Louisa Golay
4/5/12
Written Case Study
NU 607 Specialty Practicum II
Written Case Study
Patient’s age, gender, race
 Patient B.J. is a 41 year old Caucasian male who was interviewed by L.G. (APRN
student) on March 20, 2012 in the Emergency Department at Lawrence Memorial
Hospital (LMH). Student L.G. was completing her NU 607 Specialty Practicum clinical
hours with the hospitalist group at LMH with supervising preceptor Dr. G.C. APRN.
L.G. provided care to B.J. during his hospitalization as well.
Pertinent past medical history
Chief Complaint
o “I have been feeling dizzy all day, especially when I walk – I feel like I am going to
fall.”
History of present illness
o B.J. is a 41 y/o Caucasian male who resides in Lawrence, KS and has no primary care
provider. Patient was sitting in class today when he all of a sudden had a brief period
of lightheadedness followed by diaphoresis, blurry vision, and “foggy thoughts.”
Patient ambulatory to the restroom when he became “off balance and felt like he was
going to fall.” He, however, denied any syncopal episodes. Patient continued to sit
through class and stated that “symptoms gradually became worse, especially with
standing. My teacher encouraged me to have a snack; concerned symptoms could
have been hypoglycemia. I had a package of donuts and Gatorade; symptoms did not
improve afterwards.” Teacher encouraged patient to come to the Emergency Dept.
for further evaluation. Patient denies headache, nausea, vomiting, diarrhea, chest pain,
or shortness of breath. No fever or chills.
Past Medical History
o
o
o
o
o
o
Non-Insulin Dependent Diabetes (NIDDM Type II – newly diagnosed) 250.02
Dizziness (newly diagnosed) 780.4
Hypertension (untreated) 401.9
Hyperlipidemia (untreated) 272.4
Gout (untreated) 274.9
Morbid Obesity class III 278.01
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Louisa Golay
4/5/12
Written Case Study
Surgical History
1.) Right ankle ORIF (resolved) - 2012
2.) Vasectomy – 2010
3.) Left elbow irrigation for a bacterial infection (resolved) - 2005
Current Medications
ALLERGIES: PENCILLIN (patient unsure of rxn), TORADOL (rash/hives),
RIFAMPIN (facial swelling)
Name
Dose/Route/Frequency
Last Taken
allopurinol
300 mg PO Qday
Unsure, cannot afford
lisinopril
10 mg PO Qday
Unsure, cannot afford
simvastatin
20mg PO QHS
Unsure, cannot afford
metformin
1000mg PO BID
meclizine
25mg PO TID PRN dizziness
Levemir
30U SQ BID
New medication upon
discharge from hospital
New medication upon
discharge from hospital
New medication upon
discharge from hospital
Social History
o Born in Ottawa, KS
o Current Living Situation: Patient lives with his sister and brother-in-law in Lawrence,
KS.
o Marital status: Patient is divorced.
o Children: Patient does not have any children.
o Occupation: Currently unemployed; studying to be a massage therapist.
o Highest level of education completed: GED
o Tobacco use: Denies usage; exposed to second-hand smoke as a child
o ETOH use: Current usage; “social drinker – approximately 5-6 beers on the
weekends.”
o Recreational drug use: Denies usage
o Denies domestic violence; feels safe at home.
o Patient denies any disabilities including any language barriers.
o Exercise: “daily walks when weather is nice; otherwise no additional exercise.”
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Louisa Golay
4/5/12
Written Case Study
Family History
The patient’s parents are both deceased. His father died in his mid-40s from a suicide
attempt. Only known PMH included depression and obesity. His mother died at age 65 from
complications of tongue/throat cancer. Her PMH included: 2 cerebral vascular accidents
(unknown age), NIDDM, hypertension, and rheumatoid arthritis. Both of the patient’s parents
were “heavy smokers, smoked at least 1 pack per day for as long as I can remember. I was
exposed to second-hand smoke most of my childhood.” The patient has two sisters, both living.
One sister, age 43, is healthy with no known past medical history. His other sister, age 50, has
NIDDM, hypertension, and is obese. The patient has no children. There is no other known
family history of heart disease, cerebral vascular accidents, blood clots, diabetes, or cancer.
Genogram
Pat. Grandpa
Mat. Grandpa
Mat. Grandma
↓ “complications from
emphysema in his late
60s; unsure of PMH.”
↓ “ unsure of cause of
death; PMH: MI x 2,
CVA, HTN,
NIDDM.”
Pat. Grandma
↓“killed serving our
country in battle; No
PMH.”
