Case Study

ML, 65- years old, female. She is an African-american, baptist. She is married to a
business for 40 years. She has 2 daughters and 1 son. ML is a retired high school
teacher. Client states: “The main reason I am here today is to get a checkup. I have
not had one in 8 years. I probably should have had one sooner because I have type 2
diabetes. I think I have it under control, I have started to have some numbness,
burning, and tingling in my feet. It is starting to really bother me, and I thought I
should have it examined.”

Client states that pain started 2 months ago and has been getting progressively worse.
She reports constant numbness, burning, or tingling discomfort. Says that pain is
worse when not wearing shoes and walking on a firm surface. Pain started gradually—
client cannot think of any event that may have caused it. Client expressed that she
thought it was arthritis and that it just happens when “you get old.” Client states that
the pain is aggravated by tight shoes, temperature extremes, and extended periods of
walking. She rates the pain in these situation as 5-6 on a scale of 0-10. She also
notes that the pain is always present at a level of 2-3 on a scale of 0-10. ML reports
that she has taken ibuprofen; however, this did not relieve the pain. She reports that
the only time the discomfort decreases is when she is non-weight-bearing. Client
denies any edema, discoloration, lesions, or changes in temperature of bilateral feet.
Client denies any calf pain or cramping with ambulation.

Denies birth problems. Reports having usual childhood illnesses; none requiring
hospitalization. Denies allergies to medications, environment. Reports the following:
type 2 diabetes mellitus and obesity. Reports appendectomy at age 18 and
Cholecystectomy at age 56. Developed UTI at age 57. She received diabetes education
with nutritional medical therapy at the
time of her diagnosis. Her mother had history of diabetes and hypertension at age 72
and was died due to stroke. Father deceased at age 63.

Describes skin and scalp as dry Applies lotion to skin daily. Denies any bruising,
pruritus or non-healing sores. Describes nails as hard and brittle. Reports that hair is
fine and soft. Reports washing hair weekly. Denies intolerance to heat or cold.
Denies neck stiffness, swelling, difficulty swallowing, sore throat, or enlarged lymph
nodes. “I get a headache about 1-2 times a month, but I just put a cool washcloth on
my head and lie down for a bit it usually goes away without having to take medicine.”

Has worn glasses “all my life.” Cannot recall age at which they were prescribed.
Reports change from bifocals to trifocals at age 60. Complains of blurred vision
without glasses. Denies diplopia, itching, excessive tearing, discharge, redness, or
trauma to eyes.

Believes she is “a little slow to grasp, and I think it may be because of my hearing.”
Does not wear hearing aid. Cannot recall last hearing test. Denies tinnitus, pain,
discharge, or trauma to ears. Does not ask for questions to be repeated.

Wears dentures. Last dental examination 3 years ago. Denies problems with proper fit,
eating, chewing, swallowing, sore throat, sore tongue. Reports development of a
“canker sore” if she eats

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difficulty with smell, pain, postnasal drip, sneezing, or frequent nosebleeds. Denies
difficulty tasting foods.

Denies pain, lumps, dimpling, retraction, discharge. Denies dyspnea, orthopnea, with
mild cough, no wheezing, with mild sputum production.

Denies palpitations, chest pain or pressure, and fatigue but sometimes her blood
pressure increases and heart rate increases. Denies claudication, cramping, skin
lesions, or edema of legs and feet. Peripheral pulses are equally bounding bilaterally.
Denies nausea, vomiting, occasional abdominal pain, or flatulence, constipation, or
diarrhea. Denies hematemesis.

Denies stiffness, joint pain, or swelling with activity. Reports lower back pain when
carrying large amounts of food or when carrying large trays of food when she
volunteers as a cook at church social functions once monthly.

Denies difficulty with speech. Denies difficulty formulating ideas or expressing

feelings. States that she has a gradual loss of memory over past 5-6 years. Believes
long term memory is better than short term memory Reports that she must make a list
to remember items when she does grocery shopping. Reports that she learns best by
writing information down and then reviewing it. Makes major decisions jointly with
husband after prayer.

