ANP 635 History of Present Illness Assignment

ANP 635 History of Present Illness Assignment

ANP 635 History of Present Illness Assignment

Native Americans are one of minority ethnic groups in the US.  They face numerous barriers to health and health promotion attributed to social determinants of health. They have a low socioeconomic status with poverty levels above the national average, which is associated with poor health outcomes, including increased diabetes complications and poor prognosis. The purpose of this assignment is to discuss a fictional Native American patient and outline including the patient’s risk factors, quality indicators, CAM interventions, history and physical exam findings, and plan of care. 

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Part 1: Risk Factors, and CAM

The fictitious patient is a 69-year-old Native American male with a positive history of Type 2 Diabetes mellitus (T2DM), obesity, and hyperlipidemia. The risk factors of T2DM linked with the patient’s demographics include age, gender, and ethnicity/race. Older adults from 65 years have the highest T2DM prevalence. Kyrou et al. (2022) explain that aging increases the risk of developing T2DM by impairing insulin secretion and increasing insulin resistance through obesity and sarcopenia. Besides, advanced age independently predicts reduced daily physical activity levels. Older adults have more pronounced rates of inadequate physical activity and increased sedentary time.

Regarding gender, men are almost twice as likely to develop T2DM as women, with more males being diagnosed with diabetes globally (Kyrou et al., 2022). Native Americans have a high prevalence of diabetes associated with poor dietary habits that contribute to a high prevalence of diabetes risk factors like hypertension, overweight/obesity, and hyperlipidemia (Stotz et al., 2021). They are twice as likely as whites to have diabetes due to the high incidence of obesity.

The client uses various Complementary and alternative medicines (CAM) therapies to maintain glycemic control, including garlic, Aloe Vera, and bitter melon. Garlic produces a modest reduction in total cholesterol levels, lowers systolic and diastolic, and is recommended in persons with hyperlipidemia and hypertension (Kifle, 2021). Aloe Vera has been reported to decrease fasting blood glucose in patients with T2DM. Bitter melon is thought to decrease blood glucose in diabetic patients. The potential MOA for bitter melon is increased hepatic glycogen synthesis, reduced hepatic glucose production, and insulin-mimetic activity (Kifle, 2021).

The quality indicators specific to this patient include: Glycemic control with HbA1c<7%; Early detection of diabetes complications, Prompt treatment of glycemic complications; Regular monitoring of HbA1c level;  Ability to conduct self-monitoring of blood glucose; Lipid-lowering therapy; Regular screening for cardiovascular risk factors and disease.

Part 2: History and Physical

Chief Complaint or Reason for Consult: “Tingling sensation on the toes.”

History of Present Illness (HPI): D.L is a 69-year-old Native American who has come for his regular diabetic check-up with complaints of experiencing a tingling sensation on the toes. He reports that he perceives a tingling sensation on the second and third toes on his left foot. The tingling sensation began about five weeks ago. The sensation had an insidious onset. He is worried he could get foot complications like his father, who was amputated after experiencing prolonged tingling sensations. The tingling sensation occurs mostly when he is at rest and has led to sleeping difficulties.

Past Medical History: Type 2 Diabetes- diagnosed at 53 years.

                                    Hyperlipidemia- diagnosed at 48 years

                                    Obesity since his 30’s.

Past Surgical History: No history of surgery.

Family History: The father had Diabetes and diabetes foot ulcer that led to amputation. Maternal grandmother died from stroke.

Social History: The client is a retired banker and currently runs a Hardware store. He has a history of alcohol consumption and tobacco smoking which he stopped after he was diagnosed with diabetes. He denies history of illicit drug use. The client is married and has three children 40, 37, and 32 years. He denies having difficulties performing ADLs.

Allergies: None

Home Medications: Tylenol 500 mg PRN for occasional headaches.

Hospital Medications: Metformin 850 mg; Atorvastatin 20 mg.

