Posted: August 1st, 2023

Week Seven Signature Assignment

WEEK SEVEN 4

Week Seven Signature Assignment
FNP 595: Primary Healthcare of Chronic Clients/Families Across the Lifespan

Week Seven Signature Assignment

This paper discusses a case of a 64-year-old Asian male who presents to the clinic due to wheezing and a non-healing wound on his left foot. His subjective and objective information is significant for a history of Hypertension, Diabetes Mellitus Type 2, Hypothyroidism, and Anemia. This paper will present a SOAP note regarding this case, evidence-based literature, discussion, and recommendations related to the EBP literature.

SOAP Note
ID: B.V. is a 64-year-old Asian Indian male who presents to the clinic with his son. He appears to be a reliable historian and the son interpreted for his father.

CC: Wheezing and non-healing wound on the left foot.

HPI: B.V. is a 64-year-old Asian Indian male who presented to the clinic due to wheezing and a non-healing wound on his left plantar foot. This patient recently moved to the US from India a month ago and wishes to establish his PCP in this clinic. The patient noticed a wound that has not healed for more than 1 month. The patient states that the wound has no drainage, and his son has been doing home dressings at home. Also, the patient noticed that he started having continuous wheezing for more than 3 weeks. The patient is a chronic smoker x 20 years x 1 PPD. He admits to having a cough with minimal sputum (greenish). Hoarseness, dysphagia, SOB is present and he vomited 3 days ago. He feels like there is a “lump in his throat”. He has a past medical history of HTN, DM, 2, hypothyroidism, and Anemia. He denies taking any medications for his wheezing. Dyspnea is worsened by activity. He denies chest pain, palpitations, and dizziness. The son states that the patient has been non-compliant with his medications

Past Medical/Surgical History:

HTN, DM 2, Hypothyroidism, Anemia.

Hospitalization: unable to recall Allergies: NKDA

Medications: Medications from India

Vildagliptin 50 mg daily Levothyroxine 50 mcg daily

Telmisartan 40 mg daily Bisoprolol 50 mg daily

Lantus 20 units SC daily Delpran-L ½ tab at night (dosage unable to recall)

Vaccinations: Tdap- UTD, 2018 Flu- not up to date, refused vaccination; COVID vaccine- received 2 doses, other vaccinations- unknown if received

Social History:

The patient states that he has been actively smoking for 20 years x 1PPD. He stopped smoking a week ago. He drinks alcohol occasionally and denies the use of street drugs. He states that he consumes 2 cups of tea per day. He is a retired teacher and is not sexually active. He currently lives with his 2 children in a residential home. He recently moved to the US and is using his travel insurance for healthcare coverage. His children are supportive and provide for his needs.

Religious Preference: Sikhism

Family History:

Father- deceased at 55 y.o. due to respiratory failure, Mother- deceased at 80 y.o., no known past medical history.

Siblings- 1 brother- has DM 2, Children- 1 girl, 1 boy- healthy, no known medical condition

ROS:

General: Denies fever, chills, or appetite changes. Admits to feeling fatigued.

Skin: States that he has a non-healing wound on his left plantar foot that has been there for 1 month.

Head/Neck: He denies any headache or neck pain.

ENT: Denies blurry vision or rhinorrhea. Admits to having dysphagia and voice hoarseness x weeks.

Respiratory: States that he has a cough with minimal greenish sputum and dyspnea that is worsened by exertion.

C/V: denies chest pain or palpitations. Endocrine: Has a history of hypothyroidism and DM 2.

GI: Denies abdominal pain, diarrhea, constipation, nausea, or vomiting. States that he was 2-3 episodes of vomiting 3 days ago. Neuro: Denies seizures, tingling on lower extremities, numbness.

Psychiatric: Denies depression, anxiety, or insomnia

Vitals Signs:

Temperature: 98.1 (skin) BP: 125/76 (left arm, sitting), HR: 94, O2 saturation 99% on RA

RR:20 ; Weight: 144 lbs.; Height: 5ft, 8 inches, BMI: 22

Physical Examination:

General Appearance: Patient is alert and oriented x 3. He appears fatigued.

Skin: Wound noted on the left plantar foot, dime-sized and with scant clear discharge. No bleeding or purulent discharge was noted.

ENT: No discharges on ear canals. Moist and pink oral mucosa without lesions. Posterior pharynx moist, pink without any exudate.

