Case Study For Patient With Diabetes Type 1 Mellitus Assignment
Case Study For Patient With Diabetes Type 1 Mellitus Assignment
This is a paper about a random Male patient which includes their health history and physical (it can be any MALE patient with any condition -completely made up). The format is posted below. Please follow the format and attached Genogram in the paper. I’ll upload the format and another assignment that was completed for me
Paper #1: First Written History and Physical: The Health History &Physical paper must include the following: a complete history of your patient’s background, a complete review of systems, and a complete physical exam Case Study For Patient With Diabetes Type 1 Mellitus Assignment.
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• Head-to-toe review of ALL systems
• Physical exam of the cardiovascular system
• Nutrition assessment
• Family history including a genogram.
• APA style
Paper 1 Grade Guideline:
Biographical Data
Points (Total 5) • Name (only initials), age
• Source of History (Who and reliability)
History of Present Illness 0,5 • Includes a chief complaint (Reason for seeing Care)
• Appropriate dimensions of cardinal symptom are listed – Location, Quality, Severity, Timing, Setting, chronology, aggravating/alleviating, associated manifestations)
• Incorporates elements of PMH, FH, SH that are relevant to the story (e.g. includes risk factors for CAD for patient with chest pain)
• ROS questions pertinent to the chief of complaint are included in HPI (not in ROS section)Case Study For Patient With Diabetes Type 1 Mellitus Assignment
• HPI narrative flows smoothly, in a logical fashion
Past Medical History 0.1 • Childhood Illness
• Accidents & Injuries
• Serious or Chronic Illness
• Hospitalizations
Past Surgical History 0.1 Includes approximate date, Surgeries, procedures, elective or non-elective, anesthesia given? What type of anesthesia—general, local etc.
Obstetric History (females) (with PMH) Use Gravida, Parity, Aborted, Living—G2P2 etc
• Last Menstrual Period
Immunizations 0.1 Childhood, Flu, Pneumonia, etc.
Allergies 0.1 Includes nature of adverse reactions
Medications 0.1 Includes dose, route and frequency for each medication
• Includes over the counter and herbal remedies
Family History 1.0
(including Genogram) • List medical conditions of parents, siblings, children, grandparents (GENOGRAM will be based on this***)Case Study For Patient With Diabetes Type 1 Mellitus Assignment
• Important diagnosis to look out: CAD, DM, HTN and Cancer
• Age at diagnosis (MI at what age? Etc), age of family members
Social History 0.5 • Occupation, Marital status
• Tobacco, Alcohol and Substance abuse; if they quit, how and when?
• Nutrition history
• Functional status (any assistive devices? Need help with ADLs?) and living situation (alone? In an assisted living?)
• Sexual Health- how do they define themselves? Are they sexually active? To whom? Any concern for HIV? STDs? Any use of protection?
Nutrition history
0.5 • Nutrition history
Review of System
1.5 • Body systems are evaluated: Constitutional/General, Skin, HEENT, Respiratory, Cardiovascular/Peripheral Vascular, GI, GU, Muscular, Neuro, Psych, Hematologic/Lymph, Endocrine
• Should NOT include PMH (ex. Cataracts or murmur of the heart belong in PMH, NOT ROS)
• Should NOT repeat information already in HPI
• Should NOT include Physical Exam findings
• Should INCLUDE adequate depth (be very thorough, in full sentences!)Case Study For Patient With Diabetes Type 1 Mellitus Assignment
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• NO USE OF “NORMAL†is Allowed
Style 0.5 • Legible
• Not laden with spelling or grammatical errors
• Uses medical abbreviations appropriately, does not “coin†own abbreviations
• APA style, typed, double spaced with COVER PAGE
FORMAT TO FOLLOW (please add genogram)
GENERAL INFORMATION
Patient Name (initials only): Name/Initials of Examiner:
Gender: Source of Referral:
Source of History/Reliability: Date:
PROBLEM LIST (list active and inactive diagnoses)
CHIEF COMPLAINT (CC): “quote patientâ€
HISTORY OF PRESENT ILLNESS (HPI): Presenting signs & symptoms, duration of same, pertinent history relevant to the chief complaint. Include 7 attributes—location, quality, quantity/severity, timing–including onset/duration, & frequency, setting in which it occurs, factors aggravating or relieving symptom, associated manifestations
PAST CHILDHOOD ILLNESSES: i.e. measles, mumps, rubella, varicella, scarlet fever, rheumatic fever, polio, and any other childhood illnesses such as Asthma (include dates)
PAST MEDICAL HISTORY (PMH): dates in reverse chronological order.
