NURS 6501 Module 2 Assignment Case Study Analysis

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NURS 6501 Week 4: Alterations in the Cardiovascular and Respiratory Systems

INTRODUCTION

Cardiovascular and respiratory disorders can quickly become dangerous healthcare matters, and they routinely land among the leading causes of hospital admissions. Disorders in these areas are complicated by the fact that these two systems work so closely as contributors to overall health. APRNs working to form a similarly close partnership with patients must demonstrate not only support and compassion, but expertise to guide the understanding of diagnoses and treatment plans. This includes an understanding of patient medical backgrounds, relevant characteristics, and other variables that can be factors in their diagnoses and treatments.

This week, you examine alterations in the cardiovascular and respiratory systems and the resultant disease processes. You also consider patient characteristics, including racial and ethnic variables, and the impact they have on altered physiology.

LEARNING OBJECTIVES

Students will:

• Analyze processes related to cardiovascular and respiratory disorders
• Analyze alterations in the cardiovascular and respiratory systems and the resultant disease processes
• Analyze racial/ethnic variables that may impact physiological functioning
• Evaluate the impact of patient characteristics on disorders and altered physiology

CASE STUDY ANALYSIS

An understanding of the cardiovascular and respiratory systems is a critically important component of disease diagnosis and treatment. This importance is magnified by the fact that these two systems work so closely together. A variety of factors and circumstances that impact the emergence and severity of issues in one system can have a role in the performance of the other.

Effective disease analysis often requires an understanding that goes beyond these systems and their capacity to work together. The impact of patient characteristics, as well as racial and ethnic variables, can also have an important impact.

An understanding of the symptoms of alterations in cardiovascular and respiratory systems is a critical step in diagnosis and treatment of many diseases. For APRNs this understanding can also help educate patients and guide them through their treatment plans.

In this Assignment, you examine a case study and analyze the symptoms presented. You identify the elements that may be factors in the diagnosis, and you explain the implications to patient health.

To prepare:

By Day 1 of this week, you will be assigned to a specific case study scenario for this Case Study Assignment. Please see the “Announcements” section of the classroom for your assignment from your Instructor.

The Assignment

In your Case Study Analysis related to the scenario provided, explain the following

• The cardiovascular and cardiopulmonary pathophysiologic processes that result in the patient presenting these symptoms.
• Any racial/ethnic variables that may impact physiological functioning.
• How these processes interact to affect the patient.
• BY DAY 7 OF WEEK 4
• Submit your Case Study Analysis Assignment by Day 7 of Week 4
• Reminder:The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The sample paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templatesLinks to an external site.). All papers submitted must use this formatting.

Week 4 Case Study Assignment

Adma Grace Wilson-Romans

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Hello Class,

Week 4 Case Study Assignment:

A 55-year-old high school teacher begins experiencing a cough after a parent-teachers conference. Initially it was a mild cough and the teacher thought nothing of it since he had a history of asthma. As he was driving home, the cough became more intense, and he began experiencing chest tightness. He used his rescue inhaler as usual but did not get any relief. Minutes later he began experiencing chest pain, unlike the tightness that he experienced with his asthma.

He began to sweat profusely, experience light-headedness and difficulty breathing. He attempted to pull into a park but passed out and struck the curve causing his vehicle to come to a stop. A passerby saw the incident and called 9-1-1. On the scene, the paramedic found the man unconscious. His EKG revealed ST segment elevation in the anterior leads (V3 and V4), his pulse was shallow, and respirations were 10 breaths/min. Upon arrival to the ER, a troponin level was 13ng/l and his CK level was 265 U/L.

LEARNING RESOURCES

Required Readings

• McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier.
  • Chapter 32: Structure and Function of the Cardiovascular and Lymphatic Systems; Summary Review
  • Chapter 33: Alterations of Cardiovascular Function (stop at Dysrhythmias); Summary Review
  • Chapter 35: Structure and Function of the Pulmonary System; Summary Review
  • Chapter 36: Alterations of Pulmonary Function (stop at Disorders of the chest wall and pleura); (obstructive pulmonary diseases) (stop at Pulmonary artery hypertension); Summary Review

Note: The above chapters were first presented in the Week 3 resources. If you read them previously you are encouraged to review them this week.

