PREPARING THE ASSIGNMENT Follow these guidelines when completing each component

PREPARING THE ASSIGNMENT
Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions. There are three patient cases presented in this assignment. You are to use the following to answer the questions.
When you click on the resource links, the links will open in a new window so you will be able to navigate between the resources and the quiz.American Diabetes Association. (2020). Figure 9.1 [Graph]. Standards of Medical Care in Diabetes—2020 Abridged for Primary Care Providers. https://clinical.diabetesjournals.org/content/38/1/10
Rosenthal, L., Burchum, J. (2021). Lehne’s pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier.
You will be presented with a patient case and then a series of questions. This assignment is completed in a quiz format; however, it is not an exam and you are encouraged to use your textbook and course materials. There are 12 questions worth 10 points each and an attestation question worth 0 points for a total of 120 points.
Review the case information and then answer each required question with a succinct, informative answer.
Answers should be one to five sentences in length.Some questions may require a short one-sentence answer, whereas others require a five-sentence answer for a complete explanation.
Consider the most common and obvious answer.
A scholarly reference is required for answers where a source such as textbook or clinical practice guideline is used to develop your response.
Feedback is provided immediately after completing this assignment only. The feedback provided is general and non-specific to protect the integrity of this assignment due to the unfortunate nature of answer sharing among many students.
There is no time limit for this assignment.
This assignment will need to be completed in one sitting, meaning you will not be able to save your answers and come back to it later. Once you open the quiz, you will need to finish it at that time.
CASE STUDY #1: JOHN JONES
Click through the components of John’s case to learn more.
PATIENT’S CHIEF COMPLAINTS
“My wife said I’m due for an annual check-up.”
HISTORY OF PRESENT ILLNESS
John Jones is a 46-year-old male who presents for his yearly physical examination. He has no complaints. He reports a very sedentary lifestyle. He sits at a desk for 8 to 10 hours per day and when he comes home, he “just wants to relax in front of the television.” He doesn’t feel motivated enough to exercise regularly, although he knows he should. Previous labs and exam from last year are unremarkable.
PAST MEDICAL HISTORY
Previous medical history is notable for obesity and hyperlipidemia.
FAMILY HISTORY
Family history is significant for diabetes (mother, maternal grandmother, paternal grandfather) and hypertension (father and brother).
SOCIAL HISTORY
John works in real estate management.
He lives with his wife and two teenage children.
He is a nonsmoker and reports drinking “a few beers on the weekend during football season”.
His diet consists of mostly fast-food meals.
He drinks sweet tea with every meal and an additional 3-4 cups of coffee per day.
REVIEW OF SYSTEMS
General: denies weight gain over the last 6 months;
(-) fatigue on exertion, (-) appetite changes,
(-) fever or chills
Skin: (-) skin tears, lacerations, or rashes
HEENT: (-) dental intact; (+) hearing loss left ear; wears glasses—last eye exam 1 year ago
Neck: (-) lymphadenopathy; (-) pain and stiffness
Respiratory: (-) dyspnea; denies cough or wheezing;
Cardiac: (-) chest pain or heart palpitations; (-) MI
Gastrointestinal: (-) heartburn, (-) nausea/vomiting, constipation, or hemorroids
GU: (-) hesitancy or frequency; (+) nocturnia (urinates 4 times/night); (-) urgency, burning, hematuria;
(-) dribbling/incontinence;
(-) penile discharge; denies history of STI
Peripheral Vascular: (-) peripheral edema; (-) neuropathy
Musculoskeletal: (-) pain; (-) joint swelling
Neurologic: (+) occasional headache
(-) vertigo, or memory loss
Psychiatric: (-) depression, anxiety, or insomnia
Allergies:
Penicillin (hives)
Medications:Medications include atorvastatin 10mg daily and a multivitamin. He occasionally takes acetaminophen for a headache.