PAST SURGICAL HISTORY (PSH): surgical dates in reverse chronological order. Case Study For Patient With Diabetes Type 1 Mellitus Assignment
ALLERGIES: medications, OTCs, supplements, & environmental/seasonal/food allergies
UNTOWARD MEDICATION REACTIONS: include type of reaction/severity/date
IMMUNIZATION STATUS: e.g. Flu, Prevnar 13, TdaP, etc..Date must be included
SCREENING TESTS: e.g. colorectal screening, mammogram, pap test, PSA, etc…
FAMILY HISTORY: include relevant genetic risk history for living/deceased immediate relatives including grandparents, parents, siblings, children, grandchildren; for deceased relatives include cause of death and age; for sick relatives include age of onset
PERSONAL/SOCIAL: marital status, children, occupation, living arrangements, exercise, personal interests, religion, tobacco—use in pack years, if stopped smoking for how long did they smoke and when did they quit smoking; alcohol use—how many drinks/week, type of alcohol
FEMALES: LMP and relevant OB/GYN history Gravida, Para, Abortions-spontaneous vs. induced: age of menarche, menopause.
SEXUAL HISTORY: #of partners, sex of partner/s, protected/unprotected sexual relations, contraception
MEDICATIONS: dose, route, frequency (write class of medication in parentheses): Case Study For Patient With Diabetes Type 1 Mellitus Assignment
Review of Systems:
General:
Skin:
HEENT:
Head:
Eyes:
Ears:
Nose:
Throat:
Breasts:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Peripheral Vascular:
Musculoskeletal:
Neurologic:
Hematologic:
Endocrine:
Psychiatric:
Health History and Physical Assessment of Random Patient
GENERAL INFORMATION
Patient Name: B.T Name/Initials of Examiner: S. R
Gender: Male Source of Referral: Emergency unit
Source of History/Reliability: The Client Date: July 13, 2022.
PROBLEM LIST (list active and inactive diagnoses)
Type 2 Diabetes Mellitus (T2DM)
High blood pressure
Overweight
SUBJECTIVE DATA
CHIEF COMPLAINT (CC): “Chest discomfort and breathing difficulty.”
HISTORY OF PRESENT ILLNESS (HPI): The client, B.T., is a 63 years old Asian American male. The client has been referred from the emergency department where had been rushed following breathing difficultly. During the clinical examination, the client reported chest discomfort (angina). He described the discomfort as a burning, tightness, fullness, heavy, pressure, aching, numbness, dull, burning, and squeezing ache in the chest. He further added that the discomfort was radiating towards the left arm, shoulder, back, neck, and jaw. The client reported that these symptoms had persisted for the past three days. He denies aggravating or releasing factors, including physical activities, heavy meals, or rest. B.T also reported other symptoms, including feeling tired, dizziness, weakness, nausea, and lightheadedness.
PAST CHILDHOOD ILLNESSES: Diabetes type 1 Mellitus diagnosed at 8 years. Denies childhood accidents or injuries.
PAST MEDICAL HISTORY (PMH): Diabetes type 2 Mellitus, high blood pressure, and overweight.
PAST SURGICAL HISTORY (PSH): Denies minor or major surgeries.
ALLERGIES: No known allergy.
UNTOWARD MEDICATION REACTIONS: Denies medication reaction.