Required Media

• Alterations in the Cardiovascular and Respiratory Systems – Week 4 (15m) Transcript Attached

Online Media from Pathophysiology: The Biologic Basis for Disease in Adults and Children

In addition to this week’s media, it is highly recommended that you access and view the resources included with the course text, Pathophysiology: The Biologic Basis for Disease in Adults and Children. Focus on the videos and animations in Chapters 32, 33, 35, and 36 that relate to cardiorespiratory systems and alteration in cardiorespiratory systems. Refer to the Learning Resources in Week 1 for registration instructions. If you have already registered, you may access the resources at https://evolve.elsevier.com/Links to an external site.

NURS_6501_Module2_Case Study_Assignment_Rubric

Criteria Ratings Pts

This criterion is linked to a Learning Outcome Develop a 1- to 2-page case study analysis, examing the patient symptoms presented in the case study. Be sure to address the following: Explain both the cardiovascular and cardiopulmonary pathophysiologic processes of why the patient presents these symptoms.

30 to >27.0 pts

Excellent

The response accurately and thoroughly describes the patient symptoms. … The response includes accurate, clear, and detailed reasons, with explanation for both the cardiovascular and cardiopulmonary pathophysiologic processes supported by evidence and/or research, as appropriate, to support the explanation.

27 to >24.0 pts

Good

The response describes the patient symptoms. … The response includes accurate reasons, with explanation for both the cardiovascular and cardiopulmonary pathophysiologic processes supported by evidence and/or research, as appropriate, to support the explanation.

24 to >22.0 pts

Fair

The response describes the patient symptoms in a manner that is vague or inaccurate. … The response includes reasons for the cardiovascular and/or cardiopulmonary pathophysiologic processes, with explanations that are vague or based on inappropriate evidence/research.

22 to >0 pts

Poor

The response describes the patient symptoms in a manner that is vague and inaccurate, or the description is missing. … The response does not include reasons for either the cardiovascular or cardiopulmonary pathophysiologic processes, or the explanations are vague or based on inappropriate or no evidence/research.

30 pts
This criterion is linked to a Learning Outcome Explain how the cardiovascular and cardiopulmonary pathophysiologic processes interact to affect the patient.

30 to >27.0 pts

Excellent

The response includes an accurate, complete, detailed, and specific explanation of how the cardiovascular and cardiopulmonary pathophysiologic processes interact to affect the patient.

27 to >24.0 pts

Good

The response includes an accurate explanation of how the cardiovascular and cardiopulmonary pathophysiologic processes interact to affect the patient.

24 to >22.0 pts

Fair

The response includes a vague or inaccurate explanation of how the cardiovascular and cardiopulmonary pathophysiologic processes interact to affect the patient.

22 to >0 pts

Poor

The response includes a vague or inaccurate explanation of how the cardiovascular and cardiopulmonary pathophysiologic processes interact to affect the patient.

30 pts
This criterion is linked to a Learning Outcome Explain any racial/ethnic variables that may impact physiological functioning.

25 to >22.0 pts

Excellent

The response includes an accurate, complete, detailed, and specific explanation of racial/ethnic variables that may impact physiological functioning supported by evidence and/or research, as appropriate, to support the explanation.

22 to >19.0 pts

Good

The response includes an accurate explanation of racial/ethnic variables that may impact physiological functioning supported by evidence and/or research, as appropriate, to support the explanation.

19 to >17.0 pts

Fair

The response includes a vague or inaccurate explanation of racial/ethnic variables that may impact physiological functioning, and/or explanations based on inappropriate evidence/research.

17 to >0 pts

Poor

The response includes a vague or inaccurate explanation of racial/ethnic variables that may impact physiological functioning, or the explanations are based on inappropriate or no evidence/research.

25 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 to >4.0 pts

Excellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. … A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 pts

Good

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. … Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 pts

Fair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. … Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 pts

Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. … No purpose statement, introduction, or conclusion were provided.

