The case study is based off this patient:
Chamberlain College of Nursing
Patient Case Study
AJS is a 58-year-old Pacific Islander, male, who presents with numbness & tingling in his feet for the past 6 weeks. He shows you a small cut on his right index finger that happened when he was pruning the bushes in the front yard 3 months ago. He states his stomach feels bloated after every meal and he is having a hard time concentrating at work. No exercise for the past 6 months.
EKG ordered.
Current medications: OTC Pepcid 40mg daily, Vitamin D drops, Tapazole 5mg daily
PMH: Hyperthyroidism, history of heavy ETOH use, quit drinking about 6 months ago, no tobacco, occasionally smokes marijuana
FH: father CVA last year, mother Type II DM, sister/CAD, brother/heavy ETOH, Type II DM.
SH: Truck driver, divorced 2 times, currently married, 2 sons first marriage, no known health issues,
Allergies: Shellfish, peanuts
Vital signs: BP 172/100; pulse 90, regular; respiration 20, regular Height 5’10”, weight 275 pounds
General: obese male, alert, oriented and cooperative. Skin: warm dry and intact. Open Cut Right Index finger, No retinopathy. There is no clinical evidence of congestive heart failure or peripheral vascular disease.
HEENT: head normocephalic. Bald. Eyes without exudate, sclera white. Readers. 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. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, palpable goiter.
CV: S1 and S2 RRR without rubs or murmurs.
Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen: large rounded, soft, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits.
Laboratory Values:
Urinary Analysis – SpGr 1.010trace protein, pH 5.2. Glucose +1, Ketones (-), Protein trace, (-) Nitrates.
24-h urine collection = urinary albumin excretion rate 250mg/day
Lipid Panel: TC 242 mg/dl, LDL 199 mg/dl; VLDL 38 mg/dl; HDL 48mg/dl, Triglycerides 228
CBC:
Hgb 12.5 gm/dl
Hct 41%
RBC 4.3 million
WBC 4,800/mm3
MCV 87 fl
MCHC 34 g/dl
RDW 13.8%
Thyroid –
TSH: 4.2
Free T 1.9
CMP: Sodium 138, Potassium 4.8, Chloride 100, CO2 29, Glucose 94, BUN 14, Creatinine 1.0
Calcium 9.5, Total protein 7.6, Bilirubin: total 0.8, Alkaline phosphatase 72
AST 28, ALT 32, Anion gap 8.10, Bun/Creatinine 16.8
GFR est non-AA 100 mL/min/1.73, GFR est AA 101 mL/min/1.73
Hemoglobin A1C: 11.9 %
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