Running head: WEEK 5 CASE STUDY 2 WEEK 5 CASE STUDY 1 Week 5 Case Study Assignment Chamberlain University NR601: Primary Care of the Maturing and Aged Family April 2019 Week 5 Case Study Assignment The intent of this paper is to examine subjective and objective findings of a case study patient to appropriately diagnose and formulate an individualized management plan that utilizes evidence-based practice guidelines. The case study patient is a 55-year-old Hispanic female who presents to the office for her annual exam complaining of fatigue, weight gain, polyuria, polydipsia, and polyphagia for the past 3 months. This paper will identify applicable primary, secondary, and differential diagnoses; and apply national guidelines from the American Diabetes Association’s (ADA) 2019 Standards of Medical Care in Diabetes to develop a management plan that will include the appropriate diagnostics, affordable medications, education, referrals, and follow-up. Assessment Primary Diagnosis Type 2 diabetes mellitus without complications (E11.9). Pathophysiology. Type 2 diabetes mellitus (T2DM) is characterized by high levels of plasma glucose due to a decreased function of pancreatic beta cells, which causes insulin resistance and impaired insulin secretion (Dunphy, Winland-Brown, Porter, & Thomas, 2015). The most common manifestations of T2DM include the following: fatigue, polyuria (increased urination), polydipsia (increased thirst), polyphagia (increased appetite) with weight loss (Dunphy et al., 2015). Pertinent positive findings. Very fatigued and low energy, increased hunger and thirst with exercise, increased urination at night and more frequently during the day; which all have been occurring for the past 3 months and a weight gain of 3 pounds (subjective). Mrs. G is 55 years old, Hispanic, and obese according to the calculated BMI of 33.3 kg/m2; elevated hemoglobin A1C of 6.9%, urinalysis showed 1+ glucose and small protein, and dyslipidemia according to lipid panel (objective) (Dunphy et al., 2015). Pertinent negative findings. No family history of diabetes and exercising twice a week for at least 30 minutes (subjective). Glucose 95 and urinalysis negative for ketones (objective) (Dunphy et al., 2015). Rationale for the diagnosis. T2DM was selected as the primary diagnosis based on the aforementioned pertinent positive findings, which include the following: fatigue, polyuria, polyphagia, and polydipsia; along with several risk factors for T2DM, such as age, Hispanic ethnicity, obesity (BMI ≥25), and lack of physical activity (ADA, 2019). Additionally, the laboratory results showed conflicting results, a normal FPG of 95 and an elevated A1C of 6.9%. Therefore, according to the criteria for diagnosing diabetes, an A1C ≥6.5% with obvious signs and symptoms of hyperglycemia can confirm the diagnosis of T2DM without repeat testing (ADA, 2019). Lastly, the urinalysis showed 1+ glucose and small protein (albumin), which .

1. Running head: WEEK 5 CASE STUDY 2
WEEK 5 CASE STUDY 1
Week 5 Case Study Assignment
Chamberlain University
NR601: Primary Care of the Maturing and Aged Family
April 2019
Week 5 Case Study Assignment
The intent of this paper is to examine subjective and
objective findings of a case study patient to appropriately
diagnose and formulate an individualized management plan that
utilizes evidence-based practice guidelines. The case study
patient is a 55-year-old Hispanic female who presents to the

2. office for her annual exam complaining of fatigue, weight gain,
polyuria, polydipsia, and polyphagia for the past 3 months. This
paper will identify applicable primary, secondary, and
differential diagnoses; and apply national guidelines from the
American Diabetes Association’s (ADA) 2019 Standards of
Medical Care in Diabetes to develop a management plan that
will include the appropriate diagnostics, affordable medications,
education, referrals, and follow-up.
Assessment
Primary Diagnosis
Type 2 diabetes mellitus without complications (E11.9).
Pathophysiology. Type 2 diabetes mellitus (T2DM) is
characterized by high levels of plasma glucose due to a
decreased function of pancreatic beta cells, which causes insulin
resistance and impaired insulin secretion (Dunphy, Winland-
Brown, Porter, & Thomas, 2015). The most common
manifestations of T2DM include the following: fatigue, polyuria
(increased urination), polydipsia (increased thirst), polyphagia
(increased appetite) with weight loss (Dunphy et al., 2015).
Pertinent positive findings. Very fatigued and low energy,
increased hunger and thirst with exercise, increased urination at
night and more frequently during the day; which all have been
occurring for the past 3 months and a weight gain of 3 pounds
(subjective). Mrs. G is 55 years old, Hispanic, and obese
according to the calculated BMI of 33.3 kg/m2; elevated
hemoglobin A1C of 6.9%, urinalysis showed 1+ glucose and
small protein, and dyslipidemia according to lipid panel
(objective) (Dunphy et al., 2015).
Pertinent negative findings. No family history of diabetes and
exercising twice a week for at least 30 minutes (subjective).
Glucose 95 and urinalysis negative for ketones (objective)
(Dunphy et al., 2015).
Rationale for the diagnosis. T2DM was selected as the primary
diagnosis based on the aforementioned pertinent positive
findings, which include the following: fatigue, polyuria,
polyphagia, and polydipsia; along with several risk factors for

3. T2DM, such as age, Hispanic ethnicity, obesity (BMI ≥25), and
lack of physical activity (ADA, 2019). Additionally, the
laboratory results showed conflicting results, a normal FPG of
95 and an elevated A1C of 6.9%. Therefore, according to the
criteria for diagnosing diabetes, an A1C ≥6.5% with obvious
signs and symptoms of hyperglycemia can confirm the diagnosis
of T2DM without repeat testing (ADA, 2019). Lastly, the
urinalysis showed 1+ glucose and small protein (albumin),
which is an indication of diabetes and/or early sign of kidney
disease; as well as, an indication for dyslipidemia, a common
condition associated with T2DM (Dunphy et al., 2015; ADA,
2019).
Secondary Diagnosis.
Hyperlipidemia, unspecified (E78.5).
Pathophysiology. Hyperlipidemia is an acquired or genetic
metabolic condition comprising of various lipids and
lipoproteins that increase the risk of atherosclerosis, or plaque
sticking to the inner walls of arteries (Dunphy et al., 2015).
Lipoproteins are molecules that carry cholesterol in the
bloodstream and are separated by the following groups: VLDL,
LDL, and HDL; and triglycerides are large lipid molecules from
dietary fats (Dunphy et al., 2015). Characteristically, patients
do not exhibit manifestations of hyperlipidemia, but often this
condition occurs concurrently with hypertension, T2DM, and
coronary artery disease (Dunphy et al., 2015). A carotid bruit,
corneal arcus, xanthomas (yellowish skin deposits of
cholesterol), or xanthelasma (deposits around the eyelids) may
be found on physical examination (Dunphy et al., 2015).
Pertinent positive findings. T2DM, obesity, family history of
hypercholesterolemia (father), elevated blood pressure of
129/80, and lipid profile showing the following results: TC 230
mg/dL (borderline high), LDL 144 mg/dL (high), VLDL 36
mg/dL (high), HDL 38 mg/dL (low), and TG 232 mg/dL (high)
(Dunphy et al., 2015; Bibbins-Domingo et al., 2016).
Pertinent negative findings. No tobacco history, no past
medical history of atherosclerotic cardiovascular disease, and

4. has been exercising twice a week for at least 30 minutes
(Bibbins-Domingo et al., 2016).
Rationale for the diagnosis. Hyperlipidemia was selected as a
secondary diagnosis based on the laboratory results of the lipid
profile and the primary diagnosis of T2DM. According to Stone
et al. (2014), hyperlipidemia is very prevalent among Hispanics,
and is characterized by a low HDL level, an elevated LDL, and
high triglyceride levels; most likely as a result of insulin
resistance within this ethnic group. Based on Mrs. G’s LDL 144
mg/dL and HDL 38 mg/dL, she is at risk of developing
cardiovascular disease as a result of her dyslipidemia (LDL >
130 mg/dL and HDL < 40 mg/dL), T2DM, obesity, and elevated
blood pressure (Stone et al., 2014). The USPSTF recommends
using the ACC/AHA Pooled Cohort Equations to calculate 10-
year risk of cardiovascular disease events, which Mrs. G’s
calculated 10-year risk is 6.3% (Stone et al., 2014; Last,
Ference, & Menzel, 2017).
Secondary Diagnosis.
Obesity, unspecified (E66.9) & Body mass index (BMI) 33.0-
33.9, adult (Z68.33)
Pathophysiology. Obesity is a multifaceted condition that is
characterized as a dysfunction of the body’s normal metabolism
and control of one’s appetite (Dunphy et al., 2015). Obesity
results from an inequality among a high caloric intake and a
decreased number of calories burned; which can be caused by
various factors, such as sedentary lifestyles, dietary choices,
and environmental and genetic components (Dunphy et al.,
2015). The most common manifestations of obesity include the
following: fatigue, low energy levels, generalized weakness,
joint pain, shortness of breath, daytime sleepiness, and
depression; and a BMI ≥30 kg/m2 (Dunphy et al., 2015).
Pertinent positive findings. Fatigue, low energy, increased
tiredness during the day, polyphagia, an attempt to lose weight,
a weight gain of 3 pounds, (subjective). General appearance is
obese, weight is 185 pounds, BMI 33.3 kg/m2, left knee
arthritis, and elevated blood pressure of 129/80 (objective)