5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts

Good

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts

Fair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 pts

Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

5 to >4.0 pts

Excellent

Uses correct APA format with no errors.

4 to >3.0 pts

Good

Contains a few (1 or 2) APA format errors.

3 to >2.0 pts

Fair

Contains several (3 or 4) APA format errors.

2 to >0 pts

Poor

Contains many (≥ 5) APA format errors.

5 pts
Total Points: 100

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NURS 6501 Module 3: Knowledge Check Quiz

Question 14 pts

Scenario 1: Peptic Ulcer

A 65-year-old female comes to the clinic with a complaint of abdominal pain in the epigastric area. The pain has been persistent for two weeks.  The pain is described as burning, non-radiating, and worse after meals. Denies N&V, weight loss, or obvious bleeding. She admits to frequent belching with bloating.

PMH:  seasonal allergies with Chronic Sinusitis, positive for osteoarthritis,

Meds: Claritin 10 mg po daily, ibuprofen 400-600 mg po prn pain

Family Hx-non contributary

Social history: Separated recently pending divorce; stressful situation with trying to manage two homes. Works as a Legal Assistant at a local law firm. She has 35 PPY of smoking, drinks 1-2 glasses of wine a day, and has 6-7 cups of coffee per day. She denies illicit drug use, vaping, or unprotected sexual encounters.

A breath test in the office revealed + urease.

The healthcare provider suspects the client has peptic ulcer disease.

Questions:

1. Explain what contributed to the development of this patient’s history of PUD?

The patient’s peptic ulcer disease is most likely multifactorial. One of the confirmed risk factors in this patient is Helicobacter pylori infection. H. pylori infection has been confirmed by a positive breath test for urease. This gram-negative flagellated spiral bacterium is an established cause of peptic ulcer disease, among other illnesses such as acute and chronic gastritis. Another risk factor in the above patient is tobacco smoking. The patient has 35 packs per year of smoking, and this is a significant risk for PUD. Thirdly, the patient’s elderly age, above 64 years, is another risk for peptic ulcer disease.

The patient also takes alcohol, especially 1-2 glasses of wine daily, and this contributes to the development of PUD. The patient’s use of nonsteroidal anti-inflammatory drugs, especially ibuprofen, is a risk factor for PUD development in this patient.  The patient’s coffee consumption cannot be associated with her PUD. According to a review article by Nehling (2022), there has been no substantial evidence linking coffee consumption or use of any caffeinated drinks with acid-related gastrointestinal diseases such as peptic ulcer disease

McCance, K. L., & Huether, S. E. (2022). Pathophysiology: The biologic basis for disease in adults and children (9th ed.). Mosby.

Nehlig, A. (2022). Effects of coffee on the Gastrointestinal tract: A narrative review and literature update. Nutrients, 14(2), 399. https://doi.org/10.3390/nu14020399

Question 24 pts

Scenario 1: Peptic Ulcer

A 65-year-old female comes to the clinic with a complaint of abdominal pain in the epigastric area. The pain has been persistent for two weeks.  The pain is described as burning, non-radiating, and worse after meals. Denies N&V, weight loss, or obvious bleeding. She admits to frequent belching with bloating.

PMH:  seasonal allergies with Chronic Sinusitis, positive for osteoarthritis,

Meds: Claritin 10 mg po daily, ibuprofen 400-600 mg po prn pain

Family Hx-non contributory

Social history: Separated recently pending divorce; stressful situation with trying to manage two homes. Works as a Legal Assistant at a local law firm. She has 35 PPY of smoking, drinks 1-2 glasses of wine a day, and has 6-7 cups of coffee per day. She denies illicit drug use, vaping, or unprotected sexual encounters.

A breath test in the office revealed + urease.

The healthcare provider suspects the client has peptic ulcer disease.

Question:

1. What is the pathophysiology of PUD/ formation of peptic ulcers? 

This patient’s peptic ulcer disease is multifactorial. The pathophysiology of PUD in the above patient was orchestrated by an imbalance between muco-protective and destructive factors. The above factors led to the weakening of muco-protective defense mechanisms in the stomach and duodenum. When these barriers are eroded by the aforementioned factors, the mucosa is exposed to gastric acid, which leads to PUD.

