course material

1. NURS 6229-Putting It All Together.
NURS 6229-Putting It All Together. Problem statementThe client is a 58-year-old woman
who presents with a three-month history of fatigue. She reports reduced energy, increased
frequency of urination, increased fluid intake and thirst, headaches, dull and generalized
pain.ORDER NOW.Differential listDiabetes type 2Diabetes insipidusHypothyroidismIllness
ScriptDisease/Syndrome Epidemiology Time Course Mechanism of the
disease(Pathophysiology) Signs & Symptoms(Morphology) Lab/Diagnostics
Treatment PlanDiabetes type 2 85% of total diabetesMostly occur in over 45
years5,800 youths Chronic Peripheral insulin resistance, impaired regulation of
hepatic glucose production, and declining β-cell function, eventually leading toβ -cell failure.
Frequent urination, increased thirst, increase in hunger and unintended loss of
weight. Blurred vision, fatigue, frequent infections, slow healing of sores as well as
darkened neck and armpits among other areas of the skin Glucose testGlucose tolerance
testBlood glucose monitoringPostprandial glucose testHomeostatic model
assessmentHemoglobin A1C No cureHormone replacementLiothyronine Diabetes
insipidus 1.6 million Americans, about 187,000 children (Christ-Crain et al.,
2019) Americans age 65 and older Chronic Abnormality in the functioning or
levels of antidiuretic hormone (ADH)Nephrogenic DI results from lack of aquaporin
channels in the distal collecting ducta lack of ADH prevents water reabsorption and the
osmolality of the blood increases.polydipsia and polyuria cycle occur bedwetting, weak
muscles, constipation, dry skin, waking frequently through the night to urinate, excretion of
colorless or pale yellow urine, excessive amounts of urine production and extreme thirst
Water deprivation test.Magnetic resonance imaging (MRI)Genetic screening Intake
of sufficient fluids and administration of desmopressin, thiazides and aspirin
medicationsHypothyroidism One billion people globallyWomen are more likely to develop
hypothyroidism than men (7 times) Chronic Underactive thyroid gladDeficiency of
the thyroid hormones triiodothyronine (T3) and thyroxine (T4)Reduction of the basal
metabolic rate and generalized myxedema. Fatigue, weight gain, depression, constipation
and poor ability to tolerate cold conditions. Poor memory, the presence of course dry skin,
dyspepsia and shortness of breath Blood testTRH Stimulation testFine needle
aspirationThyroid function testThyroid stimulating hormone measure
Levothyroxine Most likely diagnosisThe most likely diagnosis for the client is
Diabetes type 2. This illness occurs when the body fails to effectively use insulin to bring
glucose into the body cells. It is characterized by both inadequate insulin secretion and

2. resistance by pancreatic beta cells (Chatterjee, Khunti & Davies, 2017). It is a lifelong
disease and patients with this disorder are considered to be insulin resistance, it occurs
often among the middle-aged or older adults and hence referred to as the adult-onset
diabetes. Currently, there has not been discovered any cure for diabetes type 2. However,
the treatment focuses on managing the symptoms and improving the quality of life of the
patient. The control of blood sugar is done through the administration of anti-diabetic
medication.The clinical manifestations of diabetes type 2 usually develop gradually and
hence can be detected after years of onset. The most likely symptoms include frequent
urination, increased thirst, increase in hunger and unintended loss of weight. Blurred vision,
fatigue, frequent infections, slow healing of sores as well as darkened neck and armpits
among other areas of the skin are also important signs. Itching of the skin and dry mouth
are also reported symptoms in these patients. The symptoms severe and become more
potentially dangerous as the disease progresses.In this case, is evident that the patient
suffers from diabetes type 2. This is because; she is currently at an age with increased risk
of contraction of the illness. Moreover, she presents with a history of fatigue which is the
major clinical manifestation of the illness. She has lost energy which has affected her daily
activities probably due to increased hunger and has also reported frequent urination
particularly at night which is an indicator of diabetes type 2. Occasional headaches and
