Beruflich Dokumente
Kultur Dokumente
TOPIC
Patient Profile
Health Assessment
PAGE
1
Demographic
History Taking
Physical Examination
Diagnosis
Provisional Diagnosis
Investigations
Epidemiology
12
Pathologyphysiology
Management
12
Medical Goals
13
Pharmacological Agents
15
Lifestyle Changes
17
21
22
23
PATIENT PROFILE
Mr. Brandon Quek* is 16 years old. He went to National University of Singapore
(NUH) Accident and Emergency (A&E) department, on 5 th December 2005 around
1114hrs.He was referred from the private family physician with chief complaint of
shortness of breath for 3 days and occasional poking mild chest pain. This was
accompanied with polydipsia, polyuria, sudden loss of weight and loss of appetite.
Physical examination showed no remarkable findings except dry tongue muscosae
by the accident and emergency doctor.
Clinical laboratory tests revealed the following significant findings: (1) high blood
glucose from bedside test and serum glucose (2) urine ketones and (3) metabolic
acidosis from arterial blood gases. He was subsequently diagnosed as Diabetes
Ketoacidosis by Endocrine team and admitted to the general ward. Subsequently
he was diagnosed having Type 2 Diabetes Mellitus as the cause of his condition.
This assignment will focus on (1) health assessment of Brandon (2) arriving at the
diagnosis (3) investigations arriving at the cause of the clinical problem and lastly
(4) management of the root problem. Due to the limitation of time, the acute
management of diabetes ketoacidosis will not be elaborated on.
HEALTH ASSESSMENT
Demographic
Brandon is 16 years old. He is an N-level student from Queensway Secondary
School, waiting for his N level results. He stays with his family in Telok Blangah and
has a younger brother. He hopes to enter into Information Technology course
offered by Institute of Technical Education.
History Taking
Brandons chief complaints were shortness of breath for 3 days with occasional
poking mild chest pain.
Details of Chief Complaints
Shortness of breath was sudden on onset and progressively becoming worse over
3 days. Shortness of breath was present while waking, sitting and even lying down.
No audible wheeze was heard. Shortness of breath was not relieved by positioning
or other factors. No known aggravating factors. There were no previous similar
episodes. He had fever for 1 day prior to admission but unable to quantify severity.
He also reported non-productive cough for a day. However, there was no reported
hemopytsis.
Chest pain was described as poking in nature. Pain was sudden on onset. It was
localized at the central region of the chest with no migration to other regions. Pain
score was 4 over 10. It was occasional in frequency on the day before admission
and duration for each episode was less than 2 minutes. Pain was aggravated when
he was very short of breath and breathing hard. No relieving factors were known
to him.
Symptoms were associated with nausea and vomiting of 1 episode in the accident
and emergency department of partially digested food. Vomitus is non-bilious and
bloody in nature. There is no accompanied abdominal pain.
He also had polydipsia and polyuria several days prior to admission. He reported
realizing having extreme thirst and had increased urinary frequencies about 5
times per night, 5 days before admission. There was no dysuria or haematuria. He
could not recall any event that trigger off these symptoms. He also noted loss of
appetite for 3 days and sudden loss of weight about 5 kg within a week.
There was no parasymal nocturnal dyspnea and swelling of the legs. No giddiness,
palpitations or syncope reported.
Review of Systems
Review of the neurological, musculoskeletal and haematological systems was
unremarkable.
Past Medical History
Brandon has a history of asthma since the age of five. However, he was not on any
inhalers or follow up for the management of his asthma. There is no past history of
cardiovascular diseases or recent surgery done.
Family History
Brandon has a strong family history of diabetes mellitus. His maternal
grandparents and his maternal grandmother had type 2 diabetes mellitus. His
mother had gestational diabetes and progression to diabetes at the age of 28. She
is currently on diet control and followed up by her workplace doctor.
Drug Allergy
Brandon has drug allergy to penicillin and ampicillin which will cause rashes, periorbital edema and angioedema.
(Brandon was noted to have dehydrated mucosae in the accident and emergency
department.)
