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.