Week 2 Discussion Essay

South University College of Nursing and Public Health Graduate Online

Nursing Program

Aquifer Internal Medicine

Internal Medicine 15: 50- year-old male with cough and nasal congestion

Author/Editor:Author/Editor: Jennifer Bierman, MD

INTRODUCTION HISTORY

You speak with Dr. Griffin about Mr. Taleb.You speak with Dr. Griffin about Mr. Taleb.

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It is September and you are working with Dr. Erin Griffin in her outpatient general medicine clinic. She asks you to see Mr. Fadil Taleb, a 50-year-old male with respiratory symptoms. Dr. Griffin tells you he is relatively new to the practice and has been seen only once in the past for a general physical.

HISTORY HISTORY

You begin to take a history from Mr. Taleb.You begin to take a history from Mr. Taleb.

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You enter the room and introduce yourself. You then begin taking a history.

“What brings you to the oGce today”What brings you to the oGce today?”

“I have been sick for the past three or four days. It started with my throat being scratchy and lots of sneezing. Now my nose is all stopped up, and I’m blowing it constantly. I’m also coughing a lot.”

“Have you had a fever?””Have you had a fever?”

“I felt warm the first day but now I just have the chills occasionally. I am also really tired.”

 

 

The best options are indicated below. Your selections are indicated by the shaded boxes.

“Is anyone else you know ill?””Is anyone else you know ill?”

“My kids were sick at the end of last week. One of them is still coughing but the others seem better. My kids are in school right now, and during the school year it seems like one of them picks up something at school almost every other week. I ride the bus to and from work, and there are always people coughing there.” Week 2 Discussion Essay

“Do you smoke?””Do you smoke?”

“Yeah, doc, I know it’s not good for my health, but I do smoke. Usually it’s about a half pack per day, but since I have been sick, I have been smoking only one or two cigarettes a day.”

Question What risk factors does the patient have for an upper respiratory infection (URI)? Select all that apply.

A. Exposure to sick contacts, especially children in the

home

B. Cigarette smoking

C. Season

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Answer Comment > The correct answers are A, B, C> The correct answers are A, B, C

Risk Factors for Upper Respiratory Infection Adults with children in their homesAdults with children in their homes have more frequent URIs (colds). American adults average two to four colds per year while children average six to eight. Crowded conditions predispose. Week 2 Discussion Essay

TEACHING POINTTEACHING POINT

 

 

patients to infection; thus, the incidence of colds is higher in those who spend time in schools.

Studies have shown that cigarette smokecigarette smoke causes structural changes in the respiratory tract and diminishes the immune response to both bacterial and viral respiratory infections. Also, smokers have more severe symptoms when they have an URI.

There is a seasonal incidence of viral URIseasonal incidence of viral URI correlating with colder months in temperate areas. They begin in early fall and continue through the spring. Humidity probably plays a role with virus survival.

References

Archavi L, Benowitz NL. Cigarette Smoking and Infection. Arch Intern Med. 2004;164:2206-2216.

Gwaltney JM. “The Common Cold.” Principles and Practices of Infectious Diseases. 6th ed. St. Louis, MO: Churchill Livingston; 2005.

ROS AND CHART REVIEW HISTORY

You continue your history with Mr. Taleb.You continue your history with Mr. Taleb.

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“Tell me more about your cough. Do you bring anything up?”

“No, it’s a dry cough, but it wakes me up at night several times.”

“Do you feel short of breath?”

“No, not really.”

“Does your chest hurt?”

“No. Can’t say that it does.”

“Have you tried any medicine to help?”

“My face has felt full, so I took some Actifed Cold and Allergy tablets, but they didn’t seem to do much. I’ve also taken some Cold-EEZE, vitamin C, and Waltussin DM, but nothing is helping.”

“Have you had problems like this before?”

