Clinical Decision-Making Research Proposal

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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

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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.

Research Proposal on Clinical Decision-Making Assignment

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 <200 mg/dL.

Many authorities add the advice that fasting levels be kept <= 130 mg/dL. These goals are possible in most NIDDM patients and some IDDM patients, but they must be individualized and should be modified when conditions make any risk of hypoglycemia intolerable (eg, in patients with a short life expectancy, those with cerebrovascular or cardiac disease) or increase the risks of being hypoglycemic (eg, in patients who are unreliable or who have autonomic neuropathy).

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… [END OF PREVIEW] . . . READ MORE

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