The motivation behind this contextual analysis is to survey abstract and target data on a patient and set up an essential and auxiliary conclusion.

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Description

Case
Study

The
motivation behind this contextual analysis is to survey abstract and target
data on a patient and set up an essential and auxiliary conclusion. After the
patient was evaluated and I gathered the required data from the appraisal, an
arrangement of care will be set up for the patient.

Assessment

In the wake of looking at the patient and evaluating
the test results for Mrs. G., I have closed this present patient’s essential
analysis to be Type II diabetes, ICD-10: E11. With type II diabetes, your
pancreas will create insulin, yet it doesn’t utilize the insulin suitably, and
this causes the insulin levels to rise. At the point when your blood glucose
levels rise you may experience:

1)         excessive thirst (polydipsia)

 

2)         excessive pee (polyuria)

 

3)         excessive yearning (polyphagia)

 

These are usually
alluded to as the 3 P’s (CDC.gov). Some positive discoveries in the wake of
looking at Mrs. G. are that Mrs. G. reports that she has felt exhausted, she
has had polyuria, polydipsia and polyphagia, and reports a weight gain. Mrs. G.
reports side effects for a quarter of a year. Subsequent to surveying Mrs. G’s
labs, it is found that she has a blood glucose perusing of 126, her A1C is
6.9%, and she has 1+ glucose in her pee. These outcomes are for the most part
positive discoveries for a Type II diabetes conclusion (ADA, 2020). Mrs. G.
doesn’t report having a parent with diabetes, negative for weight reduction
(ADA, 2020). I chose type II diabetes as Mrs.G’s essential determination due to
the patients revealed side effects of feeling exhausted, having polyuria,
polydipsia, and polyphagia, her weight of 185 pounds thinks of her as obese,
her lab discoveries of having 1+ glucose in her UA, and a Hgb A1C of 6.9%.
Typical discoveries should be negative for glucose in UA, an ordinary Hgb A1C
is 5.7 or lower, Mrs. G has a BMI of 33.83, which is viewed as obese, ordinary
BMI ought to be up to 24.99 for ordinary weight. These discoveries put Mrs. G
at a higher hazard for type II diabetes (ADA, 2020).

Secondary
Diagnosis

Obesity. ICD-10: E66.9.
While figuring the patient’s stature of 5’2.5 and weight of 185 her BMI is
33.83. The World Health Organization reports, on the off chance that you have a
BMI more than 30, this determines you obese (WHO.int). Obesity can put you at
higher hazard for creating other wellbeing related issues (WHO.int)

Left knee joint pain.
ICD-10: M17.12. Mrs. G. reports joint inflammation in her left knee and reports
taking Tylenol every day for the torment. It is conceivable that patient could
have torment in her left knee because of her weight issues or she could have
osteoarthritis, which is the most well-known kind of joint pain in the knee
(Arthritis.org).

Blended hyperlipidemia.
ICD-10: E78.2. Mrs. G states her dad had a past dx with elevated cholesterol.
Subsequent to exploring patient’s lab results it is discovered that she has a
high total cholesterol of 230, LDL is 144, VLDL is 36, and fatty lipids are
132.

 

Prehypertension ICD-10:
R03.0. Mrs. G’s. pulse was 129/80. Patient reports her mom has a past filled
with hypertension. As indicated by CDC.gov, patient’s pulse put’s her in a
prehypertension state. Mrs. G doesn’t report cerebral pains, dizziness, or lightheadedness,
which are basic side effects of hypertension (CDC.org).

Plan

Diagnostics: Lab test (#1) It was not expressed
clear concerning whether the patient’s labs where

fasting labs, so I would have the patient revisit
her labs while fasting. To get an

exact A1C result, the
patient should fast for 8 hours (ADA, 2020).

Lab test (#2) As
recently expressed, it was muddled with regards to whether patient’s labs were
fasting so I would have a lipid board while fasting. Patient ought to fast for
9 to 12 hours (Heart.org). Subsequent to fasting labs are come about, a statin
can be started if clinically shown necessary.

Medications

Mrs. G has an A1C of
6.9%. In the wake of affirming Mrs. G’s A1C with a fasting blood test, the
patient will be started on Metformin. Metformin is taken orally and is viewed
as a first line treatment drug for patient’s determined to have type II
diabetes (ADA, 2020).

Metformin 500mg day by day

Sig: 1 tab PO day by day

Disp# 30

RF: 0

Patient’s lipid board
is raised. Patient will be prescribed a statin to help forestall a coronary
failure or stroke (Heart.org).

Lovastatin 20mg

Sig: 1 tab PO at HS

Disp# 30

RF: 0

Mrs. G is taking
Tylenol for her left knee pain. Tylenol will be proceeded for the patient for
her knee pain.

Tylenol 500mg

Sig: 2 tabs at regular intervals varying
for left knee pain

Disp# 120

RF:3

Mrs. G reports taking
an everyday Multivitamin. This prescription will be proceeded for the patient.

Multivitamin

Sig: 1 tab PO every day

Disp# 30

RF: 3 

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