The Patient with Type I Diabetes - Case Study Example

Clinical Reasoning Assessment –Part A (Word Count 1000 words) The patient is a 51 year old male d Douglas Adams with Type I diabetes and a history of hypertension. That patient lives alone and presumably self-administered his daily medications. In the morning, the patient has been taking 26 units of Humalog Mix, followed by an additional 16 units at night. He also takes 4mg of perindopril in the morning and 100mg of aspirin daily. The patient does not report any use of alcohol, but does smoke. He has a height of 190 cm and a weight of 70 kg, putting his BMI in the normal weight range that falls between 19.39 18.5-24.9 kg/m2 (Kushner, 2007). The patient was found in his place of residence, and then admitted to emergency where his Glascow coma score was 14 on a 15 point scale, which represents only mild trauma , though no addition EMV (eye/motor/verbal) information was recorded (Teasdale, 1974). He appeared confused and disoriented and at the time his heart rate was 82 beats per minute, blood pressure was 110/87 mmHg, respiration rate was 18 breaths per minute, and temperature was 36.8°C. In emergency, the patient’s heart rate was fast, systolic blood pressure was slightly low, diastolic blood pressure was slightly high, the overall blood pressure was within normal ranges, respirations were rapid, and temperature was within normal ranges (Dugdale 2009). After the patient was admitted, his blood sugar level was monitored and he underwent neurological observation four times a day. The patient’s blood glucose level was 5.2 mmol/L before breakfast, which is within the normal range after fasting of less than 7.0 mmol (Saydah et al., 2001). At the time that the patient rings the buzzer he exhibits trembling hands, slight sweat, facial pallor, slurred speech, and disorientation. The patient is also in the process of eating breakfast, suggesting that he may have recently been hungry, though he states that he no longer feels like eating. The patient’s vital signs show an elevated heart rate of 88 beats per minute, a blood pressure on the low end of normal at 105/80 mmHg, an elevated respiration rate of 18 breaths per minute, and a normal temperature of 36.5°C (Dugdale 2009). These signs can be interpreted in order to make a hypothesis about the condition of the patient. The visible symptoms would allow the observer to generally hypothesize that the patient was suffering from hypoglycaemia, a condition in which is characterized by low blood glucose levels begin to cause symptoms. A number of cardiovascular, neuropsychological, and other miscellaneous symptoms are associated with hypoglycaemia, including prolongation of QT-interval, convulsions, ventricular tachycardia, silent myocardial ischaemia, cognitive impairment, aggressive behaviour, personality change, sweating, palpitations, trembling, anxiety, and hunger. In more serious cases, hypoglycaemia can lead to bone fracture, seizures, coma, and even premature death (McAulay et al., 2001). Hypoglycaemia also causes a condition known as neuroglycopenia, which rapidly impairs cerebral function by affecting the neurons, causing symptoms like weakness, warmth, confusion, and drowsiness to occur instead of being reduced by the pan-autonomic or adrenoceptor blockade. The symptoms of dizziness, faintness, difficulty speaking, and blurring of vision are also common (McAulay et al., 2001). Many of these symptoms were observed in the patient, and, upon the observer’s visit, the patient was concerned with the time he would see the doctor and complete tests, suggestive of mild to high levels of anxiety. The blood glucose level in patients suffering from this condition can be raised to normal level by administering ten to twenty grams of fast-acting carbohydrates (“Glucose”, 2010). Hypoglycaemia normally occurs after fasting, but this instance occurred in the middle of a meal. This allows the observer to make the additional hypothesis that this could be a case of not general hypoglycaemia, but may instead be a case of reactive hypoglycaemia. This means that hypoglycaemia is actually occurring after the patient eats a meal, generally in the period of one to three hours after consumption of sugary, low-fiber foods (Collazo-Clavell, 