elevated thirsts suggest an imbalance in the blood glucose levels of the client. In addition,
the client’s family has a history of diabetes type 2 which is a predisposing factor.Two
alternative diagnosesDiabetes insipidus is an alternative diagnosis for this client. It is a
chronic condition characterized by the release of large quantities of dilute urine and
increased thirst. It occurs when the kidneys fail to concentrate urine normally resulting in
the excretion of up to 20 liters of dilute urine (Christ-Crain et al., 2019). The lack of
antidiuretic hormone (ADH) that controls the amount of excreted water in the body causes
diabetes insipidus. Treatment involves the intake of sufficient fluids and administration of
desmopressin, thiazides and aspirin medications.The clinical manifestations of diabetes
insipidus include bedwetting, weak muscles, constipation, dry skin, waking frequently
through the night to urinate, excretion of colorless or pale yellow urine, excessive amounts
of urine production and extreme thirst. In this case, the client presents most of these
symptoms including frequent urination and getting up two to three times a night to go to
the bathroom. Her thirst is elevated resulting to her increased intake of fluids and she feels
weak from lost energy. Consequently, she has had dry skin for the last one year probably
due to dehydration. However, diabetes insipidus clients do not report fatigue which is the
chief complain of the patient. Additionally, she does not report bedwetting, constipation.
Notably, the client does not experience seizures which are common complications of the
disease.The second alternative diagnosis for Ms. Darwin is hypothyroidism. This condition
occurs when the thyroid gland is not able to produce enough thyroid hormone which
consequently disrupts the metabolism of the body. As such, individuals suffering from this
illness present slowed metabolic activities. It is often asymptomatic during the early stages
even though the symptoms and potential dangers present with severity of the symptoms. It
is treated through Levothyroxine which seeks to improve the production of sufficient
thyroid and normalize the body’s metabolism. Its onset is usually at the age of 60 years and

3. above.The signs and symptoms of hypothyroidism include fatigue, weight gain, depression,
constipation and poor ability to tolerate cold conditions. Poor memory, the presence of
course dry skin, dyspepsia and shortness of breath are also relevant manifestations
(McDermott & Ridgway, 2016). Furthermore, heavy menstruation occurs in females
accompanied by poor hearing and abnormal sensations. The chief complaint of the client is
fatigue which is an important sign in hypothyroidism. Dry skin is also reported. However,
the patient tolerates cold conditions, has no digestive or hearing issues or shortness of
breath among other signs of hypothyroidism. History of Present Illness:Ms. Dawson is a 58-
year-old woman who presents with a three-month history of fatigue. She reports that she
doesn’t seem to have as much energy as she used to for daily activities. She has also noted
increased frequency of urination, often having to get up two to three times a night to go to
the bathroom. She has increased her intake of liquids because she feels thirsty all of the
time. She is also experiencing headaches. She describes them as a dull, generalized pain,
without accompanying photophobia, phonophobia, nausea, vomiting, visual changes or focal
neurologic symptoms. Occasional headaches have been occurring over the last three
months, but in the last week they have increased in frequency and severity and are now
occurring daily. In the last week she has also noted that urination has become even more
frequent. Past Medical History:Allergic rhinitis (2000)Gastroesophageal reflux disease
(2016)Urinary tract infection x 2, resolved (2017)Tinea pedis, resolved (2017) Allergies:
NKDA Medications:loratadine 10mg po daily as needed for nasal congestionomeprazole
20mg po daily as needed for heartburnacetaminophen 1000mg as needed for headache Past
Surgical History: no prior surgeries Family History:Mother with hypertension and type 2
diabetes mellitus, died at age 71 of CVA. Father, age 79, with hypertension and coronary
artery disease. Sister, age 55, with hypertension and type 2 diabetes mellitus. Daughters
healthy at age 29 and 33. Maternal aunt died of breast cancer at age 62. Social History:Ms.
