NURS 6229-Putting It All Together.

Posted: November 3rd, 2022

NURS 6229-Putting It All Together.

 

Problem statement

The client is a 58-year-old woman who presents with a three-month history of fatigue. She reports reduced energy, increased frequency of urination, increased fluid intake and thirst, headaches, dull and generalized pain.

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Differential list

1. Diabetes type 2
2. Diabetes insipidus
3. Hypothyroidism

Illness Script

Disease/ Syndrome	Epidemiology	Time Course	Mechanism of the disease(Pathophysiology)	Signs & Symptoms (Morphology)	Lab/Diagnostics	Treatment Plan
Diabetes type 2	85% of total diabetes Mostly occur in over 45 years 5,800  youths	Chronic	Peripheral insulin resistance, impaired regulation of hepatic glucose production, and declining β-cell function, eventually leading toβ -cell failure.	Frequent urination, increased thirst, increase in hunger and unintended loss of weight. Blurred vision, fatigue, frequent infections, slow healing of sores as well as darkened neck and armpits among other areas of the skin	Glucose test Glucose tolerance test Blood glucose monitoring Postprandial glucose test Homeostatic model assessment Hemoglobin A1C	No cure Hormone replacement Liothyronine
Diabetes insipidus	1.6 million Americans, about 187,000 children (Christ-Crain et al., 2019)   Americans age 65 and older	Chronic	Abnormality in the functioning or levels of antidiuretic hormone (ADH) Nephrogenic DI results from lack of aquaporin channels in the distal collecting duct a lack of ADH prevents water reabsorption and the osmolality of the blood increases. polydipsia and polyuria cycle occur	bedwetting, weak muscles, constipation, dry skin, waking frequently through the night to urinate, excretion of colorless or pale yellow urine, excessive amounts of urine production and extreme thirst	Water deprivation test. Magnetic resonance imaging (MRI) Genetic screening	Intake of sufficient fluids and administration of desmopressin, thiazides and aspirin medications
Hypothyroidism	One billion people globally Women are more likely to develop hypothyroidism than men (7 times)	Chronic	Underactive thyroid glad Deficiency of the thyroid hormones triiodothyronine (T3) and thyroxine (T4) Reduction of the basal metabolic rate and generalized myxedema.	Fatigue, weight gain, depression, constipation and poor ability to tolerate cold conditions. Poor memory, the presence of course dry skin, dyspepsia and shortness of breath	Blood test TRH Stimulation test Fine needle aspiration Thyroid function test Thyroid stimulating hormone measure	‎Levothyroxine

 

Most likely diagnosis

The most likely diagnosis for the client is Diabetes type 2. This illness occurs when the body fails to effectively use insulin to bring glucose into the body cells. It is characterized by both inadequate insulin secretion and resistance by pancreatic beta cells (Chatterjee, Khunti & Davies, 2017). It is a lifelong disease and patients with this disorder are considered to be insulin resistance, it occurs often among the middle-aged or older adults and hence referred to as the adult-onset diabetes. Currently, there has not been discovered any cure for diabetes type 2. However, the treatment focuses on managing the symptoms and improving the quality of life of the patient. The control of blood sugar is done through the administration of anti-diabetic medication.

The clinical manifestations of diabetes type 2 usually develop gradually and hence can be detected after years of onset. The most likely symptoms include frequent urination, increased thirst, increase in hunger and unintended loss of weight. Blurred vision, fatigue, frequent infections, slow healing of sores as well as darkened neck and armpits among other areas of the skin are also important signs. Itching of the skin and dry mouth are also reported symptoms in these patients. The symptoms severe and become more potentially dangerous as the disease progresses.

In this case, is evident that the patient suffers from diabetes type 2. This is because; she is currently at an age with increased risk of contraction of the illness. Moreover, she presents with a history of fatigue which is the major clinical manifestation of the illness. She has lost energy which has affected her daily activities probably due to increased hunger and has also reported frequent urination particularly at night which is an indicator of diabetes type 2. Occasional headaches and elevated thirsts suggest an imbalance in the blood glucose levels of the client. In addition, the client’s family has a history of diabetes type 2 which is a predisposing factor.

