diabetes case study

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

Chief Complaint

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“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
Past Surgical History

C-section 14 years ago

OB-GYN History

Menarche at age 11
Last pap smear 3 years ago
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.
Mother alive and well
Father has COPD
Two other siblings alive and well
All three children are alive and well
Social History

Married 29 years with 3 children; husband is a school teacher
Family lives in a four bedroom single family home
Patient works as a seamstress
Smokes 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

Cardiac

Denies chest pain, palpitations, and difficulty breathing while lying down

Lungs

Denies cough, shortness of breath, and wheezing

GI

Denies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits occasional episodes of constipation

GU

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

EXT

Denies leg cramps or swelling in the ankles and feet; has never experienced weakness, tingling or numbness in arms or legs prior to this episode

Neuro

Has never had a seizure and denies recent headaches

Derm

Has a rash under her bilateral breast and in groin area

Endocrine

Denies a history of goiter and has not experienced heat or cold intolerance

Vital Signs

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

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