↓ “unsure of cause
of death PMH:
severe depression”
Father
Mother
↓ “committed suicide
in his 40s; PMH:
depression & obesity
↓ 65 “tongue and throat
cancer. PMH: CVA x 2,
NIDDM, HTN, RA”
Patient
Sister
Sister
43 y/o; “healthy”
PMH: NIDDM,
HTN,
hyperlipidemia, &
obesity
50 y/o “PMH: HTN,
NIDDM & obesity”
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Louisa Golay
4/5/12
Written Case Study
Cultural
o “I don’t know much about my cultural background; however, I do know that my
ancestors, from both my mother and father’s side, are from Germany.”
Spiritual
o “I am a Christian and do believe in God, but do not have a religious preference. I was
baptized in a non-denomination church when I was a child.”
Review of Systems
(Mosby, 2011)
Constitutional: Review of systems includes: patient has brief periods of dizziness as
documented in the history of present illness. Aggravating factors include standing, alleviating
factors include lying down. Patient denies any syncopal episodes. Patient had brief periods of
blurry vision, which had resolved upon arrival to the Emergency Department. Patient denies:
headache, chest pain, shortness of breath, abdominal pain, change in bowel/bladder habits, or
nausea/vomiting/diarrhea. No recent weight gain or weight loss, no weakness, fatigue, or fever.
Patient denies any medication changes, as he is currently not taking any of his prescribed
medications due to financial obligations. A 12 point review of systems is completed. All
positives are documented in review of systems or in history of present illness, other are all
negative. Patient appears to be well-groomed, has calm demeanor, overall has clean hygiene, and
is in no acute distress.
Eyes: Negative; Patient does wear glasses for reading only. He has no blurred vision (resolved
upon arrival to ED), no eye pain, redness, tearing, diplopia, flashing lights.
Ears: Negative; No hearing loss, tinnitus, discharge.
Nose/Throat/Mouth: Negative; no nasal congestion, epistaxis, no mouth dryness, throat pain,
hoarseness
Neck: Negative; no lumps or swollen glands, pain or neck
Respiratory: Negative as per HPI
Cardiac: Negative as per HPI
GI/GU: Negative as per HPI; last bowel movement this morning (3/20), states “normal.” No
blood in stool or black tarry stool. No urinary frequency, hesitancy, urgency, dysuria, or
hematuria. No penile discharge or pain, no testicular pain.
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Louisa Golay
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Musculoskeletal: Mild right ankle pain with extended ambulation secondary to trauma 2
months ago. No other join pain, stiffness, swelling or muscle pain.
Hematology: Negative; no easy bruising, bleeding or history of blood clots. No prior blood
transfusions.
Endocrine: Negative as per HPI
Skin: Negative; No rashes, dryness, color change, or abnormities of hair or nails.
Neurologic: Lightheadedness, dizziness, gait instability. No headaches, head injuries, syncope,
seizures, focal weakness, numbness, parasthesias, tremor, falls, or decline in memory
Psych: Negative; reports decent memory, concentration, and interest in daily activities. No
suicidal, homicidal, or depressive thoughts; feels optimistic about the future.
Physical Exam
(Mosby, 2011)
GENERAL APPERANCE: This is a morbidly obese Caucasian man appearing his stated age,
in no apparent respiratory distress, and sitting in bed watching television. He is alert, oriented
and cooperative with the exam.
VITAL SINS: blood pressure (left arm, large adult cuff) 138/100 mmHg, heart rate 84 bpm,
respiratory rate 18 br/min, o2 95% room air, oral temperature 36.5 DegC. Height: 179 cm (5 ft
10 in) Weight: 158.18 kg BMI: 49.26
HEENT: Head is normocephalic without scalp or facial tenderness. Eyes: conjunctivae are pink
and sclera are without injection or jaundice. Pupils are equal in size, round and reactive to light;
extraocular movements intact bilaterally. Vision remains unchanged during exam. Ears:
tympanic membranes intact without erythema, hearing grossly intact. Nasopharynx: mucosa
unremarkable with no septal deviation. Oropharynx: no lesions or exudates, mucus membranes
pink and moist.
NECK: Supple, nontender. Trachea midline, thyroid non-palable. No carotid bruits, no jugular
vein distention.
CHEST: Lungs clear to auscultation throughout all bases; non-labored breathing; breath sounds
equal bilaterally, symmetrical expansion, no chest wall tenderness.
CARDIAC: Regular rate and rhythm. No murmur, gallop, or extra sounds heard. S1/S2
normal. Normal peripheral perfusion, no edema.
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Louisa Golay
4/5/12
Written Case Study
ABDOMEN: Soft, rounded, non-tender, non-distended. Bowel sounds present in all quadrants.