GI: Normal bowel sounds. No tenderness, masses, or lumps were noted upon palpation.

Respiratory: Rhonchi and wheezing were noted bilaterally throughout upon auscultation.

Cardiovascular: No gallops, friction rubs, or murmurs noted. RRR, S1 and S2 were noted. No edema on extremities was noted.

Musculoskeletal: Able to perform ROM without difficulty.

Neurologic: No syncope, confusion, or dizziness noted. The patient is alert and oriented.

A:

COPD

Rationale: Smoking is the most significant cause of COPD. Individuals who have COPD usually present in their 5th or 6th decade of life manifesting excessive sputum production, cough, and dyspnea (Papadakis et al., 2021).

DM 2

Rationale: This patient is non-compliant and maybe have uncontrolled DM. He has an established diagnosis of DM 2. Diabetes mellitus is a syndrome of metabolic disorder and hyperglycemia due to insulin secretion deficiency and or insulin resistance (Papadakis et al., 2021)

Diabetic wound left foot

Rationale: The impaired metabolic mechanism in DM 2 leads to poor wound healing. The mechanisms of DM are due to reduced cell and growth factor response decreased blood flow in the peripheral areas, and impaired local angiogenesis (Syafril, 2018).

Diagnostics:

Random blood sugar, HbA1C, and TSH today

Lung Function Test/Spirometry- not ordered during this encounter

Management

Pharmacologic/Therapeutic:

1. Combivent Respimat 1 puff QID

2. Augmentin 875 mg 1 tab q 12 x 10 days

3. Qvar 80 mcg/puff 2 puffs BID x 7 days

4. Lantus 20 units SC daily

5. Bactroban ointment to wound BID.

Education:

1. Imparted smoking cessation information. Smoking increases the risk of developing heart diseases and worsening diabetic foot ulcers.

2. Blood sugar should be monitored regularly at home. Glycemic control goals are as follows: Fasting blood sugar- 80-120 mg/dL and Glucose at bedtime- 100-140 mg/dL

3. If the blood sugar drops below 59, follow the 15:15 rule- eat 15 grams of Carbohydrates and wait 15 minutes before taking either of the following: 3 glucose tablets, ½ cup orange juice, ½ cup apple juice, 1/3 cup grape juice, or 6 oz of regular coke (Cash et al., 2021).

4. Perform moderate-intensity exercises (jogging, cycling, walking) 20-45 minutes/day 3 to 4x per week.

5. Refrain from exercising if the fasting blood sugar is > 250 or random BS is > 300 mg/dL as this may cause diabetic ketoacidosis.

6. Regularly check feet for cuts or lesions. Perform daily dressing on the affected foot and keep clean. Daily/PRN dressing—irrigate/clean with NS, pat dry, apply Bactroban ointment, and cover with 4×4.

7. Maintain healthy body weight and consume foods that have a low glycemic index. Avoid starchy foods and vegetables.

8. Reduce exposure to environmental irritants/pollutants.

9. Perform deep breathing or pursed-lip breathing when short of breath.

Follow-up:

1. Dilated eye exam, fasting lipid profile and special foot exam should be performed annually.

2. HbA1c should be monitored every 3 months to check the patient’s blood glucose control.

3. Keep BP less than 140/80 mmHg.

4. Keep shingles, flu, pneumonia, and other vaccines up to date.

5. Urine should be checked for the presence of protein/other problems.

(Cash et al., 2021).

Referrals:

Follow up in 1-2 weeks or earlier if symptoms worsen.

Podiatrist referral for management of the diabetic wound.

Related Literature
COPD is one of the most common complications of smoking cigarettes and long-term exposure to irritants (Cash et al., 2021). The criterion that defines obstruction of airflow that is utilized in diagnosing COPD in most guidelines is an FEV1/FVC ratio of <70% (Miravitlles et al., 2016). The treatment goals in a study done by Miravitlles et al. (2016) are focused on decreasing symptoms, slowing down then natural disease progression, improving life quality, improving physical activity, preventing adverse sequelae and complications, and improving life expectancy. In addition, this study recommends a short-acting muscarinic agent (SAMA) or short-acting β2-agonist (SABA) for mild disease and a LABA or LAMA for more symptomatic patients. The combination of ICS and bronchodilator is recommended in patients with FEV1<50% or <60%, those who are at high risk for exacerbations and hose with a previous history of 2 or more exacerbations in the past year, and those who have asthma-COPD overlap syndrome (Miravitlles et al., 2016). Another study that was done by (Fazleen & Wilkinson, 2020) mentions the use of spirometry as the gold standard for COPD diagnosis. In addition, they also mention potential early diagnostic modalities in the form of diffusion capacity for carbon monoxide (DLCO), forced expiratory flow at 25-75% of FVC, total lung volume, and imaging. The second study also mentions that potential interventions for early COPD include smoking cessation, inhaled bronchodilator and steroid therapy, phosphodiesterase-4 inhibitors, macrolides, N-acetylcysteine, and vaccinations (flu, RSV, and other viral infections).