PHYSICAL EXAM
GeneralAlert, appropriately dressed, obese Caucasian male in no apparent distress. He appears his stated age.Vital Signs: BP 130/90 mm HG, pulse 82 and regular, temperature 98.7, respirations 18,Height 6’1”, Weight 235 pounds (up 3 lbs. since his visit 1 year ago).Integumentary System
Warm and dry
(-) cyanosis, nodules, masses, rashes, itching, and jaundice
(-) ecchymosis and petechiae
Good turgor
HEENT
PERRLA
EOMs intact
Eyes anicteric
Normal conjunctiva
Vision satisfactory with no eye pain
Fundi with arteriolar narrowing with no nicking, hemorrhages, exudate, or papilledema
TMs intact
(-) tinnitus and ear pain
Nares clear
Oropharynx clear with no mouth lesions
White teeth
Oral mucous membranes pink and moist
Tongue normal size
No throat pain or difficulty swallowing
Neck/Lymph Nodes
Neck supple
(-) cervical lymphadenopathy, thyromegaly, masses, and carotid bruits
Chest/Lungs
Lungs clear to auscultation, respirations even and unlabored
Heart
S1 and S2 regular rate and rhythm
Prominent S3 sound
No rubs or murmurs
Heart
S1 and S2 regular rate and rhythm
Prominent S3 sound
No rubs or murmurs
Abdomen
Obese
(+) hepatosplenomegaly, fluid wave, tenderness, and distension
(-) masses, bruits, and superficial abdominal veins
Normal BS x4 quadrants
Genitalia/Rectum
Heme (-) stool
Genitalia/Rectum
Heme (-) stool
Musculoskeletal/Extremities
Normal ROM throughout
(-) clubbing
(+) 1 bilateral ankle edema
(+) 2 dorsalis pedis and posterior tibial pulses bilaterally
(-) spine and CVA tenderness
Denies muscle aches, joint pain, and bone pain
Neurological
Alert and oriented
Cranial nerves intact
Motor 5/5 upper and lower extremities bilaterally
Strength, sensation, and deep tendon reflexes intact and symmetric
Gait steady
Denies headache and dizziness
DIAGNOSTIC TEST RESULTS
Lab
Result
Na
125meq/L
K
3.9meq/L
Cl
104 meq/L
HC03
27meq/L
Ca
9.3mg/dL
BUN
16 mg/d L
Mg
2.5 mg/dL
Cr
1.1 mg/dL
Phos
3.9 mg/dL
Glucose
200 mg/dL
AST
29IU/L
ALT
43IU/L
Aik Phos
123IU/L
GGT
119IU/L
PSA
1.3ng/ml
HgbA
1C- 8.1%
TSH
4.0mU/L
Free T4=
1.1 ng/dl
Hgb
16.9g/dL
Hct
48%
RBC
5.9 million/mm3
WBC
7.1 x103/mm3
Monos
7%
Eos
3%
Basos
1%
Segs
51%
Bands
2%
Lymphs
23%
Platelets
160 x103/10mm3
PT
14.2 sec
T. Cholesterol
190mg/dl
HDL
35mg/dl
LDL
120mg/dl
Trig
260 mg/dl
UA
(-) Ketones,(-) protein.(-) microalbuminuria
Additional Tests: None
1. Use the John Jones case study to answer the following question. Using diagnostic criteria for diabetes, what is John’s diabetic status? What treatment plan should be introduced at this time?
2. Use the John Jones case study to answer the following question. Which of John’s behaviors should be addressed to encourage lifestyle changes and decrease A1C levels?
3. Use the John Jones case study to answer the following question. Which behavior in John’s social history poses a potential concern with first line pharmacological treatment for diabetes and why?
4. Use the John Jones case study to answer the following question. Name the specific names of labs you would order and the intervals at which you would order them to monitor the safety and efficacy of metformin.
CASE STUDY #2: ALFONSO GIULIANI
Click through the components of Alfanso’s case to learn more.
PATIENT’S CHIEF COMPLAINTS
“My vision has been blurred lately and it seems to be getting worse.”