No masses palpable. Liver border smooth and palpable; spleen not palpable.
GU: No costovertebral angle tenderness; No lesions or inguinal hernias present.
EXTREMITIES: No cyanosis, clubbing, or edema. Peripheral pulses palpable, strong, and
equal bilaterally in all extremities.
MUSCULOSKELETAL: Mild reduced range of motion to right ankle without joint deformity.
No erythema, warmth, tenderness, or effusion. Normal strength. Other joints unremarkable. Gait
not assessed at time of exam.
SKIN: Warm, dry, pink, intact, and moist. No rashes or lesions. Tattoo present over right calf.
Well-healed incisions over right lateral and medial malleoli.
NEUROLOGIC: Patient is alert and oriented to person, place, time and situation. No focal
neurological deficit observed, CN II-XII intact, normal sensory observed, normal motor
observed, normal speech observed, normal coordination observed.
PSYCHIATRIC: Patient is cooperative with appropriate mood and affect. Appears to have
normal judgment.
Diagnostics:
o EKG: Normal Sinus Rhythm
o Head CT without contrast: negative, no acute abnormalities
o UA: leukocytes = negative, nitrites = negative, glucose > 1000, ketones =
negative, protein = negative,
o Labs (serum):
3/20/12 @ 1225
3/21/12 @ 0530
(non-fasting; from ED)
(in-patient; fasting)
WBC Count
RBC Count
Hemoglobin
Hematocrit
Platelet Count
PT
INR
Sodium
Potassium
Chloride
Carbon Dioxide
Glucose
Blood Urea Nitrogen
Creatinine
6.5
4.3
13.8
39.2
237
11.6
0.86
138
4.5
99
21
416
11
0.7
137
4.4
102
26
285
9
0.6
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Louisa Golay
4/5/12
Written Case Study
CK-MB
AST
ALT
Hemoglobin A1C
Calculated GFR
Cholesterol
HDL
Triglycerides
LDL
2
24
28
10.5
>60
494
38
3,227
Unable to calculate LDL
and VLDL due to high
Triglyceride level
Differential Diagnosis
1.) Hyperglycemia
2.) Dizziness
3.) Vertigo
4.) Transient Ischemic Attack
5.) Cerebral Vascular Accident
6.) Hypertension
7.) Dehydration
8.) Hyponatremia
9.) Meniere’s Disease
10.) Labyrinthitis
11.) Anemia
12.) Subarachnoid Hemorrhage
Final diagnosis with rationale
(Ferri, 2012)
(Buttaro, 2008)
(American Diabetes Association, 2012)
o Hyperglycemia - Diabetes mellitus, type 2
 Near-syncope and vertigo, due to hyperglycemia and dehydration;
resolving
o Diabetes mellitus (definition):
 a fasting plasma glucose ≥126 mg/dl, confirmed with testing on a different
day
 symptoms of hyperglycemia and a casual (random) plasma glucose ≥ 200
mg/dl without regard to time of last meal
o Clinical Presentation
 Polyuria, polydipsia, polyphagia
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Louisa Golay
4/5/12
Written Case Study








Weight loss
Blurred vision**
Postural syncope, dizziness, light-headedness**
Dehydration**
Fatigue
Obese**
Frequent infections
Numbness/tingling in hands/feet
**indicates sign/symptom patient presented with or complained of
o Diagnosis criteria
 Fasting glucose ≥ 126 mg/dl (patient’s fasting glucose 285)
 Non-fasting ≥ 200 mg/dl (patient’s random glucose = 416)
 HbA1C ≥ 6.5% (patient’s HbA1C 10.5%)
 Consider BMI > 25 (patient’s BMI 49.26)
Plan of Care
Treatment
o Diabetes mellitus, type 2 (newly discovered)
 Novolog 10U SQ in ED; Sliding Scale Insulin during course of
hospitalization (70-150 no insulin indicated, 151-200 = 4U, 201-250 = 6
U, 251-300 = 8U, 301-350 = 10U, 351-400 = 12U, >400 14U and call
MD)
 Levemir 20U SQ in ED; 30U SQ BID upon discharge
 NaCl 0.9% IV Bag 1000ml/hr x 1000ml; 125ml/hr continuous
 Metformin 1000mg PO BID upon discharge from hospital
o Dizziness
 Valium 5mg IVP in ED only
 meclizine 25 mg PO TID PRN dizziness during hospitalization and upon
discharge
 clonazepam 0.5mg PO BID PRN dizziness during hospitalization only
o Hypertension
 lisinopril 10mg PO daily during hospitalization and upon discharge
o Hyperlipidemia
 simvastatin 20 mg PO QHS upon discharge from hospital
o Gout
 allopurinol 300mg PO daily upon discharge from hospital (no acute
exacerbation during course of hospitalization)
o Morbid Obesity
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4/5/12
Written Case Study

diet and exercise counseling
Patient Education/Referrals/Follow UP
o Referral to diabetes education (hospitalization)
 Documentation provided from Diabetes Educator: “Discussed with patient
that HCA will be monitoring blood sugars closely for the next couple of
months until blood sugars are within normal range. Patient verbalized
understanding to eat low fat diet, monitor carbs, and to check blood sugars
at home AC/HS. Encouraged patient to attend Pat Holman diabetes
Education course. Briefly reviewed importance of eating three meals per
day at consistent times. Patient does not eat breakfast regularly, but I
strongly encouraged him to do so; suggested easy breakfast such as cereal
and milk with fruit. Encouraged patient to eat slowly/mindfully and to
make small changes (eat more fruit and vegetables). Patient states he has
tried the Atkins diet in the past, lost 14 lbs, but was unable to keep weight
off. He would like to lose weight, in hopes to decrease his DM
medications. Patient agrees with the above plan. Diabetes supplies
provided to patient.”
