Primary Care of the Maturing and Aged Family Case Study
Chamberlain College of Nursing
NR 601
1
CASE STUDY
Primary Care of the Maturing and Aged Family Case Study
The purpose of this paper is to analyze
...
Primary Care of the Maturing and Aged Family Case Study
Chamberlain College of Nursing
NR 601
1
CASE STUDY
Primary Care of the Maturing and Aged Family Case Study
The purpose of this paper is to analyze a case study provided with patient information,
lab work, subjective, and objective data. Diagnosis will be developed from reviewing the given
information, as well as a management plan will be implemented. Demonstrating skills, such as
writing a SOAP note, will be mastered, and this paper will help the FNP prepare for upcoming
patients and case studies in the future, by mastering this assignment.
Assessment
Primary Diagnosis: Type 2 diabetes mellitus (E11)
Pathophysiology: Type 2 diabetes mellitus is a metabolic disorder, which occurs when
the body does not utilize insulin properly (ADA, 2019). The pancreas will try to
overcompensate by making more insulin in efforts to get glucose into cells, but over time
the pancreas can not keep up, leading to an excess amount of sugar in the blood (ADA,
2019). Classic signs and symptoms include the following: polydipsia, polyuria, and
polyphagia (ADA, 2019).
Pertinent positive findings: Type 2 diabetes mellitus was chosen because of many
subjective and objective findings. The patient has risk factors such as his race (African
American), age of 57 years, and weight of 210 pounds (ADA, 2019). According to the
American Diabetes Association, people are at a higher risk of developing type 2 diabetes,
who are overweight, are of Hispanic or African American decent, and live a sedentary
lifestyle.
Pertinent negative findings: This patient does not live a sedentary lifestyle, as he has
mentioned working out at least 3-4 days a week, and walking for 30 minutes on the
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CASE STUDY
treadmill. Despite his efforts of living a more active lifestyle, he is still overweight, with
a BMI of 31 (obese), which puts him at risk for T2DM (ADA, 2019).
Rationale for the diagnosis: Lab values contributing to this diagnosis are the following:
glucose of 136, hemoglobin A1C 6.8%, and small amount of glucose (+1) found in urine.
According to the American Diabetes Association guidelines, patients with an A1C greater
than 6.5% puts you at the diabetes mark, along with a glucose over 126 mg/dl (2019).
Secondary Diagnosis: Hyperlipidemia (E78.5)
Pathophysiology: Hyperlipidemia occurs when there are high levels of fat or lipids due
to an overproduction of lipoproteins by the liver (Shattat, 2014). Patients will not
typically present with any symptoms, and it is diagnosed using lab values.
Pertinent positive findings: Patient’s total cholesterol is just a little bit over 200.
Pertinent negative findings: LDL, HDL, and tryglycerides are out of range, and much
higher than the norm.
Rationale for the diagnosis: His triglycerides are 225, LDL 134, HDL 32, TC 202; the
normal for triglycerides should be below 150, LDL should be less than 70 (for patients
with heart disease or diabetes), and HDL should be greater than 60, and the total
cholesterol should be less than 200, this would indicate hyperlipidemia (ACC, 2018).
Secondary Diagnosis: Obesity (E66.0)
Pathophysiology: Obesity is linked to the central circuit mechanisms of the brain
becoming impaired, and causing neuro-endocrinological dysfunctions of the hormones
(Zhang et al., 2014).
Pertinent positive findings: Patient does workout regularly, and is being mindful of
making lifestyle changes.
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CASE STUDY
Pertinent negative findings: Patient is overweight, 210 pounds with a height of 5’9”,
putting him in the obesity range for BMI.
Rationale for the diagnosis: The patient has a calculated BMI of 31, which puts him at
the obesity mark (ACC, 2018).
Secondary Diagnosis: Right Knee Osteoarthritis (M17.11)
Pathophysiology: Osteoarthritis is the result of the lose of cartilage between joints, and
the thickening of subchondral plates, which causes the production of new bones to form
in between joint spaces (Ashkavand, Malekinejad & Vishwanath, 2014). Common signs
and symptoms include the following: swelling of the joints, joint pain, and tenderness
(Ashkavand, Malekinejad & Vishwanath, 2014).
Pertinent positive findings: Exercising regularly.
Pertinent negative findings: Still needing to take Tylenol to relieve pain, which can be
reduced by lowering BMI.
Rationale for the diagnosis: The patient has a history of being diagnosed with arthritis,
and a contributing factor to this diagnosis is his obesity (Ashkavand, Malekinejad &
Vishwanath, 2014).
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