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.