NU 665 Week 4 Assignment 1: Comprehensive Case Study

Sample Answer for NU 665 Week 4 Assignment 1: Comprehensive Case Study

Your Medical Assistant has given you the following information:

A 68-year old patient, Mr. Michael James, has a history of diabetes. He presents with weakness and fatigue. The patient’s husband, David James, reports that the patient has been acting confused for the last two days.

The MA completed vital signs per protocol

• Temp – 99.3
• Respiratory rate – 22
• Blood pressures – 94/62
• Pulse rate – 105
• Pain – 4/10

You are getting ready to see the patient. What are you going to do first?

Before seeing the patient, I will take time to review his medical records, lab results (CBC, lipid panel, kidney function, A1C, thyroid panel, CMP), past notes, vital signs, the most recent colonoscopy, prostate-specific antigen (PSA) test, bone density scan, and any other records to familiarize with the patient. This also includes acquainting with the patient’s medical, social surgical, and family history.  I will ascertain whether the patient is uptodate with the recommended health maintenance for his age (Hektor et al., 2023).

Based on the symptoms presented by the patient, I would conduct further tests, such as measuring orthostatic blood pressure, performing an electrocardiogram (ECG), and checking blood glucose levels to exclude the possibility of hypoglycemia.

Prior to entering the patient’s room, I ensure that I have all necessary equipment prepared. Following this, I thoroughly wash my hands, maintaining proper hygiene protocols. Upon entering, I introduce myself professionally to the patient and their family members, establishing a courteous and respectful interaction.

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Subjective History lesson: can you tell me about your

Medical History – The patient has a history of neuropathy secondary to diabetes; his blood glucose is periodically out of control, as revealed by an elevated hemoglobin A1C on previous visits

Surgical History – appendectomy in 1984, spinal fusion at T4 in 2010

Social History – the patient lives with his husband and manages his own medications. He used to be a lawyer and retired at age 62.

Family History – mother (alive at age 85; DM type 2), father (deceased at age 70, stroke), sister (age 65; DM type 2 and HTN)

Please dictate your problem list

• Hypotension
• Weakness
• Fatigue
• Low grade fever
• Confusion
• Type 2 DM
• Tachypnea
• Tachycardia
• Family history: Stroke, HTN, and T2DM.

Subjective History – Can you tell me about your Medications?

Metformin XR 100mg BID

Trulicity 1.5mg Qweek

Lisinopril 20mg QD

Atorvastatin 40mg QD

After reviewing Mr. James history and medication list, what findings are you concerned about as his provider?

• Considering the symptoms observed, it is important to be mindful of the possibility of lactic acidosis. This condition is an uncommon but severe side effect that can arise from Metformin toxicity (Epocrates, 2024).  This could be attributed to the fact that the patient is responsible for managing his own medications but has experienced confusion over the past two days.
• Given the family history of stroke, I would also be apprehensive because the patient has type 2 diabetes mellitus (T2DM), which further amplifies their risk of cardiovascular problems (Hektor et al., 2023).
• Confusion and an altered mental status indicate the existence of an underlying metabolic issue.
• History of a poor glycemic control as evidenced by history of persistently elevated hemoglobin A1C
• Medication adherence
• Hyperglycemia which potentially relates to weakness, fatigue, and confusion
• Hypotension as evidenced by an office blood pressure of 94/62 mmHg
• Pain with a reported severity of 4/10. I would be interested to understand the nature and location of the pain.

Provide a list of three differential diagnoses with rationale for the altered mental status for the 68-year old patient.

