Question

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.  

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