5. (Dunphy et al., 2015).
Pertinent negative findings. Exercising twice a week for at least
30 minutes on the treadmill (subjective); normal thyroid studies
TSH 2.35 and Free T4 0.7 (objective) (Dunphy et al., 2015).
Rationale for the diagnosis. Obesity was selected as a secondary
diagnosis based on the patient’s aforementioned subjective
findings and BMI of 33.3 kg/m2. According to Dunphy et al.
(2015), in order to diagnosis obesity, one has to have a BMI
≥30 kg/m2.
Differential Diagnosis
Major depressive disorder, unspecified (F32.9).
Pathophysiology. Depression still remains not well understood,
but there are several theories on the pathophysiology; the most
appropriate theory suggesting an altered regulation or reduction
of the neurotransmitters serotonin, norepinephrine or dopamine
in the central nervous system (McCance, Huether, Brashers, &
Rote, 2014). Other theories suggest an impaired regulatory
mechanism involving the hypothalamus, which plays an
essential role in an individual’s ability to cope with stress;
thyroid hormone involvement with the variation of mood and
behavior, as well as genetics and psychosocial factors
contributing to depression (McCance et al., 2014; Dunphy et al.,
2015). The most common manifestations of depression include
the following: continuous feelings of sadness and despair,
appetite changes, weight loss or gain, sleep disturbances,
irritability, fatigue or loss of energy, anhedonia (loss of interest
or pleasure), and thoughts of self-harm or suicide (Dunphy et
al., 2015).
Rationale for the diagnosis. Depression was selected as a
differential diagnosis based on Mrs. G’s pertinent positive
subjective data, including: fatigue, loss of energy, weight gain,
and increased appetite (Dunphy et al., 2015). Even though Mrs.
G does not express thoughts of self-harm or suicide,
helplessness, and worthlessness (pertinent negatives); the
differential diagnosis of depression should still be considered
and appropriately evaluated with a screening assessment tool

6. based on the collected information (Dunphy et al., 2015).
Plan
Diagnostics
Lab test. Repeat A1C in 3 months (ADA, 2019).
Rationale. According to the ADA (2019), to properly evaluate
and manage a patient with T2DM, an A1C test can be completed
every 3 months to assess whether the patient’s glycemic goal
has been accomplished and is being managed effectively. When
evaluating the effectiveness of the T2DM treatment plan, it is
the provider’s decision to determine how frequently an A1C
needs to be completed based on the overall clinical picture of
the patient and the current treatment plan in place (ADA, 2019).
Lab test. Spot urinary albumin-to-creatinine ratio (UACR)
(ADA, 2019).
Rationale. A UACR test should be performed annually on all
patients with T2DM to assess for urinary albumin or
microalbuminuria, which is an indication of kidney damage
(ADA, 2019). The UACR test is appropriate for Mrs. G due to
the results of her urinalysis indicating small protein and her
primary diagnosis of T2DM. Normal UACR results are <30
mg/g Cr and increased levels of urinary albumin are results ≥30
mg/g Cr (ADA, 2019). Additionally, due to the inconsistency in
the excretion of urinary albumin and the possibility of false
positive results, two positive UACR results out of 3 in a 3-6-
month timeframe would be required to diagnosis a patient with
microalbuminuria (ADA, 2019).
Lab test. Repeat complete metabolic panel (CMP) in 6 weeks
(Hollier, 2018).
Rationale. A baseline CMP and CBC were performed initially.
Therefore, a repeat CMP should be performed at least annually
to monitor kidney and liver functions in diabetic patients;
however, patients started on statin therapy for the management
of hyperlipidemia, it is recommended to evaluate liver function
tests at 4-6 weeks from initiation of treatment (Hollier, 2018).
A CBC at least yearly is recommended for patients with T2DM
who are being treated with metformin, because of the potential

7. for vitamin B12 deficiency (megaloblastic anemia) caused by
long-term use of metformin (ADA, 2019).
Lab test. Repeat fasting lipid panel (FLP) in 6 weeks.
Rationale. A baseline FLP was performed initially. Following
the initiation of a statin medication or change in therapy, it is
recommended to perform a FLP within 6-8 weeks to evaluate
whether or not lipid level goals have been achieved with the
current treatment regimen (Hollier, 2018). The recommended
levels for lipids include a LDL <100 mg/dL, triglycerides <150
mg/dL, and HDL >50 mg/dL in women (ADA, 2019).
Screening test. Patient Health Questionnaire-9 (PHQ-9).
Rationale. The PHQ-9 is a self-report questionnaire based on
symptoms experienced over the past 2 weeks that comprises of 9
items, and is one of the most commonly used screening
instruments for depression in the adult population (Hirschtritt &
Kroenke, 2017). Due to Mrs. G.’s change in medical status
related to the diagnoses of T2DM and hyperlipidemia; this puts
her at an increased risk for developing depression (ADA, 2019).
Also, to rule out the differential diagnosis of depression,
utilizing a screening instrument such as the PHQ-9 is key to
diagnosing and managing this condition (Hirschtritt & Kroenke,
2017). According to Hirschtritt & Kroenke (2017), screening for
depression should occur during each patient encounter.
Medications
Medication. Rx: Metformin 500 mg tablets
Sig: Take one (1) tablet by mouth twice daily
Disp: #60 (Sixty). RF: 2(ADA, 2019).
Rationale. Metformin was the medication selected for the
treatment of T2DM because it is first-line treatment, and should
be prescribed at the time of the diagnosis unless contraindicated
(ADA, 2019). According to the ADA (2019), metformin is
effective in lowering A1C and weight, is safe and cheap, and
can possibly lower an individual’s risk of having a
cardiovascular incident or death (ADA, 2019).
Medication. Rx: Atorvastatin 20 mg tablets
Sig: Take one (1) tablet by mouth once daily

8. Disp: #30 (Thirty). RF: 2 (Stone et al., 2014).
Rationale. Atorvastatin was the medication selected for the
treatment of hyperlipidemia. According to Stone et al. (2014), a
moderate-intensity statin should be started on adults 40-75
years old who have diabetes and LDL 70-189 mg/dL as a
primary prevention strategy. The recommended ACC/AHA
Pooled Cohort Equation was utilized to calculate Mrs. G.’s 10-
year ASCVD risk of 6.3%; therefore, guideline
recommendations state that a moderate-intensity statin should
be started on patients with a 10-year ASCVD risk of 5.0% to
<7.5% (Stone et al., 2014). On average, atorvastatin lowers
LDL levels by about 30% to <50% (Stone et al., 2014).
Education
Diagnosis. Mrs. G, according to your A1C result of 6.9%, which
measures your average blood sugars for the past 3 months, is
higher than the recommended value 6.5% or lower (ADA,
2019). Along with your symptoms of feeling tired, hungry,
thirsty, and urinating more frequently, I am going to say that
you most likely have T2DM (ADA, 2019). In order to help you
better understand what T2DM is and how it develops, I will
explain in greater detail. T2DM is the most common type of
diabetes, which causes hyperglycemia or higher than normal
blood sugar levels (ADA, 2019). T2DM occurs when your body
cannot correctly use the insulin secreted from your pancreas,
which is also referred to as insulin resistance (ADA, 2019).
What happens initially is that your pancreas will produce extra
insulin, but over time the pancreas cannot keep up with the
demands expected to keep your blood sugars normal; decreasing
the amount of insulin produced, and ultimately resulting in
higher than normal blood sugars or diabetes (ADA, 2019).
There are risk factors associated with the development of
T2DM, such as family history, being overweight, certain
ethnicities, having high blood pressure, being over 45 years of
age, lack of physical activity, and having low HDL (good)
cholesterol or high triglyceride levels (ADA, 2019).
Additionally, I want to mention that your glucose level on your

9. lab work was 95 mg/dL, which is normal according to
recommendations of less than 126 mg/dL; but because your A1C
was higher than recommended and the symptoms you are
experiencing, both are indicative of diabetes (ADA, 2019). Your
blood sugar levels may be rising above the recommended value
of 180 mg/dL after eating a meal, which is called postprandial
hyperglycemia; a contributing factor for the elevated A1C and
diabetes (ADA, 2019). T2DM can be effectively managed by
eating a well-balanced diet, increasing your physical activity as
tolerated, lowering your weight, and adhering to a prescribed
medication regimen (ADA, 2019).
Medication. In order to properly manage your T2DM, I will be
prescribing you a medication called metformin that you will be
taking twice a day with breakfast and dinner. This medication
will improve your blood sugar levels, help with weight loss, and
improve your cholesterol levels by lowering your triglycerides
and bad cholesterol while raising your good cholesterol
(Dunphy et al., 2015).
Diet. Meal planning and understanding nutritional therapy will
be a key component to properly managing your T2DM, elevated
cholesterol levels, and helping you with weight loss. An
effective method to managing your blood sugar levels is by
watching your food portions and making healthier food choices
(ADA, 2019). For weight loss management, the recommended
caloric intake for a woman is 1,200-1,500 per day (ADA, 2019).
There is no established dietary distribution of calories among
carbohydrates, fats, and proteins; therefore, keeping track of
your total caloric intake is important to successfully managing
your T2DM (ADA, 2019). Knowing what encompasses a healthy
meal plan is pertinent, such as fruits and vegetables, lean
protein foods, no added sugar, and no trans-fat (ADA, 2019). To
give you a better idea of how your plate should be divided;
vegetables should take up half your plate, ¼ of the plate for a
protein, and ¼ for a carbohydrate (ADA, 2019). The ADA
(2019) recommends to fill your plate with non-starchy
vegetables, such as broccoli, cabbage, carrots, and celery;