• Diabetes Ketoacidosis (DKA) is an acute complication of Diabetes mellitus mostly associated with type 1 DM. However, it can also occur in individuals with type 2 DM (Ajmera, Sailaja & Ramulu, 2020). Its hallmark feature is a severe deficiency in insulin that ultimately results to metabolic acidosis, hyperglycemia, and ketosis with symptoms of confusion, increased thirst, increased urination, and abdominal pain (Ajmera, Sailaja & Ramulu, 2020). In DKA, the breakdown of fats to produce energy can result in fatigue and weakness.
• Medication-related adverse effect and drug interaction – the patient is on several medications for hyperlipidemia, hypertension, and diabetes type II. A medication-related issue resulting from either under dosing, overdosing, or drug-drug interaction can result in altered mental status, weakness, fatigue, or hypotension (Ajmera, Sailaja & Ramulu, 2020).  
• Stroke is a potential diagnosis that should not be overlooked. The patient’s age, family history, and medical history of type 2 diabetes mellitus (T2DM) and hypertension (HTN) elevate the risk. Common symptoms include facial drooping, weakness, headaches, confusion, lack of coordination, arm weakness, and difficulty in speech. While the patient doesn’t display all these symptoms, he experiences confusion, fatigue, and have a close relative who died from a stroke. To rule out stroke, it is essential to perform a non-contrast CT scan, complete blood count (CBC), comprehensive metabolic panel (CMP), electrocardiogram (ECG), and measure serum blood urea nitrogen (BUN) and creatinine levels (Hektor et al., 2023).

Please provide a list of three differential diagnoses with rationale for complications of diabetes for the 68-year-old patient.

• Diabetes Ketoacidosis (DKA) – this is an acute life-threatening diabetes complication that is common in patients with type I DM. However, it also occurs in type II DM. The metabolic imbalance that occurs in DKA can cause weakness, confusion, and fatigue (Ajmera, Sailaja & Ramulu, 2020).  
• Diabetic Neuropathy – The patient reports a history of diabetes-related neuropathy whose hallmark feature is nerve damage (Ajmera, Sailaja & Ramulu, 2020). Diabetic neuropathy is also associated with the symptoms of pain, fatigue and weakness (Ajmera, Sailaja & Ramulu, 2020).  
• Chronic Kidney Disease: Besides coronary artery disease (CAD), hypertension (HTN), and Type 2 Diabetes Mellitus (T2DM) can also harm the kidneys. This can lead to conditions like diabetic nephropathy or hypertensive nephropathy due to ongoing damage to the small blood vessels in the kidneys, which can result in a loss of kidney function and possibly progress to end-stage renal disease, as highlighted by Hektor et al., 2023.

Physical Exam                                                             

General –fatigued; pale-looking male with maculopapular rash on abdomen; oriented to person, place, but unable to provide time or history.

HEENT; Head-normocephalic, mild temporal wasting, no sinus tenderness or associated swelling. Eyes- sclera white, no erythema or drainage. Ears-TM’s intact bilaterally with good color and position. Nose – no nasal discharge.

Cardiovascular-Heart rate is regular, no murmur but +2 edema bilateral lower extremities.

Respiratory – rales in the lungs bilateral lower lobe

Musculoskeletal – Normal AROM/PROM

Abdomen – +BS, soft, NT

Neuro – slightly confused and unable to answer appropriately.

What do you think is causing these problems?

• The patient has both kidney disease and heart failure. These conditions can occur separately, but they can also make each other worse. Due to poorly controlled diabetes, high blood pressure, and potential medication issues, the blood vessels in the kidneys have been damaged, reducing blood flow to them. This causes the heart to work harder to pump more blood, which stresses the heart. As kidney function declines over time, it leads to problems like retaining too much fluid, imbalances in electrolytes, and the heart pumping less effectively. These issues make the symptoms of both kidney disease and heart failure worse (Hektor et al., 2023).

 What labs do you need to draw today?

• Chest x-ray- PA and lateral to assess for respiratory infection
• Complete Blood Count (CBC) – to assess for anemia as well as signs of infection
• Blood culture
• Urinalysis – to evaluate for ketones in urine as well as signs of urinary tract infection (UTI).
• Hemoglobin A1C – to evaluate for longterm glycemic control
• Random blood glucose – to evaluate for hyperglycemia/blood glucose levels
• Lipid panel – to assess blood lipid levels and effectiveness of atorvastatin.
• Brain Natriuretic Peptide (BNP) – to evaluate the patient for heart failure.
• Renal function- to assess for kidney function.

Laboratory tests

Which laboratory tests should be ordered to evaluate the patient’s suspected kidney disease at this time? Rationale.