HISTORY OF PRESENT ILLNESS
Alfonso Giuliani is a 68-year-old man who presents to his primary care provider’s office complaining of periodic blurred vision for the past month. He further complains of fatigue and lack of energy that prohibits him from working in his garden.
PAST MEDICAL HISTORY
HTN Dyslipidemia Gouty arthritis Hypothyroidism Obesity
FAMILY HISTORY
Diabetes present in mother.
Immigrated to the United States with his mother and sister after their father died suddenly for unknown reasons at age 45.
One younger sibling died of breast cancer at age 48.
SOCIAL HISTORY
Retired candy salesman, married * 46 years with three children.
No tobacco use.
Drinks one to two glasses of homemade wine with meals.
He reports compliance with his medications
REVIEW OF SYSTEMS
HEENT: (-) dental intact; (-) hearing loss; wears glasses-last eye exam 3-year ago
Neck: (-) lymphadenopathy; (-) pain and stiffness
Respiratory: (-) dyspnea; denies cough or wheezing;
Cardiac: (-) chest pain or heart palpitations; (-) Ml
Gastrointestinal: (-) heartburn, (-) nausea/ vomiting, constipation or hemorrhoids
GU: (-) hesitancy or frequency; (+) nocturia (urinates 3 times/night); (-) urgency, burning, hematuria; (-)dribbling/incontinence;
(-) penile discharge; denies history of STI (+) polydipsia
Peripheral Vascular: (-) peripheral edema; (-) neuropathy
Musculoskeletal: (-) pain; (-) joint swelling
Neurologic: (+) occasional headache
(-) vertigo, or memory loss
Psychiatric: (-) depression anxiety or insomnia
Allergies:NKDAMedications:Lisinopril 20 mg PO once daily Allopurinol 300 mg PO once daily Levothyroxine 0.088 mg PO once daily
PHYSICAL EXAM
GeneralThe patient is a centrally obese, appears to be restless and in mild distress. VS BP 124/76 mm Hg without orthostasis, P 80 bpm, RR 18, T 37.2°C; Wt 107 kg. Ht 66″; BMI 27.4 kg/m2Integumentary System
Warm and dry
(-) cyanosis, nodules, masses, rashes, itching, and jaundice
(-)ecchymosisand petechiae
Good turgor
HEENT
PERRLA
EOMs intact
Eyes anicteric
Normal conjunctiva
Vision satisfactory with no eye pain
Fundi with arteriolar narrowing with no nicking, hemorrhages, exudate, or papilledema
TMs intact
(-) tinnitus and ear pain
Nares clear
Oropharynx clear with no mouth lesions
White teeth
Oral mucous membranes pink and moist
Tongue normal size
No throat pain or difficulty swallowing
Neck/Lymph Nodes
Neck supple, no JVD
(-) cervical lymphadenopathy, thyromegaly, masses, ai carotid bruits
Chest/Lungs
Lungs clear to auscultation, respirations even and unlabored
Heart
S1 and S2 regular rate and rhythm
Prominent S3 sound
No rubs or murmurs
Abdomen
Obese(+) Central obesity
(-) hepatosplenomegaly, fluid wave, tenderness, and distension
(-) masses, bruits, and superficial abdominal veins
Normal BS x4 quadrants
Genitalia/Rectum
Heme (-) stool
Musculoskeletal/Extremities
Normal ROM throughout
(-) clubbing
(-) bilateral ankle edema
(+) 2 dorsalis pedis and posterior tibial pulses bilaterally
(-) spine and CVA tenderness
Denies muscle aches, joint pain, and bone pain
Neurological
Alert and oriented
Cranial nerves intact
Motor 5/5 upper and lower extremities bilaterally
Strength, sensation, and deep tendon reflexes intact and symmetric
Gait steady
Denies headache and dizziness
DIAGNOSTIC TEST RESULTS
Lab
Result
Na
141meq/L
K
4.0 meq/L
Cl
96 meq/L
C03
22 meq/L
BUN
24 mg/dL
SCr
1.1 mg/dL
Random Glu
202 mg/dL
Ca
9.9 mg/dL
Phos
3.2 mg/dL
AST
21 IU/L
ALT
15IU/L
Alk phos
45 IU/L
T. bili
0.9 mg/dL
AIC
8.8%
Fasting lipid profile
T. chol
280 mg/dL
HDL
27 mg/dL
LDL
193 mg/dL
Trig
302 mg/dL
UA
(-) Ketones(-) protein(-) microalbuminuria
Additional Tests: None
1. Use the Alfonso Giuliani case study to answer the following question. Atheroscleroticcardiovascular disease (ASCVD) risk factors include age, gender, race, blood pressure, cholesterol values, history of diabetes, tobacco use, treatment of hypertension, statin therapy, and aspirin therapy.Look at Alfonson’s ASCVD risk factors. Should Alfonso be taking something for hyperlipidemia? If so, what would you recommend?