Review of Systems:

• CONSTITUTIONAL: Denies fever, body weakness, or weight changes.
• EYES: Denies eye pain, vision changes, or increased lacrimation.
• EARS, NOSE, and THROAT: Denies ear pain, hearing loss, nasal discharge, epistaxis, sore throat, or pain swallowing.
• CARDIOVASCULAR: Denies dyspnea, chest pain, edema, or palpitations.
• RESPIRATORY: Denies chest pain, cough, or wheezing.
• GASTROINTESTINAL: Denies regurgitation, abdominal cramping, flatulence, or changes in bowel patterns.
• GENITOURINARY: Denies dysuria, urinary frequency, urgency, or penile discharge.
• MUSCULOSKELETAL: Denies joint pain, stiffness, or muscle pain.
• INTEGUMENTARY: Denies skin rashes, lesions, bruises, or discoloration.
• NEUROLOGICAL: Positive for tingling sensations on the extremities and occasional headaches. Denies muscle weakness, dizziness, fainting, or black spells.
• PSYCHIATRIC: Denies depressive, anxiety, or suicidal ideations.
• ENDOCRINE: Positive for increased thirst and urination. Denies cold/heat intolerance.
• HEMATOLOGIC/LYMPHATIC: Denies bleeding, bruising, or enlargement of lymph nodes.
• ALLERGIC/IMMUNOLOGIC: Denies frequent infections, hives, or allergic reactions.

Physical Exam:

• GENERAL APPEARANCE: The patient is a 69-year-old Native American male. He is calm, alert, and in no distress. He is neat, appropriately dressed, and maintains eye contact.
• VITAL SIGNS: BP- 134/86; HR- 78; RR-16; Temp- 98.4F;

Ht- 5’6; Wt-  216 pounds; BMI- 34.9

• HEENT: Head: Normocephalic and atraumatic. Eyes: Sclera is white, and conjunctiva is pink; PERRLA. Ears: Minimal pus; TMs clear and shiny. Nose: Clear nasal turbines; well-aligned nasal septum. Throat: Wet and pink mucosa membranes; Tonsillar glands are non-erythematous.
• NECK: Full ROM; Symmetrical; Trachea is well-aligned; Thyroid gland normal on palpation.
• CHEST: Unison chest rise and fall. Respirations are smooth with no use of accessory muscles.
• LUNGS: Lungs clear on auscultation.
• HEART: Regular No edema or neck vein distension. Regular heart rate and rhythm. S1 and S2 are present. No gallop sounds or murmurs were heard.
• BREASTS: Symmetrical. No skin dimpling, nipple discharge, tenderness, palpable masses, or lumps.
• ABDOMEN: The abdomen is round and moves up and down on respiration. Bowel sounds are normoactive in all quadrants. No tenderness, masses, or organomegaly on percussion and palpation.
• GENITOURINARY: Normal male genitalia.
• RECTAL: The anal sphincter is intact.
• EXTREMITIES: No clubbing, cyanosis, or edema; Full ROM of all joints.
• NEUROLOGIC: Muscle strength- 5/5; CN II-XII are intact; Intact DTRs; Decreased pinprick sensation over the second and third left toe.
• PSYCHIATRIC: Affect is appropriate. Clear speech and coherent thought process. Memory and judgment are intact.
• SKIN: Fair, warm, dry, with good turgor. No hypopigmentation, lesions, or bruises.
• LYMPHATICS: Lymph nodes are non-palpable.

Laboratory and Radiology Results:

• Lab Diagnostic Work: FBS- 8.1mmol/L

                        HbA1c- 7.3%

Differential Diagnosis:

Diabetic Peripheral Neuropathy: This is characterized by burning, numbness, or tingling sensations in the extremities that tend to worsen at night. The initial clinical sign that typically develops in diabetic neuropathy is a decrease or loss of vibratory and pinprick sensation over the toes (Gandhi et al., 2022). This differential diagnosis is based on the patient’s history of tingling sensations on the toes and decreased pinprick sensation over the second and third left toe. Peripheral neuropathy is likely a complication of high glycemic levels.

Vitamin B-12 Deficiency: A deficiency of Vitamin B-12 results in a sensation of numbness, cold, tingling, or tightness in the tips of the toes and then in the fingertips, rarely with pains. It causes neurological symptoms like isolated numbness or paresthesias, gait abnormalities, visual symptoms, lightheadedness, and altered taste and smell (Azzini et al., 2021). The patient has tingling sensations in the toes making this a differential diagnosis.

