Question

Ms. T, a 53-year-old Caucasian female smoker, has a long history of Diabetes Mellitus. Last year,...

Ms. T, a 53-year-old Caucasian female smoker, has a long history of Diabetes Mellitus. Last year, she was diagnosed with a mood disorder and has since been under the care of a psychiatrist. Recently, Ms. T has seen her primary care physician for shortness of breath and a wheezing cough that has developed over the last few months.

Chief Complaint

Encounter Type: Office Visit - Follow-Up/Established Visit 12/13/2017

Record Date/Time: 12/13/17 02:44pm

Chief Complaint: SOB and Wheezing tussis

History of Present Illness

Location: Chest

Timing: Worse at night

Quality: Wheezing

Context: Worse when supine

Severity: Consistent

Modifying Factors: Hx of DM and anxiety

Duration: 2 months

Associated Signs and Symptoms: Facial erythema, unhealed bilateral plantar lesions, cyanosis and hypothermia in pedal phalanges, rhonchi w/associated dyspnea, generalized agitation. Pt states transient lower extremity paresthesia, polydipsia, and nocturia.

General

HEENT

HEENT/2

Fever

No

HA

No

Blurred Vision

No

Chills

No

Vision Changes

No

Ringing

No

Sweats

No

Dizziness

No

Deafness

No

Fatigue

No

Ear Ache

No

Vertigo

No

Weight Gain

No

Sore Throat

No

Epistaxis

No

Weight Loss

No

Discharge

No

Hoarse

No

Cardiac

Respiratory

Gastrointestinal

Chest Pain

No

Cough

No

Constipation

No

Palpitations

No

Congestion

No

Dysphagia

No

DOE

No

Expectoration

No

N/V

No

Edema

Yes

Wheezing

Yes

Abdominal Pain

No

PND

No

SOB

Yes

Heart Burn

No

Diaphoresis

No

Hemoptysis

No

Diarrhea

No

GU

Musculoskeletal

Hem/Skin

Dysuria

No

Myalgia

No

Anemia

No

Incontinence

No

Back Pain

No

Adenopathy

No

Frequency

Yes

Radiation

No

Rashes

No

Nocturia

Yes

Joint Pain

No

Leg Ulcer

Yes

Sexual Dysfunction

No

Joint Swelling

No

Bruising

No

Irregular Menses

No

Injury

No

Itching

No

Neuro

Psych

Dental

Memory Loss

No

Depression

No

Bleeding Gums

No

Confusion

No

Anxiety

Yes

Sensitivity

No

Weakness

No

Insomnia

No

Tooth Pain

No

Ataxia

No

Agitations

Yes

Sores/Lumps

No

Tremors

No

Hallucination

No

Noisy Jaw

No

Paresthesia

Yes

Disorientation

No

Clench/Grind

No

Comments:

Patient states an overall feeling of "Stress"

Entry By:

SPN

Diagnostic / Lab Results

Date

Type

Notes

Provider Verified

12/11/2017

Path/Lab

Urinalysis:

SPN

Color - Yellow

Specific Gravity - 1.035

pH - 6.5

Nitrites - negative

Leukocytes - negative

Urobilinogen - positive

Bilirubin - negative

Blood - negative

Protein - positive

Creatinine - positive

Ketones - positive

Glucose - positive

12/13/2017

Path/Lab

Hematology:

SPN

RBC Count 5.9 million

WBC Count 7,500

Platelet Count 200,000

Hct 52%

Hgb 17 g/dL

ESR 38 mm/hr

12/15/2017

Respiratory

Pulmonary Function Testing:

SPN

FVC 2.3 L/min

Pulse Oximetry 95%

Medication List:

Alprazolam 0.25mg​​Metformin 750mg

Questions

1. Based on the medical record above, differentiate the presenting signs and symptoms with following diseases/conditions: Diabetes mellitus, COPD, and anxiety.

