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Diabetes Mellitus Case Study, Case Study Example

Pages: 3

Words: 875

Case Study

History of Present Illness

Katherine is a 64 year old known Type II diabetic who has suffered for several years from this illness. Currently, she is being seen at the urgent care center due to complications with bedsores. The bedsores, she reports, came to be after she was in bed for over two weeks suffering from an episode of influenza. Her pulmonologist reports that her illness has subsided and all systems are intact; however, she seeks treatment for the bedsores.

Definition of the Disease

Diabetes is a disease where the blood glucose levels are increased and your body cannot compensate for this (American Diabetes Association). There is not enough insulin produced to take care of the glucagon that comes from your liver and medication is often needed to control this, especially at the onset of the disease (U.S. National Library of Medicine). Over time, diabetes, if left uncontrolled, will cause multiple problems to the body. It will damage the eyes, kidneys, and nerves (which can cause thrombus in the circulatory system). It can cause diseases of the heart (such as arrhythmia), liver, and even instances of gangrene that will necessitate removal of an extremity. However, if controlled properly, patients have the ability to live normal lives as long as there is consistency in diet and exercise. They must also control their blood glucose by way of diet/exercise and medication if needed (World Health Organization).

Systemic Examination

Our patient had a complete physical examination from head to toe and the results are outlined below:

Eyes/Ears/Nose– pina normal, incus and malleus seem normal, patient admits a cochlear implant and the limbus and anterior chamber appear normal as well. Ophthalmoscopy reveals mydriasis with abnormal miosis and patient has a history of complaints of achromatopsia, which has hindered her vision for years. Upon inspection of the nasal cavity, the nares appeared intact as well as the cilia. There was sufficient mucus production. The patient had no complaints with her vocal cords. Her esophagus felt normal, epiglottis, tonsils, and tongue were also insignificant.

Endocrine System– Patient has no history of chemical thyroidectomy or other removal of the thyroid, adrenal glands seem intact, no history of nephrology or urology problems, no history of azotemia or anuria, but there is a complaint of bacteriuria. Patient has a history of increased secretion of antidiuretic hormone.  Total calcium is within normal limits. Patient admits to taking melatonin supplements for help with sleeping. She has no history of adrenal feminization, problems in the pituitary or posterior pituitary gland, or any antagonism related issues.

Cardiovascular System– Examination was conducted of the mitral valve, aortic valve, pulmonary valve, and tricuspid valve. Also an electrocardiogram was performed to detect a possible heart murmur or other heart problem. There is no history of a stent, use of vasodilators, use of thrombolytic or diuretic agents. Patient had no history of catheterization with a heart catheter, but did have a history of hypotension and bradycardia. There was no history of phlebitis, varicose veins, or use of cardiotonic or antilipidemic drugs. A holter monitor had been used before with insignificant results. Blood pressure was checked with the sphygmomanometer. The pharynx, larynx, trachea, bronchial tubes, lungs, and pleura all seemed nonsignificant. Her ventilation was normal. Her palate appeared normal on both the hard and soft portions as well as her mandible being firm. There was no problem with cricoid cartilage, hilum, or the apex.

Skin– Patient reported being allergic to bees and used epinephrine for this problem. She had a history of eczema and had a nevus on her outer right thigh. She did not suffer from lipoma, urticarial, acne vulgaris, hirsutism, alopecia, scleroderma, albinism, macules, papules, fissures, pustules, wheals, vesicles, ulcers, nodules, lacerations, impetigo, tinea, keloids, xeroderma, or cysts. She had reported petechiae as a result of over the counter vitamin supplements several months back. There was no history of paronychia or scabies.

Blood pressure was 120/84 mmHg and glucose levels were 140. This indicates a fairly controlled diet to monitor the diabetes. Our patient is not on medication at this time and does not wish to be unless necessary.

Diagnosis

The diagnosis for our patient is bedsores as a secondary condition caused from diabetes mellitus. These are due to her being in bed for such a lengthy period while being ill and unable to properly care for herself. Miraculously, there is nothing else secondary that has developed as a result of this influenza illness.

Treatment and Management

The acute treatment for these bedsores is a topical cream of triple antibiotic cream to be applied three times per day. Also, she is advised to stay active as much as possible until the bedsores heal so as to not further aggravate them. Her blood sugar tests do not necessitate starting medication because her diet and exercise is sufficient to control the diabetes. She is also advised to report back to the pulmonologist in three months for a follow-up to ensure lungs are operating at full capacity. She is also advised to report back to the urgent care clinic if she has any problems at all with the inflammation of the bedsores or with other complications from the diabetes in general.

Works Cited

American Diabetes Association. Diabetes Information. 2012. Web. 13 November 2012.

U.S. National Library of Medicine. Diabetes. November 2012. Web. 13 November 2012.

World Health Organization. Diabetes. 2012. Web. 13 November 2012.

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