• Basic Metabolic Panel (BMP) – to evaluate for Blood Urea Nitrogen and creatinine levels. Elevated BUN is suggestive of an impaired kidney function (Persson & Rossing, 2018).
• Estimated Glomerular Filtration rate (eGFR) – this is a major parameter in estimating the overall renal filtration function based on race, age, gender, and serum creatinine level.
• Urinalysis – to evaluate for proteinuria, ketones, hematuria, and sediments (cellular casts) (Persson & Rossing, 2018).
• Serum albumin – to evaluate for albumin levels. Low serum albumin is suggestive of an underlying kidney disease since the kidneys play a major role in the maintenance of the levels of albumin (Persson & Rossing, 2018).
• Serum calcium and phosphorous – in renal disease, an imbalance
• Complete Blood Count (CBC) – acute and chronic renal failure are common complications that occur in diabetes patients with chronic kidney disease. Anemia, a common complication in CKD can be evaluated for by a CBC (Persson & Rossing, 2018).  
• Serum electrolytes – in renal disease, an imbalance in electrolytes (calcium and phosphorous) can occur and this can ultimately affect bone health.

Additional Diagnostic Tests

What additional diagnostic tests should be completed to evaluate the patient’s condition? Rationale.

Arterial Blood Gas analysis (ABGs) – the metabolic imbalances associated with type II DM can cause respiratory acidosis and a decrease in respiratory function (Davies et al., 2022). ABGs help to evaluate for respiratory acidosis, respiratory alkalosis, and generally the acid-base balance.

Thyroid function Test (TFT) – to evaluate thyroid disorders. The incidence of thyroid disorders increases with advancing age can cause symptoms such as confusion and fatigue.

Coagulation studies – considering that this patient has risk factors for coagulation; hyperlipidemia, advanced age, and type II DM, coagulation studies will help to evaluate for and coagulation disorders (Davies et al., 2022).

ECG – to identify any irregularities, abnormal heart rhythms, or signs of a myocardial infarction  (Hektor et al., 2023).

Considerations

What considerations are made in providing care for this patient?

1. Initial stabilization such as administering intravenous fluids, stabilizing blood glucose levels, and blood pressure to ensure hemodynamic stability
2. The patient’s physical exam shows that he has confusion and a maculopapular rash. He should be re-evaluated for a potential infection source with blood cultures and started on empiric antibiotic therapy.
3. Given the patient’s history of poor glycemic control, he should be evaluated for medication adherence to identify and address potential factors likely to hinder compliance for a good prognosis (Davies et al., 2022).
4. Self-care and patient education are integral components in the long-term management of diabetes (Davies et al., 2022). With the patient’s consent, educate him and the husband about type II diabetes. This includes education about the etiology, management options, short term and long-term complications, prognosis, signs to identify complications and when to seek care.
5. Collaboration and coordination with other specialists; diabetes educator, dietician, nephrologist, neurologist, and cardiologist for the patient’s well-being will be resourceful (Davies et al., 2022).
6. Psychosocial support from family for medication management and ADLs (activities of daily living) considering current emotional and mental state is also important. During discharge, social services should also be involved.
7. Optimal management of underlying type II DM for optimal glycemic control. This will require re-evaluating whether the patient takes his medications as prescribed (Davies et al., 2022).
8. A complete neurological assessment and investigation of the cause of confusion and a possible consult with a neurologist
9. Evaluate the patient’s current drug regimen while making adjustments based on laboratory findings.
10. Close monitoring and recording of the vital signs, blood glucose levels, and renal function while adjusting the care plan according to ongoing assessments.

Medication Management

What medication management should be used to manage hypertension in this patient? What data do you need to help guide this decision?

The medication management to manage hypertension in this patient are those provided by the American Diabetes Association which  recommend a target blood pressure of 130/80mmHg in diabetic patients with hypertension with ACEs and ARBs(Passarella et al., 2018). While ACEs reduce cardiovascular mortality and slow progression to kidney failure, ADA recommends that patients intolerant to ACEs should be prescribed ARBs (Angiotensin Receptor Blockers) (Passarella et al., 2018). The following data will be essential to make this decision;