2. For each disease/condition stated below, discuss how the process and development of each resulted in this patient’s laboratory/diagnostic test results and medication list.

​a. Diabetes Mellitus

​b. COPD

​c. Anxiety

3. For each disease/condition stated below, discuss the complications that might develop if they are left untreated or not properly managed.

​a. Diabetes Mellitus

​b. COPD

​c. Anxiety

4. For each disease/condition stated below, identify possible plan of care options that may include patient education, treatment options, necessary referral(s), and/or further diagnostic testing.

​a. Diabetes Mellitus

​b. COPD

​c. Anxiety

Reflection Discussion

1. Describe your thoughts process and resources you used to reach the conclusions for each of the questions. Explain how what you learned as it relates to appropriate medication dosages will help you in your future career.  

Homework Answers

Answer #1

1.

DIABETES MELLITUS

  • unhealed bilateral plantar lesions
  • lower extremity paresthesia,
  • polydipsia,
  • nocturia.
  • Urinalysis- yellow
  • hypothermia in pedal phalanges
  • Edema

COPD

  • SOB and Wheezing tussis Worsen at night
  • Cyanosis
  • rhonchi w/associated dyspnea,
  • generalized agitagitation

ANXIETY

  • Patient states an overall feeling of "Stress"

2.

DIABETES MELLITUS

  • Urinalysis, color-yellow. It is due to dehydration.
  • Glucose-positive

This is due to glucosuria, presence of glucose in urine. It happens when glucose in the blood exceeds the threshold level.

  • ESR 38 mm/hr
  • RBC Count 5.9 million. DM can increase the RBC rate due to the inflammation of blood vessels.
  • Metformin - Metformin reduces the amount of sugar released by liver into blood. It also makes body respond better to insulin.

COPD

  • FVC 2.3 L/min.FVC is reduced due to reduced expiratory volume caused in COPD.
  • Hct 52%. COPD can lead to chronic hypoxemia. Chronic hypoxemia may lead polycythemia.

ANXIETY

  • ESR 38 mm/hr. ESR can be elavated in presence of stressors.
  • Alprazolam is used to treat anxiety and panic disorders. It belongs to a class of medications called benzodiazepines

3.

DIABETES MELLITUS

  • Cardiovascular disease.
  • Nerve damage (neuropathy).
  • Kidney damage (nephropathy).
  • Eye damage (retinopathy).

COPD

  • Respiratory infections.
  • Pneumonia
  • Hypoxemia
  • High blood pressure in lung arteries.

ANXIETY

  • Depression
  • Substance abuse
  • insomnia
  • Digestive or bowel problems

4.

DIABETES MELLITUS

Patent teaching

Adopt healthy eating habits through nutrition education, including meal-planning, weight-loss strategies and other disease-specific nutrition counseling. Monitor blood glucose as adviced. Talk to your doctor about an exercise plan. Educate patient about what type of exercise is appropriate for them. Keep an exercise schedule. Stay hydrated.

Medications

Anti-diabetic medication, Anticoagulant, Statin and Insulin.

COPD

Patient teaching

  • Give up smoking.
  • Eat right and exercise.
  • Take medications correctly and do not skip them abruptly.
  • Use oxygen appropriately.
  • Avoid infections, and educate about signs and symptoms of infection, pneumonia, hypoxemia etc.
  • Learn techniques to bring up mucus-deep breathing exercises, steam inhalation etc.

Treatment

Physical exercise, breathing exercises.

Medications

  • Bronchodilator and Steroid
  • Oxygen thertherapy

ANXIETY

patient teaching

  • Anxiety and strategies to deal with them.
  • Relaxation techniques
  • Support groups

Medications

SSRIs, Anxiolytic, Antidepressant, Sedative and Nerve pain medication

Other

Cognitive behavioral therapy, Psychotherapy

Resources

Lewis textbook of medical surgical nursing.

R Sreevani's A guide to mental health and psychiatric nursing

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