Cardiac Examination
The radial pulse is strong and regular. There is no radial-radial or radial-femoral
delay. Collapsing pulse is also absent. Upon cardiovascular inspection, there are
no abnormalities noted. The apex beat is palpable at 5 th intercostals space at mid
left clavicle line. It is not displaced. Thrills and heaves are absent. Dual heart
sounds heard with no additional heart sounds or murmurs.
Lung Examination
There are no surgical scars or abnormalities noted on inspection. Trachea is
central and not deviated. Chest expansion is bilaterally equal. Tactile fremitus and
vocal resonance are symmetrical and uniform throughout. Percussion tone is
symmetrical and normal. Breath sounds upon auscultation is clear and vesicular in
nature.
Lymph Nodes
The cervical, epitrochlear, supraclavicular and inguinal lymph nodes are not
palpable.
Abdominal Examination
The abdomen is not distended and has no scars or wounds on appearance. It is
soft and non-tender. There is no guarding and rebound tenderness. No lumps and
bumps felt. There is no shifting dullness. Upon auscultation, bowel sounds are
active and no renal bruits are heard. There is no hepatomegaly and splenomegaly.
Both kidneys are not ballotable. Rectal examination was not done.
Neurological Examination
Brandon is alert and orientated to time, place and person. Cranial nerves are
intact. Pupils are equal and reactive to light. There are no significant neurological
deficits found.
Joints
There are no joints swelling or tenderness.
DIAGNOSIS
Provisional Diagnosis and Differential Diagnoses
In summary, Brandon is a 17 year old gentleman was referred to the accident and
emergency department by the family physician. His chief complaints were
shortness of breath for 3 days with mild poking chest pain for a day, which were
accompanied by fever, vomiting, polydipsia, polyuria and sudden loss of weight.
His physical examination was not remarkable.
With a history of childhood asthma, a reasonable provisional diagnosis is
exacerbation of asthma. However, there was no presence of wheeze on
auscultation.
The second most probable diagnosis, given a strong family history of type 2
diabetes mellitus, is diabetes ketoacidosis (DKA) or hyperglycemic
hyperosmolar non-ketonic (HHNK). Signs and symptoms of hyperventilation
(shortness of breath), polydipsia, polyuria, sudden loss of weight, loss of appetite
and vomiting correlate with the symptoms of DKA.
Emergency diagnosis to be rule out that can present with shortness of breath and
chest pain for young people includes pneumothorax. Other diagnoses with lesser
suggest pericarditis and pulmonary embolism. Troponin T test was done, with a
result of less than 0.1, to rule out myocardial infarction.
Investigations done for Hyperglycemic Emergencies
Beside capillary blood glucose test was done with a reading of 26.8mmol/L. Urine
ketones was positive 3+. Serum ketones test was not done on the day of
admission. Arterial blood gases were done with the results shown in Table 1. Urea
and electrolytes results are shown in Table 2.
The differences between diabetes ketoacidosis (DKA) and hyperglycemic
hyperosmolar non-ketonic state (HHNK) include (1) the presence of elevated
serum ketones in DKA (2) metabolic acidosis in DKA (3) significant higher anion
gap in DKA and (4) significant higher serum osmolality in HHNK (Davidson, 1986
and Gale & Anderson, 2002).
(Normal)
11.39hrs
1257hrs
7.35 - 7.45
7.1
7.078
PaCO2 (mmHg)
35 45
16.5
16.3
PO2 (mmHg)
75 100
146
165
BEecf (mmol/L)
-2.5 to 2.5
-25
-25
HCO3 (mmol/L)
22-26
5.1
4.8
98%
99%
pH
TCO2 (mmol/L)
Sa02
Table 1: Arterial Blood Gases Results
(Normal)
1157hrs
Sodium
135-150
127
Potassium
3.5-5.0
4.9
Urea
2.5-7.5
4.9
Creatinine
65-125
120
Glucose
3.0-6.0
29.8
thyroid function tests and cortisol tests were done (All blood results can be found in
Appendix A). The final diagnosis for Brandon is Type 2 diabetes.
