Physical Exam
A physical examination reveals the following:
- Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m2
- Fasting capillary glucose: 166 mg/dl
- Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg
- Pulse: 88 bpm; respirations 20 per minute
- Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy
- Thyroid: nonpalpable
- Lungs: clear to auscultation
- Heart: Rate and rhythm regular, no murmurs or gallops
- Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally
- Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle
Lab Results
Results of laboratory tests (drawn 5 days before the office visit) are as follows:
- Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)
- Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)
- Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)
- Sodium: 141 mg/dl (normal range: 135–146 mg/dl)
- Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)
- Lipid panel
• Total cholesterol: 162 mg/dl (normal: <200 mg/dl)
• HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)
• LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)
• Triglycerides: 177 mg/dl (normal: <150 mg/dl)
• Cholesterol-to-HDL ratio: 3.8 (normal: <5.0) - AST: 14 IU/l (normal: 0–40 IU/l)
- ALT: 19 IU/l (normal: 5–40 IU/l)
- Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l)
- A1C: 8.1% (normal: 4–6%)
- Urine microalbumin: 45 mg (normal: <30 mg)
Please use the attached Care Plan outline for this assignment and post in the “Drop Box” under “Instructional”.
Credit of care study to: Geralyn Spollett, MSN, C-ANP, CDE
Reference:
American Diabetes Association. (2003, January 1). Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse. Retrieved from http://spectrum.diabetesjournals.org/content/16/1/32