She voids 4-5 times a day, clear yellow urine. Denies dysuria, hematuria, polyuria,
hesitancy, incontinence, or nocturia. Menopause at age of 50. Client is gravida 3,
para 3. No complications with pregnancy or childbirth. Has never used any form of
contraception. Client states she is sexually active—“My husband and I have good
relations.” Denies pain, discomfort, or postcoital bleeding. Denies history of any
sexually transmitted diseases. Denies vaginal itching, odor, or discharge. Last Pap
smear: negative, 4 years ago.

Soft, formed, medium brown BM every other day. Denies mucoid stools, melena, or
hematochezia. Denies rectal bleeding, change in color, consistency, or habits.

A typical day for the client is to arise at 6AM eat breakfast and perform light
housekeeping. Client goes to community center in late morning to eat lunch, quilt,
and visit. Goes home around 2:00 PM. Used to walk about four blocks with a friend
every day, however, has not done this in the past 6 months. Cleans own house
throughout the week, must space activities according to level of discomfort (includes
dusting, vacuuming, washing). Bedtime is approximately 10:00 PM.

Client states she is on a reduced carbohydrate/concentrated sweet diet that has

approximately 1,600 calories/day intake. 24-hour diet recall: Breakfast—whole-wheat
toast, one boiled egg, orange juice, and decaffeinated coffee; lunch—tuna, salad
with lettuce, tomatoes, and broccoli, an apple, and 8 oz skim milk; afternoon snack—
Snickers candy bar, small bag plain potato chips; dinner—small serving of broiled
meat, green beans, mashed potatoes, slice of peach pie, and 8-oz glass of skim milk.
Tries not

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to snack but admits that it is difficult not to. Drinks two 8-oz glasses of water a day.
Drinks decaffeinated coffee—no tea or colas. Voices no food dislikes or intolerances.

No prescribed medications. Takes the following OTC medications ibuprofen 200 mg

every 8 hours as needed, multivitamin l qd for past 4 years. Denies use of alcohol,
tobacco, and illicit drugs.

Is a retired elementary school teacher. Client volunteers to cook for church social
functions. Client expresses satisfaction with activity. However, she is concerned that
she may not be able to maintain her current level of activity if the problems with her
feet continue to progress.

Goes to bed at 10:00 PM. Denies difficulty falling asleep, remaining asleep, or early
morning awakening. Feels well rested when she arises at 6:00 AM. Denies use of sleep
medications. Enjoys reading her Bible each evening before bed.

Describes self as normal person. Talkative, outgoing, and likes to be around people,
but hates noisy environments. Happy with the person she has become and states, “I
can definitely live with myself.” States a weakness is that she worries about “little
things” more now than she used to and tends to be irritated more easily. Client states
she is capable of self-management of diabetes. Client rates own health as an 8 on a
scale of 1 (worst) to 10 (best). Five years ago, she

Client seeks health care only in emergencies. Last medical examination was 8 years
ago. Preventive health practices: wears seat belt, tests smoke alarm every 6 months,
has a carbon monoxide detector in home. Denies presence of firearms in the home.
Handrails are present in bathtub. Denies presence of throw rugs in the home.

Describes relationship with other members of the church and community groups as
friendly and “family-like.” Has casual relationship with neighbors.

Client has been married for 40 years. Describes marital relationship as the best part of
her life right now. Two daughters live in Texas with their husbands and children. Her
son and his wife and baby boy live in Minnesota. All the children have their families
come home once a year and the client and her husband visit each family once a year.
She expresses desire to visit her children and grandchildren more often and states, “I
wish my babies lived nearby. I love being a grandma and miss them so much.”
Communicates with each of them several times a month by phone. Client was the
fourth of five children in her family. Had a happy childhood, describes family as close
and loving.