“I had this same thing last fall and it lasted a couple of weeks. I hate to bother you doctors with this, but I don’t want to get any worse.” Week 2 Discussion Essay

You review Mr. Taleb’s chart and confirm the following:

Past Medical History:Past Medical History:

Hyperlipidemia (6 months ago)

Lab Values:Lab Values: Conventional:Conventional: SI:SI:

Total cholesterol 220 mg/dL 5.70 mmol/L

HDL 41 mg/dL 1.06 mmol/L

LDL 145 mg/dL 3.76 mmol/L

Medications:Medications:

 

 

None except over-the-counter medications Actifed Cold and Allergy (phenylephrine and chlorpheniramine) Cold-EEZE (zinc gluconate) Vitamin C Waltussin DM (guaifenesin and dextromethorphan).

AllergiesAllergies:

None

Family History:Family History:

Mother: Alive and well. Father: High cholesterol, HTN. Paternal uncle: Coronary artery disease, hx of MI. Three sisters: Well.

Social History:Social History:

Married and monogamous. Works as a computer specialist for the help desk at the hospital. Three children ages 12, 15, and 18 years old. Has smoked half pack per day for the past 25 years. Quit with each of his wife’s pregnancies, then resumed a year or so later. He rarely drinks alcohol and has never used IV drugs.

Review of Systems:Review of Systems:

No headache, myalgias, hemoptysis, weight loss, or night sweats.

See the associated reference ranges in conventional and SI units.

SUMMARY STATEMENT CLINICAL REASONING

Question Based on what you know about the patient so far, write a one- to three- sentence summary statement to communicate your understanding of the patient to other providers.

Guidel ines for summary statements.Guidel ines for summary statements.

 

 

Your response is recorded in your student case report.

Letter Count: 0/1000

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Answer Comment Mr. Taleb is a 50-year-old male with a history of tobacco use who has a several day history of sore throat, nasal congestion, and non- productive cough which awakens him at night. He denies chest pain, myalgias, hemoptysis, weight loss or dyspnea.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

1. Epidemiology and risk factors: 50-year-old male with a history of tobacco use. 2. Key clinical findings about the present illness using qualifying adjectives and transformative language:

rhinitis sore throat non-productive cough present at night lack of chest pain, myalgias, weight loss, hemoptysis or dyspnea. Week 2 Discussion Essay

 

 

The best options are indicated below. Your selections are indicated by the shaded boxes.

DIFFERENTIAL DIAGNOSIS 1 CLINICAL REASONING

Question Based on Mr. Taleb’s history, which of the following are the top threethree diagnoses on your differential? Select all that apply.

A. Allergic rhinitis

B. Acute bacterial sinusitis

C. Acute bronchitis

D. Asthma

E. Bacterial pneumonia

F. Influenza

G. Strep pharyngitis

H. Tuberculosis

I. Viral upper respiratory infection

J. Infectious mononucleosis

K. Pertussis

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Answer Comment > The correct answers are A, C, I> The correct answers are A, C, I

Most Likely / Important DiagnosesMost Likely / Important Diagnoses

The following are the most likely / important diagnoses at this point:

allergic rhinitis (A)allergic rhinitis (A) acute bronchitis (C)acute bronchitis (C) viral upper respiratory infection (URI) (I)viral upper respiratory infection (URI) (I)

 

 

DiUerential of Acute Respiratory Symptoms in Middle- Aged Male with Tobacco History The following diagnoses are less likely:The following diagnoses are less likely:

Acute bacterial sinusitisAcute bacterial sinusitis

Occurs when an initial viral nasopharyngeal infection spreads to become a secondary bacterial infection of the paranasal sinuses.

Viral rhinosinusitis is diagnosed when symptoms or signs of acute rhinosinusitis (nasal congestion, facial pain/pressure, purulent nasal discharge) are present less than 10 days, and the symptoms are not worsening.

Acute bacterial rhinosinusitis (ABRS) should be diagnosed when symptoms or signs of acute rhinosinusitis fail to improve within 10 days or when symptoms or signs worsen within 10 days after an initial improvement (double worsening).

AsthmaAsthma

Often presents with a chronic, nocturnal cough — or cough, dyspnea, and/or wheezing associated with exertion.

Symptoms do not include rhinorrhea, sore throat, sneezing, and chills — these are suggestive of an infectious etiology rather than asthma.