Uremic Neuropathy: This is a distal sensorimotor polyneuropathy attributed to uremic toxins. Patients report tingling and prickling sensations in the lower extremities. Symptoms are insidious in onset. The earliest symptom is paresthesia which is followed by weakness and atrophy. Increased pain sensation is a common symptom (Camargo et al., 2019). This is a differential diagnosis owing to the positive symptom of tingling sensation in the left foot that had an insidious onset. However, the patient has no worsening pain, weakness, or atrophy ruling out Uremic neuropathy as a primary diagnosis.

Geriatric or Ethical Considerations: The patient and the caregiver should be guided on how to monitor blood sugar levels and perform daily foot to identify ulcers, broken skin, or wounds. The caregiver should be instructed to ensure the client takes his medication at the indicated time and dose.

Part 3: Model or Plan of Care

The plan of care for Native American patients with diabetes using the CCM will entail the following:

Self-management support: Native Americans will be educated on lifestyle practices that can lower the risk for obesity and diabetes. Those diagnosed with DM will be educated on lifestyle modification and diabetes self-management practices to improve glycemic control and prevent complications (Ansari et al., 2022).

Community resources: Native Americans will be connected to community resources that can help them adopt healthier lifestyle practices like group weight loss programs, Local hospitals, and faith-based organizations that offer programs or seminars about T2DM prevention (Ansari et al., 2022).

Health system: The health system will incorporate culturally sensitive diabetes prevention services for Native Americans and improve access to these services for this minority community.

Delivery system design: The healthcare system will be designed to include diabetes and obesity screening services for Native Americans through lipid, blood sugar, and BMI screening (Ansari et al., 2022). This will ensure early diagnosis and treatment of diabetes, preventing complications related to late diagnosis.  

Decision support: Treatment of Native Americans with T2DM will take an interdisciplinary approach. The treatment will be planned by an interdisciplinary team comprising physicians, diabetes specialists, podiatrists, ophthalmologists, and nutritionists.

Clinical information systems: The clinical information systems will be programmed to identify Native Americans at risk of diabetes based on age, BMI, cholesterol levels, and family history (Ansari et al., 2022). The information systems will help maintain patients’ records to assess individuals’ progress with diabetes treatment effectively.

Conclusion

The fictional Native American patient has a history of diabetes, obesity, and hyperlipidemia. His age (69 years), gender (male), and ethnicity increase his risk of diabetes. He presents with symptoms of neuropathy (tingling sensations on the extremity), which is likely a complication of uncontrolled hyperglycemia. The differential diagnoses are Diabetic Peripheral Neuropathy, Vitamin B-12 Deficiency, and Uremic Neuropathy. The CCM can be employed in providing prevention interventions for Native Americans on diabetes and educating diabetic patients on self-management to reduce complications and improve health outcomes.

 References

Ansari, R. M., Harris, M. F., Hosseinzadeh, H., & Zwar, N. (2022). Implementation of Chronic Care Model for Diabetes Self-Management: A Quantitative Analysis. Diabetology, 3(3), 407-422. https://doi.org/10.3390/diabetology3030031

Azzini, E., Raguzzini, A., & Polito, A. (2021). A Brief Review on Vitamin B₁₂ Deficiency Looking at Some Case Study Reports in Adults. International Journal of Molecular Sciences, 22(18), 9694. https://doi.org/10.3390/ijms22189694

Camargo, C. R., Schoueri, J., Alves, B., Veiga, G., Fonseca, F., & Bacci, M. R. (2019). Uremic neuropathy: an overview of the current literature. Revista da Associacao Medica Brasileira (1992), 65(2), 281–286. https://doi.org/10.1590/1806-9282.65.2.281

Gandhi, M., Fargo, E., Prasad-Reddy, L., Mahoney, K. M., & Isaacs, D. (2022). Diabetes: how to manage diabetic peripheral neuropathy. Drugs In Context, 11, 2021-10-2. https://doi.org/10.7573/dic.2021-10-2