10. substitute with fruit that is fresh, frozen or canned without
added sugars if you are craving something sweet; eat foods high
in fiber, such as legumes, nuts, and whole grains; include fish in
your meal plan at least twice a week; and consume less
saturated fat and cholesterol. Also, to address your alcohol
consumption of 1-2 glasses of wine on the weekends; the ADA
(2019) recommends no more than one 5 oz glass of wine per
day, and not to forget to eat, because drinking alcohol on an
empty stomach can put you at risk for low blood sugar.
Exercise. Exercise or physical activity is another essential
component for managing your T2DM, lowering your cholesterol
levels, and assisting you with weight loss. In order for an
exercise regimen to be effective, it is important that it is
tailored towards your interests and physical condition, such
aerobic exercises, strength training, and stretching exercises
(ADA, 2019). The ADA (2019) recommends aerobic exercise
and strength training, because it allows your body to become
more sensitive to insulin and is better utilized, thus lowering
your blood sugars. In addition to lowering your blood sugar,
these exercises help to lower your blood pressure, improve your
cholesterol levels, and help with losing weight (ADA, 2019).
For example, aerobic exercise is 30 minutes of moderate
intensity exercise at least 5 days per week or 45-60 minutes is
more beneficial for weight loss, which includes brisk walking,
bicycling, swimming, or climbing stairs (ADA, 2019). In
addition to aerobic exercise, the ADA (2019) also recommends
participating in some sort of strength training, such as using
resistance bands and/or lifting light weights or objects (canned
goods) at least twice a week.
Warning signs for diagnosis and mediation. Now, I want to
discuss with you the warnings signs associated with T2DM. It is
important that you know the signs and symptoms of
hypoglycemia (low blood sugar) and hyperglycemia (high blood
sugar); along with the causes, appropriate treatments, and how
to prevent this these problems from happening. Hypoglycemia
can occur due to various reasons, such as taking too many of

11. your metformin pills, missing meals or not eating enough,
excessive exercising, and alcohol consumption (Dunphy et al.,
2015). The signs and symptoms that you and your family need
to be aware of, include sweating, hunger, feeling shaky,
dizziness, confusion, or feeling anxious (Dunphy et al., 2015).
To treat hypoglycemia, you will need to drink 6 to 12 ounces of
orange juice or another fruit juice without adding sugar, or
substitute an 8-ounce glass of milk if the other options are not
available (Dunphy et al., 2015). Signs and symptoms of
hyperglycemia include extreme thirst, frequent urination,
fatigue, listlessness, nausea, dizziness; which are some of the
symptoms you are experiencing now (Dunphy et al., 2015).
Therefore, to avoid high blood sugars it is important for you to
follow the diet and exercise recommendations previously
discussed, and take your metformin as prescribed.
Important complications that can arise from T2DM, include
diabetic neuropathy, which is a decreased sensation in your
hands and feet due to nerve damage; and retinopathy, damage to
the blood vessels in the back of the eye that can cause you to go
blind (Dunphy et al., 2015). It is important for you to know the
signs and symptoms of neuropathy, which includes pain, loss of
sensation, and muscle weakness that occurs most commonly in
the feet (Dunphy et al., 2015). Therefore, it is imperative for
you to wash and inspect your feet daily for open sores, avoid
walking barefoot, test the temperature of your bath water before
getting in, and trim your toenails to the shape of your toes and
avoid cutting the cuticles (Dunphy et al., 2015). You stated that
you wear contacts, so hopefully you see an eye doctor yearly;
and if you don’t, it is imperative that you do, so that you can be
evaluated for any damaged blood vessels in your eyes (ADA,
2019). The most common side effects associated with metformin
are stomach discomfort, nausea, vomiting, and diarrhea; which
usually goes away within a couple of weeks (Dunphy et al.,
2015). Also, metformin has a low risk for causing low blood
sugars (Dunphy et al., 2015; ADA, 2019).
Diagnosis. According to your fasting lipid panel it indicates that

12. your cholesterol levels are higher than recommended, which is
also referred to as hyperlipidemia or dyslipidemia (Dunphy et
al., 2015). Cholesterol is a waxy substance that has both pros
and cons to maintaining a healthy lifestyle, but having high
levels of bad cholesterol (LDL) and triglycerides, and low
levels of good cholesterol (HDL) circulating in your blood will
cause a buildup on the walls of your arteries making them
narrow and hardened; increasing your risk for heart attack
and/or stroke (Dunphy et al., 2015). Cholesterol is produced
naturally by your liver, and comes from the foods you eat, such
as meat, poultry, and dairy products (Dunphy et al., 2015).
Animal products contain high saturated fats and trans fats,
which causes your liver to produce extra cholesterol; therefore,
consuming large amounts of these types of foods will raise your
bad (LDL) cholesterol levels (Dunphy et al., 2015). There are
risk factors that make people more prone to having high
cholesterol, such as genetics, family history, T2DM, being
overweight, lack of physical activity, and not following a
healthy diet (Dunphy et al., 2015).
Medication. In order to properly manage your cholesterol levels
and to lower your risk for heart attack or stroke, I will be
prescribing you a medication called atorvastatin that you will be
taking once a day (Stone et al., 2014). In addition to eating a
healthy diet and exercising, this medication will help with
lowering your triglycerides and bad cholesterol, while
increasing your good cholesterol (Stone et al., 2014).
Diet and exercise. In addition to what was discussed regarding
T2DM, restricting your intake of cholesterol to less than 200
mg/day is recommended (Dunphy et al., 2015). Other
recommendations for improving your cholesterol is to eat red
meat only a couple times a month; increase your intake of fruits
and vegetables, whole grains, legumes and nuts; and use olive
oil and/or canola oil instead of butter (Dunphy et al., 2014).
Exercise recommendations for hyperlipidemia stated above.
Warning signs for diagnosis and medications. There are no true
warning signs for your elevated cholesterol except for the

13. increased risk of having a heart attack or stroke. If you develop
symptoms of chest pain, shortness of breath, weakness to one
side of your body, or slurred speech, then you need to seek
emergency care immediately. Atorvastatin is usually well
tolerated; however, there are side effects to this medication
such as muscle symptoms, which include pain, tenderness,
stiffness, cramping, weakness, or fatigue (Stone et al., 2014). If
you experience any of these symptoms it is important for you to
call the office immediately to avoid any serious muscle damage
that could be occurring from taking this medication; and it is
also recommended to avoid drinking grapefruit juice due to the
potential for a drug interaction (Last et al., 2017).
Diagnosis. According to your BMI of 33.3 kg/m2, which is
calculated from your height and weight, indicates obesity.
Obesity is characterized by having too much body fat and is
determined by a BMI greater than or equal to 30 kg/m2 (Dunphy
et al., 2015; ADA, 2019). What contributes to excessive weight
gain is when people eat too much food or consume too many
calories, and do not get enough exercise to burn off or balance
out the calories consumed (Dunphy et al., 2015). Obesity can
cause many health issues, such as T2DM, hyperlipidemia,
strokes, and coronary heart disease (Dunphy et al., 2015).
Diet, exercise, and medication. Diet and exercise
recommendations for weight loss were explained during the
discussion of your T2DM and elevated cholesterol levels, but I
strongly encourage you to follow a calorie restricted diet to
facilitate weight loss (Jones et al., 2015). No medications will
be prescribed specifically for the diagnosis of obesity.
Referral
Diabetes Educator. A referral to a diabetes educator will be
completed for Mrs. G based on her new diagnosis of T2DM.
According to the ADA (2019), every patient with diabetes
should take part in diabetes self-management education and
support because it provides patients with the necessary
education, skills, and support that is needed to effectively self-
manage and maintain their diabetes.

14. Registered Dietitian. A referral to a registered dietitian will be
completed as this is also recommended for the diagnosis of
T2DM (ADA, 2019). According to the ADA (2019), a
personalized medical nutrition therapy program; which is
provided under the direction of registered dieticians, is
pertinent for all diabetic patients in order for them to
adequately achieve their recommended treatment goals (ADA,
2019).
Ophthalmologist or Optometrist. Referral to an ophthalmologist
or optometrist is recommended by the ADA for patients to have
a dilated and comprehensive eye exam initially for the diagnosis
of T2DM, then annually thereafter (ADA, 2019). It cannot be
assumed that Mrs. G visits an eye doctor on an annual basis just
because she wears contacts; therefore, it is imperative to
ascertain whether or not a referral is still needed and to stress
the importance of this particular recommendation.
Follow up
Mrs. G will be scheduled for a 4-week follow up visit, which at
this time an evaluation for medication compliance, intolerances
or side effects from metformin and/or atorvastatin can be
evaluated; along with her psychosocial status, adherence to
recommended lifestyle modifications, such as diet and exercise;
and address any other questions or concerns that Mrs. G may
have in regards to the self-management of her diabetes,
hyperlipidemia, and obesity (ADA, 2019). Additionally, the 4-
week follow-up visit will assess her height, weight, BMI, and
blood pressure.
Medication Cost
At Walmart pharmacy, the retail price for sixty metformin 500
mg tablets is $4.00 and $9.00 for thirty atorvastatin 10 mg
tablets (GoodRx, 2019). The estimated monthly cost for Mrs.
G’s new prescriptions would be $13.00 per month. When
prescribing Mrs. G’s medications, I took into account the cost
of the medications and decided to prescribe generic
formulations (cheapest). The cost of prescription medications
should be taken into consideration when developing a treatment

