Clinical Decision Making Guide Subjective

Clinical Decision Making Guide

SUBJECTIVE DATA

Chief complaint: Acanthosis nigricans

History of Present Illness: Patient was good in health until...(put the chronological history of your patient for example..2 years prior to consult patient experienced....)

Current health data is obtained

Current medications: NA

Allergies: NA

Last physical examinations: 2 years

Immunization status: NA

LMP and type of birth control (if applicable)

Past Medical History

Illnesses / trauma: NA

Hospitalizations: NA

OB History: NA

Sexual History: NA

Emotional/Psychiatric History: NA

Family History: Family history for Diabetes, Type II maternal grandparents, and hypertension in grandparents on both sides of the family.

F. Personal/Social History: NA

G. Review of Systems (appropriate to clinical scenario)

OBJECTIVE DATA

A.

Her Vital signs from school are BP 144/92, HR 88, RR 16, Temp 97.9.Wt. 195 pounds, Ht: 62 inches, BMI =35.6.

The results of the fasting labs are as follows:

Fasting blood sugar = 118

Total Cholesterol = 190

Triglycerides = 260

HDL =33

LDL = 104

ASSESSMENT

A.

Primary Diagnosis (es) - Acanthosis nigricans (hyper pigmented velvety plaques on the neck or extensor surfaces) are dermatologic manifestation of DM, obesity. What your patient has is impaired fasting glucose based on her FBS. Acanthosis is a sign of hyperandrogenism which is due to insulin resistance, which is actually a pathogenesis behind diabetes mellitus. Dyslipidemia is a cardiovascular complication of DM.

The most common pattern of dyslipidemia is hyper triglyceridemia and reduced HDL levels.

B.

Differential Diagnosis- ICD-9 Codes with explanation of why you think this is a possible diagnosis based on subjective and/or objective data provided. This is not to be a "laundry" list of ALL diagnosis, only those that fit the data you are given. NA

C.

Rule out Nursing Diagnosis (es)- ICD 9 codes if appropriate with explanation of why you think this is an important diagnosis to rule out. Again, this is not a "laundry" list of all possible rule outs, only those that fit the scenario you are given.

D.

Nursing Diagnosis (es) x2

PLAN

A.

There is good proof that hyperglycemia suggests threat for all of the common late complications of DM, which are the most important causes of excess morbidity and mortality in diabetics. Nevertheless, there is no generally applicable and consistently effective means of maintaining persistently normal plasma glucose fluctuations in diabetics, and efforts to do so entail significant risks of causing frequent or severe hypoglycemic episodes, particularly in IDDM patients.

Treatment regimens differ in the priorities assigned to keeping the risks for hypoglycemia minimal and to keeping the diurnal plasma glucose fluctuations in a normal to near-normal range. Regimens are effective in preventing symptomatic hyperglycemia and DKA or NKHHC under most circumstances, but their ability to reduce the risks for the common late complications of DM is unknown.

The suggested target maximum acceptable plasma glucose levels vary, but postprandial plasma glucose levels >200 mg/dL should be avoided whenever possible with negligible risk of hypoglycemia. This stems from the observation in the Pima Indian population, 40% of whom have NIDDM, that diabetic complications are rare in individuals whose 2-h plasma glucose level during an OGTT is

Many authorities add the advice that fasting levels be kept

B.

A fasting plasma glucose test measures your blood glucose after you have gone at least 8 hours without eating. This test is used to detect diabetes or pre-diabetes. The FPG is the preferred test for diagnosing diabetes due to convenience and is most reliable when done in the morning.

If your fasting glucose level is 100 to 125 mg/dL, you have a form of pre-diabetes called impaired fasting glucose (IFG), meaning that you are more likely to develop type 2 diabetes but do not have it yet. A level of 126 mg/dL or above, confirmed by repeating the test on another day, means that you have diabetes.

An oral glucose tolerance test measures your blood glucose after you have gone at least 8 hours without eating and 2 hours after you drink a glucose-containing beverage. This test can be used to diagnose diabetes or pre-diabetes. OGTT is more sensitive than the FPG test for diagnosing pre-diabetes, but it is less convenient to administer. The OGTT requires you to fast for at least 8 hours before the test. Your plasma glucose is measured immediately before and 2 hours after you drink a liquid containing 75 grams of glucose dissolved in water.

If your blood glucose level is between 140 and 199 mg/dL 2 hours after drinking the liquid, you have a form of pre-diabetes called impaired glucose tolerance or IGT, meaning that you are more likely to develop type 2 diabetes but do not have it yet. A 2-hour glucose level of 200 mg/dL or above, confirmed by repeating the test on another day, means that you have diabetes.

In a random plasma glucose test, your doctor checks your blood glucose without regard to when you ate your last meal. This test, along with an assessment of symptoms, is used to diagnose diabetes but not pre-diabetes. Positive test results should be confirmed by repeating the fasting plasma glucose test or the oral glucose tolerance test on a different day.

C.

Medical therapeutics/Nursing therapeutics, prescriptions with rational for each treatment and appropriate references

D.

Patient education with references: On each physician visit, the patient should be evaluated for symptoms or signs of complications, together with a check of the feet and the pulses and sensation in the feet and legs, and a urine test for albumin.

The BUN or serum creatinine levels should be assessed regularly (at least yearly), and an ECG and complete ophthalmologic evaluation should be performed at least yearly. Coexistent hypertension or hypercholesterolemia increases the risks for specific late complications and requires special attention and appropriate treatment.

Psychological problems are frequently seen in children and adolescents with IDDM and their families as a result of the associated stresses, and professional assistance is often helpful. Because there is an increased risk of acute renal failure in diabetics, x-ray studies that require IV injection of contrast dyes should be performed only when absolutely necessary and only when the patient is well hydrated.