Hypertension Case Discussion

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DM New Onset Case
Study
Chief Complaint
• The chief complaint is a brief statement of the reason why the
patient consulted the physician, stated in the patient’s own
words. In order to convey the patient’s symptoms accurately,
medical terms and diagnoses are generally not used. The
appropriate medical terminology is used after an appropriate
evaluation (i.e., medical history, physical examination,
laboratory and other testing) leads to a medical diagnosis.
Chief Complaint
• “My gynecologist said I should have a
check-up since I am tired all the time.”
HPI
• The history of present illness is a more complete description
of the patient’s symptom(s). Usually included in the HPI are:
• Date of onset
• Precise location
• Nature of onset, severity, and duration
• Presence of exacerbations and remissions
• Effect of any treatment given
• Relationship to other symptoms, bodily functions, or activities
(e.g., activity, meals)
• Degree of interference with daily activities
HPI
• Louise Jackson is a 49-year-old woman who presents to her
primary care physician after her gynecologist recently
diagnosed her with polycystic ovarian syndrome (PCOS) during
an evaluation for amenorrhea.
• She complains of increasing fatigue, which she attributes to
being overweight. She states her last appointment with her
PCP was over 2 years ago.
PMH
• The past medical history includes serious illnesses,
surgical procedures, and injuries the patient has
experienced previously. Minor complaints (e.g.,
influenza, colds) are usually omitted unless they might
have a bearing on the current medical situation.
PMH
• PCOS × 2 months
• Hyperlipidemia × 2 years (diet controlled)
• HTN × 4 years
FH
• The family history includes the age and health of parents,
siblings, and children. For deceased relatives, the age
and cause of death are recorded. In particular, heritable
diseases and those with a hereditary tendency are noted
(e.g., diabetes mellitus, cardiovascular disease,
malignancy, rheumatoid arthritis, obesity).
FH
• Diabetes present in both mother and maternal
grandmother. Father died suddenly of colon cancer at
age 59, mother alive age 76 with history positive for DM
Type 2, HTN, and hyperlipidemia; one younger sister with
PCOS and HTN.
SH
• The social history includes the social characteristics of
the patient as well as the environmental factors and
behaviors that may contribute to the development of
disease. Items that may be listed are the patient’s marital
status; number of children; educational background;
occupation; physical activity; hobbies; dietary habits; and
use of tobacco, alcohol, or other drugs.
SH
• Married × 23 years with two children. Works full-time as
insurance consultant which is telephone based from home. No
alcohol or tobacco use. Rarely exercises and admits to trying
fad diets for weight loss with little success. She reports
adherence to her medications.
Meds:
• The medication history should include an accurate record of the
patient’s current use of prescription medications,
nonprescription products, and dietary supplements. Because
pharmacists possess extensive knowledge of the thousands of
prescription and nonprescription products available, they can
perform a valuable service to the health care team by obtaining
a complete medication history that includes the names, doses,
routes of administration, schedules, and duration of therapy for
all medications, including dietary supplements and other
alternative therapies.
Meds:
• Ortho-Novum 1/35 as directed
• Hydrochlorothiazide 50 mg po daily
ALL:
• Allergies to drugs, food, pets, and environmental factors
(e.g., grass, dust, pollen) are recorded. An accurate
description of the reaction that occurred should also be
included. Care should be taken to distinguish adverse
drug effects (“upset stomach”) from true allergies
(“hives”).
All
• Codeine
ROS
• In the review of systems, the examiner questions the patient
about the presence of symptoms related to each body system.
In many cases, only the pertinent positive and negative findings
are recorded. In a complete ROS, body systems are generally
listed by starting from the head and working toward the feet
and may include the skin, head, eyes, ears, nose, mouth and
throat, neck, cardiovascular, respiratory, gastrointestinal,
genitourinary, endocrine, musculoskeletal, and neuropsychiatric
systems.
• The purpose of the ROS is to evaluate the status of each
body system and to prevent the omission of pertinent
information. Information that was included in the HPI is
generally not repeated in the ROS.
ROS
• Frequent fatigue. Occasional polydipsia, polyphagia,
weakness, and lightheadedness upon standing. Denies
blurred vision, chest pain, dyspnea, tachycardia, dizziness,
or tingling or numbness in extremities, leg cramps,
peripheral edema, changes in bowel movements, GI
bloating or pain, nausea or vomiting, urinary
incontinence, or presence of skin lesions.
Physical Examination
• The exact procedures performed during the physical
examination vary depending upon the chief complaint and the
patient’s medical history. In some practice settings, only a
limited and focused physical examination is performed. In
psychiatric practice, greater emphasis is usually placed on the
type and severity of the patient’s symptoms than on physical
findings. A suitable physical assessment textbook should be
consulted for the specific procedures that may be conducted
for each body system. The general sections for the PE are
outlined as follows:
• Gen (general appearance)
• VS (vital signs)—blood pressure, pulse, respiratory rate,
and temperature.
• In hospital settings, the presence and severity of pain is
included as “the fifth vital sign, weight and height are
included in the vital signs section here, but they are not
technically considered to be vital signs.