Epidemiology
Classically Type 2 diabetes mellitus (T2DM) was considered a disease of the
adults and elderly. However, over the last decade, internationally there had been
an increasing trend of T2DM in children and adolescent (Piscopo et al, 2005).
Although there are no specific figures in Singapore on T2DM in youth and its
impact, this increasing trend is reported to be correlated with sedentary lifestyle
and obesity (Bloomgarden, 2004 and Piscopo et al, 2005). Pathogenesis of T2DM
in the young include (1) genetics this include beta-cell defects such as maturityonset diabetes of the young (MODY) (2) familial factors and intrauterine growth
retardation family history is evident in Brandons case study. Both grandparents
from paternal and maternal side have T2DM and his mother also have diabetes
and on diet control. (3) Obesity, which is also evident in Brandon with a BMI of
25.3. Obesity in children and young adolescent blunt the growth hormone and
epinephrine responses to exercise and causes insulin resistance in the body
(Bloomgarden, 2004).
In general, T2DM, as a whole, is a burden for healthcare in Singapore. Diabetes
was ranked the 8th leading cause of death with 3.0% of all deaths being attributable
to this disease (Ministry of Health, 2005). Due to the difference in age stratification
in both National Health Surveillance Surveys 2001 and 2004, comparisons on
diabetes and obesity could not be made for the age group between 18 years to 29
years. However, in general the prevalence of obesity among Singapore residents
as a whole rose from 6% in 1998 to 6.9% in 2004. This increasing trend is even
more significant in the abdominal fatness from 8.1% in 1998 to 11.9% in 2004 as
reported in the survey. Central obesity had been reported for pathogenesis of
T2DM in the young (Piscopo et al, 2005, Bloomgarden, 2004 and Davidson, 1986).
Pathophysiology
Classically, it is believed that Type 2 diabetes develops into HHNK and Type 1
diabetes develops into DKA. The pathphysiology section in this assignment will
explore the hyperglycemic states and answer the question Is it possible for Type 2
diabetes to develop into DKA? Yes. The factors that can contribute a Type 2
diabetes presenting with DKA are (1) undiagnosed diabetes as in Brandons case
(2) non-adherence to prescribed therapy (diet or medication) (3) alcohol abuse
(Davidson, 1986). However the presentations of hyperglycemic states, of T2DM
patients once they started on therapy, range from the spectrum of pure HHNK state
to mixed HHNK state with DKA. This is due to the complex interplay between the
compensating and de-compensating mechanisms in renal, gastrointestinal, buffers,
respiratory and cardiovascular systems (Davidson, 1986).
The simple diagram shown in Figure 1 from Frier and Fischer (2002) explained the
pathophysiology processes during the lack of insulin resulting in the signs and
symptoms that Brandon had experienced.
MANAGEMENT
There are 2 basic goals for Brandons diabetes management. (1) Reaching optimal
glucose control and (2) prevent macrovascular and microvascular complications of
diabetes mellitus. The goals will be reached by a holistic team approach involving
the physician in charge and multi-disciplinary health care team. The methods
achieving and maintaining the goals require patience, cooperation and open
communication between the patient and all the healthcare professionals who
participate in his care.
The specific medical goals that we hope to achieve for Brandon according to the
clinical guidelines from Ministry of Health (MOH), Singapore (1999) for managing
diabetes mellitus include:
Lack of Insulin
Decreased
anabolism
Fatigue
Vulvitis
Balanitis
Increased
catabolism
Hyperglycaemia
Glycogenolysis
Gluconeogenesis
Lipolysis
Wasting
Loss of weight
Glycosuria
Hyperketonaemia
Polydipsia
Polyuria
Osmotic diuresis
Acidosis
Salt and water
depletion
Tachycardia
Hypotension
Diabetic
Ketoacidosis
DEATH
Hyperventilation
Peripheral
vasodilation
Hypotension
Hypothermia
Blood pressure control: Maintain his blood pressure reading not higher
than 130/80 mmHg. Frequency to check blood pressure at least quarterly.
