Summative Cases

Summative Case #3

Corey Jackson, DNP, RN, FNP-BC

Case Study

Chief Complaint

“I’m peeing too much.”

Patient Profile

Name: John Applewhite

Age: 42 years old

Gender: male

Current Medications

Zyrtec 10 mg by mouth daily

Atorvastatin 20 mg by mouth daily

Vitamin D 1000 units by mouth daily

Assessment

J.A. is a 42-year-old African American man who presents with a complaint of frequent urination for “about a week” that “just isn’t getting any better.” Patient asks about STD testing after unprotected sexual intercourse (male/female) with a new partner. Denies dysuria, low abdominal pain, and penile discharge. Denies rash and numbness/tingling in penile region. He reports the frequent urination is “keeping me up at night,” causing daytime fatigue and morning headaches. He notes that he had similar symptoms “on and off” in the past but denies known cause. Patient reports “life is otherwise well … I’m going on a lot of dates and trying new restaurants.”

Past Medical History

  • Obesity: Chronic condition. Previously tried dieting and exercise in which BMI improved. Prior BMI 41.
  • Hypertension: Diagnosed three years ago. Previously on Chlorthalidone 25 mg daily but stopped due to frequent urination six months ago. Patient declined new pharmacologic interventions.
  • Hyperlipidemia: Diagnosed two years ago. Pharmacologic intervention: atorvastatin 20 mg by mouth daily due to ASCVD score 16%.
  • Vitamin D Deficiency: Diagnosed one year ago. Pharmacologic intervention: cholecalciferol 1000 units by mouth daily.
  • Vitiligo: Diagnosed by dermatology consult service eight months ago. Not on pharmacologic interventions for this.

Surgical History

  • Tonsillectomy at age 8.
  • Appendectomy at age 19 (most recent hospitalization). Left knee meniscal repair at age 22.

Family History

  • Mother: Alive in their 70s and is in good health with no chronic health conditions.
  • Father (deceased 72): Myocardial infarction, hypertension, coronary artery disease.
  • Brother (older, age 52): Severe autism with no other known health issues.
  • MGM (deceased 87): Arthritis of the hip, osteopenia, diabetes mellitus type II.
  • MGF (deceased 88): hypertension
  • PGM (deceased 93): Nicotine dependence, asthma, osteoporosis, diabetes.
  • MGF (deceased 86): Myocardial infarction, emphysema, nicotine dependence.

Social History

  • Works in the service office of a local automobile dealership.
  • Dating with no children. Lives alone.
  • New female partner, unprotected intercourse.
  • Has smoked ½ ppd for five years, in remission. Denies illicit drug use. He says his diet is not ideal but is trying to improve.
  • He is a veteran and says he had a “nervous breakdown” after he got out of service.

Review of Systems

  • General: Denies fever, chills, excessive sweating, flushing, or weight loss. Reports feeling fatigued.
  • Head: No other headache. No neck pain.
  • Eyes: Denies itchy, watery, or matter in eyes. No changes in vision. Ears: Denies ear pain/congestion. Denies any hearing deficit.
  • Nose: Has some nasal congestion, no nose bleeds. Throat: No sore throat or trouble swallowing.
  • Respiratory: No cough. + wheezing. Reports chronic DOE. Chest/CV: Denies chest pain, palpitations, and BLE edema. GI: Denies nausea/vomiting, constipation, and diarrhea.
  • GU: Frequent urination, denies dysuria, penile discharge, and rash.
  • Endo: fatigue
  • Psych: Denies suicidal and homicidal ideations. Denies tactile/auditory/visual hallucinations. Fatigue. Infrequent “panic attacks” to loud noises.

Physical Examination

Vital Signs

  • Temperature: 98.9ºF
  • Heart rate: 62 bpm
  • Respiratory rate: 22 bpm
  • Blood pressure: 152/78 mm Hg
  • Weight: 262 lbs
  • Height: 6 ft 1 in
  • BMI: 34.6
  • Oxygen saturation: 97% on room air

