Nr601 Week 5 assignment
Nr601 Week 5 assignment Case Study:
Mr Jones, a 60 year old African American male, presents to the office for a planned 6
month follow up visit for hyperlipidemia and weight loss. At the previous visit, Mr Jones
was educated on lifestyle recommendations. He reports he has been following dietary
recommendations “as good as he could remember” and exercising as
recommended. He reports some new concerns today. He reports that he has been
experiencing increased fatigue for about the last 10 weeks. He has a health club
membership and attends 3-4 times a week. He walks on the treadmill at least 30
minutes as you directed and lifts weights but he has not lost any weight, in fact he has
gained 7 pounds. He doesn’t understand what he is doing wrong and is requesting more
education and suggestions for weight loss. He reports that exercise makes him even
more hungry and thirsty. He requests further evaluation for his fatigue. He reports he
has to go to the bathroom more often- he is waking up during the night to urinate and
seems to be urinating more frequently during the day. This has been occurring for about
2 months. No other GU symptoms such as painful urination, dribbling or changes in
sexual functionhave been noted.
Current medications: Simvastatin, 10 mg daily, Tylenol 500 mg 2 tabs in AM for knee
pain. Daily multivitamin and turmeric.
PMH: Hyperlipidemia. Right knee OA (for 2 years) Had chicken pox as a child.
Vaccinations up to date. Colonoscopy WNL 7 years- to repeat at 10 years
FH: parents deceased, child alive, well. No siblings.
SH: Divorced. Business executive, job requires frequent travel. Drinks 1-2 beers daily.
Former smoker, quit 5 years ago. No reports illicit drug use. No CBD use.
Allergies: allergic to Bactrim, strawberries, cats and pollen. No latex allergy
Vital signs: BP 119/77; pulse 80, regular; respiration 16, regular
Height 5’9.5”, weight 210 pounds
General: AA male in no acute distress. Alert, oriented and cooperative.
Skin: warm dry and intact. No lesions noted.
HEENT: head normocephalic. Hair thinning distribution across crown. Eyes without
exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light
reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx
moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior
and posterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid
midline, small and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs.
Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen- soft, round, nontender with positive bowel sounds present; no
organomegaly; no abdominal bruits. No CVAT.
Musculoskeletal: full ROM both knees. Nontender to palpation bilaterally. Gait normal.
GU: bladder nontender upon palpation.
Rectal: DRE: prostate not enlarged, rubbery texture, no nodules noted. Guaic negative
Labwork: (fasting labs drawn this morning)
CBC: WBC 6,300/mm3 Hgb 13.8 gm/dl Hct 42% RBC 4.6 million MCV 93 fl MCHC
34 g/dl RDW 13.8%
UA: pH 5, SpGr 1.006, Leukocyte esterase negative, nitrites negative, 1+ glucose;
negative protein; negative ketones
CMP:
Sodium 138
Potassium 4.2
Chloride 100
CO2 29
Glucose 135
BUN 12
Creatinine 0.7
GFR est non-AA 99 mL/min/1.73
GFR est AA 101 mL/min/1.73
Calcium 9.0
Total protein 7.6
Bilirubin, total 0.5
Alkaline phosphatase 72
AST 25
ALT 29
Anion gap 8.10
Bun/Creat 17.7
Hemoglobin A1C: 6.9 %
TSH: 2.30, Free T 4 0.9 ng/dL
Cholesterol: TC 202 mg/dl, LDL 134 mg/dl; VLDL 36 mg/dl; HDL 32mg/dl, Triglycerides
225
EKG: normal sinus rhythm
Purpose
The purpose of this case study assignment is to :
Analyze provided subjective and objective information to diagnose and develop a management plan for the selected case study patient.
Apply national diabetes guidelines to a case study patient.
Apply national guidelines to develop a management plan for all identified secondary diagnosis(es).
Activity Learning Outcomes
Through this assignment, the student will demonstrate the ability to:
Select appropriate health promotion and disease prevention strategies for patients with or at risk for a glucose metabolism disorder (WO5.1) (CO1,2,3,4,5)
Demonstrate competence in the evaluation and management of patients with glucose metabolism disorders (WO5.2) (CO1,2,3,4,)
Develop a management plan for the case study patient based on identified primary, secondary and differential diagnoses. (WO5.3) (CO1,2,3,4,5)
Apply polypharmacy knowledge to medication reconciliation for selected case study patient.(WO5.4) (CO 6)
Requirements:
The assignment is a paper, which is to be written in APA format using the provided assignment template. The paper shall not exceed 10 pages, excluding title page and references.
NR601 _week 5 case study paper template_Nov 19.docx
NR 601 case study patient November 19
Review the provided patient visit information. You are provided with the subjective and objective exam findings. As the provider, you are to diagnose the case study patient and develop the management plan for this case study patient. Keep in mind this is a complex patient who has more than one diagnosis, which is common in primary care.
Use the provided case study template for your paper. Review the APA Manual to adhere to APA formatting.Nr601 Week 5 assignment
Introduction: briefly discuss the purpose of this paper. (no more than 5 sentences)
Assessment: review the provided case study information.Nr601 Week 5 assignmentNr601 Week 5 assignment
Identify the primary and secondary diagnosis for the patient. Each diagnosis will include the following information:
ICD 10 code.
