MRS.JONES CASE STUDY

Mrs. Jones is a 32 year old Caucasian female who presents for follow up on her gestational diabetes. She is 3 months postpartum and was diagnosed with gestational diabetes. This was her first pregnancy. She has a strong family history of diabetes and was told to get it checked out once she stopped breastfeeding. She has not checked her glucose since she came home from the hospital, stating she has been too busy.

Allergies: Sulfa

Current medications: Multivitamin

PMH: Gestational Diabetes

PSH: Tonsillectomy, Wisdom teeth extraction

Social: Denies tobacco, Alcohol, or illegal drug use. She is married and lives with her husband and new baby. She works as an elementary teacher. She follows a regular diet and walks 2 days a week when she has recess duty.

Immunizations: flu: 2019

Family: Father: alive, +DM, CAD, Hyperlipidemia, Mother: alive, +DM, CKD

ROS: 

Constitutional: Complains of increase fatigue

HEENT: Denies any headache, nasal congestion, ear pain

Cardiovascular: Denies chest pain

Respiratory: Denies any SOB or DOE

GI: Denies any issues, last BM 1 day ago.

GU: Denies any painful urination, urgency, hesitancy

Musculoskeletal: denies.

Neurological: Denies

Psychiatric: Denies suicidal ideations, depression. Does report difficulty falling asleep

Endocrine: Denies any weight changes, intolerance to heat/cold

Hematologic/ Lymphatic: Denies any bruising

OBJECTIVE:

Vital signs: Ht: 66, Wt: 185, BP 130/78, HR 76, Resp: 16, SaO2: 98%

Constitutional: Well developed, overweight female

HEENT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses

Cardiovascular: RRR, No murmurs or rubs noted.

Respiratory: Clear all fields

GI: Abdomen round, soft, with bowel sounds noted in all four quadrants.

GU: Deferred

Musculoskeletal: Crepitus noted bilateral knees, fluid wave noted to Rt knee

Integumentary: Skin warm and dry, No rashes noted

Neuro: Follows commands without difficulty

Working with your group, utilize the above case study a, develop a Voice Over PowerPoint presentation for your patient covering the problems identified in the case study and content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following:

  • Nutrition Counseling for Health Promotion
  • Exercise
  • Stress Management