Clinical Reasoning Assessment - Essay Example

Clinical Reasoning Assessment Introduction Diabetes is a disorder which needs constant vigilance by the patient as well the healthcare professionals caring for the patient. Although the aetiological factors for Diabetes Type I and Type II are entirely different, the disorder can lead to emergency situations which can be critical to the patient’s life. As diabetes is a disorder which disturbs the normal physiological control of blood sugar (glucose), both hyperglycaemia (excess glucose in the bloodstream) and hypoglycaemia (low glucose) can precipitate unique pathophysiological sequels. The current patient, Douglas Adams, a 51 years old male has an established diagnosis of Diabetes Type I i.e. insulin dependent diabetes, as well as hypertension. He is 190 cm tall and weighs 70 kg, which translates into a BMI (Body Mass Index) of 19.39 at his age (Web, NHS). This is a fairly healthy value for his age and sex and therefore complications that could have arisen due to obesity can be ruled out. However, as he smokes a pack of cigarettes daily, that can contribute to complications and may be a factor for his present clinical condition. As Douglas does not consume alcohol at all, complications arising due to its ill effect can also be ruled out. However, as the patient lives alone, his compliance with the recommended medication, daily routine, loneliness and other lifestyle factors can have a definite influence on his health. Thesis Statement As the patient has been presented at the emergency after having with discovered by an acquaintance to be in a confused and disoriented state in his rooming apartment, this assessment will endeavour to establish a diagnosis and the further sequel of diagnostic tests and interventions necessary for restoration to health, with a focus on his medical history of being diabetic as well as suffering from hypertension. Data Information Subjective Data: Douglas lives alone, is a heavy smoker, suffers from diabetes Type I and hypertension and his been discovered by his friend to be in a delirious state on the day of his presentation to the emergency. Objective Data: Douglas’s medical history reveals that he is allergic to penicillin and has been on a regimen of HumalogMix 25, an insulin preparation, at 26 & 16 units bid, along with 4 mg of Perindopril and 100 mg Aspirin once a day to control his diabetes and blood pressure respectively. At the emergency, his Glasgow coma score was established as 14/15. On admission, his vital signs were monitored and a HR (Heart rate) of 82, BP (Blood Pressure) at 110/87 mmHg, RR (Respiration rate) of 18 per minute and T (body temperature) were recorded as 36.8oC. His blood sugar level (BSL) was measured at 5.2 mmol/L prior to breakfast and he was kept under observation for neurological symptoms. He was given an appropriate amount of the recommended breakfast which was later discovered to be half eaten. The patient was observed to be sweating slightly and exhibiting hand tremor when observed. He appeared pale and his speech was slurred. His vital signs were rechecked which revealed a HR of 88bpm, BP at 105/80 mm of Hg, RR of 18 and T at 36.5oC. A CT scan has been recommended for Douglas later in the day. Discussion (Part A) Douglas’s medical history, symptoms and vital signs reveal that he has an elevated HR, slightly elevated diastolic blood pressure, slight hypothermia and a markedly high RR. The symptoms are highly suggestive of a hypoglycaemic crisis along with its associated complications. The following 4 hypotheses can be construed for the patient: 1. Decreased level of consciousness 2. Possible coma 3. Anxiety precipitated by hypoglycaemia 4. Possible Syncope Hypoglycaemia is a common complication of insulin treatment when the patient tries to achieve glucose control and approach near-normoglycaemia. Symptoms of hypoglycemia include headache, palpitations, light-headedness, blurred vision, agitation, and confusion. In some patients, a hypoglycaemic crisis may produce stroke like symptoms leading to delusional state, coma, myocardial infarction and sudden death. If the BSL falls to levels, below 3 mmol/L, delusional symptoms can occur as the brain is starved of necessary glucose. As Douglas has been brought to the emergency exhibiting the initial symptoms