2. Use the Alfonso Giuliani case study to answer the following question. Which diabetic drug classes should be considered in addition to metformin to prescribe for Alfonso and why?
3. Use the Alfonso Giuliani case study to answer the following question. There are two drug classes to consider for prescribing for Alfonso in addition to metformin. What baseline data will you need to obtain for each of those drug classes? Provide the name of the drug class and the baseline data needed for that drug class.
4. Use the Alfonso Giuliani case study to answer the following question. You decide to prescribe liraglutide (Victoza) in addition to metformin for Alfonso. What patient teaching do you need to provide when prescribing medication from this drug class?
CASE STUDY #3: HELEN SMITH
Click through the components of Helen’s case to learn more.
PATIENT’S CHIEF COMPLAINTS
“My water pills have me using the bathroom more than usual.”
HISTORY OF PRESENT ILLNESS
Helen Smith is a 63-year-old white female who presents with complaints of increased polyuria and nocturia. These symptoms have increased beyond what is typical while taking a prescribed diuretic. She is fatigued by having to get up so often during the night. She also reports that a recent bruise she had on her leg took a long time to go away.
PAST MEDICAL HISTORY
HTN
Dyslipidemia
HFrEF (LVEF ~40%)
Osteoarthritis
Obesity
FAMILY HISTORY
Diabetes present in mother.
Father died of Ml at age 66.
Two siblings with similar health issues.
SOCIAL HISTORY
Helen works as an administrative assistant at the county courthouse.
Lives with her husband of 32 years.
Two adult grown children live nearby.
Reports never having used tobacco products or alcohol.
Reports breakfast and dinner are cooked at home and lunch usually consists of fast food on workdays.
Reported compliance with medications.
REVIEW OF SYSTEMS
(-) feverorchills
Skin: (-) skin tears, lacerations, or rashes(+) dry skin
HEENT: (-) dental intact; (-) hearing loss (-) doesn’t
recall when her last eye exam was
Neck: (-) lymphadenopathy; (-) pain and stiffness
Respiratory: (-) dyspnea; denies cough or
wheezing;
Cardiac: (-) chest pain or heart palpitations; (-) Ml
Gastrointestinal: (+) Occasional heartburn
controlled with TUMs, (-) nausea/vomiting,
constipation, or hemorrhoids
GU: (-) hesitancy or frequency; (+) nocturia
(urinates 4 times/night); (-) urgency, burning,
hematuria;
(-) dribbling/incontinence;
Peripheral Vascular: (-) peripheral edema; (-) neuropathy
Musculoskeletal: (-) pain; (-) joint swelling
Neurologic: (+) occasional headache
(-) vertigo, or memory loss
Psychiatric: (-) depression anxiety or insomnia
Allergies Amoxicillin Medications Irbesartan 150 mg PO once daily Carvedilol ER 40mg PO every morning Furosemide 20mg PO every morning Naproxen 500 mg PO every 12 hours Estradiol 1 mg PO once daily
PHYSICAL EXAM
GeneralAlert, appropriately dressed obese Caucasian female in no apparent distress. She appears her stated age.Vital Signs: BP 118/76 mm Hg, pulse82 and regular, temperature 97.6, respirations 18, height 5*7″, weight 242 lbsIntegumentary System
Warm and dry