IMMUNIZATION STATUS: He reports all his childhood immunizations being up to date. He was immunized against COVID-19 in October 2020.
SCREENING TESTS: He undergoes a prostate specific antigen (PSA) test and digital rectal exam (DRE) since 50 years of age. Case Study For Patient With Diabetes Type 1 Mellitus Assignment
FAMILY HISTORY:
Father: Died of heart attack at 87 years.
Paternal grandfather: Died of cardiovascular arrest at 78 years.
Paternal grandmother: Died of breast cancer at 83.
Paternal Uncle: Alive at 90 years with history of Type 2 Diabetes Mellitus (T2DM).
Paternal Auntie: Alive at 84 years with hypertension.
Mother: Alive at 91 years with hypertension and T2DM.
Maternal grandfather: Died of Hypertension accident at 78 years.
Maternal grandmother: Died of cardiac arrest at 80 years.
Maternal Uncle: Alive at 80 years and healthy.
Maternal auntie: Alive at 86 years with breast cancer.
Brother: Alive at 72 with hypertension and obesity.
Sister: Alive at 57 years and healthy.
Son: Alive at 30 years and struggling with substance abuse
Daughter: Alive at 25 years and healthy.
The genogram below indicates relationship of the family members and their health status.
PERSONAL/SOCIAL:
The client is a divorcee and lives with his son and daughter. He is a manager for a private insurance company, which is based in the city. He reports sending most of his time in his office or attending meetings with various key stakeholders. He reveals mainly being focused toward achieving company goals. The client reports spending most of his free time reading motivational books or watching documentaries. He denies engaging in physical activities. The client also reveals being a smoker for over 29 years. He further added taking 4 to 5 beers daily before retiring to bed. However, the client denies abusing other substances, including cocaine and marijuana.
SEXUAL HISTORY: The client reports being heterosexual. However, he denies being sexually active since divorcing his wife five years ago. Case Study For Patient With Diabetes Type 1 Mellitus Assignment
MEDICATIONS:
Metformin 850 mg orally once daily taken to manage his blood sugar level.
Lisinopril 10 mg orally once daily for managing blood pressure.
Daily multivitamins.
Review of Systems:
General: The client reports feeling tired and weakness.
Skin: The client denies skin rashes, itching, or redness
HEAT:
Head: He denies injuries on the head. He reports lightheadedness.
Eyes: The client denies eye redness or drainage. He reports dizziness.
Ears: The client denies ear pain.
Nose: He denies nasal drainage or blockage.
Throat: The client denies pain with swallowing.
Respiratory: Reports breathing difficulty. Denies wheezing sound.
Cardiovascular: Reports shortness of breath. Reports chest discomfort, tightness, pressure, and fullness that spreads to the left arm, sholder, back, and neck.
Gastrointestinal: Reports nausea.
Genitourinary: Denies frequent urge to urinate or blood in the urine.
Peripheral Vascular: Reports numbness. Denies changes in temperature.
Musculoskeletal: Denies muscle stiffness. Reports pressure on the neck, jaw, and back.
Neurologic: Reports general weakness, dizziness, and numbness.
Hematologic: Denies bleeding or history of anaemia.
Endocrine: Denies changes in appetite. Denies increased hunger or thirst.
Psychiatric: Denies suicidal ideations or insomnia.
OBJECTIVE DATA
Physical Exam
Vital signs: HR-91 bpm, Temp-97.9*F, B/P-119/65, RR-18, Pulse Ox-95%, Weight – 196lbs, Height – 5’8″, and BMI score 29.8.
General: General: The client is a 63yo Asian American male. The client is well-nourished, well-developed, and looks younger than his actual age. The client is smartly dressed, well-groomed, and presentable. His dressing code is appropriate for today’s weather and time of the year. He maintains eye contact and remains attentive throughout the clinical interview. His concentrations remains high throughout the interview and responds to interview questions correctly. He moves his eyes around the room during the interview although it does not seem to affect his concentration. The client seems to be in acute distress. His self-reported mood is “fantastic.” He is alert and oriented to persons and situations. His affect and judgment are good. He is future-oriented. Case Study For Patient With Diabetes Type 1 Mellitus Assignment
HEENT
Head: No scars were seen on his head. The client is bald-headed with no lesions.