Bacterial pneumoniaBacterial pneumonia

Characterized by persistent fever, cough with purulent sputum, dyspnea, and often pleuritic chest pain.

Require symptoms present long enough to suggest a secondary bacterial infection such as pneumonia.

InfluenzaInfluenza

Characterized by upper and lower respiratory tract symptoms accompanied by systemic symptoms. High fever of 102 to 104 F and chills are very common, along with severe myalgias and headache.

Stuffy and runny nose can be present in influenza, but are more

South University College of Nursing and Public Health Graduate Online

Nursing Program

Aquifer Internal Medicine

Internal Medicine 08: 55-year- old male with chronic disease management

Author/Editor:Author/Editor: Cynthia A. Burns, MD

INTRODUCTION HISTORY

You review Mr. Morales’ records on the computer.You review Mr. Morales’ records on the computer.

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You are working with Dr. Clay in her outpatient diabetes clinic this morning.

 

 

Your first patient, Mr. Morales, was seen by Dr. Clay once before, eight years ago, but was lost to follow-up after that time.

Based on review of the electronic medical record you are able to collect the following information prior to heading into the room to meet Mr. Morales:

Mr. Morales is a 55-year-old Hispanic male, diagnosed with Type 2 diabetes mellitus thirteen years ago after experiencing a 20-pound unintentional weight loss, blurry vision, and nocturia.

He was hospitalized six weeks ago with a non-ST elevation myocardial infarction and required three vessel coronary artery bypass grafting. During his admission, he was found to have a reduced ejection fraction of 20%.

He was referred for today’s visit by the cardiologist to focus on optimizing his glycemic control and reducing his risk of the comorbidities associated with poorly controlled Type 2 diabetes mellitus.

His last hemoglobin A1c (HbA1c) was 9.5% eight years ago, and he had microalbuminuria at that time.

DIABETES CHRONIC DISEASE MANAGEMENT 1

MANAGEMENT

You review diabetes chronic disease management with Dr. Clay.You review diabetes chronic disease management with Dr. Clay.

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Before you see Mr. Morales, Dr. Clay reviews diabetes chronic disease management with you.

Diabetes Chronic Disease Management Evaluate for and optimize prevention of diabetic complicationsEvaluate for and optimize prevention of diabetic complications

Macrovascular complications:

Cardiovascular disease Cerebrovascular disease

Microvascular complications:

Retinopathy Nephropathy Neuropathy

In particular, cardiovascular disease is the No. 1 cause of mortality for people with diabetes, and one of the top causes of morbidity.

Hypoglycemia, infections, foot ulcers, and amputations are additional causes of morbidity and mortality in patients with diabetes.

The American Diabetes Association publishes annual guidelines to assist in the management of a patient with diabetes.

Remember the large role that the psychosocial aspects of a diabetesRemember the large role that the psychosocial aspects of a diabetes diagnosis play in managementdiagnosis play in management

Non-adherence with medical recommendations could be due to economic, work-related, religious, social, or linguistic barriers to care. Care must be taken to assess the psychosocial status of each person with diabetes at each clinic visit to ensure that barriers to successful diabetes care are minimized.

Question Which of the following does the American Diabetes Association recommend to minimize the risk of cardiovascular disease in patients with diabetes? Select all that apply.

TEACHING POINTTEACHING POINT

 

 

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Smoking cessation

B. Daily aspirin therapy

C. Blood pressure less than 140/90 mmHg (if it can be

achieved without increased treatment burden, a systolic target of < 130

is appropriate in younger, healthier patients)

D. If > 40 years old, regardless of other atherosclerotic

cardiovascular disease risk factors, statin therapy

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Answer Comment > The correct answers are A, B, C, D> The correct answers are A, B, C, D

ADA Recommendations to Minimize the Risk of Cardiovascular Disease in Patients with Diabetes Smoking cessationSmoking cessation, daily aspirindaily aspirin, blood pressure controlblood pressure control and lipid controllipid control are all recommended to reduce the risk of cardiovascular disease.

Please note that as of 2018, ADA recommendations were published with the older definition of hypertension (140/90). It always takes time before multiple different organizations agree on the same thresholds.

