A.S , 50 y.o male, presents to her family physician with a 3 month history of back pain HISTORY PMH : Patient states that she has enjoyed excellent health Mother and brother have been diagnosed with Type 2 Diabetes Mellitus Family history negative for heart disease / hypertension On Metformin (decreases hepatic glucose production Social History : Married with three children - ages 20, 15, and 10, driver, denies smoking or use of drugs . Inactive lifestyle Diet History: Estimate energy intake of approximately 2800 kcal/day with approximately 1400 kcal from carbohydrates . Patient states that he consumes sandwich with sweetened pop (24 oz)-as Dinner, ice cream and chocolate candy daily ANTHROPOMETRICS Height 5’9’’ Current Weight 225 # Usual weight 200 # ( for the past five years ) Lowest adult weight was 170 pounds at the age of 25 Waist Circumference 54 inches PHYSICAL EXAMINATION Blood Pressure 130/85 mm Hg Review of systems normal LABORATORY VALUES TZ Values Reference Values Fasting Blood Glucose 150mg/dL <100 mg/dL A1C 7.0 % 4 - 6 % Total Cholesterol 300 mg/dL < 200 mg/dL HDL 40 mg/dL > 40 mg/dL LDL 140 mg/dL < 130 mg/dL Triglycerides 250 mg/dL < 150 mg/dL PROBLEM LIST Type 2 Diabetes Obese Prehypertension PLAN Lifestyle modifications (diet and physical activity). RD to consult Write ADIME including PES statement for this case.

Phlebotomy Essentials

6th Edition

ISBN:9781451194524

Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Chapter1: Phlebotomy: Past And Present And The Healthcare Setting

Section: Chapter Questions

Problem 1SRQ

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Question

A.S , 50 y.o male, presents to her family physician with a 3 month history of back pain

HISTORY

PMH : Patient states that she has enjoyed excellent health

Mother and brother have been diagnosed with Type 2 Diabetes Mellitus

Family history negative for heart disease / hypertension

On Metformin (decreases hepatic glucose production

Social History : Married with three children - ages 20, 15, and 10, driver, denies smoking or use of drugs . Inactive lifestyle

Diet History:

Estimate energy intake of approximately 2800 kcal/day with approximately 1400 kcal from carbohydrates .

Patient states that he consumes sandwich with sweetened pop (24 oz)-as Dinner, ice cream and chocolate candy daily

ANTHROPOMETRICS

Height 5’9’’

Current Weight 225 #

Usual weight 200 # ( for the past five years )

Lowest adult weight was 170 pounds at the age of 25

Waist Circumference 54 inches

PHYSICAL EXAMINATION

Blood Pressure 130/85 mm Hg

Review of systems normal

LABORATORY VALUES

TZ Values Reference Values

Fasting Blood Glucose 150mg/dL <100 mg/dL

A1C 7.0 % 4 - 6 %

Total Cholesterol 300 mg/dL < 200 mg/dL

HDL 40 mg/dL > 40 mg/dL

LDL 140 mg/dL < 130 mg/dL

Triglycerides 250 mg/dL < 150 mg/dL

PROBLEM LIST

Type 2 Diabetes
Obese
Prehypertension
PLAN

Lifestyle modifications (diet and physical activity). RD to consult

Write ADIME including PES statement for this case.

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