Kifle, Z. D. (2021). Prevalence and correlates of complementary and alternative medicine use among diabetic patients in a resource-limited setting. Metabolism Open, p. 10, 100095. https://doi.org/10.1016/j.metop.2021.100095

Kyrou, I., Tsigos, C., Mavrogianni, C., Cardon, G., Van Stappen, V., Latomme, J., … & Manios, Y. (2020). Sociodemographic and lifestyle-related risk factors for identifying vulnerable groups for type 2 diabetes: a narrative review with emphasis on data from Europe. BMC Endocrine Disorders, 20(1), 1-13.https://doi.org/10.1186/s12902-019-0463-3

Stotz, S. A., McNealy, K., Begay, R. L., DeSanto, K., Manson, S. M., & Moore, K. R. (2021). Multi-level diabetes prevention and treatment interventions for native people in the USA and Canada: a scoping review. Current Diabetes Reports, 21(11), 1–17. https://doi.org/10.1007/s11892-021-01414-3

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Assessment Traits
Requires Lopeswrite
Assessment Description
For this assignment, create a fictitious patient within the population you selected for the assignment in Topic 4 and complete the three parts of the assignment for your patient, as outlined below.

Part 1: Risk Factors, Quality Indicators, and CAM:

Identify the following regarding the health of your fictitious patient:

Risk factors associated with the patient’s demographics.
Complementary and alternative medicines (CAM).
Quality indicators specific to the patient.
Part 2: History and Physical

Develop a history and physical (H&P) examination for the fictitious patient chosen. In previous courses in the program, you have used this subjective, objective, assessment, and plan format to document H&P examinations. Refer to the “History and Physical Note” template to complete this assignment.

Part 3: Model or Plan of Care

Develop a model or plan of care for the patient population pertinent to the above-mentioned patient. This could include community or health system programs as an approach or what seems appropriate. Incorporate the 6 components of the chronic care model in your model or plan of care.

Self-management support
Community resources
Health system
Delivery system design
Decision support
Clinical information systems
General Requirements

You are required to cite three to five sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Submit all three parts as one deliverable.

OUR POPULATION FOR TOPIC 4 WAS THE NATIVE AMERICAN POPULATION WHICH YOU WILL USE FOR THIS ASSIGNMENT.

History of Present Illness – Rubric

Part 1 – Risk Factors, Complementary and Alternative Medicines, and Quality Indicators

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45 points

Criteria Description

Part 1 – Risk Factors, Complementary and Alternative Medicines, and Quality Indicators

5. Target 45 points

Part 1 is thoroughly developed with a comprehensive discussion of the required topics. Ideas are thoroughly developed with supporting details related to the health of the patient.

4. Acceptable 40.5 points

Part 1 includes a discussion of the required topics as they relate to the health of the fictitious patient. The discussion is well developed.

3. Approaching 36 points

Part 1 includes an overview of the required topics as they relate to the health of the fictitious patient. Details may be generalized and some details may be missing.

2. Insufficient 22.5 points

Part 1 lacks detail or is incomplete.

1. Unsatisfactory 0 points

Part 1 is not included.

Part 2 – History and Physical 45 points

Criteria Description

Part 2 – Subjective Component

5. Target 45 points

Part 2, the history and physical, includes a comprehensive discussion of the component. Each part is thoroughly developed with supporting details. Three differential diagnoses are appropriate for the patient.

4. Acceptable 40.5 points

Part 3 – Model or Plan of Care 37.5 points

Criteria Description

Part 3 – Model or Plan of Care

Required Sources   7.5 points

Criteria Description Required Sources

Mechanics of Writing (includes spelling, punctuation, grammar, and language use)

7.5 points

Criteria Description

Mechanics of Writing (includes spelling, punctuation, grammar, and language use

language are employed.

2. Insufficient 3.75 points

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.

1. Unsatisfactory 0 points

Documentation of Sources                                                                                                                                   7.5 points

Criteria Description

Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)

5. Target 7.5 points

Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.

4. Acceptable 6.75 points

Sources are documented, as appropriate to assignment and style, and format is mostly correct.

3. Approaching 6 points

Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.

2. Insufficient 3.75 points

Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.

Total 150 points