Daily low dose aspirin is recommended for primary prevention of cardiovascular disease in diabetic patients with a 10-year risk of atherosclerotic cardiovascular disease of >10%. It is also recommended for secondary prevention of all diabetic patients with a history of atherosclerotic disease.

Reduction of cardiovascular risk is achieved with a goal of optimal glycemic control, as well as control of many other health factors that raise cardiovascular risk, such as tobacco use, obesity, poorly controlled hypertension, and hypercholesterolemia. Week 2 Discussion Essay

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References Economic Costs of Diabetes in the U.S. in 2012. American Diabetes Association. Diabetes Care. April 2013; 36(4):1033-1046. http://care.diabetesjournals.org/content/36/4/1033. Accessed May 11, 2018.

PATIENT HISTORY HISTORY

Mr. Morales tells you about his heart attack.Mr. Morales tells you about his heart attack.

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You enter the exam room and introduce yourself to Mr. Morales.

“What brought you to the oRce today?” “I had a heart attack about a month ago and had to have open-heart surgery. The heart doctors told me that my heart is weak now. My cardiologist told me that I have to get my blood sugar under control so I don’t have another heart attack. I am here to get down to work.”

“Tell me more about that.” “I didn’t come back to see Dr. Clay because my job at the furniture factory wouldn’t give me time off for clinic appointments, and I couldn’t risk losing

” DEEP DIVEDEEP DIVE

 

 

The best option is indicated below. Your selections are indicated by the shaded boxes.

my job. I wasn’t checking my blood sugar before my heart attack because the testing strips are so expensive and my supervisor wouldn’t let me off the line to check anyway. Since my surgery, I haven’t gone back to work, and I’ve been checking my sugar before each meal and before bed. The hospital social worker got me two months’ worth of testing strips and lancets before I went home, but I’m going to run out in a couple of weeks. I’m worried that I won’t be able to check anymore.”

He also tells you that while he was in the hospital, they had to use insulin through his vein to keep his blood sugar controlled, and that was very upsetting to him.

Question True or False: In a critically ill medical patients, tight blood sugar control with intravenous insulin therapy, with a goal blood sugar of 80-110 mg/dL, is associated with lower mortality than less tight blood sugar control (e.g. 140-180 mg/dL).

A. True

B. False

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Answer Comment > The correct answer is B> The correct answer is B

EUectiveness of Intravenous Insulin for Blood Glucose Control Blood sugar control in critically ill patients has been the subject of considerable investigation. Previous research suggested that tight control (80-120 mg/dL) was desirable, but more recent research shows that aggressive blood sugar control can be associated with higher mortality. Week 2 Discussion Essay

Hypoglycemia (serum glucose concentration <70 mg/dL), with rates as high as 40% in some studies, is associated with tight glycemic control.

TEACHING POINTTEACHING POINT

 

 

A meta-analysis of 29 controlled trials involving more than 8,000 adult ICU patients showed no difference in in-hospital mortality between the group assigned to tight glucose control versus usual care.

The current recommended blood glucose target for mostThe current recommended blood glucose target for most hospitalized patients is 140 to 180 mg/dL.hospitalized patients is 140 to 180 mg/dL.

References Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300(8):933.

MEDICATION REVIEW HISTORY You review Mr. Morales’ medications with him:

MedicationsMedications

metformin 1000 mg twice daily pioglitazone 15 mg daily glipizide 5 mg daily aspirin 81 mg daily clopidogrel 75 mg daily long-acting metoprolol 100 mg daily furosemide 80 mg twice daily lisinopril 20 mg daily amlodipine 10 mg daily ranitidine 150 mg twice daily gabapentin 300 mg twice daily potassium chloride 10 mEq twice daily atorvastatin 80 mg daily. Week 2 Discussion Essay

Mr. Morales says, “The hospital doctors sent me home on an insulin shot – 40 units in my belly every night before I go to bed. I don’t like giving myself the shot, so sometimes I just don’t, but I take all the rest of my medicines like they told me to.”

He takes out the vial of insulin, and you see that it is insulin glargine.