Mrs. Jones is a 32 year old Caucasian female who presents for follow up on her gestational diabetes. She is 3 months postpartum and was diagnosed with gestational diabetes. This was her first pregnancy. She has a strong family history of diabetes and was told to get it checked out once she stopped breastfeeding. She has not checked her glucose since she came home from the hospital, stating she has been too busy. Allergies: Sulfa Current medications: Multivitamin PMH: Gestational Diabetes PSH: Tonsillectomy, Wisdom teeth extraction Social: Denies tobacco, Alcohol, or illegal drug use. She is married and lives with her husband and new baby. She works as an elementary teacher. She follows a regular diet and walks 2 days a week when she has recess duty. Immunizations: flu: 2019 Family: Father: alive, +DM, CAD, Hyperlipidemia, Mother: alive, +DM, CKD ROS: Constitutional: Complains of increase fatigue HEENT: Denies any headache, nasal congestion, ear pain Cardiovascular: Denies chest pain Respiratory: Denies any SOB or DOE GI: Denies any issues, last BM 1 day ago. GU: Denies any painful urination, urgency, hesitancy Musculoskeletal: denies. Neurological: Denies Psychiatric: Denies suicidal ideations, depression. Does report difficulty falling asleep Endocrine: Denies any weight changes, intolerance to heat/cold Hematologic/ Lymphatic: Denies any bruising OBJECTIVE: Vital signs: Ht: 66, Wt: 185, BP 130/78, HR 76, Resp: 16, SaO2: 98% Constitutional: Well developed, overweight female HEENT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses Cardiovascular: RRR, No murmurs or rubs noted. Respiratory: Clear all fields GI: Abdomen round, soft, with bowel sounds noted in all four quadrants. GU: Deferred Musculoskeletal: Crepitus noted bilateral knees, fluid wave noted to Rt knee Integumentary: Skin warm and dry, No rashes noted Neuro: Follows commands without difficulty Working with your group, utilize the above case study a, develop a Voice Over PowerPoint presentation for your patient covering the problems identified in the case study and content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following: Nutrition Counseling for Health Promotion Exercise Stress Management
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