Sample Nursing Paper on primary care to determine the patient’s type of diabetes

  1. You must use at least one scholarly reference to provide pathophysiology statements. For this class, use of the textbook for pathophysiology statements is acceptable. You may also use an appropriate evidence-based journal.
  2. You must use the current Clinical Practice Guideline (CPG) for the Standards of Medical Care in Diabetes -Abridged for Primary Care Providers provided by the American Diabetes Association to determine the patient’s type of diabetes and answer the treatment recommendation questions. The most current guideline can be found at the following web address: https://professional.diabetes.org/content-page/practice-guidelines-resources(Links to an external site.). At the website, locate the current year’s CPG for use.

 

 

CASE STUDY

 

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
  • 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
  • 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.