2008). Reactive hypoglycaemia is also more likely to occur if the patient has not been eating regularly, patients with eating disorders, or patients that have skipped meals, as the patient is likely to have done before his friend found him and brought him to emergency (Yasuhara et al., 2003). Some researchers believe that some patients are over-sensitive to the release of epinephrine or suffer from a deficiency in glucagon, which causes the onset of hypoglycaemia after meals (Collazo-Clavell, 2008). A number of direct questions to the patient may help to establish hypoglycaemia as the cause of the patient’s symptoms. The observer should ask if the patient how he is doing in order to gauge his anxiety and aggression levels as well as cognitive functioning, then inquire about the patients eating habits. Starvation, eating disorders, or commonly skipping meals can cause an elevated risk for reactive glycaemia (Yasuharaet al., 2003). The patient may also be asked if he feels warm, or has any pain in joints. Other questions include, did the patient take insulin, and if so, how much did the patient take. Overdose of insulin can result in hypoglycaemia as well. If the patient has ever suffered from adrenal insufficiency, alcoholism, drugs use—such as acetaminophen and anabolic steroids—extensive liver disease, hypopituitarism, hypothyroidism, or insulinomas he will be at a higher risk for hypoglycaemia, and the line of questioning should establish if he has any of these conditions (“Glucose,” 2010; Sharma et al., 2008). A physical assessment should test respiration rate, temperature, auxiliary pulse, and heart rate. It should note signs of lethargy, hunger, strained joints, and abnormal physical signs, such as bodily sores, excessive perspiration, or edema. The patient’s cognitive function should be gauged and reported. The position of the bed and patient in the bed should be reported. A blood glucose test would measure the patient’s blood glucose levels as the exact time that symptoms appear, and be using to verify the hypothesis of hyperglycaemia or hypoglycaemia occurring in the diabetic patient (“Glucose,” 2010). Monitoring blood glucose can be critical to recovery and treatment. In nursing, it is critical to be able to analyze and react to changes in a patient’s physical state or behavior. By observing these changes, multiple symptoms suggest evidence of a critical condition. The observer should form the hypothesis that the patient is not only suffering from hypoglycaemia, but also that neuroglycopenia has progressed to an extent that impairs the patient’s cognitive function and could threaten his health. Because the onset occurs after the consumption of food, the observer should also form the hypothesis that the case may likely be reactive hypoglycaemia. References Teasdale G., Jennett B. (13 July 1974). Assessment of coma and impaired consciousness: A practical scale. Lancet, 2(7872), 81-84. Kushner, Robert. (2007). Treatment of the Obese Patient (Contemporary Endocrinology). Totowa, NJ: Humana Press. Dugdale, David. (2009). Vital Signs. MedlinePlus: U.S. National Library of Medicine from the National Institutes of Health. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/002341.htm Saydah SH, Miret M, Sung J, Varas C, Gause D, Brancati FL (August 2001). Postchallenge hyperglycemia and mortality in a national sample of U.S. adults. Diabetes Care, 24 (8), 1397–402. Glucose. (July 2010). Lab Tests Online. American Association for Clinical Chemistry (AACC). Retrieved from http://www.labtestsonline.org/understanding/analytes/glucose/test.html Collazo-Clavell, M. (2008). Reactive hypoglycemia: What causes it? MayoClinic. Mayo Foundation for Medical Education and Research (MFMER). Brochure. Yasuhara, D, Deguchi, D, Tsutsui, J, Nagai, N, Nozoe, S and Naruo, T. (July 2003). A Characteristic Reactive Hypoglycemia Induced by Rapid Change of Eating Behavior in Anorexia Nervosa: A Case Report. International Journal of Eating Disorders, 34(2), 273-277. McAulay, V, Deary, J, and Frier, M. (September 2001). Symptoms of hypoglycaemia in people with diabetes. Diabetic Medicine, 18(9), 690–705. Sharma, T, Katz, C, Rutecki, G. (August 2008). Unexplained Hypoglycemia: A Focused Approach to Finding the Cause. Consultant, 48(9). Read More