Dawson works as a bank teller. She is married and has two adult daughters. She has smoked
half a pack of cigarettes daily for the last 30 years. She drinks a beer or glass of wine
approximately once a week and denies other drug use. She is sexually active in mutually
monogamous relationship with her husband. Ms. Dawson has recently begun trying to lose
weight. She walks for exercise about 20 minutes every other week. She is attempting to eat
a healthier diet by purchasing low fat versions of the products she usually buys at the
grocery store. Health Maintenance:Last pap smear 2 years ago, negative. No history of
abnormal pap smears.Last mammogram one year ago, normal.Last colorectal cancer screen:
colonoscopy 7 years ago, normal other than diverticulosis.Influenza immunization in
November of last year.Does not recall if her cholesterol or blood sugar have ever been
tested. Review of Systems:General: Increasing fatigue over the last 3 months, per HPI. Ten
lb. weight gain over the last 18 months. No recent fever or chills. Intermittent
headache.Eyes: Has noted blurred vision last 3 weeks. No eye pain,
redness.Ear/Nose/Throat: No hearing loss, tinnitus, vertigo, earaches, nasal congestion,
discharge, epistaxis, dental problems, sore throat.Neck: no lumps, pain, stiffness.Skin: no
rashes, reports “dry” skin for the last year.Breasts: No lumps, pain, discharge.Pulmonary: No
shortness of breath, cough, hemoptysis, wheezing.Cardiovascular: No chest pain, dyspnea
on exertion, palpitations, orthopnea, PND, peripheral edema.Gastrointestinal: heartburn 1-2

4. times per month if she ears spicy food. No nausea, vomiting, abdominal pain, diarrhea,
constipation, blood in stools or melena.Genitourinary: Three-day history of scant white
vaginal discharge and itching in vaginal area. Nocturia 2-3x per night. No hematuria,
urgency. LMP 8 years ago. Gravida2/Para2/Abortion0Musculoskeletal: No pain, stiffness,
swelling in joints or muscles.Neurologic: No focal weakness or numbness. She did say she
noticed some “pins & needles” sensation in both feet and hands that comes and goes for
approximately 3 months.Hematologic: No easy bruising or bleeding.Endocrine: +Polyuria,
+polydipsia per HPI. No heat or cold intolerance,Psychiatric: No depression,
anxiety. Physical Exam:Vital signs: P 84, RR 16, BP 137/82 T 37.2, weight 189 lbs., height
5’6”, BMI 30General: Alert, well-appearing, in no acute distress.Skin/Hair/Nails: No rashes,
lesions, scars; hair is brown and evenly distributed; no clubbing of the nails; nailbeds
pinkHEENT: Normocephalic; Facial features symmetrical; TMJ palpated without tenderness,
without clicking/crepitus; buccal mucous membranes somewhat dry, good dentition, gums
pink without redness or swelling, uvula midline, tonsillar pillars pink and symmetric;
bilateral nares are patent, nasal septum is midline with pink moist turbinates; ears are
symmetric, auricles are aligned, no nasal discharge, nasal septum slightly deviated to the
left, but does not obstruct airflow, inferior and middle turbinates dark pink, moist, and free
of lesions, frontal and maxillary sinuses are nontender to palpation and percussion.Neck:
supple, without masses. Trachea mid-line. Has smooth, controlled, full range of motion of
neck. Thyroid gland nonvisible but palpable when swallowing. Lymph nodes
nonpalpable.Pulmonary: Lungs clear to auscultation bilaterally with good air movement
and symmetrical expansion. Tactile fremitus symmetric. Percussion tones resonant over all
lung fields. No adventitious sounds present.Cardiovascular: Normal S1, S2 without
murmurs, rubs or gallops. Radial and dorsalis pedis pulses symmetric, 2+ bilaterally, no
peripheral edema. Carotid pulse equal bilaterally, 2+, elastic. No bruits auscultated over