Muco-protective factors include gastric mucus, stable blood flow, intact epithelial cell lining, and prostaglandin production. Acids and toxins destroy these barriers. Helicobacter pylori release toxins that irritate the already defenseless mucosa to cause an inflammatory response. NSAIDs decrease prostaglandin production by inhibiting cyclooxygenase production.

Thus, the use of these medications increases acid production and decreases gastric mucus production. Stress such as physiological and psychological stress can increase acid production. All these factors lead to mucosa erosion. The outcome is epigastric pain, vomiting, nausea, hematemesis, and sometimes melena stool

McCance, K. L., & Huether, S. E. (2022). Pathophysiology: The biologic basis for disease in adults and children (9th ed.). Mosby.

Question 34 pts

Scenario 2: Gastroesophageal Reflux Disease (GERD)

A 44-year-old morbidly obese female comes to the clinic complaining of  “burning in my chest and a funny taste in my mouth”. The symptoms have been present for years but the patient states she had been treating the symptoms with antacid tablets which helped until the last 4 or 5 weeks. She never saw a healthcare provider for that. She says the symptoms get worse at night when she is lying down and has had to sleep with 2 pillows. She says she has started coughing at night which has been interfering with her sleep. She denies palpitations, shortness of breath, or nausea.

PMH-HTN, venous stasis ulcers, irritable bowel syndrome, osteoarthritis of knees, morbid obesity (BMI 48 kg/m²)

FH: non-contributory

Medications: Lisinopril 10 mg po qd, Bentyl 10 mg po, ibuprofen 800 mg po q 6 hr prn

SH: 20 PPY of smoking, ETOH rarely, denies vaping

Diagnoses: Gastroesophageal reflux disease (GERD).

Question:

1. If the client asks what causes GERD how would you explain this as a provider? 

I would let this patient know that her gastroesophageal reflux disease (GERD) was multifactorial in that not only one factor would have led to her illness. She would know that in GERD, the contents of the stomach move up the esophagus through the lower sphincter in the junction between the esophagus and the stomach. The stomach contents are majorly acidic and thus will cause corrosion of the esophageal inner lining, leading to inflammation.

Factors such as obesity, pregnancy, smoking, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) can cause GERD. In some individuals, hiatal hernia, a condition in which part of the stomach or whole of the stomach moves into the chest cavity, can cause GERD. Also, when the movement of gastric contents is slowed or delayed, GERD can develop. Therefore, gastroparesis, gastric ulcers, and duodenal ulcers can cause GERD.

McCance, K. L., & Huether, S. E. (2022). Pathophysiology: The biologic basis for disease in adults and children (9th ed.). Mosby.

Question 44 pts

Scenario 3: Upper GI Bleed

A 64-year-old male presents to the clinic with complaints of passing dark, tarry, stools. He stated the first episode occurred last week, but it was only a small amount after he had eaten a dinner of beets and beef. The episode today was accompanied by nausea, sweating, and weakness. He states he has had some mid-epigastric pain for several weeks and has been taking OTC antacids. The most likely diagnosis is upper GI bleed which won’t be confirmed until further endoscopic procedures are performed.

Question:

1. What are the variables here that contribute to an upper GI bleed? 

This patient’s advanced age and a likely peptic ulcer disease are key risks for his upper GI bleed. Peptic ulcer disease has ulcer pits that, if not allowed to heal properly, can bleed. With advanced age comes various risks that increase the likelihood of having an upper GI bleed. The pieces of evidence of upper GI bleeding in this patient are passing dark tarry stool, epigastric pain, nausea, and weakness. Weakness can arise from anemia or shock from this type of bleeding. Intake of beets could have given the stool an abnormal color. Therefore, the endoscopy is warranted to ascertain the presence and cause of upper GI bleeding in this patient.

McCance, K. L., & Huether, S. E. (2022). Pathophysiology: The biologic basis for disease in adults and children (9th ed.). Mosby.

