once daily by mouth
Aspirin 81 mg once daily by mouth
Multivitamin once daily by mouth
Review of Systems
Constitutional: - fever, - chills, - weight loss.
Neurological: denies dizziness or disorientation
, Week 6 Case Study - Diabetes
HEENT: Denies nasal congestion, rhinorrhea or sore throat.
Chest: (-)Tachypnea. Denies cough.
Heart: Denies chest pain, chest pressure or palpitations.
Lymph: Denies lymph node swelling.
General Physical Exam
Constitutional: Alert and oriented male in no acute distress
Vital Signs: BP-136/80, T-98.6 F, P-78, RR-20
Wt. 240 lbs., Ht. 5'8", BMI 36.5
HEENT
Eyes: Pupils equal, round and reactive to light and accommodation, normal conjunctiva.
Ears: Tympanic membranes intact.
Nose: Bilateral nasal turbinates without redness or swelling. Nares patent.
Mouth: Oropharynx clear. No mouth lesions. Teeth present and intact; Oral mucous
membranes and lips dry.
Neck/Lymph Nodes
Neck supple without JVD.
No lymphadenopathy, masses or carotid bruits.
Lungs
Bilateral breath sounds clear throughout lung fields. Breathing quality deep with fruity
breath odor
Heart
S1 and S2 regular rate and rhythm; - tachycardia; no rubs or murmurs.
Integumentary System
Skin warm, dry; Nail beds pink without clubbing.
Labs
Test Patient's Result Reference
Glucose (fasting) 132 60-120 mg/dL
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