carotids. Jugular venous pulsation disappears when upright. Apical impulse palpated in the
fifth ICS at the left MCL.Peripheral vascular: Capillary refill time less than 2 seconds, radial
and brachial pulses +2 bilaterally. Extremities are pink in color and warm to touch
bilaterally, normal distribution of hair, no ulcers or edema. Dorsalis pedis, radial,
and posterior tibial pulses +2 bilaterally. No apparent varicosities or superficial
thrombophlebitis noted.Abdomen: Skin of abdomen is free of striae, scars, lesions, or
rashes. Umbilicus is midline and recessed with no bulging. Nontender, nondistended, no
masses or organomegaly, Centralized adiposity. Unable to palpate the liver edge. No
peristaltic movements seen. Soft clicks and gurgles heard at a rate of 15 per
minute. Percussion reveals generalized tympany over all four quadrants.GU/Genitalia:
Normal pubic hair distribution, no lesions, masses, or swelling. Labia majora pink, smooth,
and free of lesions, excoriation, and swelling. Labia minora dark pink, moist, and free of
lesions, excoriation, swelling. No discharge from urethral opening. No malodorous
discharge noted from vagina.Scant amount of thick, white discharge in vaginal vault. No
cervical motion tenderness, fundal or adnexal tenderness.Musculoskeletal: Gait smooth,
with equal stride and good base of support. Normal curves of cervical, thoracic, and lumbar
spine. Paravertebral spine is nontender. Full smooth ROM of cervical and lumbar
spine. Upper and lower extremities symmetric without lesions, nodules, deformities, or

5. swelling. Full smooth ROM against gravity and resistance in all extremities.Neurological: No
atrophy, tremors, weakness, full ROM of all extremities. Get-up-and Go test was normal; No
fasciculations, tics, or tremors. Gait and tandem walk normal and steady. Negative Romberg
test. Performs repetitive alternating movements, finger to nose at smooth, good pace. Runs
each heel down each shin with no deviation. Identifies light touch, dull and sharp sensations
to trunk and bilateral extremities. Vibratory sensation, stereognosis, graphesthesia, two-
point discrimination intact. Reflexes 2+ bilaterally, except Achilles 1+.Cranial Nerves:#1.
Identifies correct scents#2. Vision 20/20 OS, 20/20 OD, full visual fields intact.#3,4,6 No
ptosis, full extraocular movements (EOM) pupils equally round, react to lightand
accommodation (PERRLA)#5. Temporal and masseter muscles contract bilaterally. Able to
identify light, sharp, dulltouch to forehead, cheek, and chin. Corneal reflex present.#7. Able
to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raiseeyebrows,
and close eyes against resistance.#8. Whispered 2 syllable words heard bilaterally.#9,
10. Uvula and soft palate rise symmetrically on phonation. Gag reflex present andswallows
without difficulty.#11. Equal shoulder shrug against resistance; turns head in both
directions againstresistance.#12. Protrudes tongue in midline with no tremors, able to push
tongue blade to right andleft without difficulty. Read the case scenarioWrite a problem
statement.Develop a differential list of the three most likely diagnoses. List these in priority
of which you think is the most likely first.Develop an Illness script of the three diseases
using the format you are familiar with. Include the risk factors and key discriminating
features.Write an explanation of the reasoning in choosing the most likely diagnosis.Write
an explanation of the reasoning in choosing the two-alternative diagnosis.The Problem
Statement:Age & gender; highly relevant medical history; primary symptoms using
semantic qualifiers; highly relevant diagnostic data, using clinical syndromes when possible.