15. plan for all patients. Diabetes can negatively impact a patient’s
financial status; therefore, as a future nurse practitioner I will
strive to facilitate improved patient care and outcomes by
utilizing cost containment resources and strategies. The
utilization of GoodRx.com allows providers to compare prices
of generic and brand name medications among various
pharmacies to reduce the financial burden that many patients
experience with the healthcare industry. The ADA recommends
providers to evaluate the patient’s social situation for financial
barriers; which may lead to non-adherence of the prescribed
management plan, thus resulting in suboptimal patient outcomes
(ADA, 2019).
Conclusion
Mrs. G was evaluated based on the collected subjective and
objective information; and was provided with a management
plan that was developed from evidence-based practice
guidelines for the diagnoses of T2DM, hyperlipidemia, and
obesity. Lastly, the cost of the prescription medications was
taken into consideration, and only generic formulations were
prescribed to help facilitate patient adherence and to optimize
outcomes.
Clinical Chart SOAP Note
Patient Information:
Mrs. G., 55, Female, Hispanic
S:
Chief Complaint:
HPI:
Mrs. G., a 55-year-old Hispanic female, presents to the office
for her annual exam. She reports that lately she has been very
fatigued and just does not seem to have any energy. This has
been occurring for 3 months. She is also gaining weight since
menopause last year. She joined a gym and forces herself to go
twice a week, where she walks on the treadmill at least 30
minutes but she has not lost any weight, in fact she has gained 3

16. pounds. She doesn’t understand what she is doing wrong. She
states that exercise seems to make her even more hungry and
thirsty, which is not helping her weight loss. She wants get a
complete physical and to discuss why she is so tired and get
some weight loss advice. She also states she thinks her bladder
has fallen because she has to go to the bathroom more often,
recently she is waking up twice a night to urinate and seems to
be urinating more frequently during the day. This has been
occurring for about 3 months too. This is irritating to her, but
she is able to fall immediately back to sleep.
Current Medications: Tylenol 500 mg 2 tabs daily for knee pain.
Daily multivitamin.
Allergies: NKDA, allergic to cats and pollen. No latex allergy
PMHx: Left knee arthritis. Had chicken pox and mumps as a
child. Vaccinations up to date.
GYN Hx: G2 P1. 1 SAB, 1 living child, full term, wt. 9 lbs. 2
oz. LMP 15 months ago.
Health Screening: No history of abnormal pap smear
Soc Hx: Works from home as a part time planning coordinator.
Married. No tobacco history, 1-2 glasses wine on weekends. No
illicit drug uses.
Fam Hx: Parents alive, well, child alive, well. No siblings.
Mother has HTN and father has high cholesterol.
ROS:
Constitutional: Reports fatigue, low energy, and weight gain of
3 lbs.
Genitourinary: Reports frequent urination and nocturia.
Endocrine: Reports increased hunger, thirst, and urination.
O:
Physical Exam:
BP: 129/80; HR: 76; RR: 16; Height: 5' 2.5"; Weight: 185 lbs.;
BMI: 33.3
General: obese female in no acute distress. Alert, oriented and

17. cooperative.
Skin: warm dry and intact. No lesions noted.
HEENT: head normocephalic. Hair thick and distribution
throughout scalp. Eyes without exudate, sclera white. Wears
contacts. Tympanic membranes gray and intact with light reflex
noted. Pinna and tragus nontender. Nares patent without
exudate. Oropharynx moist without erythema. Teeth in good
repair, no cavities noted. Neck supple. Anterior cervical lymph
nontender to palpation. No lymphadenopathy. Thyroid midline,
small and firm without palpable masses.
CV: S1 and S2, RRR without murmurs no rubs.
Lungs: clear to auscultation bilaterally, respirations regular,
unlabored
Abdomen: soft, round, nontender with positive bowel sounds
present; no organomegaly; no abdominal bruits. No CVAT.
Diagnostic or Lab results:
CBC: WBC 6,000/mm3 Hgb 12.5 gm/dl Hct 41% RBC 4.6
million MCV 88 fl MCHC 34 g/dl RDW 13.8%
UA:pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites
negative, 1+ glucose; small protein; negative for ketones
CMP:
Sodium 139, Potassium 4.3, Chloride 100, CO2 29, Glucose 95,
BUN 12, Creatinine 0.7, GFR est non-AA 92 mL/min/1.73,
GFR est AA 101 mL/min/1.73, Calcium 9.5, Total protein 7.6,
Bilirubin, total 0.6, Alkaline phosphatase 72, AST 25, ALT 29,
Anion gap 8.10, Bun/Creat 17.7
Hemoglobin A1C: 6.9 %
TSH: 2.35, Free T4: 0.7
Cholesterol: TC 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl;
HDL 38mg/dl, Triglycerides 232
EKG: normal sinus rhythm

18. A:
Primary Diagnosis: Type 2 Diabetes Mellitus (E11.9)
Secondary Diagnosis: Hyperlipidemia (E78.5); Obesity (E66.9);
Body mass index (BMI) 33.0-33.9, adult (Z68.33)
Differential Diagnosis: Major depressive disorder, unspecified
(F32.9)
P:
Diagnostics:
Spot urinary albumin-to-creatinine ratio
PHQ-9 screening
CMP in 6 weeks
FLP in 6 weeks
Repeat A1C in 3 months
Medications:
· Rx: Metformin 500 mg tablets
Sig: Take one (1) tablet by mouth twice daily. Disp: #60
(Sixty). RF: 2
· Rx: Atorvastatin 20 mg tablets
Sig: Take one (1) tablet by mouth once daily. Disp: #30
(Thirty). RF: 2
Education:
Discussed T2DM, hyperlipidemia, and obesity diagnoses.
Diabetes education.
Discussed foot care.
Education provided about hypoglycemia and hyperglycemia.
Reviewed medications.
Discussed the need for repeat lab work.
Discussed lifestyle modifications with diet and exercise.
Referrals: Diabetic Educator, Registered Dietician for medical
nutrition therapy, Optometrist or Ophthalmologist for dilated
and comprehensive eye examination
Follow up: Return to office in 4 weeks to evaluate for adherence
to prescribed medications and management plan.

19. References
American Diabetes Association. (2019). Standards of medical
care in diabetes-2019. Diabetes Care, 42(Supplement 1), S1-
S193. Retrieved from
http://care.diabetesjournals.org/content/42/Supplement_1
Bibbins-Domingo, K., Grossman, D. C., Curry, S. J., Davidson,
K. W., Epling, J. W., Jr, García, A. R., … Pignone, M. P.
(2016). Statin use for the primary prevention of cardiovascular
disease in adults: US Preventive Services Task Force
recommendation statement. The Journal of the American
Medical Association, 316(19), 1997-2007.
doi:10.1001/jama.2016.15450
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas,
D. J. (2015). Primary care: The art and science of advanced
practice nursing (4th ed.). Philadelphia, PA: F.A. Davis.
GoodRx. (2019). Atorvastatin. Retrieved from
https://www.goodrx.com/atorvastatin
GoodRx. (2019). Metformin. Retrieved from
https://www.goodrx.com/metformin

20. Hirschtritt, M. E., & Kroenke, K. (2017). Screening for
depression. Journal of the American Medical
Association, 318(8), 745-746. Retrieved from
https://doi.org/10.1001/jama.2017.9820
Hollier, A. (2018). Clinical guidelines in primary care (3rd
ed.). Lafayette, LA: Advanced Practice Education Associates.
Kennedy-Malone, L., Plank, L. M., & Duffy, E. G.
(2019). Advanced practice nursing in the care of older
adults (2nd ed.). Philadelphia: F.A. Davis Company.
Lambert, M. (2014). ACC/AHA release updated guideline on the
treatment of blood cholesterol to reduce ASCVD risk. American
Family Physician, 90(4), 260-265. Retrieved from
https://www.aafp.org/afp/2014/0815/p260.html
Last, A. R., Ference, J. D., & Menzel, E. R. (2017).
Hyperlipidemia: Drugs for cardiovascular risk reduction in
adults. American Family Physician, 95(2), 78–87. Retrieved
from https://www.aafp.org/afp/2017/0115/p78.html
McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S.
(2014). Pathophysiology: The biologic basis for disease in
adults and children (7th ed.). St. Louis, MO: Mosby.
Stone, N. J., Robinson, J. G., Lichtenstein, A. H., Bairey-Merz,
C. N., Blum, C. B., Eckel, R. H., & ... Wilson, P. W. (2014).
Practice guideline: 2013 ACC/AHA guideline on the treatment
of blood cholesterol to reduce atherosclerotic cardiovascular
risk in adults. Journal of the American College of
Cardiology, 63(25), 2889-2934. doi:10.1016/j.jacc.2013.11.002
After reviewing the resources assigned for this week, I
have reflected on three important considerations that I have
learned regarding the American Psychology Association (APA)
style in the field of Psychology. I am already slightly familiar
with APA formatting as I have been using it for all my college
career. But as I was reviewing this week’s assigned resources, I