Biographic data:

 Name: ML (Initials only)

 Age: 65 years old
 Gender: Female

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  Ethnicity: African-American
 Religious Affiliation: Baptist
 Marital Status: Married for 40 years
 Children: 2 daughters and 1 son
 Occupation: Retired high school teacher
 Volunteer Activities: Cooks for church social functions

Reasons for seeking Health care:

ML's main reason for seeking healthcare is to get a checkup. She mentions that she has not had one in
8 years, despite having type 2 diabetes, and is experiencing numbness, burning, and tingling in her feet.
She is concerned about the progression of this discomfort and believes it may be related to arthritis or
her age.

History of present health concern:

ML reports that she has been experiencing numbness, burning, and tingling discomfort in her feet for
the past 2 months. The pain has been progressively worsening and is aggravated by certain factors like
tight shoes, temperature extremes, and extended periods of walking. She rates the pain as 5-6 on a scale
of 0-10 in these situations and notes that there is constant discomfort at a level of 2-3 on the same scale.
She has tried taking ibuprofen, which did not relieve the pain. The only time the discomfort decreases is
when she is not putting weight on her feet.

Past Surgical History:

 Appendectomy at age 18
 Cholecystectomy at age 56
 Developed UTI at age 57

Past Health History:

 Denies birth problems.

 Reports having usual childhood illnesses; none requiring hospitalization.
 Denies allergies to medication and environment.
 Reports type 2 diabetes mellitus and obesity.

Family History:

 Mother had a history of diabetes and hypertension and died due to a stroke at age 72.
 Father deceased at age 63.

REVIEW OF BODY SYSTEMS FOR CURRENT HEALTH PROBLEMS

Skin, Hair and Nails

 ML describes her skin as dry and applies lotion daily.

 No mention of bruising, pruritus, or non-healing sores.
 Nails are described as hard and brittle.

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  Hair is fine and soft.
 Reports washing hair weekly.
 Denies intolerance to heat or cold.

Head and Neck

 Denies neck stiffness, swelling, difficulty swallowing, sore throat, or enlarged lymph nodes.
 Complains of occasional headaches (1-2 times a month) relieved with a cool washcloth and rest.

Eyes:

 Glasses have been worn for a long time

 Cannot recall age at which the glasses were prescribed
 There has been a recent change from bifocals to trifocals.
 Reports blurred vision without glasses.
 No complaints of diplopia, itching, excessive tearing, discharge, redness, or trauma to the eyes.

Ears:

 Believes hearing loss may contribute to a feeling of being "a little slow to grasp."
 ML does not wear a hearing aid.
 Cannot recall the last hearing test.
 Denies tinnitus, pain, discharge, or trauma to the ears.
 Does not ask for questions to be repeated.

Mouth, Throat, Nose and Sinuses:

 Wears dentures with no reported issues with fit, eating, chewing, or swallowing.
 Reports developing a "canker sore" if she eats certain foods.
 Denies difficulty with smell, pain, postnasal drip, sneezing, or frequent nosebleeds.
 Denies difficulty tasting foods.

Breasts:

 No complaints of pain, lumps, dimpling, retraction, or discharge.

Thorax and Lungs:

 Denies dyspnea, orthopnea, wheezing, or significant cough.

 Reports mild cough with mild sputum production.

Heart and Neck Vessels:

 Denies palpitations, chest pain or pressure, and fatigue.

 Reports occasional increases in blood pressure and heart rate.

Peripheral Vascular:

 Denies claudication, cramping, skin lesions, or edema in the legs and feet.

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  Peripheral pulses are equally bounding bilaterally.

Abdomen:

 Denies nausea, vomiting, occasional abdominal pain, flatulence, constipation, or diarrhea.

 Denies hematemesis.

Musculoskeletal:

 Denies stiffness, joint pain, or swelling with activity.