The list of recommendations for diabetic foot management by Pérez-Panero et al., (2019) includes the following: screening inspection of the leg and feet; use of therapeutic footwear, pressure offloading, debridement, dressings, antibiotic therapy, adjuvant treatments (G-CSF), management of neuropathic pain and a multi-disciplinary approach. In a study by (Chawla et al., 2020) that involved the diagnosis of DM among Indian patients, the panel suggests an A1c of greater than or equal to 6.5% for the diagnosis of DM among Indian patients. In addition, screening and early detection include the use of a risk assessment questionnaire and glycemic measure among high-risk individuals. Medical nutrition therapy in this study recommends a diet with the following breakdown: 50-60% carbohydrates with low glycemic load, 30% fats-avoid saturated fatty acids, 15% proteins-limit red meat and the rest include leafy vegetables, nuts, whole grains, and unsaturated fats (Chawla et al., 2020). Metformin is the drug of choice in combination with lifestyle modification. Dual therapy is needed if glucose targets are not accomplished. A sulfonylurea, or thiazolidinediones, or SGLT2 inhibitor or DPP-4 inhibitor or AGI may be added.

Assignment help – Discussion
Based on the knowledge gained, the author believes that most of the diagnostic and management orders are appropriate for this patient. Some additions, however, may improve the management of this patient. For the patient’s COPD, to establish a proper diagnosis, lung function tests such as spirometry should be incorporated. The use of QVAR and Combivent Respimat is appropriate for this patient. Qvar contains a corticosteroid that helps with the inflammatory responses associated with the patient’s symptoms. The Combivent Respimat helps relax the smooth muscles of the airways. Some appropriate interventions that could be added include a referral to a podiatrist and an ophthalmologist. Depending on the result of the A1c, this patient should be referred to a diabetes specialist. People who are of Asian Indian descent may be exposed to excessive consumption of sugary sweets that have significant cultural relevance. In addition, this patient just recently moved from India and may have a hard time looking for western equivalents or previously consumed Indian foods. In this case, a nutritional consult with a registered dietician should be done. Clinical evidence demonstrates that people with Diabetes who are on medical nutrition therapy accomplish a 1-2% reduction in A1c, comparable to the outcomes of antidiabetic therapy, leading to a reduction in costs and improvement in the quality of life (Viswanathan et al., 2019).

References

Cash, J. C., Glass, C. A., & Mullen, J. (2021). Family Practice Guidelines (5th ed.). Springer Publishing Company, LLC.

Papadakis, M., McPhee, S., & Rabow, M. (2021). Current medical diagnosis and treatment. McGraw Hill

Pérez-Panero, A. J., Ruiz-Muñoz, M., Cuesta-Vargas, A. I., & Gónzalez-Sánchez, M. (2019). Prevention, assessment, diagnosis and management of diabetic foot based on clinical practice guidelines: A systematic review. Medicine, 98(35), e16877.

Syafril, S. (2018, March). Pathophysiology diabetic foot ulcer. In IOP Conference Series: Earth and Environmental Science (Vol. 125, No. 1, p. 012161). IOP Publishing.

Viswanathan, V., Krishnan, D., Kalra, S., Chawla, R., Tiwaskar, M., Saboo, B., Baruah, M., Chowdhury, S., Makkar, B. M., & Jaggi, S. (2019). Insights on Medical Nutrition Therapy for Type 2 Diabetes Mellitus: An Indian Perspective. Advances in therapy, 36(3), 520–547. https://doi.org/10.1007/s12325-019-0872-8

SEVENTH WEEK 4

Signature Assignment for Week Seven

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