21. learned I only knew the bare minimum about APA. Upon this
week I learned one of the APA formatting protects writers from
plagiarism. “Plagiarism in an act of fraud. It involves both
stealing someone else’s work and lying about it afterward”
("What is Plagiarism?", 2017). Plagiarism is very wrong, and I
understand the reasoning's why and why there are such “harsh”
consequences. Second, I learned that APA manuscript structure
is broken down into eight parts, which are the “title page,
abstract, introduction, method, results, discussion, references
and appendices” ("Basics of APA Style Tutorial", 2015). When
writing my papers prior to this week’s article I only did a title
page, abstract, introduction and references, sometimes I
included an appendix if it was required. I feel a little silly now
knowing that there are more components to an APA manuscript
structure, and that I wasn’t really doing the best I now know I
can. It’s almost like I was doing half of my assignments and my
professors never made mention of it. Third, I learned APA style
is needed to “express the key elements of quantitative results,
choose the graphic form that will best suit our analyses, report
critical details of our research protocol, and describe
individuals with accuracy and respect.” To me that means that
APA style is needed as a better way to simplify the reading.
As, a graduate student three examples on what I would
be doing to avoid plagiarism would be paraphrasing, quoting my
sources and using my own words. My second example is so
important because as a graduate student we do a lot of research
which requires getting information from other places than our
thoughts. So, always no matter what credit must be given. No
matter how many few words are used giving credit is important.
Paraphrasing is a remix of what the author/owner said but
putting it into your own words. While paraphrasing is okay and
perfectly legal, I’m going to try my very hardest to just use my
own words if I can. Even when we least think it sometimes
paraphrasing can turn into plagiarism. Out of this week’s
assigned resources the main and most important thing I learned
is always give credit, when credit is due. Plagiarism is a crime

22. and it’s silly to be punished for stealing words, when it
could’ve been avoided. To also avoid plagiarism, I will use a
check paper software to ensure I have quoted and paraphrased
correctly. Plagiarism should always be double checked to
ensure authenticity.
References
What is Plagiarism? (2017, May 18). Retrieved July 24, 2019,
from https://www.plagiarism.org/article/what-is-plagiarism
Basics of APA Style Tutorial. (n.d.). Retrieved July 24, 2019,
from http://flash1r.apa.org/apastyle/basics-
html5/index.html?_ga=2.115233159.1636305233.1559507973-
1841274510.1559507973
How to Paraphrase. (2017, June 7). Retrieved July 24, 2019,
from https://www.plagiarism.org/article/how-to-paraphrase
Clinical Chart Soap Note Example
Patient Information:
Initials, Age, Sex, Race,
S:
Chief Complaint: left hip pain
HPI:
Mrs L, a 66 year old Caucasian female present to the clinic with
complaints of left hip pain which she first noticed 3 weeks ago.
She reports experiencing pain more frequently now, it is almost
constant with walking or standing for a long period of time. It is
a throbbing pain with does not radiate. The pain is aggravated
by walking, bending, standing, squatting and relief is noted with
rest. She has taken Ibuprofen 800 mg intermittently for the pain,
and states at worst the pain rated as 8/10, at best 0/10 when at
rest.
Current Medications:
Ibuprofen 200-800 PRN hip pain
Allergies: None stated

23. PMHx:
No chronic illness. Chicken pox as a child. No hx previous
fractures.
All vaccines up to date
PSHX: Hysterectomy 20 years ago, Cholecystectomy 20 years
ago
Health screening:
Last mammogram 5 years ago, colonoscopy WNL, no history of
DEXA
Soc Hx:
Single, Retired x 4 years, previous office management, non-
smoker, occasionally has a glass of wine with dinner, no illicit
drugs, walks 1 mile a day.
Fam Hx:
Parents are deceased, siblings in good health.
ROS:
General: denies headache, vision changes, night sweats, fever
CV: No chest pain, palpitations
Respiratory: No SOB, no cough
Musculoskeletal: Reports pain with standing, walking,
squatting, no back pain,
Neuro: No numbness, tingling, or weakness noted in extremities
O:
Physical Exam:
BP: 123/84; HR 80; RR 20; T: 98.5; Hgt: 5'2"; Wgt: 120 lbs;
BMI: 20 (weight loss of 7 lbs from last year)
General: No acute distress
HEENT: Head normocephalic without evidence of masses or
trauma.
PERRLA, EOMs intact, non-injected. Ear canal without redness
irritation, TMs clear, pearly, bony landmarks visible, no
discharge, no pain noted. Neck negative for masses, no
thyromegaly. No JVD distention.
Skin: intact. No bruising noted.
CV: S1/S2, RRR, no murmurs, no rubs
Lungs: CTA bilaterally.

24. Abdomen: Soft, non-tender, non-distended, BS present x 4, no
organomegaly, no bruits
Musculoskeletal: No pain to palpation of left or right hip ;
Right leg: full active and passive ROM Left leg: Decreased
active and passive ROM with stiffness and report of discomfort.
Antalgic gait noted with rise from seated position, to standing,
and initiation of ambulation
Neuro: Sensation intact bilateral upper and lower extremities,
bilateral UE/LE strength 5/5
Psych: PHQ 9 score 5
Diagnostic or Lab results: None Available
A:
Primary Diagnosis: Osteoarthritis (M16.12):
Secondary Diagnosis: Health maintenance, Gait Disturbance
(ICD-10 R26.89):
Differential Diagnoses:
Hip fracture (stress fracture) (ICD-10 M84.352):
Osteoporosis (M81.0):
P:
Diagnostics:
25-hydoxyvitamin D, calcium level
X-ray of the left hip
DEXA
Medications:
· Ibuprofen 200 mg tablet (treatment of OA)
Sig: Take 2 tablets three times daily, Disp: 120 Refill: 3
· Tramadol 25 mg tablet
Sig: take one tablet every 6 hours as needed for severe pain.
Disp: 20 Refill: 0
Education:
Discussed OA diagnosis and will screen for osteoporosis with
DEXA
Reviewed medications
Recommend water aerobic/hydrotherapy
Exercises should stress range of motion and stretching such as
yoga or tai chi

25. Hot and cold therapy as tolerated. Heat applied prior to exercise
to reduce aches, cold following exercise to reduce swelling and
relieve pain. Use heat no longer than 15 minutes at a time and
cold therapy for no longer than 20 minutes at a time to prevent
thermal injury
Discussed fall prevention. Recommend removing throw rugs
from the home due to gait.
Physical therapy referral to assist with gait
PHQ 9 score 5: discussed to call office if experiences increased
signs of depression
mammogram scheduled
Referrals: GI for colonoscopy, physical therapy
Follow up: return to office in 2 weeks to evaluate pain level and
review diagnostics results.
Case Study Assignment
Guidelines with Scoring Rubric
Purpose
The purpose of this case study assignment is to
1) Analyze provided subjective and objective information to
diagnose and develop a management plan for the case study
patient.
2) Apply national diabetes guidelines to case study patient
management plan.
3) Demonstrate mastery of SOAP note writing.
Course Outcomes
Through this assignment, the student will demonstrate the
ability to:
1. Employ appropriate health promotion guidelines and disease
prevention strategies in the management of mature and aging
individuals and families.
2. Formulate appropriate diagnoses and evidence-based plans of
care for mature and aging individuals and families using

26. subjective and objective data.
3. Incorporate unique patient cultural preferences, values, and
health beliefs in the care of mature and aging individuals and
families
4. Integrate theory and evidence based practice in the care of
mature and aging individuals and their families
6. Conduct pharmacologic assessment addressing polypharmacy,
drug interactions and other adverse events in the care of mature
and aging individuals and their families.
7. Apply evidence-based screening tools to perform functional
assessments with aging individuals and their families as
appropriate.
Due Date: Sunday 11:59 p.m. MT at the end of Week 5
Total Points Possible: 200 pointsPreparing the Assignment
The assignment is a paper, which is to be written in APA format
using the provided assignment template. The paper shall not
exceed 20 pages.
Review the attached patient visit information. You are provided
with the subjective and objective exam findings. As the
provider, you are to diagnose the case study patient and develop
the management plan for this case study patient.
Use the provided case study template for your paper. Review
the APA Manual to adhere to APA formatting.
Introduction: briefly discuss the purpose of this paper.
Assessment: review the provided case study information.
Identify the primary, secondary and differential diagnoses for
the patient. Use the 601 Clinical SOAP note format as a guide
to develop your diagnoses.
Each diagnosis will include the following information:
1. ICD 10 code.
2. A brief pathophysiology statement which is no longer that
two sentences, paraphrased and includes common signs and
symptoms of the diagnosis and proper citation.
3. The patient’s pertinent positive and negative findings,
including a brief 1-2 sentence statement, which links the
subjective and objective findings (including lab data and

27. interpretation).
4. A rationale statement, which summarizes why the diagnosis
was chosen.
5. Do not include quotes, paraphrase all scholarly information
and provide an in text citation to your scholarly reference. Use
the Reference Guidelines document for information on scholarly
references.
Plan (there are five (5) sections to the management plan)
1. Diagnostics. List all labs and diagnostic test you would like
to order. Each test includes a rationale statement following the
listed lab, which includes the diagnosis for the test, the purpose
of the test and how the test results will contribute to your
management plan. Each rationale statement is cited.
2. Medications: Each medication is listed in prescription format.
Each prescribed and OTC medication is linked to a specific
diagnosis and includes a paraphrased EBP rationale for
prescribing.
3. Education: section includes personalized detailed education
on all five (5) subcategories: diagnosis, each medication
purpose and side effects, diet, personalized appropriate exercise
recommendations and warning sign for diagnosis and
medications if applicable. All education steps are linked to a
diagnosis, paraphrased, and include a paraphrased EBP
rationale. Review the NR601 Clinical SOAP note guideline for
more detailed information.
4. Referrals: any recommended referrals are appropriate to the
patient diagnosis and current condition, is linked to a specific
diagnosis and includes a paraphrased EBP rationale with in text
citation.
5. Follow up: Follow up includes a specific time, not a time
range, to return to PCP office for next scheduled appointment.
Includes EBP rationale with in text citation.
Medication costs: in this section students will research the costs
of all prescribed and OTC monthly medications that you have
prescribed and that the patient is currently taking that you
would like to continue. Students may use Good Rx, Epocrates