General Survey

  • General: No acute distress. No coughing spells observed.
  • HEENT: Face is symmetric. No frontal or maxillary sinus pain with palpation, frontal and maxillary sinuses are transilluminated.
  • Eyes: Bulbar conjunctiva not injected. No exudates noted.
  • Ears: TMs are pearly gray and intact, not bulging and without erythema.
  • Nose: Nares pink and moist without exudates, no polyps on speculum exam.
  • Throat: Pharynx pink and moist without tonsillar enlargement or exudates.
  • Lymph: No cervical or clavicular lymphadenopathy noted, no Sentinel node.
  • Skin: within normal limits
  • Chest/Respiratory: Breathing is even, unlabored. Lung sounds are clear bilaterally in the anterior and posterior lobes. Egophony and bronchophony are within normal limits.
  • CV: Heart has a RRR without murmurs, no pulsation or heaves. S1, S2 regular. No S3, S4, rubs, snaps, or clicks noted.
  • GI: Normoactive bowel sounds, non-distended. No ascites. Bi-manual liver hook within normal limits.
  • Skin: Hyperpigmentation of the posterior neck. Surgical scar on left knee well healed.
  • Psych: PHQ9 score 0

Diagnostic Tests and Results

Urinalysis

  • Color: yellow
  • Clarity: clear
  • pH: 6.0
  • Specific Gravity: 1.030
  • Glucose: 3+
  • Ketones: 0
  • Protein: 2+
  • Red Blood Cells: 0
  • White Blood Cells: 0
  • Bacteria: none
  • Squamous epithelial cells: 0

STI testing

  • Gonorrhea: negative
  • Chlamydia: negative
  • Trichomonas: negative
  • Syphilis: negative
  • HIV: negative
  • Hepatitis C: negative
  • HSV 1 & HSV 2: not assessed

Basic Metabolic Panel (BMP) plus eGFR

  • Sodium: 134
  • Potassium: 4.1
  • Chloride: 93
  • Carbon Dioxide: 18
  • Anion Gap: 18
  • UN: 18
  • Creatinine: 1.2
  • eGFR 89
  • Calcium: 8.6
  • Glucose: 561

Hemoglobin A1C

  • 11.2 %

More on the Diagnostics

Urine specific gravity is an assessment method to determine how concentrated the urine is when compared to water. In this patient, a specific gravity of 1.030 is indicative of dehydration. Urine glucose is commonly known as glucosuria. Glucosuria, or glucose present in the urine is common when the renal system is unable to reabsorb glucose filtered from the blood. Subsequently, glucose is excreted in the urine. Glucosuria can be a sign of diabetes mellitus, renal disease, genetic disorders, and medication side effects (SGLT2 inhibitors) (Dunphy et al., 2023). The presence of protein in the urine is often known as proteinuria. Urine protein is suggestive of underlying processes such as kidney damage from diabetes, hypertension, heart failure, preeclampsia, medication side effects, and strenuous exercise. A suboptimal carbon dioxide level on BMP is often known as hypocarbia. Hypocarbia can be secondary to metabolic acidosis, a common presentation for patients with diabetic ketoacidosis. A hemoglobin A1c is a blood test that measures the average blood sugar over a three-month timespan. This lab test is a key indicator of diabetes diagnosis and glucose control (Dunphy et al., 2023). A level equal to or above 6.5% supports the probable diagnosis of diabetes. Higher hemoglobin A1c levels are indicative of severity of uncontrolled diabetes. The goal of hemoglobin A1c for someone with diabetes mellitus II is less than 7%.

Diabetes mellitus II is a disorder caused by the body’s inability to secrete and or utilize insulin effectively. The diagnosis of diabetes mellitus II is completed by four different methods (Dunphy et al., 2023).

  1. Glycosylated hemoglobin (A1c) of 6.5% or higher.
  2. Fasting plasma glucose level of 126 mg/dL or higher following 8 hours of no caloric intake.
  3. Two-hour plasma glucose level of 200 mg/dL or higher during an oral glucose tolerance test with a 75-gram glucose load.
  4. Symptoms of diabetes (i.e., nocturia, weight loss, polyuria, polydipsia) with a random plasma glucose level of 200 mg/dL or higher (Dunphy et al., 2023).

In this case, the patients’ hemoglobin A1c is 11.2. This is indicative of uncontrolled diabetes mellitus with an average blood glucose level of 275 mg/dL.