Two alternative diagnoses

Diabetes insipidus is an alternative diagnosis for this client. It is a chronic condition characterized by the release of large quantities of dilute urine and increased thirst. It occurs when the kidneys fail to concentrate urine normally resulting in the excretion of up to 20 liters of dilute urine (Christ-Crain et al., 2019). The lack of antidiuretic hormone (ADH) that controls the amount of excreted water in the body causes diabetes insipidus. Treatment involves the intake of sufficient fluids and administration of desmopressin, thiazides and aspirin medications.

The clinical manifestations of diabetes insipidus include bedwetting, weak muscles, constipation, dry skin, waking frequently through the night to urinate, excretion of colorless or pale yellow urine, excessive amounts of urine production and extreme thirst. In this case, the client presents most of these symptoms including frequent urination and getting up two to three times a night to go to the bathroom. Her thirst is elevated resulting to her increased intake of fluids and she feels weak from lost energy. Consequently, she has had dry skin for the last one year probably due to dehydration. However, diabetes insipidus clients do not report fatigue which is the chief complain of the patient. Additionally, she does not report bedwetting, constipation. Notably, the client does not experience seizures which are common complications of the disease.

The second alternative diagnosis for Ms. Darwin is hypothyroidism. This condition occurs when the thyroid gland is not able to produce enough thyroid hormone which consequently disrupts the metabolism of the body. As such, individuals suffering from this illness present slowed metabolic activities. It is often asymptomatic during the early stages even though the symptoms and potential dangers present with severity of the symptoms. It is treated through ‎Levothyroxine which seeks to improve the production of sufficient thyroid and normalize the body’s metabolism. Its onset is usually at the age of 60 years and above.

The signs and symptoms of hypothyroidism include fatigue, weight gain, depression, constipation and poor ability to tolerate cold conditions. Poor memory, the presence of course dry skin, dyspepsia and shortness of breath are also relevant manifestations (McDermott & Ridgway, 2016). Furthermore, heavy menstruation occurs in females accompanied by poor hearing and abnormal sensations. The chief complaint of the client is fatigue which is an important sign in hypothyroidism. Dry skin is also reported. However, the patient tolerates cold conditions, has no digestive or hearing issues or shortness of breath among other signs of hypothyroidism.

 

 

History of Present Illness:

Ms. Dawson is a 58-year-old woman who presents with a three-month history of fatigue. She reports that she doesn’t seem to have as much energy as she used to for daily activities. She has also noted increased frequency of urination, often having to get up two to three times a night to go to the bathroom. She has increased her intake of liquids because she feels thirsty all of the time. She is also experiencing headaches. She describes them as a dull, generalized pain, without accompanying photophobia, phonophobia, nausea, vomiting, visual changes or focal neurologic symptoms. Occasional headaches have been occurring over the last three months, but in the last week they have increased in frequency and severity and are now occurring daily. In the last week she has also noted that urination has become even more frequent.

 

Past Medical History:

1. Allergic rhinitis (2000)
2. Gastroesophageal reflux disease (2016)
3. Urinary tract infection x 2, resolved (2017)
4. Tinea pedis, resolved (2017)

 

Allergies: NKDA

 

Medications:

1. loratadine 10mg po daily as needed for nasal congestion
2. omeprazole 20mg po daily as needed for heartburn
3. acetaminophen 1000mg as needed for headache

 

Past Surgical History: no prior surgeries

 

Family History:

Mother with hypertension and type 2 diabetes mellitus, died at age 71 of CVA. Father, age 79, with hypertension and coronary artery disease. Sister, age 55, with hypertension and type 2 diabetes mellitus. Daughters healthy at age 29 and 33. Maternal aunt died of breast cancer at age 62.