28. or another resource (students may use local pharmacy websites)
which provides medication costs. Students will list each
medication, the monthly cost of the medication and the
reference source. Students will calculate the monthly cost of the
case study patient’s prescribed and OTC medications and
provide the total costs of the month’s medications. Reflect on
the monthly cost of the medications prescribed. Discuss if
prescriptions were adjusted due to cost. Discuss if will you use
medication pricing resources in future practice.
SOAP note: A focused SOAP note, written on a separate page,
follows the assignment. The SOAP note is written following the
provided Clinical SOAP note format.
· The subjective section is organized to follow the Clinical
SOAP note format. The ROS is focused; only pertinent body
systems are included. Only provided information is included in
the ROS. No additional data is added.
· The objective section is maintained as written, no additional
information is added.
· The assessment section includes only the diagnoses and ICD
10 codes. Diagnosed are labeled as primary, secondary or
differential diagnoses. Rationale is not included in the SOAP
note.
· The plan includes five sections. Rationale is not included in
the SOAP note.
The assignment will be submitted through TurnItIn. Due to the
common language in a large group assignment, it is possible
that similarity scores can exceed 25%. It is the student’s
responsibility to review the TII paper and assure that sections of
original work contain low similarity. If there are concerns,
please contact your instructor.
Category
Points
%
Description
Assessment

29. 50
25
Each diagnosis, primary, secondary and differential, includes
the ICD10 codes in parentheses next to each diagnosis.
Diagnosis is consistent with the guideline recommendations or
scholarly reference.
Each diagnosis includes a one to two sentence paraphrased
pathophysiology statement explains the diagnosis and a
rationale statement. The rationale statement includes pertinent
positive and negative subjective and objective findings from the
history and physical exam, which links this diagnosis to your
patient. Pertinent lab results are interpreted within the rationale
statement.
Evidence-Based Practice (EBP)
50
25
National guidelines, including the American Diabetes
Association Standards and Medical Care in Diabetes-2018 or
later (or article related to 2018 Guidelines) are used to support
the primary diagnosis and develop the plan.
Every diagnosis rationale must include an in text citation to a
scholarly reference. Each action step or order within all plan
sections includes an in text citation to an appropriate reference
as listed in the Reference Guidelines document. All cited
information is paraphrased, no quotes included. Reference
interpretation is accurate. Diagnoses plans are consistent with
the guideline recommendations.
Plan: diagnostics
10
5
All ordered diagnostics tests are linked to a diagnosis and
include a paraphrased EBP rationale with citation. Each
diagnosis is included in the plan.
Plans are consistent with the guideline recommendations or
scholarly reference.
Plan: medications

30. 10
5
Each prescribed and OTC medication is linked to a diagnosis,
and include a paraphrased rationale EBP rationale. Diagnosis is
clearly stated in the rationale statement.
Plans are consistent with the guideline recommendations or
scholarly reference
Plan: education
10
5
All education steps are linked to a diagnosis, paraphrased, and
include an EBP rationale. Section includes personalized detailed
education on diagnoses, medications, diet, exercise and warning
signs. Personalized diet and exercise recommendations are
included.
Plans are consistent with the guideline recommendations or
scholarly reference.
Plan: Referrals
10
5
All recommended referrals are appropriate for the patient
diagnosis; each referral is linked to a specific diagnosis and
includes a paraphrased EBP rationale.
Plans are consistent with the guideline recommendations or
scholarly reference
Plan: Follow up
10
5
Follow up includes a specific time/date to return to PCP office.
Includes EBP rationale with in text citation. Only follow up
information is listed in this section. Plans are EBP and
consistent with the guideline recommendations.
Medication costs
10
5
Monthly medication costs are calculated and a total cost for the

31. month’s medication is included.
All medications including OTCs are included.
Medication cost citation is included. Summary/reflection
statement is included.
SOAP note
20
10
This SOAP note is an example of a patient chart entry. SOAP
note included at end of assignment before the reference page.
SOAP note includes all elements and is formatted exactly as
described in the Clinical SOAP note guidelines document.
Rationales are not included. Only provided information is
included in the SOAP note.
Grammar, Syntax, APA
10
5
APA format, grammar, spelling, and/or punctuation are
accurate, or with zero to one errors. All referenced information
is cited, “according to” is not used.
Organization
10
5
Paper is developed in a logical, meaningful, and understandable
sequence using the provided assignment template
Rationale length does not exceed template directions. SOAP
note presents case study findings in a logical, meaningful, and
understandable sequence following provided format.
The paper does not exceed 20 pages.
Total
200
100
A quality assignment will meet or exceed all of the above
requirements.
Chamberlain College of Nursing NR601

32. CCK01/19
1
Grading Rubric
Criterion
Exceptional
Outstanding or highest level of performance
Exceeds
Very good or high level of performance
Meets
Satisfactory level of performance
NeedsImprovement
Poor or failing level of performance
Developing
Unsatisfactory level of performance
Content
Possible Points = 180
Assessment
50 Points
44 Points
41 Points
20 Points
0 Points
All three diagnostic categories are present.
Each diagnosis, primary, secondary and differential, includes
the ICD10 codes in parentheses next to each diagnosis.

33. Diagnosis is consistent with the guideline recommendations or
scholarly reference.
Each diagnosis includes a one to two sentence paraphrased
pathophysiology statement explains the diagnosis and a
rationale statement. The rationale statement includes pertinent
positive and negative subjective and objective findings from the
history and physical exam, which links this diagnosis to your
patient. Pertinent all lab results are interpreted within the
rationale statement.
All three diagnostic categories are present.
Each diagnosis, primary, secondary and differential includes the
ICD10 codes in parentheses next to each diagnosis. Diagnosis is
consistent with the guideline recommendations or scholarly
reference.
Each diagnosis includes a one to two sentence paraphrased
pathophysiology statement explains the diagnosis and a
rationale statement.
The rationale statement includes pertinent positive and negative
subjective and objective findings from the history and physical
exam, which links this diagnosis to your patient.
Pertinent lab or diagnostic results are not interpreted within the
rationale statement.
All three diagnostic categories are present.
Each diagnosis, primary, secondary and differential includes the
ICD10 codes in parentheses next to each diagnosis. Diagnosis is
consistent with the guideline recommendations or scholarly
reference.
The pathophysiology statement is not present or not
paraphrased,
The rationale statement includes pertinent positive and negative

34. subjective and objective findings from the history and physical
exam, which links this diagnosis to your patient.
Pertinent lab or diagnostic results are not interpreted within the
rationale statement.
Not all three diagnostic categories are developed: a primary,
secondary or differential diagnosis category is not included.
Any diagnosis is not consistent with the guideline
recommendations or scholarly reference.
OR
Includes treatment information
OR
Includes information that does not pertain to the case study
patient such as pregnancy information or gender information
that does not pertain to the case study patient’s listed gender or
age.
Diagnoses are not present.
Evidence-Based Practice
50 Points
44 Points
41 Points
20 Points
0 Points
National guidelines, including the American Diabetes
Association Standards and Medical Care in Diabetes-2018 or
later, (or article related to 2018 Guidelines) are used to support
the primary diagnosis and develop the plan.
Every diagnosis rationale must include an in text citation to a
scholarly reference. Each action step or order within all plan
sections includes an in text citation to an appropriate reference
as listed in the Reference Guidelines document. All cited

35. information is paraphrased, no quotes included. Reference
interpretation is accurate.
Diagnoses plans are consistent with the guideline
recommendations.
National guidelines, including the American Diabetes
Association Standards and Medical Care in Diabetes-2018 or
later, (or article related to 2018 Guidelines), are used to support
the primary diagnosis and develop the plan.
Every diagnosis rationale must include an in text citation to a
scholarly reference.
One or two steps or orders within all plan sections may be
missing an in text citation to an appropriate reference as listed
in the Reference Guidelines document. All cited information is
paraphrased, no quotes included.
Diagnoses plans are consistent with the guideline
recommendations.
National guidelines, including the American Diabetes
Association Standards and Medical Care in Diabetes-2018 or
later, (or article related to 2018 Guidelines), are used to support
the primary diagnosis and develop the plan.
Every diagnosis rationale does not include an in text citation to
an appropriate reference as listed in the Reference Guidelines
document.
OR
One or two steps or orders within all plan sections may be
missing an in text citation to an appropriate reference as listed
in the Reference Guidelines document. All cited information is
paraphrased, no quotes included.
Diagnoses plans are consistent with the guideline
recommendations.
The American Diabetes Association Standards and Medical Care
in Diabetes-2018 or later (or article related to 2018 Guidelines)
is not used to support the primary diagnosis.

36. OR
Not every diagnosis rationale includes an in-text citation to an
appropriate reference as listed in the Reference Guidelines
document. Reference interpretation is not accurate, diagnosis or
plan is not consistent with the guideline recommendations.
OR
Three steps or orders within any/all plan section are missing an
in text citation to an appropriate reference as listed in the
Reference Guidelines document.
Scholarly information includes quotations.
Diagnoses and/or plan are not consistent with the guideline
recommendations.
National guidelines, including the American Diabetes
Association Standards and Medical Care in Diabetes-2018 or
later, (or article related to 2018 Guidelines) are not used as
references.
10 Points
9 Points
8 Points
4 Points
0 Points
Plan: Diagnostics
All ordered diagnostics tests are linked to a diagnosis and
include a paraphrased EBP rationale with citation. Each
diagnosis is included in the plan.
Plans are consistent with the guideline recommendations or
scholarly reference.
All ordered diagnostics tests are linked to a diagnosis listed in
the assessment section and includes an EBP rationale.
Plans are consistent with the guideline recommendations or
scholarly reference.
A diagnosis is not included within the rationale statement.