Body weight: Achieve and maintain a BMI of 22.9 and prevent increase
central obesity. Frequency to check body weight as least quarterly.
These medical goals will be achieved in due time by pharmacological agents and
lifestyle changes.
Pharmacological Agents
Brandon was discharged with subcutaneous insulin injection Mixtard 30/70 with the
dosage 35 units every morning and 20 units every night. He was prescribed this
regimen upon before his C peptide results were out. The question whether should
Brandon have invasive or non-invasive (oral) medication regimen since it has been
confirmed that he has Type 2 diabetes mellitus is a concern. In United States
clinical practice, approximately one-half of young patients with type 2 diabetes
receive insulin and the other half oral medications agents, most commonly
metformin, for their treatment.
According to Bloomgarden (2004), it is reasonable to start the youths with Type 2
diabetes mellitus with insulin with a few reasons. First, the physician is familiar with
Lifestyle Changes
Diet (Medical Nutrition Therapy)
Brandon has been seen by the hospital dietician before his discharge. It is
important to stress to Brandon that the diabetic diet is principally a healthy diet
that is also recommended to the population in general. As Brandon is overweight
with a BMI of 25.3, he needs to lose around 8 kg for his height to reach a BMI of
22.9. Gradual weight reduction of 1 to 2 kg in a month or maintenance of current
weight could be a short term goal till Brandon is more used to the changed lifestyle.
According to MOH, (1999), there is clear evidence of the effect of weight loss and
diet modification in obese T2DM patients on restoring normal carbohydrate
metabolism.
Counseling of the diet not only has to focus on the reduction of the overall caloric
intake as well as the basics of a diabetic diet. These basics include saturated fats
not exceeding 10%, with carbohydrate 50-60%, and protein 15-20% of the total
caloric intake (MOH, 1999). Other recommended dietary points include daily
consumption of cholesterol less than 300mg and 20 to 35 grams of dietary fiber.
Diet should also include a variety of foods from each basic food groups and contain
adequate vitamins and minerals.
Besides the basics, Brandon also has to learn to be sensitive to the pattern and
portion of his meals. Ideally, other skills that the dietician should equip Brandon
include food label reading, carbohydrate counting, food exchange, glycemic index,
insulin to carbohydrate ratio and moderating food portions using blood glucose
results. Unfortunately, not all skills will be imparted to Brandon, it depends on
Brandons motivation and even health literacy level and a lot of patience and
encouragement from the healthcare professionals involve.
Eating, a simple act which most of us take for granted everyday has become a
medication to Brandon. The consciousness and self awareness of every portion
of food he is going to take can be tiring and requires a lot of discipline. Needing to
reduce or even abstain from his favorite food and drinks like Laksa (high in
saturated fats and cholesterol), potato chips and pepsi and Grass Power. (Grass
Power is a wheatgrass drink which contains 45grams of carbohydrates in 1
serving). It is definitely a challenge for both the patient and healthcare
professionals to find substitutes for these favorite food and drinks which can fit into
his diet. Substitutes, which he can enjoy as favorites. Although most of the time,
conveniently most healthcare professionals request that patients stay away from
these food items.
Exercise
To achieve an ideal BMI of less than 22.9 and prevent weight gain from insulin
injections, exercise is a must. Exercise had been reported by studies having a
positive impact on the glucose level of Type 2 diabetes patients by improving
insulin sensitivity and insulin-mediated glucose utilization (Devlin, 2000). The
recommended exercise regimen for diabetes mellitus patients should be tailored
according to Brandons aptitude, fitness and interest (MOH, 1999). Although earlier
studies reported that strength training improved glucose tolerance comparable to
aerobic exercise training. However, the mechanisms of aerobic exercise improve
insulin sensitivity whereas strength exercises increase total muscle volume with
unchanged insulin sensitivity (Devlin, 2000). Thus, it will definitely be appropriate to
encourage Brandon to take up some aerobic exercise regimen.