Question 54 pts

Scenario 4: Diverticulitis

A 54-year-old schoolteacher is seeing your today for complaints of passing bright red blood when she had a bowel movement this morning. She stated the first episode occurred last week. The episode today was accompanied by nausea, sweating, and weakness. She states she has had some LLQ pain for several weeks but described it as “coming and going”. She says she has had a fever and abdominal cramps that have worsened this morning.

The diagnosis is lower GI bleeding secondary to diverticulitis.

Question:

1. What can cause diverticulitis in the lower GI tract? 

Outpouching that occurs on the bowel wall is called diverticula. Diverticula can occur in anyone, but the presence is mostly detected when symptoms of active disease are present. These diverticula can become infected or can have inflammation to cause diverticulitis. Diverticulitis can be caused by various factors such as reduced fiber in the diet, obesity, smoking, advanced age, lack of physical exercise, and medication use. Abnormal colonic motility and alteration in intestinal microbiota can contribute to diverticulitis. Sometimes, visceral hypersensitivity is implicated. Medications such as aspirin and NSAIDs also predispose one to diverticulitis.

McCance, K. L., & Huether, S. E. (2022). Pathophysiology: The biologic basis for disease in adults and children (9th ed.). Mosby.

Week 6: Concepts of Endocrine Disorders

WEEK 6: AT A GLANCE

CONCEPTS OF ENDOCRINE DISORDERS

INTRODUCTION

Endocrine disorders are complex matters, and there is not always a one-size-fits-all treatment. Particularly in matters requiring the adjustment of hormone levels, treatment may require a custom approach tailored to individual patients. An understanding of these complications is essential to supporting these individual treatment plans.

This week, you examine alterations in the endocrine system and the resultant disease processes. You also consider patient characteristics, including racial and ethnic variables, and the impact they have on altered physiology.

LEARNING OBJECTIVES

Students will:

• Analyze concepts and principles of pathophysiology across the lifespan

LEARNING RESOURCES

• McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children(8th ed.). St. Louis, MO: Mosby/Elsevier.
  • Chapter 21: Mechanisms of Hormonal Regulation, including Summary Review
  • Chapter 22: Alterations of Hormonal Regulation, including Summary Review
  • Chapter 23: Obesity and Disorders of Nutrition, including Summary Review
• American Diabetes Association (2020). Standards of medical care of patients with diabetes mellitus. Diabetes Care, 26(suppl 1), pp. s33-s50. https://care.diabetesjournals.org/content/26/suppl_1/s33
• Orlander, P. R. (2018). Hypothyroidism. Retrieved from https://emedicine.medscape.com/article/122393-overview
• Hoorn, E. J., & Zietse, R. (2017). Diagnosis and treatment of hyponatremia: Compilation of the guidelines. Journal of the American Society of Nephrology, 28(5), 1340–1349
• Document: NURS 6501 Midterm Exam Review (PDF)Download NURS 6501 Midterm Exam Review (PDF)
  Note: Use this document to help you as you review for your Midterm Exam in Week 6.

• Module 4 Overview with Dr. Tara Harris

Dr. Tara Harris reviews the structure of Module 4 as well as the expectations for the module. Consider how you will manage your time as you review your media and Learning Resources throughout the module to prepare for your Knowledge Check and your Midterm. (3m

Transcript below:

TARA HARRIS: Hi. Welcome to Module 4 of Advanced

Pathophysiology NURS 6501. I’m Dr. Tara Harris, and I will

provide you with an overview. During Module 4, we will

discuss endocrine disorders. This module only covers week 6. During week 6, you will

analyze concepts and principles of pathophysiology

across the lifespan as it relates to

endocrine disorders. You have several required

readings and articles. You also have required media

that you can access online. You will need to focus on videos

and animations in chapters 21 through 23 as they relate to

endocrine system and disorders. You can access this through

the [? elsevier ?] website. There is also an optional

resource that you can access. This is actually an

interactive tutorial that you can use at

home, and you also have access to this through

the Walden University website. During week 6, you will have

a knowledge check questions. These will be 10 to 20 questions

to gauge your understanding of this module’s content. The week 6 knowledge checks