37. All ordered diagnostics tests are linked to a diagnosis listed in
the assessment section.
Plans are consistent with the guideline recommendations or
scholarly reference.
EBP rationale within text citation is missing;
OR
Rationale is a quotation.
Ordered diagnostics tests are not linked to a diagnosis listed in
the assessment section
OR
Plans are not consistent with the guideline recommendations.
Diagnostic tests are not included
10 Points
9 Points
8 Points
4 Points
0 Points
Plan: Medications
Each prescribed and OTC medication is linked to a diagnosis,
and include a paraphrased rationale EBP rationale. Diagnosis is
clearly stated in the rationale statement.
Plans are consistent with the guideline recommendations or
scholarly reference.
All prescribed and OTC medication include a paraphrased EBP
rationale. The diagnosis is not clearly listed within the rationale
statement.
Plans are consistent with the guideline recommendations or
scholarly reference.
Each prescribed and OTC medication is linked to a specific
diagnosis. The diagnosis is clearly listed within the rationale
statement. An EBP rationale is not included
OR
Rationale is a quotation.

38. Plans are consistent with the guideline recommendations or
scholarly reference.
Prescribed medications are listed but OTC medications are not
present.
OR
Not every medication is linked to a diagnosis, and include a
paraphrased rationale EBP rationale.
OR
Plans are not consistent with the guideline recommendation or
scholarly references.
Prescribed and OTC medications are not included in the case
study.
10 Points
9 Points
8 Points
4 Points
0 Points
Plan: Education
All education steps are linked to a diagnosis, paraphrased, and
include an EBP rationale. Section includes personalized detailed
education on diagnoses, medications, diet, exercise and warning
signs. Personalized diet and exercise recommendations are
included.
Plans are consistent with the guideline recommendations or
scholarly reference.
All education steps are linked to a diagnosis, paraphrased and
include an EBP rationale.
One or 2 educational areas are not detailed or personalized to
the patient.
Plans are consistent with the guideline recommendations or
scholarly reference.
All education steps are linked to a diagnosis and includes an
EBP rationale.
EBP rationale
is a quotation.

39. OR
Three (3) or more education areas do not include personalized
detailed information or scholarly reference.
Plans are consistent with the guideline recommendations or
scholarly reference.
Any education step is not linked to a diagnosis, not paraphrased
or an EBP rational is not provided.
OR
Plans are not consistent with the guideline recommendations or
scholarly reference.
Education section is not present.
10 Points
9 Points
8 Points
4 Points
0 Points
Plan: Referral
All recommended referrals are appropriate for the patient
diagnosis; each referral is linked to a specific diagnosis and
includes a paraphrased EBP rationale.
Plans are consistent with the guideline recommendations or
scholarly reference.
Some recommended referrals are appropriate for the patient
diagnosis and condition, each referral is linked to a specific
diagnosis and includes a paraphrased EBP rationale for
ordering.
Plans are consistent with the guideline recommendations or
scholarly reference.
All recommended referrals are appropriate for the patient
diagnosis and condition, includes a paraphrased EBP rationale
but specific diagnosis is not stated for every referral.
OR
EBP rationale
is a quotation.

40. Plans are consistent with the guideline recommendations or
scholarly reference.
Some recommended referrals are appropriate for the patient
diagnosis and condition
Does not include a paraphrased EBP rationale for referral.
OR
Plans are not consistent with the guideline recommendations.
Referral section is not present.
10 Points
9 Points
8 Points
4 Points
0 Points
Plan: Follow Up
Follow up includes a specific time/date to return to PCP office.
Includes EBP rationale with in text citation. Only follow up
information is listed in this section. Plans are EBP and
consistent with the guideline recommendations.
Follow up is included in the plan but a specific time/date is not
included (a range is included). Includes EBP rationale with in
text citation. Only follow up information is listed in this
section.
Plans are EBP and consistent with the guideline
recommendations.
Follow up is included in the plan but a specific time is not
included. Only follow up information is listed in this section.
Plans are consistent with the guideline recommendations.
Follow up is included in the plan; recommended follow up visit
time frame is not EBP. Additional information, such as future
testing, education or referrals are listed.
Plans are not consistent with the guideline recommendations.
Follow up section not present.

41. 20 Points
18 Points
16 Points
8 Points
0 Points
SOAP note
SOAP note included at end of assignment before reference
page.
SOAP note includes all elements and is formatted exactly as
described in the SOAP note guidelines document. Rationales are
not included. Only provided information is included in the
SOAP note.
SOAP note included at end of assignment before reference
page.
SOAP note includes all elements as listed in the SOAP note but
not exactly as formatted in guidelines document.
Rationales are not included.
Only provided information is included in the SOAP note.
SOAP note included at end of assignment before the reference
page.
SOAP note is formatted exactly as listed in the SOAP note
guidelines document but is missing provided subjective or
objective information. Subjective or objective information is
not consistent with the case study. Provided information is
missing or additional information is added to the SOAP note
SOAP note included, but not located at end of assignment
before the reference page.
OR
SOAP note is not formatted exactly as shown in the SOAP note
guidelines document and missing provided subjective or
objective information.
Rationales are included.

42. SOAP note not included in assignment.
10 Points
9 Points
8 Points
4 Points
0 Points
Medication costs
Monthly medication costs are calculated and a total cost for the
month’s medication is included.
All medications including OTCs are included.
Medication cost citation is included. Summary/reflection
statement is included.
Monthly medication costs are calculated and a total cost for the
month’s medications is included.
All medications including OTCs are included.
Medication cost reference is not included. Summary/reflection
statement is included.
Monthly medication costs are calculated. A total cost for the
month is included.
All medications including OTCs are included.
Summary/reflection statement is not included.
Monthly medication costs are calculated.
Summary statement/reflection is included.
Monthly medication costs are not totaled.
OR
OTCs are not included in monthly medication calculations.
Medication costs not calculated.
Content Subtotal
_____of 180 points
Format
Possible Points = 20

43. Grammar, Syntax, APA
10 Points
9 Points
8 Points
4 Points
0 Points
APA format, grammar, spelling, and/or punctuation are
accurate, or with zero to one errors. All referenced information
is cited at the end of the phrase or sentence, “according to” or
the reference name is not used within cited information
Two to four errors in APA format, grammar, spelling, and
syntax noted. All referenced information is cited at the end of
the phrase or sentence, “according to” or the reference name is
not used within cited information.
Five to seven errors in APA format, grammar, spelling, and
syntax noted.” According to” is used as part of cited
information.
Eight to nine errors in APA format, grammar, spelling, and
syntax noted.
Post contains ten or greater errors in APA format, grammar,
spelling, and/or punctuation.
Organization
10 Points
9 Points
8 Points
4 Points
0 Points
Paper is developed in a logical, meaningful, and understandable
sequence using the provided assignment template

44. Rationale length does not exceed template directions.
SOAP note presents case study findings in a logical,
meaningful, and understandable sequence following provided
format.
The paper does not exceed 20 pages.
Assignment contains all elements but may not be written
following provided assignment template
SOAP note presents case study findings in a logical,
meaningful, and understandable sequence following provided
format.
Each diagnosis and action step in the plan lists the step
followed by the rationale. Rationale length does not exceed
template directions.
The paper length does not exceed 20 pages.
Paper does not contain all components and/or may be missing
data.
OR
SOAP note is not written in SOAP note format as outlined in
the NR 601 SOAP note format document. Rationale length does
not exceed template directions..
The paper length does not exceed 20 pages.
Paper is missing three or more required sections or
Diagnoses or
plans are sometimes unclear to follow and may not always be
relevant to topic. Rationale length exceeds template directions.
OR
The paper exceeds 20 pages.
Paper is not relevant to case study patient
OR

45. SOAP note is not relevant to case study.
Format Subtotal
_____of 20 points
Participation
Assignment is submitted by the deadline Sunday @11:59 pm
MT
Assignment submitted after the due date:
Deduction of 10% per day late up to 3 days after which a zero
“0” will be recorded for the assignment.
One day late: -20 points
(Monday 12:00 am –Monday 11:59 PM MT)
Two day late: -40 points
(Tuesday 12:00 am –Tuesday 11:59 PM MT)
Three days late: -60 points
(Wednesday 12:00 am –Wednesday 11:59 PM MT)
After Wednesday 11:59pm MT- grade of zero
Total Points
_____of 200 points
_____of 200 points
NR601 Week 5 Directions & Rubric_1_2019
14
CASE STUDY TITLE 2
Assignment Title
Title page per APA format