This should be 2 sentences.Differential ListThis is three diagnoses (not symptoms). The one
you think is most likely is listed first.Develop an Illness ScriptUse the format you are
familiar with from class. There is a blank Illness scrip uploaded in the course documents if
needed.Explanation of Most Likely DiagnosisWrite an explanation of the reasoning in
choosing the most likely diagnosis. This will include the data from the case scenario itself to
support your decision as well as two references from peer reviewed books or journals
within the last 5 years. This explanation is to be at least 400 words, maximum of 600
words.Explanation of the two-alternative diagnosisWrite an explanation of the reasoning in
choosing the two-alternative diagnosis. This will include the data from the case scenario
itself to support your decision as well as two references from peer reviewed books or
journals within the last 5 years. Include why this was NOT your most likely diagnosis. This
explanation is to be at least 300 words for EACH alternative diagnosis (600 words total),
maximum 800 words.NOTE: The references need to be different. They also need to be other
than your required books. It will mean that you have six peer reviewed, scholarly articles
within the last 5 years. References are on a separate page, APA style, spelling & correct APA
style as well as grammar will be considered in the grading rubric. There is to be a title page
(running head/page number). Do NOT use quotes and do not copy and paste. Illness
ScriptDisease/Syndrome Epidemiology Time Course Mechanism of the
disease(Pathophysiology) Signs & Symptoms(Morphology) Lab/Diagnostics

6. Treatment Plan Demographics (age, sex, race)Risk
factorsPrevalence/Incidence How does the disease present (acute, chronic, intermittent,
acute with exacerbations, etc.)The pathogenesis of a disease is the biological mechanism
that leads to the disease state. It describes the origin and development of the disease. The
pathogenic mechanisms of a disease are set in motion by the underlying causes, which if
controlled would allow the disease to be prevented. Specifically, the cellular events and
reactions and other pathologic mechanisms occurring in the development of the disease.
Classic signs/symptoms. This includes subjective, objective, pertinent positive &
negative findings. May include lab and diagnostics such as MRI, CT, and clinical tools
such as CAGE, PHQ9, Centor strep scale, etc. May include medications, herbals, behavioral,
consult & referral, education.
PIAT Rubric Unsatisfactory: 0-13 points
Developing: 14-15 points Accomplished: 16-17 points Exemplary: 18-20
points Total Problem Statement There are significant errors in use of semantic
qualifiers used in the statement. There are significant missing data or data that is not
pertinent. The statement is more than 2 sentences long. There are several errors in
use of semantic qualifiers used in the statement. There are several missing data or data that
is not pertinent. The statement is more than 2 sentences long. There are few errors
in use of semantic qualifiers used in the statement. There are a few missing data or data that
is not pertinent. The statement is more than 2 sentences long. Provides a concise
summary statement that uses semantic vocabulary to highlight the most important
elements from the case scenario to represent the patient’s main problem in 2 sentences.
/20 Unsatisfactory: 0-13 points Developing: 14-15 points Accomplished:
16-17 points Exemplary: 18-20 points Total Differential Diagnosis Offering less
than three diagnostic possibilities. The list does not accurately reflect the information from
the case study. Offering less than three relevant diagnostic possibilities, committing to the
most likely. The list does not accurately reflect the information from the case study.
Offering three relevant diagnostic possibilities, committing to the most likely. The
list is prioritized with the most likely first and somewhat accurately reflects the information
from the case study (maybe the list is not in correct order) Offering three relevant
diagnostic possibilities, committing to the most likely. The list is prioritized with the most
likely first and accurately reflects the information from the case study. /20
Unsatisfactory: 0-13 points Developing: 14-15 points Accomplished: 16-17
points Exemplary: 18-20 points Total Illness Script Demographic findings are
lacking detail and not correlated to the disease. Classic assessment findings are lacking
detail. Pathophysiology is limited. The parameters listed for time course do not correspond
to the disease and semantic qualifiers are not used. Limited presentation of the lab,
procedures, treatment for the disease is listed. . No key/differentiating features are in red.
No sub-headings used. Classic demographics are somewhat listed. Classic assessment
findings are somewhat listed. Limited overview of the biomedical causes of the disease.
Incomplete listing of based time course of the disease listed using semantic qualifiers.