Eyes: The client has clear conjunctiva and white scleral. No swelling seen in both eyes.
Ears: Normal external ear structures with clear canals.
Nose: No obstruction to turbinate’s nor external lesions.
Throat: No erythema to posterior pharynx was detected.
Neck: Swollen neck veins were noted.
Breasts: No lumps on both breasts.
Respiratory: Soft cracking sound was heard.
Cardiovascular: Irregular heart rhythm and rapid heartbeats detected. Extra heart sounds and murmurs were heard.
Gastrointestinal: Changes in blood flow were heard upon listening to the abdomen.
Genitourinary: Omitted.
Musculoskeletal: Swollen feet and legs were noted. Neurological: Symmetrical movement was detected in in all extremities.
Diagnostic results:
- Electrocardiography (ECG or EKG): The results indicated rapid heartbeat.
- Stress echocardiography test: The results were positive, indicating reduced blood flow to the heart muscle.
ASSESSMENT
Client’s health history, physical examination findings, and diagnostic tests results indicated likelihood of various health conditions, necessitating differential diagnosis. Three potential diagnoses for this client are listed below in the order of the most likely to the least likely diagnosis.
- Coronary Artery Disease (CAD) – Primary diagnosis
- Angina Pectoris
- Acute Pericarditis
- Gastroesophageal Reflux Disease (GERD)
Coronary Artery Disease (CAD) – Pertinent Diagnosis
CAD is the primary diagnosis for this client. This condition is characterized by various clinical manifestations, including chest pain or discomfort, weakness, light-headedness, nausea, discomfort or pain in the arms or shoulder, faster heart rate, or shortness of breath. The client reported these, including shortness of breath, chest discomfort that was radiating towards the left arm, shoulder, back, neck, and jaw, feeling tired, dizziness, weakness, nausea, and lightheadedness (Winzer et al., 2019). Additionally, heart failure is characterized by various physical examination findings, including bulging neck veins, extra heart sounds, fluid buildup in the abdomen, fluid in the lungs, swelling in the legs and feet, or enlarged liver. During physical exam, the healthcare provider noted these symptoms, including swollen neck veins, soft cracking sound in the lung, irregular heart rhythm, rapid heartbeats, extra heart sounds, and murmurs, and swollen feet and legs due to fluid retention. Furthermore, electrocardiography (ECG) results indicated rapid heartbeat, while stress echocardiography test results were positive result, indicating reduced blood flow to the heart muscle. Thus, CAD qualifies as the primary diagnosis for this client. Case Study For Patient With Diabetes Type 1 Mellitus Assignment
Angina Pectoris
Angina Pectoris is another potential diagnosis for this client. This condition is characterized squeezing, heaviness, pressure, tightness, or discomfort in the chest. The discomfort occurs suddenly are recurs after sometime. In most case, the pain is prompted by exertion or physical exercise. Additionally, patients with angina pectoris report dizziness, inability to exercise, fatigue, light-headedness, or sweating, indigestion, nausea, shortness of breath or rapid breathing, or fast heart rate (Ford & Berry, 2020). The client qualifies for this diagnosis since he reported squeezing, heaviness, pressure, tightness, or discomfort in the chest. The discomfort occurs suddenly are recurs after sometime. In most case, the pain is prompted by exertion or physical exercise. He also reported other symptoms of angina pectoris, including weakness, light-headedness, nausea, or shortness of breath. However, this condition was ruled out since the client did not report that the discomfort occurred suddenly nor did it recur overtime. More so, the client did not report that the pain was prompted by exertion or physical exercise.