of a hypoglycaemic crisis, chances of his recovery are fair. His confusion and disorientation, along with a baseline value of BSL at 5.2 mmol/L, pallor, slight sweating and slurred speech suggest that he is at a risk of slipping into hypoglycaemic coma unless he is adequately treated. His Glasgow coma score of 14/15 is however a positive sign. The CT scan can reveal whether he is having any cardiomyopathy which might be complicating the issue, as his smoking habit can be a contributing factor. It has been established that patients with diabetes Type I with impaired awareness have a higher risk of suffering from hypoglycaemia (Choudhary et al, 2010). Another study has revealed that those with impaired awareness of hypoglycaemia had a sevenfold higher incidence of asymptomatic hypoglycaemia than those with normal awareness (Schopman et al, 2011). Educating diabetics regarding their susceptibility has been found to reduce the incidence of further such episodes (Thomas et al, 2007). Physical exertion is another factor which can precipitate hypoglycaemia in patients suffering from diabetes type I (Graveling & Frier, 2010). Several barriers in protecting against hypoglycemia which include decreased insulin release, human neuroendocrine system and activation of the sympathoadrenal system have been identified which necessitate the education of patients to recognize tell tale symptoms (Fowler, 2011). Moreover, the tight control exerted by extraneous insulin dosage can in itself be another precipitating factor for a hypoglycaemic episode (Briscoe et al, 2007). Discussion (Part B) As Douglas has a tentative diagnosis of hypoglycaemic crisis based upon his medical history, laboratory results and present symptoms, he can be asked the following questions: 1. Whether he had indulged in any physical activity which might have exerted him. 2. Whether he had changed or missed his recommended dosage regimen of the prescribed medications. 3. Whether he had smoked more or had any emotional issues during the period preceding his present condition. 4. Whether he was aware of the fact that he could be confronted with such a situation as he was diabetic. Based on the patient’s history, his vital parameters need to be monitored continuously and he should be watched for any changes in his BSL, HR and blood pressure. His neurological symptoms also need continuous monitoring so that adequate therapeutic interventions can be initiated at the right time. References BMI healthy weight calculator, Accessed August 13, 2011 at: http://www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx Choudhary, P. P., Geddes, J. J., Freeman, J. V., Emery, C. J., Heller, S. R., & Frier, B. M. (2010). Frequency of biochemical hypoglycaemia in adults with Type 1 diabetes with and without impaired awareness of hypoglycaemia: no identifiable differences using continuous glucose monitoring. Diabetic Medicine, 27(6), 666-672. Clinical Laboratory Tests Normal Values, Accessed August 13, 2011 at: http://www.mcc.ca/objectives_online/objectives.pl?lang=english&loc=values Fowler, M. J. (2011). The Diabetes Treatment Trap: Hypoglycemia. Clinical Diabetes, 29(1), 36-39. Glasgow Coma Score, Retrieved August 13, 2011 from: http://www.trauma.org/archive/scores/gcs.html Graveling, A. J., & Frier, B. M. (2010). Risks of marathon running and hypoglycaemia in Type 1 diabetes. Diabetic Medicine, 27(5), 585-588. Hypoglycemia (Low blood glucose), retrieved August 13, 2011 from: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html Hypoglycaemia Guideline, Retrieved August 14, 2011 from: http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5134 Jones Briscoe, V., Bowman Tate, D., & Davis, S. (2007). Type 1 diabetes: exercise and hypoglycemia. Applied Physiology, Nutrition & Metabolism, 32(3), 576-582 Schopman, J. E., Geddes, J. J., & Frier, B. M. (2011). Frequency of symptomatic and asymptomatic hypoglycaemia in Type 1 diabetes: effect of impaired awareness of hypoglycaemia. Diabetic Medicine, 28(3), 352-355. Thomas, R. M., Aldibbiat, A. A., Griffin, W. W., Cox, M. A., Leech, N. J., & Shaw, J. M. (2007). A randomized pilot study in Type 1 diabetes complicated by severe hypoglycaemia, comparing rigorous hypoglycaemia avoidance with insulin analogue therapy, CSII or education alone. Diabetic Medicine, 24(7), 778-783. Read More