• Skin (integumentary)
• HEENT (head, eyes, ears, nose, and throat)
• Lungs/Thorax (pulmonary)
• Cor or CV (cardiovascular)
• Abd (abdomen)
• Genit/Rect (genitalia/rectal)
• MS/Ext (musculoskeletal and extremities)
• Neuro (neurologic)
Gen:
• Patient is an African-American woman with
central obesity in no apparent distress
VS
• BP 152/88 sitting R arm, BP 130/70 standing R arm, P 82, RR
18, T 37.2°C; Wt 95.5 kg, Ht 5'6'‘
•
•
•
•
•
•
•
BP = Blood Pressure.
HR = Heart rate.
Bpm = beat per minute.
RR = Respiratory rate.
T = Temperature.
Wt = Weigt
Ht= Hight
Skin
• Dry with poor skin turgor; no ulcers or rash
HEENT
• PERRLA; EOMI; TMs intact; no hemorrhages or exudates on
funduscopic examination; mucous membranes normal; nose and
throat clear w/o exudates or lesions
• PERRLA = Pupils equal, round, and reactive to light and
accommodation
• EOMI = Extraocular movements (or muscles) intact
• TM = Tympanic membrane.
Neck/Lymph Nodes
• Supple; without lymphadenopathy, thyromegaly, or JVD
Lungs:
• CTA = Clear To Auscultation
CV:
• RRR; normal S1 and S2; no S3, S4, rubs,
murmurs, or bruits
• RRR = Regular rate and rhythm.
• S = Sound.
Abd:
• Soft, NT, central obesity; normal BS; no
organomegaly, or distention.
• NT / ND = Non-tender/non-distended.
• BS = Bowel sounds; breath sounds or blood
sugar
Genit/Rect:
• Deferred
Ext:
• Normal ROM and sensation; peripheral pulses 2+ throughout;
no lesions, ulcers, or edema
• ROM = Range of motion
Neuro:
• A & O × 3, CN II–XII intact; DTRs 2+ throughout; feet with
normal vibratory and pinprick sensation (5.07/10 g
monofilament)
• CN II–XII = Cranial Nerves 2 to 12.
• A & O × 3 = Awake and oriented to person, place, and time.
• DTR = Deep-tendon reflex
LABS:
UA:
• (–) ketones, (–) protein, (–) microalbuminuria
Assessment:
1.
Elevated random glucose; presumed newly diagnosed Type 2
diabetes mellitus; will obtain a fasting blood glucose level to
confirm the diagnosis and also check A1C
2.
Elevated total cholesterol; will obtain fasting lipid profile to
evaluate LDL, HDL, and triglycerides
3.
Hypertension with suboptimal treatment and possible side effects
due to diuretic
4.
Obesity
5.
PCOS
Clinical Course
• The patient returned to clinic 3 days later for lab work, which
revealed: FBG 189 mg/dL; A1C 9.4%; FLP: T. chol 263 mg/dL,
HDL 31 mg/dL, LDL 152 mg/dL, Trig 260 mg/dL.
Problem Identification
• 1.a. What risk factors for Type 2 DM are present
in this patient?
Problem Identification
• 1.b. What information (signs, symptoms, laboratory
values) supports the diagnosis of Type 2 DM?
Problem Identification
• 1.c. What information indicates the presence of
insulin resistance?
Problem Identification
• 1.d. Create a list of this patient’s drug
therapy problems.
Desired Outcome
• 2.a. What are the desired goals for the treatment
of this patient’s diabetes?
Desired Outcome
• 2.b. Considering her other medical problems, what other
treatment goals should be established?
Therapeutic Alternatives
• 3.a. What nonpharmacologic therapies
might be useful in the management of this
patient?
Therapeutic Alternatives
• 3.b. What feasible pharmacotherapeutic alternatives are
available for the treatment of this patient’s DM? Identify
the factors that will influence your choice of initial
therapy.
Optimal Plan
• 4.a. Outline a complete pharmacotherapeutic plan to manage
this patient’s current problems, including drug, dosage form,
dose, schedule, and rationale for your selections.
• 4.b. What changes in therapy would you recommend if your
initial plan fails to achieve adequate glycemic control?
Outcome Evaluation
• 5.a. What clinical and laboratory parameters will you
monitor to evaluate glycemic efficacy and to detect or
prevent adverse effects?
Outcome Evaluation
• 5.b. The patient’s physician suggested that she obtain a blood
glucose meter for self-testing. What are the health care provider’s
responsibilities with respect to patients and self-monitoring of blood
glucose (SMBG)?
Outcome Evaluation
• 5.c. Identify at least four potential situations in which the
information provided by SMBG would be useful to
patients and health care providers.
Outcome Evaluation
• 5.d. What factors should be considered in the selection
of an appropriate blood glucose meter?
Patient Education
• 6.a. What information should be provided to the
patient about diabetes and its treatment to
enhance compliance, ensure successful therapy,
minimize adverse effects, and prevent future
complications?
Patient Education
• 6.b. How would you educate the patient
regarding how and when to check her blood
glucose?
Follow-up Questions
• 1. Which over-the-counter products could be
recommended for patients to use in treating
hypoglycemic episodes?
• 2. List several potential sources of error in SMBG.
Follow-up Questions
• 3. When starting patients on insulin, the use of combination oral
antihyperglycemic agents and insulin offers several advantages over
switching entirely to insulin:
• a. What are the advantages of adding insulin to existing therapies
with oral agents?
• b. List an appropriate method of starting insulin therapy to
adequately control fasting hyperglycemia in patients on combination
oral agents.
Questions?
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