Acute Pericarditis
The client could also be diagnosed with Acute Pericarditis, which is characterized by a stabbing and sharp chest pain, which usually occurs quickly. A person with this condition experiences pain at the middle or left side of the chest. In some cases, the pain spreads to one or both shoulders. The pain is released by leaning forward or sitting down. On the contrary, the pain worsens with a deep breath. The client qualifies for this diagnosis since he reported chest pain that spreads to the left arm and shoulder. Nonetheless, this condition is ruled out since the reported pain is not stabbing or sharp. Additionally, the client denied aggreviating or releasing factors; hence disqualifying for this diagnosis. Case Study For Patient With Diabetes Type 1 Mellitus Assignment
GERD
The last potential diagnosis for this client is GERD, which is characterized by a burning sensation in the chest (heartburn), which usually occurs after eating a heavy meal and tends to worsen at night. Other symptoms, include chest pain, difficulty swallowing, regurgitation of food, and sensation of a lump in the throat (Clarrett & Hachem, 2018). The client qualifies for this diagnosis since he reported a burning chest pain. However, GERD is ruled out since the chest pain did not occur after meals nor worsen at night. Additionally, other significant symptoms of GERD, including difficulty swallowing, regurgitation of food, and sensation of a lump in the throat were not reported. Case Study For Patient With Diabetes Type 1 Mellitus Assignment
PLAN
The treatment for coronary artery disease (CAD) involves medications and non-pharmacological treatment interventions. Various drug types can be used in treating this client who is presented with CAD. First, the client will be prescribed cholesterol drugs to reduce cholesterol level and minimize plaque buildup in the blood arteries. Secondly, the client will be prescribed aspirin to assist in thinning the blood to prevent formation of blood clots in the vessels. Additionally, prescribing the client low-dose aspirin will reduce the risk of stroke and prevent heart attack. According to Davidson et al. (2022) low-dose aspirin reduces the risk of stroke or myocardial infarction in individuals at a high risk of developing these cardiovascular diseases. Lastly, this client will be prescribed beta blockers to slow the heart rate and lower the blood pressure.
On the other hand, non-pharmacological treatment interventions for CAD involves lifestyle changes. According to Piepoli and Villani (2017), lifestyle modification, including dietary changes and increasing physical activities reduces cardiovascular risk. Thus, the client will be advised to take foods low in saturated fats, trans fats, simple sugars, and sodium, but rich if fiber. Additionally, the client will be advised to quit smoking since tobacco smoking a significant factor contributing to cardiovascular diseases. Furthermore, the client will be advised to increase his physical activity levels. He should engage in moderate of vigorous physical activities for approximately 30 minutes daily. Lastly, the client will be advised to maintain a healthy body weight to reduce the risk of cardiovascular events. Case Study For Patient With Diabetes Type 1 Mellitus Assignment
References
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri medicine, 115(3), 214. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140167/
Davidson, K. W., Barry, M. J., Mangione, C. M., Cabana, M., Chelmow, D., Coker, T. R., … & US Preventive Services Task Force. (2022). Aspirin use to prevent cardiovascular disease: US Preventive Services Task Force recommendation statement. JAMA, 327(16), 1577-1584. Doi:10.1001/jama.2022.4983
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Ford, T. J., & Berry, C. (2020). Angina: contemporary diagnosis and management. Heart, 106(5), 387-398. Doi: 10.1136/heartjnl-2018-314661.
Ismail, T. F. (2020). Acute pericarditis: update on diagnosis and management. Clinical Medicine, 20(1), 48.
Piepoli, M. F., & Villani, G. Q. (2017). Lifestyle modification in secondary prevention. European journal of preventive cardiology, 24(3_suppl), 101-107. doi: 10.1177/1559827616651402.
Winzer, E. B., Woitek, F., & Linke, A. (2018). Physical activity in the prevention and treatment of coronary artery disease. Journal of the American Heart Association, 7(4), e007725. https://www.researchgate.net/publication/336922246_Coronary_Artery_Disease_Prevention Case Study For Patient With Diabetes Type 1 Mellitus Assignment