This document provides a case study for a 42-year-old Caucasian woman presenting with numbness and weakness in her left foot for 3 weeks. She has a family history of type 2 diabetes in her brother and grandfather. She was previously found to have elevated blood sugar and cholesterol but did not follow up. Currently, she reports increased thirst and urination. On examination, her blood pressure is elevated and she is overweight. The assignment is to develop an evidence-based management plan including diagnostics, patient education, and follow up for this patient.

1. Assignment Details
Diabetes Case Study
Chief Complaint
“My left foot feels weak and numb. I have a hard time pointing
my toes up.”
History of Present Illness
D.T. is 42-year-old Caucasian woman who has had an elevated
blood sugar and cholesterol 2 years ago but did not follow up
with a clinical diagnostic work-up. She had participated in the
state’s annual health screening program and noticed her fasting
blood sugar was 160 and her cholesterol was 250. However, she
felt “perfectly fine at the time” and did not want to take any
more medications. Except for a number of “female infections,”
she has felt fine recently.
Today, she presents to the clinic complaining that her left foot
has been weak and numb for nearly 3 weeks and that the foot is
difficult to flex. She denies any other weakness or numbness at
this time. She does report that she has been very thirsty lately
and gets up more often at night to urinate. She has attributed
these symptoms to the extremely warm weather and drinking
more water to keep hydrated. She has gained a total of 50
pounds since her last pregnancy 10 years ago, 20 pounds in the
last 6 months alone.
Past Medical History
Seasonal allergic rhinitis (since her early 20s)

2. Breast biopsy positive for fibroadenoma at age 30
Gestational diabetes with second child 10 years ago
Multiple yeast infections during the past 3 years that she has
self-treated with OTC antifungal creams and salt bath
Hypertension for 10 years
Past Surgical History
C-section 14 years ago
OB-GYN History
Menarche at age 11
Last pap smear 3 years ago
Family History
Type 2 DM present in older brother and maternal grandfather.
Both were diagnosed in their late 40s. Brother takes both pills
and shots.
Mother alive and well
Father has COPD
Two other siblings alive and well
All three children are alive and well

3. Social History
Married 29 years with 3 children; husband is a school teacher
Family lives in a four bedroom single family home
Patient works as a seamstress
Smokes 1 pack per day (since age 16) and drinks two alcoholic
drinks 4 days per week
Denies illegal drug uses
Never exercises and has tried multiple fad diets for weight loss
with little success. She now eats a diet rich in fats and refined
sugars.
Allergies
NKDA
Medications
Lisinopril 10 mg daily
Loratadine 10 mg daily
Review of Systems
General

4. Admits to recent onset of fatigue
HEENT
Has awakened on several occasions with blurred vision and
dizziness or lightheadedness upon standing: Denies vertigo,
head trauma, ear pain, difficulty swallowing or speaking
Cardiac
Denies chest pain, palpitations, and difficulty breathing while
lying down
Lungs
Denies cough, shortness of breath, and wheezing
GI
Denies nausea, vomiting, abdominal bloating or pain, diarrhea,
or food intolerance, but admits occasional episodes of
constipation
GU
Has experienced increased frequency and volumes of urination,
but denies pain during urination, blood in the urine, or urinary
incontinence
EXT
Denies leg cramps or swelling in the ankles and feet; has never
experienced weakness, tingling or numbness in arms or legs
prior to this episode

5. Neuro
Has never had a seizure and denies recent headaches
Derm
Has a rash under her bilateral breast and in groin area
Endocrine
Denies a history of goiter and has not experienced heat or cold
intolerance
Vital Signs
BP 165/100, T 98 F, P 88 regular, HT 5 feet 4 inches, RR 20
non labored, WT 210 lbs
What you need to do:
Develop an evidence-based management plan.
Include any pertinent diagnostics.
Describe the patient education plan.
Include cultural and lifespan considerations.
Provide information on health promotion or health care
maintenance needs.
Describe the follow-up and referral for this patient.
Prepare a 3–5-page paper (not including the title page or
reference page).

6. Format
The paper should be no more than 3–5 pages (not including the
title page and reference pages.
Assignment Requirements:
Before finalizing your work, you should:
be sure to
read the Assignment description carefully
(as displayed above);
consult the Grading Rubric
(under the Course Resources) to make sure you have included
everything necessary; and
utilize
spelling
and
grammar check
to minimize errors.
Your writing Assignment should:
follow the conventions of
Standard American English
(correct grammar, punctuation, etc.);
be
well ordered

7. ,
logical
, and
unified
, as well as
original and insightful
;
display
superior content, organization, style,
and
mechanics
; and
use
APA 6th Edition
format as outlined in the
APA Progression Ladder
.