Unit 7 Discussion 1: Diabetes Treatment
10781You have a newly diagnosed, type 2 diabetic, 16-year-old female in your clinic. The patient is the goalie of her high school soccer team. Her BMI is 37.
Your treatment plan for the new diagnosis of type 2 diabetes – structure your plan using the format outlined in the SOAP note assignment instructions (e.g. diagnostics, therapeutics, educational, consultation/collaboration)
Citations for each of the evidence-based practice (EBP) interventions included in your plan
For each article, you cited in support of an element of the plan, provide your thoughts about the strength of the evidence presented in the article(s)
Bickley, L.S. (2021). Overview: Physical examination and history taking. Bates’ guide to physical examination and history-taking, 13th ed. New York: Lippincott, Williams, & Wilkins. ISN-13:9781496398178
Chapter 25 – Children: Infancy through Adolescence
Chapter 27 – Older Adult
Chapter 5 – Clinical Reasoning, Assessment, and Plan
Chapter 7 – Evaluating Clinical Evidence
LECTURE NOTES for this week:
Unit 7 – Lecture
You have analyzed elements of assessment for several systems. Remember when completing a comprehensive physical examination, you want to have as much information from the patient as possible. Remember:
Location: be specific: ask the person to point to the location e.g. if the problem is pain note the precise site. “Head pain “is vague; “pain behind the eyes”, “jaw pain” are more precise and diagnostically significant. Localized to this site or radiating to other regions of the body.
Character or quality: Use specific descriptive terms like –burning, sharp, dull, aching, throbbing, and shooting. Use similes-Does it look like sticky tar— (blood in stool) or coffee grounds (blood in vomitus)
Quantity or severity: Attempt to quantify the symptom or sign, for example— “profuse menstrual bleeding soaking 5 pads/hour”. Pain is difficult to quantify due to variable perceptions—horrible for one person might not be too bad for another. Avoid adjectives and ask how it affects daily activities. “I was so sick had to come home and go to bed—doubled up could not move”.
Timing or onset, duration, frequency: When first appeared—specific date, and time, want to get to how long-ago symptom started prior to arrival or being seen (PTA). “The pain started yesterday” does not mean much when read in the future—Include questions like how long did the symptom last (duration)? Was it steady or constant or did it come and go during that time (intermittent)? Cycle or remission or exacerbation—Did it resolve and reappear days or weeks later?
Setting: Where was the person or what was the person doing when the symptom started? What brings it on, for example “Did you notice the pain after shoveling snow or did it start by itself”?
Aggravating or relieving factors (Precipitating or palliative): What makes it worse? What relieves it? Is it aggravated by weather, activity, food, medication, standing, bending over, season etc.? What is the effect of any treatment? Ask what have you tried or what seems to help?
Associated factors: Is the primary symptom associated with any others e.g. urinary frequency is it associated with burning, fever, chills, nausea & vomiting. Review the body system (s) related to this symptom. e.g. urinary frequency, the abdomen, Genitourinary system are related to this symptom.
Patient’s Perception or Understanding: Find out the meaning of the symptom by asking how it affects daily activities. Ask directly “What do you think it means?” Alerts you to potential anxiety if the patient thinks it is worrisome or ominous.
Organize your assessment using the mnemonic PQRSTU:
P: Provocative or Palliative: What brings it on? What were you doing when you first noticed it? What makes it better worse?
Q: Quality or Quantity: How does it look, feel, sound? How intense severe is it?
R: Region or Radiation: Where is it? Does it spread anywhere?
S: Severity Scale. How bad is it? (On a scale of 1-10). Is it getting better worse or staying the same?
T: Timing. Onset—Exactly when did it first occur? Duration—How long did it last? Frequency—How often does it occur?
U: Understanding. Patient’s perception of the problem. Why do you think it means or what do you think is going on?
Assessing Children from Infancy Through Adolescents
Infants: The parent should always be present to provide feelings of security and to understand normal growth patterns of the child; older than 6 months, the exam will likely go more smoothly if the parent holds the child for the exam. Try to schedule the examination for one or two hours after feeding, keep the environment warm, and remove clothing for the exam. Be sure your hands and stethoscope are warm so as not to startle the infant. Keep the invasive parts of the exam, such as Moro or “startle” reflex, ears, nose, and throat, for the end.
Toddlers and Preschoolers: Be prepared for the toddler to be attached to the parent, resistant to the exam, and generally independent. Start the exam while the toddler is in the parent’s lap and have the parent participate in holding the child for more difficult parts such as ears, nose, and throat. Having something that the toddler is familiar with, such as a favorite toy or blanket, can provide feelings of security. You may choose to “show” the child how you will examine him or her by demonstrating the technique on the parent.
Schooled Aged Children: Allow school-age children to sit on the exam table and with an older child (11 years or over) encourage parent attendance, if agreeable. Use a gown or drape, leave on underwear, and allow the child to change clothes himself or herself. Explain procedures and equipment—these children are curious and enjoy learning. Talk with them according to their age level and comprehension.
Developmental Specific History
Infant: Start the history with inquiring about prenatal history. Was the mother diagnosed with any health conditions during her pregnancy, such as hypertension, rubella in the first trimester, unexplained fever, or other infections? What medications did the mother take during her pregnancy? Were there any abnormalities in the prenatal ultrasounds? Next inquire about any abnormalities that the mother may have observed in the infant. Ask the mother if she has seen any facial color change of the baby while nursing or crying. Does the baby sweat while drinking? Is the baby able to finish feeding without resting? Does the baby play without tiring quickly? How much sleep does the baby seem to require daily? How many naps and for how long? Is this pattern consistent? Is the baby meeting its motor-skill milestones as anticipated? Has the baby grown as expected when compared to siblings or developmental growth charts?
Toddler/Children: Start by obtaining a history. Is there a family history of heart defects—in particular, a sibling? Is there a family history of chromosomal abnormalities such as Down syndrome? Does the child keep up with playmates in activity endurance? Can the child climb, ride a bike, walk, run, or play without having to rest after a brief time? Does the child assume a squatting position to rest during play or a knee-to-chest position during sleep? Are there any facial skin color changes or “blue spells” during playtime or activity? Does the child complain of unexplained joint pain or fevers, or suffer from frequent headaches or nose bleeds? Does the child have recurrent respiratory infections? How many per year and how are they treated? Is there any documentation of streptococcal infections? Has growth been maintained?
The Older Adult Physical Examination
You may need to adjust your examination pace to allow for rest periods in older patients. Be ready to adapt to their needs—they may not be able to sit on the exam table or may have difficulty with sight or hearing. Do not mistake visual or auditory problems for memory loss and vice versa. Do include a brief memory assessment, such as the clock draw test or Mini-Cog, at least once a year and more often, if indicated.
Geriatric approach to primary care
Learn to quickly identify frail elderly patients
Look for common geriatric syndromes including falls, cognitive impairment, functional dependence, and urinary incontinence in every patient.
Learn assessment tools for the geriatric population.
Be familiar with community resources, such as fall prevention programs and senior centers.
Consider a patient’s goals, life expectancy, and functional states before considering testing or procedure.
Review advanced directives and goals of care periodically with patients.
Be knowledgeable about the Beers criteria (see page 972 in Bate’s Guide).
Adopt an evidenced based practice approach to health screening.
Watch carefully for mood disorders in the frail elderly and consider geriatric specific screening tools.
Provide Caregiver support when possible.
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