Limited presentation of the lab, procedures, treatment for the disease is listed. Minimal
key/differentiating features are in red. No sub-headings used. Classic demographics

7. are partially listed. Classic assessment findings are partially listed. Partial overview of the
mechanism of the disease. Partial listing of based time course of the disease listed using
semantic qualifiers. Partial presentation of the lab, procedures, treatment for the disease is
listed. Most key/differentiating features are in red. Some sub-headings used. Classic
demographics listed. Substantial classic assessment findings listed. Substantial overview of
the mechanism of the disease. Evidenced based time course of the disease listed using
semantic qualifiers. Evidenced based lab, procedure, treatment is
complete.Key/differentiating features are in red.Sub-headings used.One page per disease.
/20 Unsatisfactory: 0-13 points Developing: 14-15 points Accomplished:
16-17 points Exemplary: 18-20 points Total Explanation of the Most Likely
Diagnosis Explains the reasoning behind the most likely diagnosis, uses few data or
inaccurate data from the case scenario, without how these compare and contrast with the
patient’s presentation. Shows unsatisfactory understanding of the disease in relation to the
case study. Entry is less than 300 words. Explains the reasoning behind the most likely
diagnosis, including some data or inaccurate data from the case scenario and cited how
these compare and contrast with the patient’s presentation. Shows developing
understanding of the disease in relation to the case study. Entry is less than 300 words.
Explains the reasoning behind the most likely diagnosis, including data from the
case scenario and cited how these compare and contrast with the patient’s presentation.
Shows good understanding of the disease in relation to the case study. Entry is less than 300
words. Explains the reasoning behind the most likely diagnosis, including data from the
case scenario and cited how these compare and contrast with the patient’s presentation.
Shows excellent understanding of the disease in relation to the case study. A minimum of
400 words, maximum of 600 words. /20 Unsatisfactory: 0-13 points Developing:
14-15 points Accomplished: 16-17 points Exemplary: 18-20 points
Total Explanation of Two Alternative Diagnoses Explains the reasoning behind
the most likely diagnosis, uses few data or inaccurate data from the case scenario, without
how these compare and contrast with the patient’s presentation. Shows unsatisfactory
understanding of the disease in relation to the case study. Entry is less than 400 words.
Explains the reasoning behind the most likely diagnosis, including some data or
inaccurate data from the case scenario and cited how these compare and contrast with the
patient’s presentation. Shows developing understanding of the disease in relation to the
case study. Entry is less than 400 words. Explains the reasoning behind the most likely
diagnosis, including data from the case scenario and cited how these compare and contrast
with the patient’s presentation. Shows good understanding of the disease in relation to the
case study. Entry is less than 400 words. Explains the reasoning behind the alternative
diagnosis (why it is not the most likely and why it was chosen to be on the list), including
data from the case scenario and cited how these compare and contrast with the patient’s
presentation. Shows excellent understanding of the disease in relation to the case study. A
minimum of 600 (300 each) words maximum of 800 words. /20 Unsatisfactory: 7-15
pts. deducted Developing: 4-6 pts. deducted Accomplished: 1-3 pts. deducted
Exemplary: No pts. deducted Total Organization(Includes title & reference page)
Substantial errors in APA/grammar/spelling. Citations to non-scholarly websites

8. given as rationale. No evidence-based, peer reviewed journal article cited. Several errors
in APA/grammar/spelling.Partially supported by evidence from three or less sources; may
be outdated or non-scholarly. Minimal errors in APA/grammar/spelling.Partially
supported by evidence from four appropriate sources published within the last 5 years.
No errors in APA/grammar/spelling. Supported by evidence from six appropriate
sources published within the last 5 yrs.Appropriate sources are scholarly evidenced based
& peer reviewed articles. Comments NOTE: The references need to be different. It
will mean that you have six peer reviewed, scholarly articles within the last 5 years. I need
to be able to access the article. References are on a separate page, APA style, spelling &
correct APA style as well as grammar will be considered in the grading rubric. There is to be
a title page (running head/page number). Do NOT use quotes and do not copy and paste.
Grade 1/9/20 KH