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: SulfaCurrent medications: MultivitaminPMH: Gestational DiabetesPSH: Tonsillectomy, Wisdom teeth extractionSocial: 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: 2019Family: Father: alive, +DM, CAD, Hyperlipidemia, Mother: alive, +DM, CKDROS:Constitutional: Complains of increase fatigueHEENT: Denies any headache, nasal congestion, ear painCardiovascular: Denies chest painRespiratory: Denies any SOB or DOEGI: Denies any issues, last BM 1 day ago.GU: Denies any painful urination, urgency, hesitancyMusculoskeletal: denies.Neurological: DeniesPsychiatric: Denies suicidal ideations, depression. Does report difficulty falling asleepEndocrine: Denies any weight changes, intolerance to heat/coldHematologic/ Lymphatic: Denies any bruisingOBJECTIVE:Vital signs: Ht: 66, Wt: 185, BP 130/78, HR 76, Resp: 16, SaO2: 98%Constitutional: Well developed, overweight femaleHEENT: 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 massesCardiovascular: RRR, No murmurs or rubs noted.Respiratory: Clear all fieldsGI: Abdomen round, soft, with bowel sounds noted in all four quadrants.GU: DeferredMusculoskeletal: Crepitus noted bilateral knees, fluid wave noted to Rt kneeIntegumentary: Skin warm and dry, No rashes notedNeuro: Follows commands without difficultyWorking 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 PromotionExerciseStress Management

 

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