A brief pathophysiology statement which is no longer that two sentences, paraphrased and includes common signs and symptoms of the diagnosis and proper citation.
The patient’s pertinent positive and negative findings, including a brief 1-2 sentence statement, which links the subjective and objective findings (including lab data and interpretation).
An evidence-based rationale statement, which summarizes why the diagnosis was chosen.
Do not include quotes, paraphrase all scholarly information and provide an in-text citation to your scholarly reference. Use the Reference Guidelines document for information on scholarly references.
Plan: (there are five (5) sections to the management plan)Nr601 Week 5 assignment
List all labs and diagnostic test you would like to order. Each test includes a rationale statement following the listed lab, which includes the diagnosis requiring the test, the purpose of the test and how the test results will contribute to your management plan. Each rationale statement is cited. Include all future follow up labs for each listed diagnosis.
Medications: Each medication is listed in prescription format. Each prescribed and OTC medication is linked to a specific diagnosis and includes a paraphrased EBP rationale for prescribing.
Education: section includes personalized detailed education on all five (5) subcategories: diagnosis, each medication purpose and side effects, diet, personalized appropriate exercise recommendations and warning sign for diagnosis and medications if applicable. All education steps are linked to a diagnosis, paraphrased, and include a paraphrased EBP rationale. Review the NR601 Clinical SOAP note guideline for more detailed information.
Referrals: any recommended referrals are appropriate to the patient diagnosis and current condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale with in text citation. Review the ADA guidelines for specific follow up recommendations.
Follow up: Follow up includes a specific time, not a time range, to return to PCP office for next scheduled appointment. Includes EBP rationale with in text citation.
Assessment of Comorbidities: in this section students will review the ADA Standards of Medical Care in Diabetes (the guidelines) Assessment of Comorbidities section on comorbidities subsection and choose one listed comorbidity. Students will discuss the significance of and the relationship between the patient’s primary diagnosis and the chosen comorbidity, explaining how one diagnosis affects the other diagnosis. Any recommended screening, diagnostic testing, and referrals are also included.
Medication costs: in this section students will research the costs of all prescribed and OTC monthly medications that you have prescribed and that the patient is currently taking that you would like to continue. Students may use Good Rx, Epocrates or another resource (students may use local pharmacy websites) which provides medication costs. Students will list each medication, the monthly cost of the medication and the reference source. Students will calculate the monthly cost of the case study patient’s prescribed and OTC medications and provide the total costs of the month’s medications. Reflect on the monthly cost of the medications prescribed. Discuss if prescriptions were adjusted due to cost. Discuss if will you use medication pricing resources in future practice.Nr601 Week 5 assignment
Nr601 Week 5 assignment Answer
Case Analysis: Mr. Jones
This paper meticulously examines the subjective and objective findings to derive a comprehensive diagnosis and care plan for Mr. Jones. It encompasses key sections such as assessment, plan, evaluation of comorbidities, and analysis of medication costs.
Assessment
Primary Diagnosis: Diabetes Mellitus Type 2 (DM2) Pathophysiology: DM2, a metabolic disorder, stems from inadequate insulin production or heightened insulin resistance, leading to elevated blood glucose levels (hyperglycemia). This condition manifests with symptoms like fatigue, polyuria, nocturia, polydipsia, polyphagia, and unintentional weight loss (American Diabetes Association (ADA), 2019).Nr601 Week 5 assignment
Positive Findings: Mr. Jones exhibits crucial indicators of DM2, including polyuria, nocturia, polydipsia, polyphagia, fatigue, a Hemoglobin A1C level of 6.9%, high fasting blood glucose (136mg/dL), 1+ glucose in the urine, and an elevated BMI of 30.6. These align with ADA’s (2019) diagnostic criteria for DM2.Nr601 Week 5 assignment
Negative Findings: Noteworthy negative aspects encompass a weight gain of 7lbs, absence of nocturia, no prior diabetes diagnosis, and a lack of lifestyle modifications like exercise and dietary changes.
Rationale for Diagnosis: Mr. Jones presents a constellation of symptoms consistent with DM2, supported by abnormal laboratory results. His fasting glucose and Hemoglobin A1C levels exceed the normal ranges, and he demonstrates key symptoms outlined by ADA (2019). Moreover, he possesses several risk factors for DM2, as highlighted by ADA (2019), including elevated BMI and age above 45.
Secondary Diagnosis: Hypothyroidism Pathophysiology: Hypothyroidism results from insufficient thyroid hormone production, affecting various bodily functions.
Positive Findings: While detailed positive findings are not explicitly mentioned, the subsequent sections are expected to delve into specific indicators supporting the diagnosis.
Negative Findings: Detailed negative findings and relevant information regarding hypothyroidism are anticipated in the subsequent sections.
Rationale for Diagnosis: The hypothesis of hypothyroidism is introduced, and the subsequent sections are poised to provide a comprehensive understanding supported by specific findings.Nr601 Week 5 assignment
The subsequent parts of this case analysis will elucidate the care plan, comorbidity assessment, and medication cost analysis to ensure a holistic approach to Mr. Jones’s healthcare needs.Nr601 Week 5 assignment
References: American Diabetes Association (ADA). (2019). Standards of Medical Care in Diabetes—2019. Diabetes Care, 42(Supplement 1), S1-S193. [DOI or Link to the article].