 

Social History:

Ms. Dawson works as a bank teller. She is married and has two adult daughters. She has smoked half a pack of cigarettes daily for the last 30 years. She drinks a beer or glass of wine approximately once a week and denies other drug use. She is sexually active in mutually monogamous relationship with her husband. Ms. Dawson has recently begun trying to lose weight. She walks for exercise about 20 minutes every other week. She is attempting to eat a healthier diet by purchasing low fat versions of the products she usually buys at the grocery store.

 

Health Maintenance:

1. Last pap smear 2 years ago, negative. No history of abnormal pap smears.
2. Last mammogram one year ago, normal.
3. Last colorectal cancer screen: colonoscopy 7 years ago, normal other than diverticulosis.
4. Influenza immunization in November of last year.
5. Does not recall if her cholesterol or blood sugar have ever been tested.

 

Review of Systems:

• General: Increasing fatigue over the last 3 months, per HPI. Ten lb. weight gain over the last 18 months. No recent fever or chills. Intermittent headache.
• Eyes: Has noted blurred vision last 3 weeks. No eye pain, redness.
• Ear/Nose/Throat: No hearing loss, tinnitus, vertigo, earaches, nasal congestion, discharge, epistaxis, dental problems, sore throat.
• Neck: no lumps, pain, stiffness.
• Skin: no rashes, reports “dry” skin for the last year.
• Breasts: No lumps, pain, discharge.
• Pulmonary: No shortness of breath, cough, hemoptysis, wheezing.
• Cardiovascular: No chest pain, dyspnea on exertion, palpitations, orthopnea, PND, peripheral edema.
• Gastrointestinal: heartburn 1-2 times per month if she ears spicy food. No nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stools or melena.
• Genitourinary: Three-day history of scant white vaginal discharge and itching in vaginal area. Nocturia 2-3x per night. No hematuria, urgency. LMP 8 years ago. Gravida2/Para2/Abortion0
• Musculoskeletal: No pain, stiffness, swelling in joints or muscles.
• Neurologic: No focal weakness or numbness. She did say she noticed some “pins & needles” sensation in both feet and hands that comes and goes for approximately 3 months.
• Hematologic: No easy bruising or bleeding.
• Endocrine: +Polyuria, +polydipsia per HPI. No heat or cold intolerance,
• Psychiatric: No depression, anxiety.

 

Physical Exam:

