Health Medical Homework Help

Clinical Patient 

Viktoria Azure Kraig 81-year-old female 

Chart 000601200 

Good afternoon Viktoria. How are you? Did you stop by the lab and have your blood work done? 

You know how much I hate coming to the office. I like you but I hate being poked and prodded. I don’t like answering questions either. I was trying to tell my daughter what you said the last time I was here. I think it was about a year ago. 

Let me check your chart. It was about 14 months ago. We talked about checking blood sugars. You saw the dietician, right? 

No. I didn’t go to that appointment.

Did you see the diabetic educator to learn about the glucometer & strips. 

No, I missed the appointment. I didn’t think I had a diagnosis for high blood sugar. I don’t need to check my blood. My diet is okay. I do like candy but I limit myself to 2 candy bars a week. My daughter was commenting on my health and the things she was saying reminded me of our last conversation. She comes over at 7am and wants me to get up to go for a walk and I don’t like to get up that early. I like to stay up late and watch my shows and make popcorn. I usually make a diet Pepsi over ice. She said if I didn’t come see you today she would make an appointment and come with me. I don’t want her to know about the blood sugar. I told her I was tired and now she thinks I am sick.

Your lab results from last year included possible hyperglycemia. Your A1C was higher than it should be.

Let’s take a look at your current lab results and start there. Then we can talk about next steps. 

General Overview: complete in your outline document 

BP 136/90, P 88, RR 16, HT 5’2.5”, WT 188lbs 

Allergies: Peanuts, Peanut oil/hives, swelling 

Current Medications: Vegan PO chewable B6/B12/Folate 

Past Medical History includes: 2 NSVD births, Bronchitis, Cholecystectomy 2000. Vaccinations up to date. 2 doses Pfizer for COVID, 2021. 

FH: mother deceased MI, father deceased Kidney Failure, 2 children no health issues 

SH: Retired volleyball coach, married, No ETOH or tobacco, no illicit drug use. 

Physical Exam – 

HEENT: normocephalic, Bilateral eyes, sclera white, Bifocals. 

Bilateral Tympanic membranes gray & intact. No tenderness tragus & pinna. Bilateral nares no exudate. Neck supple. No lymphadenopathy. Thyroid midline, small & firm, no palpable masses. 

Cardiovascular: S1 & S2 RRR, no rubs or murmurs. 

Respiratory: bilaterally clear to auscultations. 

Abdomen: soft, round, no tenderness reported, BS x 4 quads, No bruits. 

Derm: dry skin arms, hands, shins 

+ Bilateral pedal pulses Laboratory Tests 

  

UA   

pH 5.2 RBC (-) 

Leukocyte   Esterase (-) 

Nitrates (-) 

Glucose 1+ 

Protein none 

Ketone (-) 

 

Complete   Blood Count 

RBC 4.4   million 

HGB 12.8gm/dl   

HCT 41% 

MCV 84 fl 

MCHC 32 g/dl 

RDW 13.6% 

WBC 4400/mm3 

 

CMP   

NA+ 134 

K+ 4.2 

Chloride 98 

Glucose 98 

BUN 12 

Creatinine   1.92 

GFR non-AA   105mL/min 

GFR est AA   100 mL/min 

CA 9.5 

Total Protein   7.7 

Bilirubin   total 0.6 

Alk phos 74 

AST 34 

ALT 36 

Bun/Creatinine   10 

 

Thyroid

Free T4 0.7 TSH 2.05 

 

HbA1c

7.7% 

 

Lipid   Panel (fasting) 

LDL-C 177   mg/dL 

   

HDL-C 50   mg/dL 

Total-C 248   mg/dL 

Triglycerides   130 mg/dL 

Diagnostics: 

EKG: NSR w/occasional PVC 

Requirements:

1: List 1 primary diagnosis and 2 differential diagnoses, with their ICD-10. Include each diagnosis pathophysiology. pertinent lab results that confirms the diagnosis. Must use ADA 2019.

2: What labs will you order and why. Provide an explanation in your own words for each lab test you order for your patient. Cite CPG and/ or scholarly provider journal articles.

3:  What medications will you order for the patient? Provide a detailed explanation as to why the patient needs each medication.

4: Patient education. For each diagnosis provide education to your patient  in your own words.

5:  Fully describe education for each medication, mechanism of action, contraindications, side effects and special instructions.

6: Fully describe education for fluids, calories, meal, diet, snack planning, physical activity, exercise, cardiovascular strength, muscle strength. Assist your patient with understanding the importance of health.

7: Does your patient need any referrals, list and explain 4.