will include clue questions related to endocrine disorders. You will be provided

with immediate feedback after you have

posted your answers. These knowledge

check questions are to be completed and

submitted by day 7 of week 6. This week, you also

have your midterm exam. Your midterm will cover topics

from weeks 1, 2, 3, 4, 5, and 6. You have two hours

to complete the exam, and you have 100 questions

within this exam. Your exam will automatically

shut off after the two hour mark . Please complete this

exam in one sitting. Do not stop and

restart the exam. Should your system remain

idle for a period of time, it may shut off,

and you will not be able to complete the exam. You must submit your midterm

exam by day 7 of week 6.

Concepts of Endocrine Disorders – Week 6 (24m)  Transcript below

ELISABETH BUCHANAN:

Hello, everyone and welcome to Advanced

Pathophysiology, week six. My name is Dr. Buchanan. This week’s topic of

discussion is concepts of the endocrine disorders. Very interesting topic. Before we get started

on the overview. Let’s look at a few things that

are reminders for week six. We want to make sure

that you’re understanding the Knowledge Check is due

by day seven of week six. However to prepare

you for your midterm, we want to make

sure that you try to get it done at least 48 hours

before so that at least you can reach out if you

have any questions. You develop a conceptual

learning pattern instead of a memorizing pattern. And it helps you to critically

think outside and around the box on your midterm exam. Note that you would

also need your materials from previous knowledge checks. So make sure you review all

those before your midterm exam as well. Let’s look at some of the topics

that we’re going to go over. One of them is very prominent

in our culture, diabetes. We also have hyperthyroidism

and hypothyroidism, adrenal disorders,

parathyroidism, both hyper and hypo. The checks and balances

and the negative feedback we’re talking about the

homeostasis within the system. Whenever there is a check

and balance out of place, then we know we have suffering

normally of the renal. –syndrome of inappropriate

antidiuretic hormone, pheochromocytosis,

diabetes insipidus, and diabetic ketoacidosis. Let’s start with diabetes. So that’s something that’s

very prominent in our culture. We see it quite a bit, all ages. We’re getting to see it more

so in our younger generation. One of the things that I would

like and suggest that you do. On your resources, make sure

that you go and look at those, there is an arrow to the

right of those resources. Click on that and

that will take you to some of the study guidelines

and comparative table values that I’m sure you’ll use. There is some really

good ones in there. Another place that you can look

at for diabetic information for your patients is the

American Diabetic Association. Wonderful. Absolutely wonderful tools there

that you should be able to see. So let’s go over some

of the diabetic problems or some of the things

that we see in diabetes just as a brief overview. Some of the things that you want

to make sure that you always ask as far as risk

factors, you want to look at their

physical inactivity. You want to look at their

first degree relatives. Do they have diabetes? You want to look at the high

risk ethnic populations. You want to look at women

who have delivered babies weighing greater than 9 pounds

and had gestational diabetes at the time of

their prenatal care. Hypertension, you want

to look at if they are greater than or equal on

a systolic of 140 greater than or equal to a systolic of 90

or on hypertensive therapy. A lot of times you’re going to

see diabetes and hypertension go together. I almost know there are research

papers out there where you’re going to see where diabetes

can actually have influence on their blood pressure. So if their diabetes is high

for that evening that day or whenever you’re probably

more than likely going to see hypertension play

a role in being higher than their normal

number as well. Whenever they’re sick. We know their diabetes

is going to go higher. So probably blood pressure

could go higher as well. We want to look at impaired

glucose tolerance test. We’re going to look at

other clinical conditions such as insulin resistance. Somebody that’s

severe morbidly obese. We’re going to look at history

of cardiovascular disease, somebody with atherosclerosis,

coronary artery disease, problems

peripheral swelling, edema, kidney malfunction. The one thing that

I want to let you know too, when we look

at these risk factors, we’re looking at age of

initiation in a lot of them even in asymptomatic children. We want to look at anybody