Diabetes Mellitus Type II

Pathophysiology of Disorder

Diabetes mellitus type II is driven by a combination of insulin resistance, beta cell dysfunction, genetic factors, and/or lifestyle and environmental factors. Insulin resistance occurs when body cells are less responsive to insulin (Dunphy et al., 2023). This results in ineffective glucose uptake within the cells even when insulin is present, causing elevated blood sugar levels (hyperglycemia). Beta cell dysfunction is a result of insulin resistance progressing. The beta cells within the pancreas struggle to maintain enough insulin to compensate for insulin resistance, resulting in impaired insulin secretion; this contributes to hyperglycemia and increases the risk for diabetes mellitus (Dunphy et al., 2023). Genetic factors are linked to the development of diabetes mellitus II, however, genetics alone do not cause diabetes mellitus. People with one parent with diabetes mellitus II are 1.7 times more likely to develop diabetes mellitus II and three times higher if both parents have diabetes mellitus II (Dunphy et al., 2023). Environmental and lifestyle factors that play a role include physical inactivity, unhealthy diet, and obesity.

Mechanisms of Disease

Diabetes mellitus II is a chronic metabolic disorder that is linked to two factors: insufficient insulin production by pancreatic beta cells and decreased insulin sensitivity in tissues that respond to insulin. As a complication of these factors, the blood glucose levels rise and increase the risk of diabetes mellitus.

Clinical Manifestations: Symptoms and Signs Associated with the Disorder

Diabetes mellitus II is a metabolic disorder that presents with a variety of clinical manifestations. These symptoms include polyuria, nocturia, polydipsia, polyphagia, fatigue, blurred vision, unintended weight loss, dry/itchy skin, peripheral neuropathy, frequent infections, and poor wound healing (Dunphy et al., 2023). Other symptoms may include acanthosis nigricans, gastroparesis, and sexual dysfunction.

Complications arising from the disorder if untreated or monitored during treatment. Untreated and mismanaged diabetes mellitus may lead to complications that are debilitating or fatal. Mismanagement of diabetes includes the lack of adequate monitoring and treatment plan revision. These complications include endocrine disease, cardiovascular disease, eye disease, renal disease, genitourinary disease, neurological changes, and integumentary disease (Dunphy et al., 2023). Endocrine complication(s) may include diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). Cardiovascular complications can include myocardial infarction, cerebral vascular accidents, and peripheral vascular disease. Eye complication(s) may include diabetic retinopathy, cataracts, and glaucoma. Renal complication(s) may include proteinuria, glucosuria, chronic kidney disease, and kidney failure (Dunphy et al., 2023). Genitourinary complication(s) may include frequent urinary tract infections, balanitis, vulvovaginal candidiasis, and erectile dysfunction. Neurological complication(s) may include numbness/tingling in the hands and feet, erectile dysfunction, autonomic dysfunction, and gastroparesis. Integumentary complication(s) may include poor wound healing and result in amputation.

Relevant Pharmacology Information

Diabetes mellitus II often requires pharmacological interventions for disease management. This may include oral glucose and injectable glucose lowering agents.

Biguanides is commonly first-line therapy for treating diabetes mellitus II. This drug class mechanism of action decreases hepatic gluconeogenesis, intestinal absorption, and peripheral tissue insulin sensitivity and utilization. Subsequently, biguanides lower fasting and postprandial hyperglycemia with an expected 1-2% hemoglobin A1c reduction. An example of this medication includes metformin (Dunphy et al., 2023). Biguanides can be considered for those with a Creatinine less than 1.5 and GFR greater than 30 mL/minute. Common adverse effects include gastrointestinal upset (nausea, diarrhea, lack of appetite, and abdominal discomfort). These symptoms may resolve when utilizing long-acting formulations. Another rare adverse effect involves lactic acidosis that may be fatal. It is important to avoid use in those with underlying liver impairments and alcohol dependence. For this patient, metformin 500 mg by mouth twice daily is reasonable, with a plan to increase to 1000 mg by mouth twice daily at follow-up. When starting this medication, it is important to include patient education regarding gastrointestinal side effects. Additionally, patients should be advised to notify all providers about metformin use due to interactions with contrast dye, surgical procedures (particularly those that require fasting), and acute kidney injury (Dunphy et al., 2023). If patients require contrast dye or surgical procedures, Metformin should be held 24-48 hours prior to surgical procedures or contrast dye exposure. Additionally, clinicians should monitor vitamin B12 levels once annually if using metformin chronically (Dunphy et al., 2023).

