Week 5 Case Study

In healthcare, there are many different patients that present with a variety of symptoms. It is the duty of the practitioner to assess new findings, and link them with subjective and objective findings, patient history and risk factors to assess and treat each unique patient properly. This paper will do just that, as a case study is reviewed of a patient who presents to the office with new complaints; The patient’s possible diagnoses will be reviewed with rationale, as well as a plan of care that would be implemented for the patient, including testing, medication, education, referrals, and follow up; Lastly, the an assessment of comorbidities will be reviewed along with the patient’s average medications costs. By performing this case study, it creates an example of how each patient who presents to an office must be assessed and treated in the primary care setting.  

Assessment 

Primary Diagnosis:   Diabetes type II without complications (E11.9) 

Pathophysiology: Skyler et al. (2017) detailed that when a person has type II diabetes, the body develops insulin resistance when excess fat is deposited in different areas of the body, including the muscles, liver and pancreas, which overtime, impairs B-cell function. When this occurs, it is explained that the body does not produce enough insulin in response to increased blood glucose levels, resulting in the signs and symptoms of hyperglycemia; These symptoms include polyuria, polydipsia, increased appetite, fatigue, vision changes, weight changes (initially weight loss) and skin changes. 

Pertinent positive findings: The patient in this case study presented with complaints of difficulty losing weight, increased hunger and thirst during exercise, polyuria, nocturnal polyuria, and fatigue. The patient’s urinalysis was positive for 1+ glucose and the bloodwork resulting a fasting blood glucose of 135 and a hemoglobin a1c of 6.9%. The patient had a 7lb weight gain after attempting weight loss exercises and diet. Skyler et al. (2017) detailed that having increased hunger, thirst, urination and fatigue are all common symptoms of diabetes. It was also explained that when blood glucose levels are elevated, the kidneys cannot absorb all of the excess and therefore excretes the glucose through the urine. This would confirm that the patient has excess glucose and can aid in the confirmation of the diagnosis of diabetes for the patient. Lastly Skyler et al. (2017) detailed that it in diabetes, the individual will have an elevated fasting blood glucose and an elevated hemoglobin a1c, both of which the patient presented with. 

Pertinent negative findings: Skyler et al. (2017) detailed that individuals may have skin changes, weight loss and vision changes; The patient in this case study did have any complaints of these symptoms, and in fact had weight gain, rather than weight loss. These symptoms, however, may differ in different stages of the disease, as well as in different individuals. 

Rationale for the diagnosis: The American Diabetes Association (2015) explained that patients older than the age of 45, with a BMI over 25kg/m2 are at a higher risk of developing diabetes, and therefore should be monitored and screened by checking the patient’s hemoglobin a1c and fasting blood glucose. It is detailed that a hemoglobin a1c greater than 6.5% and a fasting blood glucose greater than 126 can diagnose a patient with diabetes. In this patient’s case, he is 60 years old and has a BMI of 30.6, he is classified as a risk for diabetes. His fasting blood glucose of 135 and his a1c of 6.9%, according to ADA standards, confirms the diagnosis of diabetes for Mr. Jones.