Description
Diabetes Case Study
Chief Complaint
“My left foot feels weak and numb. I have a hard time pointing my toes up.”
History of Present Illness
D.T. is 42-year-old Caucasian woman who has had an elevated blood sugar and cholesterol 2 years ago but did not follow up with a clinical diagnostic work-up. She had participated in the state’s annual health screening program and noticed her fasting blood sugar was 160 and her cholesterol was 250. However, she felt “perfectly fine at the time” and did not want to take any more medications. Except for a number of “female infections,” she has felt fine recently.
Today, she presents to the clinic complaining that her left foot has been weak and numb for nearly 3 weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. She does report that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 50 pounds since her last pregnancy 10 years ago, 20 pounds in the last 6 months alone.
Past Medical History
- Seasonal allergic rhinitis (since her early 20s)
- Breast biopsy positive for fibroadenoma at age 30
- Gestational diabetes with second child 10 years ago
- Multiple yeast infections during the past 3 years that she has self-treated with OTC antifungal creams and salt bath
- Hypertension for 10 years
Past Surgical History
C-section 14 years ago
OB-GYN History
- Menarche at age 11
- Last pap smear 3 years ago
Family History
- Type 2 DM present in older brother and maternal grandfather. Both were diagnosed in their late 40s. Brother takes both pills and shots.
- Mother alive and well
- Father has COPD
- Two other siblings alive and well
- All three children are alive and well
Social History
- Married 29 years with 3 children; husband is a school teacher
- Family lives in a four bedroom single family home
- Patient works as a seamstress
- Smokes 1 pack per day (since age 16) and drinks two alcoholic drinks 4 days per week
- Denies illegal drug uses
- Never exercises and has tried multiple fad diets for weight loss with little success. She now eats a diet rich in fats and refined sugars.
Allergies
NKDA
Medications
- Lisinopril 10 mg daily
- Loratadine 10 mg daily
Review of Systems
General
Admits to recent onset of fatigue
HEENT
Has awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing: Denies vertigo, head trauma, ear pain, difficulty swallowing or speaking
Cardiac
Denies chest pain, palpitations, and difficulty breathing while lying down
Lungs
Denies cough, shortness of breath, and wheezing
GI
Denies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits occasional episodes of constipation
GU
Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in the urine, or urinary incontinence
EXT
Denies leg cramps or swelling in the ankles and feet; has never experienced weakness, tingling or numbness in arms or legs prior to this episode
Neuro
Has never had a seizure and denies recent headaches
Derm
Has a rash under her bilateral breast and in groin area
Endocrine
Denies a history of goiter and has not experienced heat or cold intolerance
Vital Signs
BP 165/100, T 98 F, P 88 regular, HT 5 feet 4 inches, RR 20 non labored, WT 210 lbs
Explanation & Answer
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Running head: DIABETES CASE STUDY
Diabetes Case Study
Student’s Name
Institutional Affiliation
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DIABETES CASE STUDY
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Diabetes Case Study
Evidence-Based Management Plan
Mrs. D.T exhibit signs and symptoms of diabetes since the blood sugar and cholesterol
levels are high. Furthermore, the other medical issues such the leg pain are diabetes-related
illnesses. Also, the patient family history report, Mrs. D.T is at risk of getting diabetes as the
father and brother both suffer from diabetes, implying it is in the family genes. The other issue
that raises alertness that the patient might have diabetes is the lifestyles that constitute smoking,
high –intake of sugar, and no exercise. Thus, all signs and data show Mrs. D.T might be diabetic,
which will need to be confirmed with diagnostic tests. Moreover, even the symptoms are enough
to confirm Mrs. D.T has diabetes; it is impossible to identify which type. Hence, the only way to
verify is through tests. Therefore, my priority in the patient evidence-based management plan is
conducting significant diagnostics to reveal the type of diabetes. Powers and Vivian (2017)
suggest that the next item in the plan is developing the patient education plan. I will also factor
the cultural and life span elements of the patient to optimize the patient self-management and
relieve the severity of the disease or cure diabetes. Lastly, the evidence-based management plan
will include health promotion, follow up, and referral of the patient.
Pertinent Diagnostics
Fasting plasma glucose test
This is one of the diagnostic tests that will be conducted on the patient. It will be carried
out early in the morning when the patient has not eaten anything. Therefore, the patient is
requested not to take any food for the past 8 hours. This is to get the actual blood glucose level
that doesn't constitute the glucose added with the food and drinks one has taken. American
Diabetes Association (2016) elaborates that the patient is normal if the FPG level is 99 and
DIABETES CASE STUDY
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below. The blood glucose level stands at 100 to 125 when the patient has prediabetes.
Nevertheless, the patient has diabetes if the blood glucose level is 126 and above.
AIC test
AIC test is the other diagnostic test that will be conduc...