Glucagon Like Peptide (GLP-1) Receptor Agonist is now considered first-line therapy for the management of diabetes mellitus II. GLP-1 is expressed from proglucagon genes in several anatomical locations including the pancreatic beta cells, immune cells, hypothalamus, gastric mucosa, stomach, heart, lungs, and skin. GLP-1 receptor agonists bind to these receptors to stimulate glucose dependence insulin release (Dunphy et al., 2023). Consequently, the agonizing effect causes early satiety, delayed gastric emptying, and reduced inappropriate post-meal glucagon release. GLP-1 receptor agonists are most appropriate for those with underlying atherosclerotic disease, obesity, chronic kidney disease, and/or a hemoglobin A1c above goal (greater than 1.5% above target). Prior to starting therapy, it is imperative to conduct a personal and family health history to screen for pancreatitis, medullary thyroid cancer, and multiple endocrine neoplasia syndrome (Dunphy et al., 2023). These conditions are contradictions to therapy and alternative therapy would be indicated. For this patient, an injectable GLP-1 is most appropriate. The starting dose of this medication is Ozempic 0.25 mg subcutaneously every seven days for one month, then increase dose based on patient symptoms, blood glucose levels, and side effects. Prior to initiating therapy, it is important to review common side effects. This drug class can affect the autoimmune, gastrointestinal, biliary, renal, and endocrine systems (Dunphy et al., 2023). Autoimmune side effects include hypersensitivity such as angioedema and anaphylaxis, though very rare. GLP-1 receptor agonists cause gastrointestinal side effects the most. Effects may include nausea, vomiting, diarrhea, constipation, and symptomatic gastroparesis. Biliary side effects include the risk of acute pancreatitis, cholelithiasis, and cholecystitis (Dunphy et al., 2023). Renal side effects include the risk of acute kidney injury, secondary to nausea, vomiting, diarrhea, and/or dehydration. Endocrine side effects may include the development of thyroid C-cell tumors. Interactions to consider is any separate therapeutic class requiring gastric metabolism. Because of delayed gastric motility, medications like levothyroxine and oral contraceptives absorption may be affected (Dunphy et al., 2023). Patient education is imperative for compliance and safety management. Education must include the common side effects involving the gastrointestinal system and risk for nausea, vomiting, diarrhea, and/or constipation.

Case Study Conclusion

This patient has evidence of proteinuria and elevated blood pressure. It is reasonable to start an angiotensin receptor blocker (ARBs). ARBs act by selectively inhibiting the angiotensin II binding to the receptor. This prevents vasoconstrictive effects caused by angiotensin II from lowering blood pressure. Additionally, the decreased vasoconstriction includes the arterioles of the kidney, therefore minimizing the leaking of protein into the urine.

For this patient, olmesartan 20 mg by mouth daily is an option to treat both elevated blood pressure and proteinuria. Prior to starting therapy, clinicians must consider side effects. These effects include dizziness, hypotension, headache, diarrhea, angioedema, anaphylaxis, gastroenteritis, hyperkalemia, and increased serum creatinine. It is important to monitor potassium and creatinine levels after starting therapy (often one months after initiating therapy) and include patient education. Patient education must include the risk of dizziness and hypotension. Patient should be instructed to change positions slowly, particularly from laying to sitting, sitting to standing, and when standing upright after bending over. Patients should check their blood pressure at least twice weekly and keep a log for provider appointments.

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. When completing the assessment portion of your SOAP note for John Applewhite, what diagnoses will be included? Select all that apply.
    1. Diabetes mellitus II
    2. Obesity
    3. Proteinuria
    4. Acute kidney injury
    5. Elevated blood pressure
    6. Hypertension
Answer:

A. Diabetes mellitus II; B. Obesity; C. Proteinuria; E. Elevated blood pressure

Feedback: We do not have the clinical data to diagnose John Applewhite with an acute kidney injury. This requires a comparison of prior lab work. Hypertension is diagnosed with two blood pressure assessments on two separate occasions.

  1. After reviewing the subjective history for John Applewhite, what symptoms raised the suspicion of diabetes mellitus II? Select all that apply.
    1. Fatigue
    2. Nocturia
    3. Darkening of the skin
    4. Frequent balanitis
Answer:

A. Fatigue; B. Nocturia

Feedback: While darkening of the skin and frequent yeast infections are common in diabetes mellitus II, John Applewhite has not reported these symptoms.