46. Running head: CASE STUDY
CASE STUDY 7
· This assignment template serves as a paper template to
develop the week 5 case study and may not be all inclusive. You
must also refer to the assignment rubric for specific
requirements for this assignment. Your paper is graded to the
rubric requirements. *
CCK 4/19
Title matches title on title page
The introductory paragraph is written here. Remember to
remove all instructions from your paper. These are in red ink.
Assessment
Primary Diagnosis diagnosis (ICD10 code)
pathophysiologyA brief pathophysiology statement which is no
longer that two sentences, paraphrased and includes common
signs and symptoms of the diagnosis. Includes citation to an
approved source (author, year).Review the Reference Guidelines
for FNP Case Study document. This applies to all sections of
this paper.
pertinent positive findingsincludes citation to an approved
source (author, year).Review the Reference Guidelines for FNP
Case Study documents. This applies to all sections of this paper.
pertinent negative findingsincludes citation to an approved
source (author, year).Review the Reference Guidelines for FNP
Case Study documents. This applies to all sections of this paper.
rationale for the diagnosisincludes a brief 1-2 sentence
statement, which links the subjective and objective case study
findings including provided lab data and interpretation of the
labs. Include a statement linking those lab results to your ADA
guideline reference. Includes citation to the ADA guideline
used to determine this diagnosis.
Secondary Diagnosis diagnosis (ICD10 code)
*You can have more than one secondary diagnosis. A

47. minimum is required. Secondary diagnoses are additional
diagnoses you have identified from the exam, lab findings today
or the PMH*
Pathophysiology A brief pathophysiology statement which is no
longer that two sentences, paraphrased and includes common
signs and symptoms of the diagnosis (author, year).
pertinent positive findings(author, year).
pertinent negative findings(author, year).
rationale for the diagnosis-includes a brief 1-2 sentence
statement, which links the subjective and objective findings
including any provided lab data and interpretation of the
diagnostic testing. The rationale includes a citation to a
scholarly reference (author, year)
Differential Diagnosisdiagnosis (ICD10 code)
*You can have more than one differential diagnosis. A
minimum of one is required. Differential diagnoses are
additional diagnoses you are considering but require further
testing to confirm or rule out based on the appropriate
guidelines for the diagnosis. *Additional testing must be listed
within the diagnostics section.*
pathophysiology-A brief pathophysiology statement which is no
longer that two sentences, paraphrased and includes common
signs and symptoms of the diagnosis (author, year).
rationale for the diagnosis-includes a brief 1-2 sentence
statement explaining why you are considering this differential
diagnosis. The statement includes the pertinent subjective and
objective findings and any diagnostic data, which supports
further evaluation. Includes citation (author, year).
Plan
Diagnostics
Lab test(each lab/diagnostic test is listed individually with
rationale to follow). Include the timeframe of when the lab is to
be drawn. *This is labs or tests you will order in the future, not
an explanation of the labs that have already been completed.*
rationale: each rationale contains the EBP statement supporting

48. the necessity of the test and includes the name of the diagnosis
which is listed in the assessment section.* If this diagnosis is
not listed in the assessment section then it must be added to
order the diagnostic testing*. Includes a citation to an approved
reference from the Reference Guidelines for FNP Case Study
document which supports not only the test but the timing of the
lab draw.
Medications *each medication is listed individually with
rationale, including the required OTC*
Medication- written in prescription format (see NR 601
Resources)
Rationale.The rationale for each medication includes the
diagnosis which is listed in the assessment section and contains
the EBP statement supporting the necessity of the medication. If
this diagnosis is not listed in the assessment section then it must
be added to include any medication. Includes a citation to an
approved reference from the Reference Guidelines for FNP Case
Study document.
Educationsection includes personalized detailed education on
all five (5) subcategories: diagnosis, each medication purpose
and side effects, diet, personalized appropriate exercise
recommendations and warning sign for diagnosis and
medications if applicable. You do not need an introduction
paragraph. All education steps are linked to a listed diagnosis,
paraphrased, and include a paraphrased EBP rationale. If this
diagnosis is not listed in the assessment section then it must be
added to include the education content here. Each education
section includes a citation to an approved reference from the
Reference Guidelines for FNP Case Study document
Diagnoses.
Includes personalized detailed education for each diagnosis
listed in the assessment section. This includes specific
information for this particular client. Education includes a
citation to an appropriate reference. No listed education is
common knowledge, all statements must include an in text

49. citation to an appropriate reference.
Medications.
includes personalized detailed education for each medication
listed in the medication section. Each medication is listed and
then explained. No listed education is common knowledge, all
statements must include an in text citation to an appropriate
reference.
Diet.
includes personalized detailed education for dietary
recommendations as determined by the listed diagnoses in the
assessment section. This includes specific dietary information.
A referral to cover this requirement is not sufficient. If weight
loss is recommended then specific weight loss targets must be
included. No listed education is common knowledge, all
statements must include an in text citation to an appropriate
reference.
Exercise.
includes personalized detailed education for exercise
recommendations as determined by the listed diagnoses in the
assessment section.. List specific exercises that are appropriate
for this patient. No listed education is common knowledge, all
statements must include an in text citation to an appropriate
reference.
Warning Signs for diagnoses and mediations
includes personalized detailed education as determined by the
listed diagnoses and medications. No listed education is
common knowledge, all statements must include an in text
citation to an appropriate reference..
Referral
Specialty practice or service (each referral is listed
individually with rationale to follow)
rationale: each rationale contains the EBP statement supporting
the necessity of the referral and includes the name of the
diagnosis which is listed in the assessment section. Includes a
citation to an approved reference from the Reference Guidelines

50. for FNP Case Study document. Any referrals for the listed
primary diagnosis must be cited from the chosen ADA
guideline.
Follow up
Follow up includes a specific time frame ( 1week, 1 month) ,
not a time range, to return to PCP office for next scheduled
appointment. Includes EBP rationale with in text citation. Refer
to the rubric for full section requirements.
Medication Cost
See rubric for section requirements.
Conclusion
A summary paragraph
Clinical Chart SOAP note
See rubric instructions for this section. This clinical SOAP note
summarizes this case study patient encounter. All included
information must be consistent with provided case study
information and your assessment and plan listed above. No
additional information should be added here.
References
Are listed on a separate page and formatted per APA guidelines.
NR601 W5 Case Study
1
Apr 19 CCK, CU 041419MT

51. Mrs. Wong, a 59-year-old Asian female, presents to the office
for a planned 3 month follow up
visit for her recently diagnosed right knee arthritis. She is
experiencing less knee pain and
increased mobility with the treatment plan but reports some new
concerns today. She reports that
she has been experiencing increasing fatigue for about the last 2
months. She is also gaining
weight since menopause 4 years ago. She has a health club
membership and attends twice a
week. She walks on the treadmill at least 30 minutes as you
directed and lifts light weights but
she has not lost any weight, in fact she has gained 4 pounds.
She doesn’t understand what she is
doing wrong. She reports that exercise seems to make her even
more hungry and thirsty, which is
not helping her weight loss. She requests evaluation as to why
she is so tired and get some
weight loss advice.
Current medications: Tylenol 500 mg 2 tabs in AM for knee
pain. Daily multivitamin and
turmeric. USES CBD oil for her knee, find it helps.
PMH: Has right knee arthritis diagnosed 3 months ago. Had

52. German measles as a child.
Vaccinations up to date. Colonoscopy WNL 4 years- repeat in
10 years
GYN hx: G1 P1: daughter [email protected] weeks, wt 8lbs
15oz. LMP 4 years ago. ASCUS pap
1998, all further paps WNL. Mammogram last year BI-RADS 1.
FH: parents deceased, child alive, well. No siblings.
SH: Divorced. works from home as an administrative assistant.,
1-2 glasses wine one or two
times a week. Former smoker, quit 12 years ago.
Allergies: allergic to Bactrim, cats and pollen. No latex allergy
Vital signs: BP 112/76; pulse 80, regular; respiration 16,
regular
Height 5’1.5”, weight 165 pounds
General: female in no acute distress. Alert, oriented and
cooperative.
Skin: warm dry and intact. No lesions noted.
HEENT:. Eyes without exudate, sclera white. Wears contacts.
Tympanic membranes gray and
intact with light reflex noted. Pinna and tragus nontender.
Nares patent without exudate.
Oropharynx moist without erythema. Teeth in good repair, no

53. cavities noted. Neck supple.
Anterior and posterior cervical lymph nontender to palpation.
No lymphadenopathy. Thyroid
midline, small and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs.
Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen- soft, round, nontender with positive bowel sounds
present; no organomegaly; no
abdominal bruits. No CVAT.
Musculoskeletal: full ROM both knees. Nontender to palpation
bilaterally. Gait normal.
NR601 W5 Case Study
2
Apr 19 CCK, CU 041419MT
GU: bladder nontender upon palpation
Labwork: (fasting labs drawn this morning)
CBC: UA:
WBC 6,300/mm3 pH 5
Hgb 12.8 gm/dl SpGr 1.010

54. Hct 42% Leukocyte
esterase
negative
RBC 4.6 million nitrites negative
MCV 93 fl Glucose 1+
MCHC 34 g/dl Protein negative
RDW 13.8% ketones negative
CMP:
Sodium 136 Hemoglobin
A1C
6.6%
Potassium 4.4
Chloride 100 TSH 2.31
CO2 29 Free T 4 0.9 ng/dL
Glucose 127
Cholesterol:
BUN 12
Creatinine 0.7 TC 215 mg/dl

55. GFR est non-
AA
99
mL/min/1.73
LDL 144 mg/dl
GFR est AA 101
mL/min/1.73
VLDL 36 mg/dl
Calcium 9.4 HDL 32mg/dl
Total protein 7.6 Triglycerides 229
Bilirubin, total 0.5 EKG:
Alkaline
phosphatase
72
normal sinus rhythm
AST 25
ALT 29
Anion gap 8.10

56. Bun/Creat 17.7