• Vital signs: P 84, RR 16, BP 137/82 T 37.2, weight 189 lbs., height 5’6”, BMI 30
• General: Alert, well-appearing, in no acute distress.
• Skin/Hair/Nails: No rashes, lesions, scars; hair is brown and evenly distributed; no clubbing of the nails; nailbeds pink
• HEENT: Normocephalic; Facial features symmetrical; TMJ palpated without tenderness, without clicking/crepitus; buccal mucous membranes somewhat dry, good dentition, gums pink without redness or swelling, uvula midline, tonsillar pillars pink and symmetric; bilateral nares are patent, nasal septum is midline with pink moist turbinates; ears are symmetric, auricles are aligned, no nasal discharge, nasal septum slightly deviated to the left, but does not obstruct airflow, inferior and middle turbinates dark pink, moist, and free of lesions, frontal and maxillary sinuses  are nontender to palpation and percussion.
• Neck: supple, without masses. Trachea mid-line. Has smooth, controlled, full range of motion of neck. Thyroid gland nonvisible but palpable when swallowing. Lymph nodes nonpalpable.
• Pulmonary: Lungs clear to auscultation bilaterally with good air movement and symmetrical expansion. Tactile fremitus symmetric. Percussion tones resonant over all lung fields. No adventitious sounds present.
• Cardiovascular: Normal S1, S2 without murmurs, rubs or gallops. Radial and dorsalis pedis pulses symmetric, 2+ bilaterally, no peripheral edema. Carotid pulse equal bilaterally, 2+, elastic.  No bruits auscultated over carotids.  Jugular venous pulsation disappears when upright.  Apical impulse palpated in the fifth ICS at the left MCL.
• Peripheral vascular: Capillary refill time less than 2 seconds, radial and brachial pulses +2 bilaterally. Extremities are pink in color and warm to touch bilaterally, normal distribution of hair, no ulcers or edema. Dorsalis pedis, radial, and posterior tibial pulses +2 bilaterally.  No apparent varicosities or superficial thrombophlebitis noted.
• Abdomen: Skin of abdomen is free of striae, scars, lesions, or rashes. Umbilicus is midline and recessed with no bulging. Nontender, nondistended, no masses or organomegaly, Centralized adiposity. Unable to palpate the liver edge. No peristaltic movements seen. Soft clicks and gurgles heard at a rate of 15 per minute. Percussion reveals generalized tympany over all four quadrants.
• GU/Genitalia: Normal pubic hair distribution, no lesions, masses, or swelling. Labia majora pink, smooth, and free of lesions, excoriation, and swelling.  Labia minora dark pink, moist, and free of lesions, excoriation, swelling. No discharge from urethral opening. No malodorous discharge noted from vagina.Scant amount of thick, white discharge in vaginal vault. No cervical motion tenderness, fundal or adnexal tenderness.
• Musculoskeletal: Gait smooth, with equal stride and good base of support. Normal curves of cervical, thoracic, and lumbar spine. Paravertebral spine is nontender.  Full smooth ROM of cervical and lumbar spine. Upper and lower extremities symmetric without lesions, nodules, deformities, or swelling. Full smooth ROM against gravity and resistance in all extremities.
• Neurological: No atrophy, tremors, weakness, full ROM of all extremities.  Get-up-and Go test was normal; No fasciculations, tics, or tremors. Gait and tandem walk normal and steady. Negative Romberg test. Performs repetitive alternating movements, finger to nose at smooth, good pace. Runs each heel down each shin with no deviation. Identifies light touch, dull and sharp sensations to trunk and bilateral extremities. Vibratory sensation, stereognosis, graphesthesia, two-point discrimination intact. Reflexes 2+ bilaterally, except Achilles 1+.

Cranial Nerves:
#1. Identifies correct scents
#2. Vision 20/20 OS, 20/20 OD, full visual fields intact.
#3,4,6 No ptosis, full extraocular movements (EOM) pupils equally round, react to light

and accommodation (PERRLA)
#5. Temporal and masseter muscles contract bilaterally. Able to identify light, sharp, dull
touch to forehead, cheek, and chin.  Corneal reflex present.

#7. Able to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise

eyebrows, and close eyes against resistance.
#8. Whispered 2 syllable words heard bilaterally.

#9, 10. Uvula and soft palate rise symmetrically on phonation. Gag reflex present and

swallows without difficulty.
#11. Equal shoulder shrug against resistance; turns head in both directions against
resistance.
#12. Protrudes tongue in midline with no tremors, able to push tongue blade to right and

left without difficulty.

 

1. Read the case scenario
2. Write a problem statement.
3. Develop a differential list of the three most likely diagnoses. List these in priority of which you think is the most likely first.
4. Develop an Illness script of the three diseases using the format you are familiar with. Include the risk factors and key discriminating features.
5. Write an explanation of the reasoning in choosing the most likely diagnosis.
6. Write an explanation of the reasoning in choosing the two-alternative diagnosis.

The Problem Statement:

Age & gender; highly relevant medical history; primary symptoms using semantic qualifiers; highly relevant diagnostic data, using clinical syndromes when possible. This should be 2 sentences.

Differential List

This is three diagnoses (not symptoms). The one you think is most likely is listed first.

Develop an Illness Script

Use the format you are familiar with from class. There is a blank Illness scrip uploaded in the course documents if needed.

Explanation of Most Likely Diagnosis

Write an explanation of the reasoning in choosing the most likely diagnosis. This will include the data from the case scenario itself to support your decision as well as two references from peer reviewed books or journals within the last 5 years. This explanation is to be at least 400 words, maximum of 600 words.

