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