 “After instruction, patient was able to perform a blood sugar. We
discussed the causes, symptoms, and treatment for hypoglycemia. I
demonstrated use of the insulin pen and provided written instruction.
Patient to perform insulin injection prior to discharge. I encouraged him
to return to the Diabetes Education Center after he obtains a referral from
HCA.”
o Referral to physical therapy for dizziness likely due to vertigo (hospitalization)
 Per physical therapy documentation: “Patient’s symptoms not consistent
with BPPV or vestibular dysfunction, Epley maneuver not indicated. Will
monitor continue to monitor patient for ambulatory safety. Patient’s
dizziness likely due to prolong hyperglycemia. Patient near baseline from
mobility perspective.”
o Referral to Health Care Access (HCA) to establish care and for hospital follow up
 Follow up with HCA within one week. Patient does not have health
insurance and therefore should qualify for services at HCA. Continue to
monitor blood sugar control and recheck lipid panel in a month or two
when hyperglycemia under better control. HCA to manage prescription
medications as well.
o Patient was able to answer all of the interview questions independently. Support
was provided to the patient only, as family members were not available at the
time of the interview. Plan of care, rationale behind hospitalization, and all
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Louisa Golay
4/5/12
Written Case Study
interventions/treatmenst reviewed with patient. Patient agreed to above plan and
referrals; verbalized understanding with no further questions.
Synopsis
o B.J. was admitted from the LMH Emergency Department to Inpatient Telemetry
for 24 hour observation. He had improved clinically with the treatments provided
and reported “I am feeling much better, even the dizziness and lightheadedness
has resolved with standing. I feel comfortable administering insulin and checking
my blood sugars at home.” Patient verbalized understanding of above treatment
plan, medication regimen, and importance of following up with HCA upon
hospital discharge. He feels as though his sister and brother-in-law are a “good
support system and will help me succeed with weight loss goals and increasing
my exercise.”
o I spent approximately 65+ minutes obtaining an H&P, performing a ROS,
physical assessment, and implementing a plan with interventions. I feel that I
obtained a thorough HPI, review of systems and physical assessment.
Additionally, I felt as though I was able to independently formulate most of the
differential diagnoses and develop a plan of care with minimal assistance from my
preceptor. I was able to dictate the H&P with minimal corrections from my
preceptor as well. If I could do one thing differently, I would spend more time
providing diabetes education to the patient, since I am diabetic myself. I not only
feel as though I could offer helpful eating habits, but could also provide support to
him as well. Overall, this was a positive patient interaction and learning
experience.
References
Buttaro, TM., Trybulski, J., Bailey, P.P., & Sandberg-Cook, J. (2008). Primary care: A
collaborative practice (3rd ed.). St. Louis: Elsevier-Mosby.
Diabetes Basics. (2012). American Diabetes Association. Retrieved from
http://www.diabetes.org/diabetes-basics/symptoms/?loc=DropDownDB-symptoms
Ferri, F.E. (2012). Ferri’s clinical advisor instant diagnosis and treatment. St. Louis: ElsevierMosby.
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4/5/12
Written Case Study
Seidel, H., Ball, J., Dains, J., Flynn, J., Solomon, B., Stewart, R. (2011). Mosby’s guide to
physical examination (7th ed.). St. Louis: Elsevier-Mosby.
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