10 years of age or older, puberty also. So be conscientious

of those age groups when you look at that as well. Some of the diabetes, diagnosing

prediabetes and diabetes mellitus in adults

and adolescents, their plasma glucose fasting,

which means no caloric intake for greater than 8 hours,

anything greater than 126 and/or a random blood

sugar greater than 200, with symptoms including

polyphagia, polyurea, polydipsia, and

unexplained weight loss. So those are things

that you want to look for when you’re

looking at the diabetic or diagnosing a diabetic. When you look at Oral Glucose

Tolerance Test, the OGTT, you want to look at the two

hour plasma glucose anything greater than or equal

to a 200 after a 75 gram of glucose load. A1Cs are a little

tricky because you have a lot of

differentiations out there across the lines of health

care and the insurance world. CMS, Center for Medicare

and Medicaid Services, in their quality checks

when they do risk factors or they look at risk

factors among patients in the geriatric or the

disabled population, they’re looking at anything

less than eight on an A1C. And you’re like, well, wait

a minute that’s pretty high. For us as providers it might be. But anything less than eight to

the Medicare world or Medicare is the mom of all the

insurance industries even though they won’t admit

to it, Medicare world a lot of times anything

less than eight is an indication

of a safety issue– somebody on anticoagulation

therapy, somebody with syncope, somebody with vertigo, somebody

that’s just not stable, somebody that might have

OA, RA, osteoporosis, frailty in general, wheelchair,

using assistive devices. Any of those things and

they have hypoglycemia, they’re probably

going to go down and could cause definitely head

trauma with hemorrhagic issues. So you want to make sure that

if you are wanting tighter controls less than

six, less than 6.5, whatever the parameters based on

evidence based in your practice area are, you want to make

sure that you’re dealing with not only the diabetes. You’re dealing with these safety

issues of that patient as well. So remember anything less than

eight in the insurance world is normal for us. When I say for us, if I was

in insurance world, anything less than 6.5, 6.9 is

probably in the world of you as a provider. You want optimal always

for your patients. But that’s not

always obtainable. Make sure whatever

you want for them is something they can meet. If they find they

can’t meet what you want they’ll either

switch providers. They’ll play doctor shop. They’ll play medicine shop. In other words, they’ll take

a medicine here and there. You prescribe two pills. They’ll take one

today because you know they’re playing

with their blood sugars. So just remember that when you

say somebody is prediabetic, please explain to

them what that means. You give them metformin. You give them a glipizide. You give them something

for their diabetes. Then they in the

insurance world have become pretty much diabetic. Because you are now

giving them therapy. You’re treating their diabetes. If somebody is prediabetic, try

to put them on a 90 day diet and exercise program

giving them an idea of how many carbs for intake. Refer them to a dietitian. Get their blood sugar

or blood pressure down. Have them exercise. But when you say

exercise make sure that you’re not

telling this patient to go out and exercise 30 to

40 minutes every single day or five days a week. If they miss one day,

they feel really horrible most of the time. And they won’t come

and follow up with you because they didn’t do

what you asked them to do. And they know that. And their sugar

levels is not right. It won’t be right. I just know it. my blood test

isn’t going to be normal. So when you set expectations

that you can meet, you’re really not meeting

the value and belief system of the patient. Make sure you evaluate their

belief and value system and not just yours

especially related to the endocrine system. Those hormones, those stress

hormones can be activated. And you can cause a boomerang or

a cascading effect of problems. So remember what you always want

is and what they always want, you have to come the halfway. We can give them the tools. We can write a prescription. We can do as much as

we can educate them. We don’t follow them home. We don’t monitor them 24/7. That’s their job. We have to give them the

tools to own their illness. If we don’t, then that illness

will eventually overtake them. And they’re going

to be a repeated revolving door at the hospital. So make sure you have them own

their illness by you providing them with knowledge

and education and the appropriate

means of evidence based effective treatment. Sorry to get off on that. So we want to make

sure that we look at anybody’s lab tests, A1Cs. Don’t just do those once a year. Medicare, all the

insurances will pay for those three

to four times a year, every three to six months. Try and do that. Give them an objective. If you do an A1C March,

