J.T. is a 48-year old male who presents to the primary care clinic with fatigue, weight loss, and extreme thirst and increased appetite

Case Study Scenario

Chief Complaint

J.T. is a 48-year old male who presents to the primary care clinic with fatigue, weight loss, and extreme thirst and increased appetite.

History of Present Illness

J.T. has been in his usual state of health until three weeks ago when he began experiencing symptoms of fatigue, weight loss, and extreme thirst. He reports that he would like to begin a walking program, but he feels too fatigued to walk at any point during the day. Now he is very concerned about gaining more weight since he is eating more. He reports insomnia due to having to get up and urinate greater than 4 times per night.

Past Medical History 

Hypertension

Hyperlipidemia

Obesity

Family History

Both parents deceased

Brother: Type 2 diabetes 

Social History

Denies smoking

Denies alcohol or recreational drug use

Landscaper  

Allergies

No Known Drug Allergies 

Medications

Lisinopril 20 mg once daily by mouth

Atorvastatin 20 mg once daily by mouth

Aspirin 81 mg once daily by mouth

Multivitamin once daily by mouth

Review of Systems

Constitutional: – fever, – chills, – weight loss.

Neurological: denies dizziness or disorientation

HEENT: Denies nasal congestion, rhinorrhea or sore throat.  

Chest: (-)Tachypnea. Denies cough.

Heart: Denies chest pain, chest pressure or palpitations.

Lymph: Denies lymph node swelling.

General Physical Exam  

Constitutional: Alert and oriented male in no acute distress   

Vital Signs: BP-136/80, T-98.6 F, P-78, RR-20

Wt. 240 lbs., Ht. 5’8″, BMI 36.5

HEENT 

Eyes: Pupils equal, round and reactive to light and accommodation, normal conjunctiva. 

Ears: Tympanic membranes intact. 

Nose: Bilateral nasal turbinates without redness or swelling. Nares patent. 

Mouth: Oropharynx clear. No mouth lesions. Teeth present and intact; Oral mucous membranes and lips dry. 

Neck/Lymph Nodes 

Neck supple without JVD. 

No lymphadenopathy, masses or carotid bruits. 

Lungs 

Bilateral breath sounds clear throughout lung fields. Breathing quality deep with fruity breath odor

Heart 

S1 and S2 regular rate and rhythm; – tachycardia; no rubs or murmurs. 

Integumentary System 

Skin warm, dry; Nail beds pink without clubbing.  

Labs

Test Patient’s Result Reference

Glucose (fasting)

132

Normal reference range 60-120 mg/dL

BUN

20

Normal reference range 7-24 mg/dL

Creatinine

0.8

Normal reference range 0.7-1.4 mg/dL

Sodium

141

Normal reference range 135-145 mEq/L

Chloride

97

Normal reference range 95-105 mEq/L

HCO3

24

Normal reference range 22-28 mEq/L

A1C

7.2

Urinalysis

Protein – Negative

Glucose Positive

Ketones Negative

Oral glucose tolerance test (OGTT)

220 mg/dL

J.T. is diagnosed with diabetes. Review all information provided in the case to answer the following questions.

*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.

Utilizes the required Clinical Practice Guideline (CPG) to support the chosen treatment recommendations @ https://professional.diabetes.org/content-page/practice-guidelines-resources

Pathophysiology & Clinical Findings of the Disease

1. Based on the review of the history, physical and lab findings what is the most likely diabetes diagnosis for this patient?

2. Explain the pathophysiology associated with the chosen diabetes diagnosis.

3. Identify at least three subjective findings from the case which support the chosen diagnosis.

4. Identify at least three objective findings from the case which support the chosen diagnosis

Management of the Disease

*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.

1. Utilizes the required Clinical Practice Guideline (CPG) to support the chosen treatment recommendations.

2. Identify two (2) “Evidence A” recommended medication classes for the treatment of this condition and provide an example (drug name) for each.

3. Describe the mechanism of action for each of the medication classes identified above.

4. Identify two (2) “ Evidence A” recommended non-pharmacological treatment options for this patient.

References

[Must be on a separate page and in APA format]

Week 6 Case Study Template

Read the case study listed below.

You must use at least one scholarly reference to provide pathophysiology statements. For this class, use of the textbook for pathophysiology statements is acceptable. You may also use an appropriate evidence-based journal.

You must use the current Clinical Practice Guideline (CPG) for the Standards of Medical Care in Diabetes -Abridged for Primary Care Providers provided by the American Diabetes Association to determine the patient’s type of diabetes and answer the treatment recommendation questions. The most current guideline can be found at the following web address: https://professional.diabetes.org/content-page/practice-guidelines-resourcesLinks to an external site. At the website, locate the current year’s CPG for use.

Proper APA format (in-text citations, reference page, spelling, English language, and grammar) must be used.