It is also important exercise precaution information on proper footwear, adequate
hydration and avoidance of exercise during periods of severe hypoglycemia and
hyperglycemia be imparted to Brandon as part of the exercise program. According
to the MOH (1999) guidelines on diabetes management, it is important that
patients on insulin treatment be specially warned on prevention of exercise-
induced hypoglycemia. The prevention of the symptoms can be achieved with the
following steps: (1) Appropriate reduction of medication prior to exercise (2)
consume some carbohydrate 30-60 minutes before exercise especially if
blood glucose <5.5 mmol/L, and after every 30 minutes of moderately
intense exercise (3) have a gradual progression of exercise intensity and lastly (4)
avoid late-night exercise.
Brandon is not a very physically active teenager. When he was asked if he had any
physical activities he enjoys most, he was not able to give an answer. It is a
challenge for healthcare professionals to finally engage Brandon in an exercise
regimen.
Self Management
Effective self management for Brandon can be achieved by education given by the
diabetes nurse educator. Components of effective self management include the
following:
Rollink and Millers motivational interviewing which is defined as a directive, clientcentered counseling style for eliciting behavior change by helping clients explore
and resolve ambivalence (Miller and Rollnick, 2002). The key elements include (1)
motivation to change is elicited from the person not the health care professionals,
(2) it is the persons task not the health care professionals to identify and resolve
ambivalence, (3) direct pressure is not useful in resolving ambivalence, (4)
counseling style employed is quiet and eliciting, (5) readiness to change is not a
trait but fluctuates over time.
It is also important, during consultation, healthcare professionals should not focus
on self-management activities only but how Brandon think of these selfmanagement activities. It might be even necessary to refer Brandon to a
psychologist to make these self-management tasks more manageable if need
arises.
Special Issues in Adolescents
Adolescence is a period of transition from childhood to adulthood. It is also a period
of time which adolescents find themselves seeking their own identities and defining
their own territories. It is a time when peer influence is stronger than parental
guidance. It is a time when teenagers want to break free from the care of
authoritative figures. Healthcare professionals like physicians, nurses are viewed
as authoritative figures to the adolescents. It is a stressful period of time when
teenagers experience stress from puberty, love relationships and friendships, yet at
the same time deal with their school work and plan for their future as adults.
Skinner, Channon, Howells and McEvilly (2000) believed that, first; clinicians must
maintain contact with the young people. Maintaining contact Brandon using other
means such as emails, mobile phone messaging etc. is necessary even if face to
face contact is not possible. This is because without this contact, an honest, open
and trusting relationship which the foundation of diabetes care is built will be
difficult to maintain. Second; when contact is established, try not to make diabetes
the be-all and end-all exchange. Example, Brandon was actually anxious about his
N level results at that time when I did the history interviewing. After the history
interviewing, we explored on the pros and cons of different education institutions
and career paths.
Although at that time, I have tried to assess Brandons negative feelings towards
himself because of diabetes such as feelings of sadness, guilt, anger, anxiety or
frustration, I was not able to elicit much information. Still helping Brandon to make
the distinction between their emotional responses to their diabetes and those that
are natural part of the adolescent being when need arises can help him to live
successfully with diabetes (Skinner, Channon, Howells and McEvilly, 2000).
Lastly, involving the family in the care of Brandon and yet at the same time to have
an open communication with Brandons family to help them interplay between a
gate-keeper role and friend role. Helping the family members to tide over the
negative feelings towards diabetes like feelings of guilt is also necessary for
effective holistic management
CONCLUSION
Managing diabetes mellitus in adolescence is a delicate task. Brandon has a long
road to go, much longer than someone who is diagnosed with diabetes at the age
of 50. Patience, perseverance, faith and passion are essential qualities of an
Advanced Practice Nurse involve in the care of an adolescent with diabetes
mellitus.
REFERENCES
Anderson, R. et al (2000). Facilitating self-care through empowerment. In F.J.
Snoek and T.C. Skinner (Eds), Psychology in diabetes care (pp.69 - 89). England:
John Wiley and Sons, Ltd.
Bloomgarden, Z.T. (2004). Type 2 diabetes in the young the evolving epidemic.
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Davidson, J. (1986). Diabetic ketoacidosis and the hyperglycemic hyperosmolar
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