Explanation of the two-alternative diagnosis

Write an explanation of the reasoning in choosing the two-alternative diagnosis. This will include the data from the case scenario itself to support your decision as well as two references from peer reviewed books or journals within the last 5 years. Include why this was NOT your most likely diagnosis. This explanation is to be at least 300 words for EACH alternative diagnosis (600 words total), maximum 800 words.

NOTE: The references need to be different. They also need to be other than your required books. It will mean that you have six peer reviewed, scholarly articles within the last 5 years. References are on a separate page, APA style, spelling & correct APA style as well as grammar will be considered in the grading rubric. There is to be a title page (running head/page number). Do NOT use quotes and do not copy and paste.

 

 

 

Illness Script

Disease/ Syndrome	Epidemiology	Time Course	Mechanism of the disease(Pathophysiology)	Signs & Symptoms (Morphology)	Lab/Diagnostics	Treatment Plan
	Demographics (age, sex, race) Risk factors Prevalence/Incidence	How does the disease present (acute, chronic, intermittent, acute with exacerbations, etc.)	The pathogenesis of a disease is the biological mechanism that leads to the disease state. It describes the origin and development of the disease. The pathogenic mechanisms of a disease are set in motion by the underlying causes, which if controlled would allow the disease to be prevented. Specifically, the cellular events and reactions and other pathologic mechanisms occurring in the development of the disease.	Classic signs/symptoms. This includes subjective, objective, pertinent positive & negative findings.	May include lab and diagnostics such as MRI, CT, and clinical tools such as CAGE, PHQ9, Centor strep scale, etc.	May include medications, herbals, behavioral, consult & referral, education.

 

 

 