• Current blood pressure reading (94/62mmHg) is hypotensive.  I will need the patient’s previous blood pressure records to ascertain whether this is an acute change or has had a chronic pattern.
• Assessment of evidence for any end-organ damage as a result of hypoperfusion. This will help to make any appropriate medication adjustments until all parameters return to baseline (Passarella et al., 2018).  
• Determine blood pressure targets/goals with blood pressure medications
• A complete profile of the side effects he experiences from the current antihypertensive he takes; lisinopril, and to evaluate for any contraindications, adverse effects, and drug-drug interactions.
• Individual patient characteristics such as race/ethnicity and age which directly influence the effectiveness and choice of antihypertensives.
• A comprehensive assessment of the patient’s renal function including the estimated glomerular filtration rate (eGFR) and serum creatinine considering that antihypertensives directly impact renal function (Passarella et al., 2018).  
• The patient’s preferences for shared decision making and adherence history to the currently prescribed antihypertensive. Noncompliance contributes to uncontrolled blood pressure and addressing factors that contribute to non-compliance can ultimately result to good blood pressure management outcomes (Passarella et al., 2018).

Patient Education

What patient education should be provided?

(Give 10-15 individual points)

• As a chronic lifelong disease, diabetes is overwhelming hence comes with myths, anger or even fear (Powers et al., 2020). Use a patient-centered approach to educate the patient about type II DMM, addressing any myths, misconceptions, and concerns from the patient and the family.
• Educate the patient about the natural history of type II DM, signs and symptoms, acute, short-term, and long term complications, medication management, and lifestyle modification.
• Educate the patient about the essence of incorporating family members in ongoing care and support (Powers et al., 2020).
• Educate the patient about the essence of medication compliance to achieve glycemic targets. Include factors likely to hinder adherence such as psychosocial, financial, medication side-effects, misinformation and fears, misconceptions and distress, and cultural barriers (Powers et al., 2020).
• Collaborate with the patient to establish a support plan, highlighting the essence of the initial and ongoing support plan
• Offer the patient a referral to a registered dietician for individualized dietary assessment and management plan.
• Offer the patient referral to a mental health practitioner with expertise in diabetes management for a mental health assessment
• Educate the patient about the signs of hyperglycemia and hypoglycemia so that he can be able to identify warning signs earlier and seek immediate medical attention.
• Educate the patient about how risky sedentary lifestyles such as alcohol consumption, tobacco smoking, physical inactivity and poor dietary choices negatively impact the treatment outcomes and increase the overall risk of complications (Powers et al., 2020).
• Educate the patient about dietary awareness considering his current diagnoses; hypertension, hyperlipidemia, and type II DM. This includes the role of dietary sodium in hypertension hence reducing salt intake, and maintaining a DASH/Mediterranean diet.
• To prevent long-term complications such as diabetic food, considering that he currently is diagnosed with neuropathy, educate the patient about the need for appropriate and protective footwear to prevent injuries.

References

Ajmera, P., Sailaja, P., & Ramulu, P. R. (2020). Microvascular and Macrovascular Complications In Type 2 Diabetes Milletus. Academia Journal of Medicine, 3(2), 16-19.

Davies, M. J., Aroda, V. R., Collins, B. S., Gabbay, R. A., Green, J., Maruthur, N. M., & Buse, J. B. (2022). Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia, 65(12), 1925-1966.

Epocrates. metformin: Dosing, contraindications, side effects, and pill pictures – epocrates

online. (n.d.). https://www.epocrates.com/online/drugs/787/metformin#drug-interactions.

Hektor, D. L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2023). Primary care:

The art and science of advanced practice nursing – an interprofessional approach. F.A.

Davis.

Passarella, P., Kiseleva, T. A., Valeeva, F. V., & Gosmanov, A. R. (2018). Hypertension management in diabetes: 2018 update. Diabetes Spectrum, 31(3), 218-224.

Persson, F., & Rossing, P. (2018). Diagnosis of diabetic kidney disease: state of the art and future perspective. Kidney international supplements, 8(1), 2-7.

Powers, M. A., Bardsley, J. K., Cypress, M., Funnell, M. M., Harms, D., Hess-Fischl, A., & Uelmen, S. (2020). Diabetes self-management education and support in adults with type 2 diabetes: a consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Journal of the American Pharmacists Association, 60(6), e1-e18.