Mr W A 63-year-old Cuban Male Presents To The Office For His Annual Exam

Mr W A 63-year-old Cuban male presents to the office for his annual exam He reports that lately he has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. He complains that he seems like he cannot get enough to drink. He also is having nocturia 2-3 times per night. He has gained approximately 10 lbs. over the last year.

He joined a gym and forces himself to go twice a week, where he walks on the treadmill at least 30 minutes but has not lost any weight, in fact he has gained 5 pounds. He does not understand what he is doing wrong. He states that exercise seems to make him even more hungry and thirsty, which is not helping his weight loss. He wants to get a complete physical and to discuss why he is so tired and get some weight loss advice.

Current medications: Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin. PMH: Has left knee arthritis. Had chickenpox and mumps as a child. Vaccinations up to date.

FH: parents deceased due to CAD, 3 children alive, well. + two siblings. Both siblings with CAD. Sister w/ breast cancer.

SH: owns a restaurant. Married. No tobacco history, 1-2 glasses of wine on weekends.

No illicit drug use.

Allergies: NKDA, allergic to cats and pollen. No latex allergy

Vital signs: BP 129/80; pulse 76, regular; respiration 16, regular Height 5’2.5”, weight

185 pounds

General: obese male in no acute distress. Alert, oriented and cooperative. Skin: warm, dry and intact. No lesions noted.

HEENT: head normocephalic. Hair thick and distributed throughout the scalp. Eyes without exudate, sclera white. Wear contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.

CV: S1 and S2 RRR without murmurs or rubs.

Lungs: Clear to auscultation bilaterally, respirations unlabored. Mr W A 63-year-old

Cuban male presents to the office for his annual exam

Abdomen: soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.

Labwork:

CBC:

WBC 6,000/mm3

Hgb 12.5 gm/dl

Hct 41%

RBC 4.6 million

MCV 88 fl

MCHC 34 g/dl

RDW 13.8%

UA: pH 5,

SpGr 1.013,

Leukocyte esterase negative,

Nitrites negative,

Glucose 1+;

Protein: Small; Mr W A 63-year-old Cuban male presents to the office for his annual exam

Ketones: Negative

CMP:

Sodium 139

Potassium 4.3

Chloride 100

CO2 29 Glucose 95

BUN 12

Creatinine 0.7

GFR est non-AA 92 mL/min/1.73

GFR est AA 101 mL/min/1.73

Calcium 9.5

Total protein 7.6

Bilirubin, total 0.6

Alkaline phosphatase 72

AST 25

ALT 29

Anion gap 8.10 Bun/Creat 17.7 exam

Hemoglobin A1C: 6.9 %

TSH: 2.35,

Free T 4 0.7

Lipid Panel:

TC 230 mg/dl,

LDL 144 mg/dl;

VLDL 36 mg/dl;

HDL 38 mg/dl,

Triglycerides 232

EKG: normal sinus rhythm

Week 5: Case Study Assignment

Due Saturday by 11:59pm Points 160

THE FOLLOWING PAPER COMES WITH A CASE STUDY THAT WILL ADDED BELOW AND IT ALSO COMES WITH A TEMPLATE THAT MUST BE USED.

CASE STUDY IS AS FOLLOWS:

He reports that lately he has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. He complains that he seems like he cannot get enough to drink. He also is having nocturia 2-3 times per night. He has gained approximately 10 lbs. over the last year. He joined a gym and forces himself to go twice a week, where he walks on the treadmill at least 30 minutes but has not lost any weight, in fact he has gained 5 pounds. He does not understand what he is doing wrong.

He states that exercise seems to make him even more hungry and thirsty, which is not helping his weight loss. He wants to get a complete physical and to discuss why he is so tired and get some weight loss advice. Current medications: Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin.PMH: Has left knee arthritis. Had chickenpox and mumps as a child. Vaccinations up to date. FH: parents deceased due to CAD, 3 children alive, well. + two siblings. Both siblings with CAD. Sister w/ breast cancer.SH: owns a restaurant. Married. No tobacco history, 1-2 glasses of wine on weekends. No illicit drug use.

Allergies: NKDA, allergic to cats and pollen. No latex allergy Vital signs: BP 129/80; pulse 76, regular; respiration 16, regular Height 5’2.5”, weight 185 pounds General: obese male in no acute distress. Alert, oriented and cooperative. Skin: warm, dry and intact. No lesions noted. HEENT: head normocephalic. Hair thick and distributed throughout the scalp. Eyes without exudate, sclera white. Wear contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema.

Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. CV: S1 and S2 RRR without murmurs or rubs. Lungs: Clear to auscultation bilaterally, respirations unlabored. Abdomen: soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT. Labwork: CBC: WBC 6,000/mm3

Hgb 12.5 gm/dl Hct 41% RBC 4.6 million MCV 88 fl MCHC 34 g/dl RDW 13.8% UA: pH 5,

SpGr 1.013, Leukocyte esterase negative,Nitrites negative, Glucose 1+; Protein: Small; Ketones: NegativeCMP: Sodium 139 Potassium 4.3 Chloride 100 CO2 29 Glucose 95

BUN 12 Creatinine 0.7 GFR est non-AA 92 mL/min/1.73 GFR est AA 101 mL/min/1.73

Calcium 9.5 Total protein 7.6 Bilirubin, total 0.6 Alkaline phosphatase 72

AST 25 ALT 29 Anion gap 8.10 Bun/Creat 17.7 Hemoglobin A1C: 6.9 % TSH: 2.35, Free T

4 0.7 Lipid Panel: TC 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 38 mg/dl,

Triglycerides 232 EKG: normal sinus rhythmAST 25 ALT 29 Anion gap 8.10 Bun/Creat 17.7 Hemoglobin A1C: 6.9 % TSH: 2.35, Free T 4 0.7 Lipid Panel: TC 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 38 mg/dl, Triglycerides 232 EKG: normal sinus rhythm Mr W

A 63-year-old Cuban male presents to the office for his annual exam

THIS IS THE TEMPLATE THAT NEEDS TO BE USED:

Title page per APA format

This assignment template serves as a paper template to develop the week 5 case study and may not be all inclusive. You must also refer to the assignment rubric for specific requirements for this assignment. Your paper is graded to the rubric requirements.

*Please make sure that you are following APA guidelines as you will be graded on APA.

Make sure your paper meets APA Criteria

The introductory paragraph is written here. Remember to remove all instructions from your paper. These are in red ink. AssessmentPrimary Diagnosis diagnosis (ICD10 code) pathophysiologyA brief pathophysiology statement which is no longer than two sentences, paraphrased and includes common signs and symptoms of the diagnosis.

Includes citation to an approved source (author, year).

Review the Reference Guidelines for FNP Case Study document. This applies to all sections of this paper. pertinent positive findings includes citation to an approved source (author, year).Review the Reference Guidelines for FNP Case Study documents. This applies to all sections of this paper. pertinent negative findings includes citation to an approved source (author, year).Review the Reference Guidelines for FNP Case Study documents. This applies to all sections of this paper.

rationale for the diagnosis includes a brief 1-2 sentence statement, which links the subjective and objective case study findings including provided lab data and interpretation of the labs. Include a statement linking those lab results to your ADA guideline reference. Includes citation to the ADA guideline used to determine this diagnosis. Secondary Diagnosis diagnosis (ICD10 code)*You can have more than one secondary diagnosis.

A minimum is required. Secondary diagnoses are additional diagnoses you have identified from the exam, lab findings today or the PMH*Pathophysiology A brief pathophysiology statement which is no longer than two sentences, paraphrased and includes common signs and symptoms of the diagnosis (author, year).pertinent positive findings as explained above (author, year).

3 pertinent negative findings as explained above (author, year).rationale for the diagnosis-includes a brief 1-2 sentence statement, which links the subjective and objective findings including any provided lab data and interpretation of the diagnostic testing. The rationale includes a citation to a scholarly reference (author, year) Mr W, a

63-year-old Cuban male, presents to the office for his annual exam.

Plan Diagnostics

Lab test (#1) (each lab/diagnostic test is listed individually with rationale to follow AND is linked to a diagnosis listed in the assessment section of the paper. Include the timeframe of when the lab is to be drawn. *This is labs or tests you will order in the future, not an explanation of the labs that have already been completed.*rationale: each rationale contains the EBP statement supporting the necessity of the test and includes the name of the diagnosis which is listed in the assessment section.*

If this diagnosis is not listed in the assessment section then it must be added to order the diagnostic testing*. Includes a citation to an approved reference from the Reference Guidelines for FNP Case Study document which supports not only the test but the timing of the lab draw. Lab test (#2) includes the same criteria.

Do the same for each lab you want to order. Medications *each medication is linked to a diagnosis listed in the assessment section of the paper AND is listed individually with rationale, including the required OTC*Medication (#1) – written in prescription format (see NR 601 Resources) Rationale.

The rationale for each medication includes the diagnosis which is listed in the assessment section and contains the EBP statement supporting the necessity of the medication. If this diagnosis is not listed in the assessment section, then it must be added to include any medication. Includes a citation to an approved reference from the Reference Guidelines for FNP Case Study document.Medication (#2) includes the same criteria. Do the same for each medication listed

4Educationsection includes personalized detailed education on all five (5) subcategories: diagnosis, each medication purpose and side effects, diet, personalized appropriate exercise recommendations and warning sign for diagnosis and medications if applicable. You do not need an introduction paragraph. All education steps are linked to a listed diagnosis, paraphrased, and include a paraphrased EBP rationale.