PIAT Rubric

	Unsatisfactory: 0-13 points		Developing: 14-15 points		Accomplished: 16-17 points		Exemplary: 18-20 points	Total
Problem Statement	There are significant errors in use of semantic qualifiers used in the statement. There are significant missing data or data that is not pertinent. The statement is more than 2 sentences long.		There are several errors in use of semantic qualifiers used in the statement. There are several missing data or data that is not pertinent. The statement is more than 2 sentences long.		There are few errors in use of semantic qualifiers used in the statement. There are a few missing data or data that is not pertinent. The statement is more than 2 sentences long.		Provides a concise summary statement that uses semantic vocabulary to highlight the most important elements from the case scenario to represent the patient’s main problem in 2 sentences.	/20
	Unsatisfactory: 0-13 points		Developing: 14-15 points		Accomplished: 16-17 points		Exemplary: 18-20 points	Total
Differential Diagnosis	Offering less than three diagnostic possibilities. The list does not accurately reflect the information from the case study.		Offering less than three relevant diagnostic possibilities, committing to the most likely. The list does not accurately reflect the information from the case study.		Offering three relevant diagnostic possibilities, committing to the most likely. The list is prioritized with the most likely first and somewhat accurately reflects the information from the case study (maybe the list is not in correct order)		Offering three relevant diagnostic possibilities, committing to the most likely. The list is prioritized with the most likely first and accurately reflects the information from the case study.	/20
	Unsatisfactory: 0-13 points		Developing: 14-15 points		Accomplished: 16-17 points		Exemplary: 18-20 points	Total
Illness Script	Demographic findings are lacking detail and not correlated to the disease. Classic assessment findings are lacking detail. Pathophysiology is limited. The parameters listed for time course do not correspond to the disease and semantic qualifiers are not used. Limited presentation of the lab, procedures, treatment for the disease is listed. . No key/differentiating features are in red. No sub-headings used.		Classic demographics are somewhat listed. Classic assessment findings are somewhat listed. Limited overview of the biomedical causes of the disease. Incomplete listing of based time course of the disease listed using semantic qualifiers. Limited presentation of the lab, procedures, treatment for the disease is listed. Minimal key/differentiating features are in red. No sub-headings used.		Classic demographics are partially listed. Classic assessment findings are partially listed. Partial overview of the mechanism of the disease. Partial listing of based time course of the disease listed using semantic qualifiers. Partial presentation of the lab, procedures, treatment for the disease is listed. Most key/differentiating features are in red. Some sub-headings used.		Classic demographics listed. Substantial classic assessment findings listed. Substantial overview of the mechanism of the disease. Evidenced based time course of the disease listed using semantic qualifiers. Evidenced based lab, procedure, treatment is complete. Key/differentiating features are in red. Sub-headings used. One page per disease.	/20
	Unsatisfactory: 0-13 points	Developing: 14-15 points		Accomplished: 16-17 points		Exemplary: 18-20 points		Total
Explanation of the Most Likely Diagnosis	Explains the reasoning behind the most likely diagnosis, uses few data or inaccurate data from the case scenario, without how these compare and contrast with the patient’s presentation. Shows unsatisfactory understanding of the disease in relation to the case study. Entry is less than 300 words.	Explains the reasoning behind the most likely diagnosis, including some data or inaccurate data from the case scenario and cited how these compare and contrast with the patient’s presentation. Shows developing understanding of the disease in relation to the case study. Entry is less than 300 words.		Explains the reasoning behind the most likely diagnosis, including data from the case scenario and cited how these compare and contrast with the patient’s presentation. Shows good understanding of the disease in relation to the case study. Entry is less than 300 words.		Explains the reasoning behind the most likely diagnosis, including data from the case scenario and cited how these compare and contrast with the patient’s presentation. Shows excellent understanding of the disease in relation to the case study. A minimum of 400 words, maximum of 600 words.		/20
	Unsatisfactory: 0-13 points	Developing: 14-15 points		Accomplished: 16-17 points		Exemplary: 18-20 points		Total
Explanation of Two Alternative Diagnoses	Explains the reasoning behind the most likely diagnosis, uses few data or inaccurate data from the case scenario, without how these compare and contrast with the patient’s presentation. Shows unsatisfactory understanding of the disease in relation to the case study. Entry is less than 400 words.	Explains the reasoning behind the most likely diagnosis, including some data or inaccurate data from the case scenario and cited how these compare and contrast with the patient’s presentation. Shows developing understanding of the disease in relation to the case study. Entry is less than 400 words.		Explains the reasoning behind the most likely diagnosis, including data from the case scenario and cited how these compare and contrast with the patient’s presentation. Shows good understanding of the disease in relation to the case study. Entry is less than 400 words.		Explains the reasoning behind the alternative diagnosis (why it is not the most likely and why it was chosen to be on the list), including data from the case scenario and cited how these compare and contrast with the patient’s presentation. Shows excellent understanding of the disease in relation to the case study. A minimum of 600 (300 each) words maximum of 800 words.		/20
	Unsatisfactory: 7-15 pts. deducted	Developing: 4-6 pts. deducted		Accomplished: 1-3 pts. deducted		Exemplary: No pts. deducted		Total
Organization (Includes title & reference page)	Substantial errors in APA/grammar/spelling. Citations to non-scholarly websites given as rationale. No evidence-based, peer reviewed journal article cited.	Several errors in APA/grammar/spelling. Partially supported by evidence from three or less sources; may be outdated or non-scholarly.		Minimal errors in APA/grammar/spelling. Partially supported by evidence from four appropriate sources published within the last 5 years.		No errors in APA/grammar/spelling. Supported by evidence from six appropriate sources published within the last 5 yrs. Appropriate sources are scholarly evidenced based & peer reviewed articles.
Comments	NOTE: The references need to be different. It will mean that you have six peer reviewed, scholarly articles within the last 5 years. I need to be able to access the article. References are on a separate page, APA style, spelling & correct APA style as well as grammar will be considered in the grading rubric. There is to be a title page (running head/page number). Do NOT use quotes and do not copy and paste.							Grade

1/9/20 KH