How would you treat patient using appropriate guidelines

Reference no: EM133310650

Question 1. List the pertinent positives and negatives.

Question 2. What additional questions/information would you ask?

Question 3. Name three differential diagnosis.

Question 4. How would you treat this patient using appropriate guidelines?

Case Study: C.C. "My blood sugar has been elevated."

HPI: M.J. 71 y.o. M reports that his blood sugars are 280-320 when he checks them. He has not been checking them lately because he ran out of testing strips. Therefore, he has not been using the sliding scale insulin three times per day. He reports increase thirst and urination. He does not count his carbohydrates but feels his diet has been "good." Denies lightheaded, dizziness, abdominal pain, nausea or vomiting. He has been having numbness and tingling in his feet and feels worse on some days, but he denies pain or wounds.

PMH: DM with neuropathy, hyperlipidemia, HTN, Allergies: Lyrica: causes swelling in lower extremities (side effect)

Medication: Losartan 100 MG tablet 1 tablet orally once a day, Rosuvastatin Calcium 40 MG tablet 1 tablet orally once a day, Gabapentin 600 MG capsule 1 capsule three times a day, Metformin 1000 MG tablet 1 tablet orally twice a day, Humalog 100 UNIT/ML solution use per sliding scale (70-150: 0 Units; 125-150: 2 UNITS; 151-200 4 Units; 201-250: 6 Units; 251-300: 8 Units; 301-350: 10 Units; 351-400: 12 units. Tresiba FlexTouch 200 UNITS/ML solution pen-injector Inject 72 UNITS twice daily.

Social history: Patient is single, lives with girlfriend. Denies tobacco use, recreational drug use. Drinks alcohol socially. He drinks sweet tea for caffeine intake. He is sexually active with one partner. He works full time as mechanic.

Family history: Father (deceased): CABG x2 at age 50, aortic valve replacement at age 72, Heart disease. Mother (deceased): hyperlipidemia. Paternal grandfather: deceased, heart attack and heart disease. Maternal grandfather: deceased, heart attack and heart disease. Maternal grandmother: decease, hypothyroidism, heart disease.

Health Maintenance/Promotion: Flu vaccine this year and recommended to get new Shingles vaccines (Shingrix). ROS: General: Denies fever, chills, fatigue. Denies recent weight changes or changes in appetite.

Skin: Denies any wounds, cuts, sores, or open skin that will not heal. Denies lesions or rash.

Eyes: Reports eye doctor visit 1 year ago with no observed changes of vision or retinopathy. Follow up in 1 year. ENT: denies any concerns

CV: Denies chest pain, chest pressure, chest tightness. Denies heart racing or palpitations. Denies any swelling. Lungs: Denies shortness of breath at rest or with exercising. Denies difficulty breathing or moments of respiratory distress. Denies cough or wheezing. GI: Denies diarrhea or constipation. Reports normal bowel movements daily. Denies any blood in stool. Denies abdominal pain or loss of appetite. GU: Denies difficulty urination, frequent urination, or excessive urination.

MSK: Denies muscle weakness or pain.

Neuro: Patient reports numbness and tingling in bilaterally feet. Denies numbness or tingling in upper extremities. Denies headaches.

Endo: Patient states blood sugars are 280-320ish when he checks them. Denies feeling clammy, diaphoretic, dizzy or lightheaded. Denies feeling hot or dry. Has been having increase thirst and urination.

Psych: Denies depression

Objective: Gen: Patient in no acute distress, well developed, well nourished.

VS: Ht: 74.5 in, Wt: 242 lbs, Temp: 98.6 F, HR: 81 BPM, RR: 16 BPM, BP: 130/75 mm Hg. Oxygen sat 98% on room air. BMI 30.65 Index.

Skin: No evidence of lesions. Moist, erythema noted under pannus, no visible open areas. Bilaterally plantar are intact without any signs of wounds.

HEENT: Normocephalic. PERRLA. Thyroid no enlargement or nodules palpable.

CV: Regular rate and rhythm, S1 and S2. No carotid bruit heard on auscultation, No murmurs.

Lungs: Clear to auscultation bilaterally. Chest rise symmetric without evidence of respiratory distress.

Abd: Bowel sounds present. No abdominal tenderness observes. Abdomen round and soft. Nondistended, no masses. Obese.

PV: Peripheral pulses normal, 2+ radial pulses bilaterally. 2+ posterior tibial and dorsal pedis pulse

MSK: Normal range of motion and muscle tone

Neuro: Strength 5/5 and equal throughout all extremities

Reference no: EM133310650

Questions Cloud

Describe how different sap modules would impact the general : Every transaction that is processed via an ERP system would have an impact on organisation's general ledger. Describe how different SAP modules would impact

Describe the process of how the ehr can be used to promote : Describe the process of how the Electronic Health Record (EHR) can be used to promote evidence-based practice. Use a specific problem

What is an organisations mission and vision statement : Describe what is an organisations Mission and Vision Statement. Give an example of a Procurement goal that can be aligned to the organisation's overall goals

Explain how the canadian government may affect : Explain how the Canadian government may affect strategic implementation-in an alliance or another form of entry strategy, for chevron

How would you treat patient using appropriate guidelines : List the pertinent positives and negatives. What additional questions/information would you ask?How would you treat this patient using appropriate guidelines?

What economic risks are implicit in hallorans logistics : What economic risks are implicit in Hallorans logistics choices? How has the firm endeavored to reduce these? How successful have they been

Briefly describe how rfid can be used : Briefly describe how RFID can be used to manage inventory and discuss the benefits and drawbacks of the use of RFID in the company. Excude Walmart, Amazon

Local community in westchester county : Your good friend Operetta tells you that she wants to open a jazz club and coffeehouse in her local community in Westchester County.

Jazz club and coffeehouse in local community : Your good friend Operetta tells you that she wants to open a jazz club and coffeehouse in her local community in Westchester County.

User Account

All Pages