Diabetes Case Study

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Description

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

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.

Social History

  • Married 29 years with 3 children; husband is a school teacher
  • Family lives in a four bedroom single family homSmokes 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

GU

Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in the urine, or urinary incontinence

Derm

Has a rash under her bilateral breast and in groin area

Vital Signs

BP 165/100, T 98 F, P 88 regular, HT 5 feet 4 inches, RR 20 non labored, WT 210 lbs

What you need to do:

  • Develop an evidence-based management plan.
  • Include any pertinent diagnostics.
  • Describe the patient education plan.
  • Include cultural and lifespan considerations.
  • Provide information on health promotion or health care maintenance needs.
  • Describe the follow-up and referral for this patient.


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Explanation & Answer

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Running head: DIABETES

1

Diabetes
Name
Course
Tutor
Date

DIABETES

2

Diabetes
Diabetes is a disease that develops due to the inability of the body to respond properly to
insulin hormone, this leads to elevated levels of sugar in the body (ADA, 2016). Diabetes
condition requires a proper management plan for the patient living with this condition. For the
management of this condition, several issues have to be addressed and followed. The
management plan, the patient has to constantly check their blood sugar levels before breakfast,
before lunch, before dinner, and before snacks. The patient should also do extra sugar check
before and after exercises, also when the patient experience symptoms of any kind. In this case
study, the patien...


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