History of Present Illness
D.T. is 42-year-old Caucasian woman who has had an elevated blood sugar and cholesterol 2 years ago but did not follow up with a clinical diagnostic work-up. She had participated in the state’s annual health screening program and noticed her fasting blood sugar was 160 and her cholesterol was 250. However, she felt “perfectly fine at the time” and did not want to take any more medications. Except for a number of “female infections,” she has felt fine recently.
Today, she presents to the clinic complaining that her left foot has been weak and numb for nearly 3 weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. She does report that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 50 pounds since her last pregnancy 10 years ago, 20 pounds in the last 6 months alone.
Past Medical History
• Seasonal allergic rhinitis (since her early 20s)
• Breast biopsy positive for fibroadenoma at age 30
• Gestational diabetes with second child 10 years ago
• Multiple yeast infections during the past 3 years that she has self-treated with OTC antifungal creams and salt bath
• Hypertension for 10 years
Past Surgical History
C-section 14 years ago
• Menarche at age 11
• Last pap smear 3 years ago
• Type 2 DM present in older brother and maternal grandfather. Both were diagnosed in their late 40s. Brother takes both pills and shots.
• Mother alive and well
• Father has COPD
• Two other siblings alive and well
• All three children are alive and well
• Married 29 years with 3 children; husband is a school teacher
• Family lives in a four bedroom single family home
• Patient works as a seamstress
• Smokes 1 pack per day (since age 16) and drinks two alcoholic drinks 4 days per week
• Denies illegal drug uses
• Never exercises and has tried multiple fad diets for weight loss with little success. She now eats a diet rich in fats and refined sugars.
• Lisinopril 10 mg daily
• Loratadine 10 mg daily
Review of Systems
Admits to recent onset of fatigue
Has awakened on several occasions with blurred vision and dizziness or lightheadedness upon standing: Denies vertigo, head trauma, ear pain, difficulty swallowing or speaking
Denies chest pain, palpitations, and difficulty breathing while lying down
Denies cough, shortness of breath, and wheezing
Denies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits occasional episodes of constipation
Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in the urine, or urinary incontinence
Denies leg cramps or swelling in the ankles and feet; has never experienced weakness, tingling or numbness in arms or legs prior to this episode
Has never had a seizure and denies recent headaches
Has a rash under her bilateral breast and in groin area
Denies a history of goiter and has not experienced heat or cold intolerance
BP 165/100, T 98 F, P 88 regular, HT 5 feet 4 inches, RR 20 non labored, WT 210 lbs
What you need to do:
• Develop an evidence-based management plan.
• Include any pertinent diagnostics.
• Describe the patient education plan.
• Include cultural and lifespan considerations.
• Provide information on health promotion or health care maintenance needs.
• Describe the follow-up and referral for this patient.
• Prepare a 3–5-page paper (not including the title page or reference page).
The paper should be no more than 3–5 pages (not including the title page and reference pages.
Before finalizing your work, you should:
• be sure to read the Assignment description carefully (as displayed above);
• consult the Grading Rubric (under the Course Resources) to make sure you have included everything necessary; and
• utilize spelling and grammar check to minimize errors.
Your writing Assignment should:
• follow the conventions of Standard American English (correct grammar, punctuation, etc.);
• be well ordered, logical, and unified, as well as original and insightful;
• display superior content, organization, style, and mechanics; and
• use APA 6th Edition format as outlined in the APA Progression Ladder.
How to Submit:
Submit your Assignment to the unit Dropbox before midnight on the last day of the unit.
When you are ready to submit your Assignment, select the unit Dropbox then attach your file. Make sure to save a copy of the Assignment you submit.
When doing the write up of the case study this week, you don’t need to re-write the case study in your assignment. This takes up space. I have the case study information. You can certainly refer to the aspect of the case study you are discussing, but don’t re-write the case study. The format for this assignment is 3-5 pages plus the reference list and title page.
As a graduate student and future nurse practitioner, you need to be specific in your discussion. In the week three case study, many students discussed hypertension, the management in general, classes of drugs or diagnostic tests yet never really stated what they would do for the patient. The wrong answer is to send the patient to the emergency department for evaluation and management.
Yes, the emergency department can be helpful in managing patients, however, the emergency department does not do a comprehensive work-up of any patient. Their role is simply to determine the patient has no life threatening thing that will kill them at the moment. They will discharge the patient and the follow-up will be to see their primary care provider (you) for continuing care.
Yes, the week three and week seven patient are complex and need many things. This is a typical primary care patient. This is the time for you with minimal risk to say what you see, give your impression of what needs to be done, write your plan specifically. If you are recommending medication, state the medication and the dose and how much you will prescribe right now. If you don’t do these activities now while you are in class, you won’t be ready to do them when you get out and are practicing.
Yes, evidence based guidelines are important. Other factors must be taken into consideration when developing a plan of care for patients. If care is not patient-centered, and you don’t have a good relationship with the patient, much of your care will be in-effective. Research has demonstrated that the patient-centeredness of the provider contributes to patient satisfaction, patient adherence to treatment, and the patient returning to see you again.
Safety is a big issue, cost is another big one when determining a treatment plan for the patient. Whether you like it or not, you will get involved in the business side of practice as a provider, you will become familiar with insurance, billing and coding, and generally how to manage patients in a 15-20 minute visit. The expectations for most providers in primary care is to see a patient every 15 minutes (20 if you are lucky). Thirty minutes might be allowed if it is a first-time patient visit; because this is a more comprehensive visit, you can bill at a higher level. Experience is a great teacher as well, you will learn through experience and this will inform how you manage patients as you progress in your career.
This is the last week to practice before the graded case study in week eight. Only five students have logged in and actually attempted to complete an iHuman case study. Only four students have completed a case. There are no do overs next week, you have one attempt to complete the case study for a grade.
Several students are electing not to participate in discussions, not take an exam or complete some course assignment. This is really short sighted, you should attempt every course requirement and assignment. It is entirely possible some of you could get to the end of the course, need a few points to pass the course, yet there are no remaining assignments to complete for those points. If you have not attempted some assignment, those lost points could be the difference between passing and not passing the course.
There is a writing center to access for help with writing assignments. Please consider accessing the resources that Purdue Global has to offer you to develop your writing skills.
Please let me know if you have questions or concerns as the week progresses. Thank you.