If this diagnosis is not listed in the assessment section, then it must be added to include the education content here. Each education section includes a citation to an approved reference from the Reference Guidelines for FNP Case Study document Mr W, a

63-year-old Cuban male, presents to the office for his annual exam.

Diagnoses.

Includes personalized detailed education for each diagnosis listed in the assessment section. This includes specific information for this particular client. Education includes a citation to an appropriate reference. No listed education is common knowledge, all statements must include an in text citation to an appropriate reference.Medications.includes personalized detailed education for each medication listed in the medication section.

Each medication is listed and then explained. No listed education is common knowledge, all statements must include an in text citation to an appropriate reference.Diet.includes personalized detailed education for dietary recommendations as determined by the listed diagnoses in the assessment section. This includes specific dietary information. A referral to cover this requirement is not sufficient. If weight loss is recommended, then specific weight loss targets must be included. No listed education is common knowledge, all statements must include an in text citation to an appropriate reference.

Exercise.includes personalized detailed education for exercise recommendations as determined by the listed diagnoses in the assessment section. List specific exercises that are appropriate for this patient. No 4 Education Section includes personalized detailed education on all five (5) subcategories: diagnosis, each medication purpose and side effects, diet, personalized appropriate exercise recommendations and warning sign for diagnosis and medications if applicable. You do not need an introduction paragraph. All education steps are linked to a listed diagnosis, paraphrased, and include a paraphrased EBP rationale.

Diagnosis.Includes personalized detailed education for each diagnosis listed in the assessment section. This includes specific information for this particular client. Education includes a citation to an appropriate reference. No listed education is common knowledge, all statements must include an in text citation to an appropriate reference.Medications.includes personalized detailed education for each medication listed in the medication section.

This includes specific dietary information. A referral to cover this requirement is not sufficient. If weight loss is recommended, then specific weight loss targets must be included. No listed education is common knowledge, all statements must include an in text citation to an appropriate reference.Exercise.includes personalized detailed education for exercise recommendations as determined by the listed diagnoses in the assessment section. List specific exercises that are appropriate for this patient.

No 5 listed education is common knowledge, all statements must include an in text citation to an appropriate reference. Warning Signs for diagnoses and medications includes personalized detailed education as determined by the listed diagnoses and medications. No listed education is common knowledge, all statements must include an in text citation to an appropriate reference.

ReferralSpecialty practice or service (each referral is linked to a diagnosis listed in the assessment section of the paper and is listed individually with rationale to follow) rationale: each rationale contains the EBP statement supporting the necessity of the referral and includes the name of the diagnosis which is listed in the assessment section. Includes a citation to an approved reference from the Reference Guidelines for

FNP Case Study document.

Any referrals for the listed primary diagnosis must be cited from the chosen ADA guideline.Referral(#2) includes the same criteria. Do the same for each referral Follow upFollow up includes a specific time frame (1week, 1 month) , not a time range, to return to PCP office for next scheduled appointment. Includes EBP rationale within text citation. Refer to the rubric for full section requirements. Follow up does not include other upcoming plans.

Diagnostics and referrals are discussed within that section above. Assessment of comorbidities See rubric for section requirements. Medication CostSee rubric for section requirements.

6 Conclusion A summary paragraph no more than 5 sentences

Purpose

The purpose of this case study assignment is to :

Analyze provided subjective and objective information to diagnose and develop a management plan for the selected case study patient.

Apply national diabetes guidelines to a case study patient.
Apply national guidelines to develop a management plan for all identified secondary diagnosis(es).

Activity Learning Outcomes

Through this assignment, the student will demonstrate the ability to:

Select appropriate health promotion and disease prevention strategies for patients with or at risk for a glucose metabolism disorder (WO5.1) (CO1,2,3,4,5)
Demonstrate competence in the evaluation and management of patients with glucose metabolism disorders
Develop a management plan for the case study patient based on identified primary, secondary and differential diagnoses.
Apply polypharmacy knowledge to medication reconciliation for selected case study patients.

Due Date:

This assignment is submitted through Turn It In (TII).* Students are allowed two opportunities to submit. The first Turn It In submission allows the student to view the Turn It In Score and edit the assignment if necessary. The second submission is considered the final submission and will be graded. Any further Turn IT In submissions will not be considered for grading.

*Due to the amount of common case study content it is not unusual that the TII may exceed 25%. It is the original work, such as rationale statements and treatment plans that are evaluated for similarity by the faculty.

Total Points Possible: 160

Requirements:

The assignment is a paper, which is to be written in APA format using the provided assignment template. The paper shall not exceed 10 pages, excluding title page and references.

NR601 _week 5 case study paper template_Nov 20.docx download

Mr W A 63-year-old Cuban male presents to the office for his annual exam