Patient Assessment and Analysis

Patient Assessment

DIAGNOSIS AND TREATMENT PLAN

Diagnosis and Disease Processes

Using an appropriate patient assessment form (Sample Forms, 2013), D.M. has been found to have uncontrolled Type 2 diabetes, hypercholesterolemia, uncontrolled hypertension, chronic anemia, and probable hypothyroidism (Sample Forms).

Diabetes Type 2

is most probably on a poorly controlled diet of high cholesterol and high simple sugars. Diabetes mellitus type 2 is a metabolic disease wherein the body is not able to properly use ingested food because of insulin resistance. If more simple or refined sugars are consumed, the less the body is able to process them as nutrients. These tend to stay and float in the blood stream, un-used, and in this condition, they cause trouble in the different parts of the body. These include the end organs, such as the brain, the eyes, the kidneys, the heart, and even the feet. A poorly controlled diet and the lack of physical activities in many diabetic persons also lead to complications related to other organ systems. This is most often due to the resulting presence of visceral fat, which in turn leads to hypertension and hypercholesterolemia.

Chronic Anemia

D.M. is also most probably anemic as a consequence of a poor diet. Anemia may also develop because of bleeding from the gut or intestinal parasitism. This can produce a positive gulac test.

Possible Hypothyroidism

This may seem unrelated as a medical condition to the above metabolic problems. But it can develop because of poor diet.

Plan

The plan is in two phases: diagnostic and therapeutic .

Diagnostic

The diagnostic plan consists of 8 parts. The patient's blood pressure shall be regularly monitored. A CT scan and MRI of the brain shall be performed in order to detect possible cardiovascular troubles, such as hemorrhage or embolism. Serum cholesterol and other parameters shall be tested on a monthly basis. His blood sugar and HBA 1 C. shall be checked every month. His weight, waistline and BMI or body mass index shall be tested and checked monthly. A 2-D echocardiogram shall also be performed with Doppler. A fecalysis and peripheral smear shall be performed. And an ultrasound of his prostate and KUB shall also be conducted.

Therapeutic

The patient's lifestyle and diet shall be appropriately modified. His diet shall be low-fat, low-salt, low-carbohydrate, such as simple carbohydrates, but more green leafy vegetables and fruits but in moderation. A dietitian shall be consulted in computing the servings and frequency to achieve adequacy.

He shall be prescribed adequate exercises for weight loss and the strengthening of his cardiovascular system. He or someone in charge shall make sure he takes his medicines on time and at the right doses. There shall be no change in the current prescriptions, except additional iron supplements after iron injections 1M in order to raise a very low serum iron level. The caregiver or caretaker shall make sure that the patient eats adequately and regularly.

His therapist shall conduct regular follow-ups of D.M. He shall also be provided with dietary counseling whenever possible. And whenever warranted, he shall be referred to appropriate specialists, such as a neurologist, endocrinologist, or a genitor-urinologist in case of prostatic enlargement.

The PACIC for Patient Assessment

The Patient Assessment of Chronic Illness Care of PACIC has been recommended for use as a practical and reliable instrument in evaluating the extent of chronic illness (Glasgow et al., 2005). This can be used as basis of care, which conveniently aligns with the Chronic Care Model. This Model is favored because it is patient-centered, proactive, and thoroughly planned. It also includes support for collaborative goal-setting, problem-solving and follow-up (Glasgow et al.).

The instrument was tested on participants who were surveyed with the Model's 20-ite questionnaire (Glasgow et al., 2005). The test also measured the demographic factors, a patient activation scale, and subscales drawn from a primary case assessment tool. It was used to evaluate the measurement performance, construct and the validity of the PACIC. The test was conducted with a total of 283 adult patients with one or more chronic illnesses from a big and integrated healthcare delivery system (Glasgow et al.).