History: The patient is a 57 year-old Hispanic male with multiple medical problems. He has a long history of type 2 diabetes, complicated with end stage renal disease requiring dialysis. He was also shown to have a positive x-ray for pneumonia. He is free of any cough, difficulty breathing, or chest pain. He is actually feeling great, he said.
The patient also has a history of surgeries including left above knee amputation, jejunostomy tube placement and multiple left eye surgeries.He has no known allergies.He denies any substance abuse. .
He is divorced and lives with his family. He spoke of a son and daughter. Says his daughter assist him with his care at home including administering his insulin.
Diagnosis/Disorder: Type 2 diabetes.
Causes: Hyperglycemia resulting from defects in insulin secretion, insulin action or both. (Rosdahl pg.1248).
Text Book Comparison: .
Text Book Symptoms Present In Patient.
Polyuria No.
Polydipsia Yes.
Polyphagia No.
Fatigue Yes.
Blurred Vision Yes .
Mood Change No.
Numbness & Tingling In Extremeties No.
Dry Skin No.
Infections Yes (pneumonia).
Weight Loss No.
(http://www.Medscape.com).
Complications: neuropathy, kidney disease, heart disease, eye disorders (including cataracts and glaucoma) that may lead to blindness, foot problems (including ulcers and calluses) which may lead to amputation, higher risk for gum problems/gum disease. (http://www.diabetes.org).
Diagnosis/Disorder: End-Stage Renal Disease.
Causes: Kidney infection/inflammation, upper or lower urinary tract obstruction, systemic disease and toxicities (including hypercalcemia, hypertension, Lupus, atheroma, and diabetes. (Anderson pg 1218).
Text Book Comparison:.
Text Book Symptoms Present In Patient.
Anemia Yes .
Itching No.
Anorexia No.
Nausea Yes.
Vomiting Yes .
Fatigue Yes.
Potassium Retention Yes.
Nerve Conduction Defects Unknown.
Decreased immune response Yes.
Dementia No .