  1. Current guidelines support the diagnosis of diabetes including which of the following methods? Select all that apply.
    1. Hemoglobin A1c of 6.5% or higher.
    2. Fasting plasma blood level of 110 or higher following 8 hours of no caloric intake.
    3. Glucose level of 200 mg/dl or greater after 75-gram glucose load during a two-hour oral glucose tolerance test.
    4. Symptoms of diabetes plus a random plasma glucose level of 150 mg/dl.
Answer:

A. Hemoglobin A1c of 6.5% or higher; C. Glucose level of 200 mg/dl or greater after 75-gram glucose load during a two-hour oral glucose tolerance test

Feedback: Fasting plasma blood glucose must be greater than 110 mg/dl after eight hours of fasting. Symptoms of diabetes plus a random plasma glucose level must be 200 mg/dl or higher.

  1. After initiating pharmacologic therapy for diabetes, John Applewhite asks when he should repeat his hemoglobin A1c. You instruct the patient:
    1. 1 month
    2. 3 months
    3. 6 months
    4. 12 months
Answer:

B. 3 months

Feedback: Hemoglobin A1c is an average of the blood glucose over the period of 3 months. Re-assessment should be done every 3 months until stable.

  1. When completing patient education, what complications of diabetes mellitus require frequent laboratory work? Select all that apply.
    1. Chronic kidney disease
    2. Diabetic retinopathy
    3. Proteinuria
    4. Gastroparesis
Answer:

A. Chronic kidney disease; C. Proteinuria

Feedback: Chronic kidney disease and proteinuria require frequent laboratory tests. Diabetic retinopathy requires an ophthalmologic exam. Gastroparesis requires advanced testing and subjective history.

  1. Which of the following is the most common cause of uncontrolled blood glucose levels in those with diabetes mellitus II?
    1. Insulin deficiency
    2. Overproduction of glucagon
    3. Increased carbohydrate intake
    4. Insulin resistance
Answer:

D. Insulin resistance

Feedback: The cells stop responding properly to insulin decreasing glucose absorption and increasing serum levels.

  1. John Applewhite is started on a biguanide for newly diagnosed diabetes mellitus II. Biguanides mechanism of action includes which of the following options?
    1. Increase pancreatic beta cell function and insulin secretion
    2. Increase insulin resistance
    3. Increase insulin sensitivity
    4. Delays gastric motility
Answer:

C. Increase insulin sensitivity

Feedback: Biguanides inhibit gluconeogenesis and suppress the liver’s ability to create new glucose stores. They suppress glucagon signaling deceasing the release of stored glucose into the blood.

  1. Utilizing GLP-1 receptor agonists is most appropriate in patients with underlying: Select all that apply.
    1. Obesity
    2. Atherosclerotic disease
    3. Hemoglobin A1c 6.2%
    4. Low back pain
Answer:

A. Obesity; B. Atherosclerotic disease

Feedback: Hemoglobin A1ctarget is <6.5% and at this time GLP-1s are not indicated for low back pain.

  1. Which of the following are side effects of losartan?
    1. Hyponatremia
    2. Hyperkalemia
    3. Bradycardia
    4. Decreased creatinine
Answer:

B. Hyperkalemia

Feedback: Angiotensin II receptor blockers (ARB) reduce aldosterone secretion which decreases potassium excretion.

  1. One month after starting John Applewhite on Ozempic therapy, he reports a family history of papillary thyroid cancer. He is concerned about his risk of developing thyroid cancer. What are your next steps?
    1. The patient should be instructed to stop therapy immediately.
    2. Continue therapy as prescribed and re-educate on the contraindications of GLP therapy.
    3. Order a thyroid ultrasound STAT.
    4. Order thyroid function test.
Answer:

B. Continue therapy as prescribed and re-educate on the contraindications of GLP therapy

Feedback: GLP-1 agonist is contraindicated in those with a family history of medullary thyroid cancer. While caution is necessary for those with a family history of papillary thyroid cancer, it is not a contraindication.

References

Dunphy, L M., Winland-Brown, JE, Porter, BO, & Thomas DJ (2023). Primary Care: The Art and Science of Advanced Practice Nursing – An Interprofessional Approach (6th ed.). FA Davis.

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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