(-) cyanosis, nodules, masses, rashes, itching, and jaundice
(-)ecchymosisand petechiae
Good turgor
HEENT
PERRLA
EOMs intact
Eyes anicteric
Normal conjunctiva
Vision satisfactory with no eye pain
Fundi with arteriolar narrowing with no nicking, hemorrhages, exudate, or papilledema
TMs intact
(-) tinnitus and ear pain
Nares clear
Oropharynx clear with no mouth lesions
White teeth
Oral mucous membranes pink and moist
Tongue normal size
No throat pain or difficulty swallowing
Neck/Lymph Nodes
Neck supple
(-) cervical lymphadenopathy, thyromegaly, masses, and carotid
Chest/Lungs
Lungs clear to auscultation, respirations even and unlabored
Heart
S1 and S2 regular rate and rhythm
Prominent S3 sound
No rubs or murmurs
Abdomen
Obese
(+) hepatosplenomegaly, fluid wave, tenderness, and distension
(-) masses, bruits, and superficial abdominal veins
Normal BS x4 quadrants
Genitalia/Rectum
Heme (-) stool
Musculoskeletal/Extremities
Normal ROM throughout
(•) clubbing
(+) bilateral ankle edema
(+) 2 dorsalis pedis and posterior tibial pulses bilaterally
(-) spine and CVA tenderness
Denies muscle aches, joint pain, and bone pain
Neurological
Alert and oriented
Cranial nerves intact
Motor 5/5 upper and lower extremities bilaterally
Strength, sensation, and deep tendon reflexes intact and symmetric
Gait steady
Denies headache and dizziness
DIAGNOSTIC TEST RESULTS
Lab
Result
Albumin:
3.4 to 5.4 g/dL (34 to 54 g/L)
Alkaline phosphatase:
50 U/L
ALT (alanine aminotransferase):
18U/L
AST (aspartate aminotransferase):
20 U/L
BUN (blood urea nitrogen):
12 mg/dL
Calcium:
9mg/dL
Chloride:
102 mEq/L
C02
26 mEq/L
Creatinine:
0.8 mg/dL
Glucose:
189 mg/dL
Potassium:
4.3 mEq/L
Sodium:
142 mEq/L
Total bilirubin:
0.6 mg/dL
Total protein:
7g/dL
T. Cholesterol
240 mg/dl
HDL
35mg/dl
LDL
120mg/dl
Trigycerides
260 mg/dl
TSH
24 mU/L
Free T4
0.2 ng/dl
Hgb
15.3g/dL
Hct
48%
RBC
5.1 million/mm3
WBC
4.3 x10*/mm3
Neutrophils
47%
Monocytes
5%
Eosinophils
2%
Basophilss
0.7%
Bands
2.4%
Lymphocytes
29%
HgbAIC-
9.2%
Platelets
220x10Vmm3
PT
12.4 sec
INR
0.9
Additional Tests: None
1. Use the Helen Smith case study to answer the following question. Why is caution indicated if metformin was prescribed for Helen?
2. Use the Helen Smith case study to answer the following question. If the standardstarting dose of levothyroxine 1.6 mcg/kg/dose is prescribed for Helen, what is the correct dose? Would this be the correct starting dose for Helen? Why or why not?
3. Use the Helen Smith case study to answer the following question.Which of Helen’s lab values require consideration for possible treatment? Provide the lab name and Helen’s result. Use these sources for lab reference values: https://labtestsonline.org/ Links to an external site. https://www.thyroid.org/wp-content/uploads/publica… Links to an external site.
4. Use the Helen Smith case study to answer the following question. Which DM drug class is contraindicated in patients with heart failure and why? The why portion of this question will require some independent web or article searching to understand why this contraindication exists. Be sure to cite your sources.