 Reports lower back pain when carrying heavy loads during church social functions.

Neurologic:

 Denies difficulty with speech.

 Denies difficulty formulating ideas or expressing feelings.
 Reports a gradual loss of memory over the past 5-6 years, with better long-term memory than
short-term memory.
 Uses lists to remember items and learns best by writing information down.

Genitourinary:

 Voiding frequency of 4-5 times a day with clear yellow urine.

 Denies dysuria, hematuria, polyuria, hesitancy, incontinence, or nocturia.
 Menopause at the age of 50.
 Had three pregnancies and three live births.
 No complications reported with pregnancy or childbirth.
 Active sexual life with her husband, denies pain, discomfort, or postcoital bleeding.
 No history of sexually transmitted diseases.
 Denies vaginal itching, odor, or discharge.
 Last Pap smear was negative and done 4 years ago.

Anus and Rectum:

 Reports soft, formed, medium brown bowel movements every other day.
 Denies mucoid stools, melena, or hematochezia.
 No complaints of rectal bleeding, change in color, consistency, or habits.

Lifestyle and Health Practices:

 Reports to rise 6 AM and go to bed at 10 PM

 Client goes to community center in late morning to eat lunch, quilt, and visit.
 Goes home around 2:00 PM.
 Used to walk about four blocks with a friend every day, however, has not done this in the past 6
months.
 Cleans own house throughout the week, must space activities according to level of discomfort
(includes dusting, vacuuming, washing).
 Reports wears seat belt
 Tests smoke alarm every 6 months
 Has a carbon monoxide detector in home.
 Denies presence of firearms in the home.

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  Handrails are present in bathtub.
 Denies presence of throw rugs in the home.
Nutritional Habits and Weight Management:

 Follows a reduced carbohydrate/concentrated sweet diet with approximately 1,600 calories/day.

 Breakfast—whole-wheat toast, one boiled egg, orange juice, and decaffeinated coffee
 Lunch—tuna, salad with lettuce, tomatoes, and broccoli, an apple, and 8 oz skim milk
 Afternoon snack—Snickers candy bar, small bag plain potato chips
 Dinner—small serving of broiled meat, green beans, mashed potatoes, slice of peach pie, and 8-
oz glass of skim milk.
 Reports difficulty avoiding snacks.
 Drinks two 8-oz glasses of water a day.
 Drinks decaffeinated coffee and avoids tea or colas.
 Voices no food dislikes or intolerances.

Medications/Substance use:

 No prescribed medications.
 Takes ibuprofen 200 mg every 8 hours as needed and a multivitamin daily for the past 4 years.
 Denies use of alcohol, tobacco, and illicit drugs.

Activity level and Exercise:

 Retired elementary school teacher who volunteers to cook for church social functions.
 Expresses satisfaction with activity but is concerned about the progression of foot problems
affecting her activity level.

Sleep/ Rest:

 Rises at 6:00 AM and goes to bed at 10:00 PM.

 Denies difficulty falling asleep, remaining asleep, or early morning awakening.
 Feels well rested.
 Does not use sleep medications.
 Enjoys reading her Bible each evening before bed.

Self- concept, Self-esteem, and Body Image:

 Describes herself as a normal, talkative, outgoing person who enjoys being around people but
dislikes noisy environments.
 Generally happy with herself but notes an increase in worrying about "little things" and being
more easily irritated.

Self- Care Responsibilities:

 Believes she can self-manage her diabetes.

 Reports to seeks health care only in emergencies.

Social Relationships:

 Describes friendly and "family-like" relationships with members of her church and community

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 groups.
 Has casual relationships with neighbors.

Family Relationships:

 Has been married for 40 years and considers her marital relationship the best part of her life.
 Has two daughters in Texas and one son in Minnesota, along with their families.
 Desires to visit her children and grandchildren more often.
 Communicates with each of her children several times a month by phone.
 Reports to have a happy childhood, describes family as close and loving.