they don’t see you till next January. You’ve got three

holidays in there. You’ve got Halloween,

Thanksgiving, Christmas, and New Year’s. Whether they believe

those or not, those are winter months

regardless of people’s values or belief systems. You’ve got four holidays in

there and/or maybe something else January 1st, the new year. The problem is you

do an A1C check and I almost guarantee

you it’s going to be a sky high off the rocker. They’re going to do

a confession with you and say all the things they

ate during the holidays. They know better and whatever. It’s up to you. I usually try to

space my patients out so that I’m not

measuring it during one of those times of the year. Because you’ve got

to remember if it’s going to measure

three months, those are the three months

of where everybody has a lot of family gatherings. So just be conscientious of

that when you try to measure. But do an A1C more

than once a year. The insurances

have it where they pay for those every three

to six months for a reason. It’s because insurance

industry is driven by evidence based quality practice of care. Standards of care,

standards of care. I can’t say that enough. Recommended immunizations,

obviously the influenza, pneumococcal vaccines. Make sure that the patient

understands their blood pressure controls. You’re looking at

basically anything greater than 130 systolic,

greater than 80 diastolic is a little bit high for

those that are diabetic. 120 over 80 less

than or equal to. Optimal is great but get him

down to a specific means level first and then work with them. Don’t say you’re 20

points high on systolic. We really need you

at the 110 to 120. That’s like telling a

diabetic who’s 200 to 300, we want you down to

110 by next month. A lot of times

they’re unachievable. You’re setting them up to fail. And we don’t want

patients failing because then their

compliance goes down and obviously chronic

disease goes up. Comorbidities go up and the

ER revolving door comes up. When you also look

at self management, make sure you explain to the

patients about healthy choices, medical nutrition

therapy if they get sick, support groups for diabetes,

diagnostic evaluation therapeutic options, ongoing

such as believe it or not sexual problems. Husband and wife

they’re on medication, their love life is down. Psychologically that’s

an impact on them to be compliant for their

physiological needs. Make sure that you

are always addressing psychological with

physiological whenever these patients have these

type of endocrine issues or any issues. Chronic disease in general is

going to cause some impairment to their psychological state. And you need to be addressing

that each and every time that they come in. If you ask them if

they are depressed, if you ask them if they have

anxiety, if you ask them if they have sleep

problems, they’re probably going to tell you no. Because they’ve

got enough going on with somebody that’s

been recently diagnosed with these type of illnesses

and/or cardiovascular disease. They don’t want to add

anything else to the plate. Let alone being called, quote,

the status in our country how bad we look at mental

illness which is very sad. So they don’t want

to be categorized as somebody like that. So as in passing you’re

listening to their heart. How are you sleeping? Are you sleeping pretty good? As you’re listening or

checking their DTRs, so tell me a little bit about

any problems with energy, any problems with

anxiety lately, any problems with concentration. Ask them the questions that you

would normally get on a PHQ-9. But in general don’t read it. In general ask them as

you’re assessing them. So diabetes in general,

a multitude of treatment modalities you can look at. Those should be covered. Make sure that you understand

the insulin concepts. Really when glucose values

get greater than 250 to 300, we’re looking at some insulin. It depends on the patient. If I have a patient I know

evidence based drives us to say what and do what we do. But if I have a patient

that’s adamant they’re going to do x, y, z,

come back in two weeks. Let me see you. Let’s do a fasting

glucose at that time. Two weeks isn’t a

lot of time but hey, you’re keeping them

in tuned with you. So you’re keeping them alert. You say come back in

six months, come back in three months,

sometimes that’s too long. Even if you just say

come back next month, that’s better than three months,

four months or six months because you’re trying

to identify and get them on board with their illness. And if that’s the way you need

to do it by seeing them once a month and kind

of collaborating with them on their therapeutic

regimen and their value and belief system, then

I think that’s going to work better for compliance. So let’s talk a little bit

about hyper and hypothyroidism. On your resources, if you

go over on your resources and over to the right,

on the resources hyper and hypothyroidism. There’s a table there. If you click on that, it’s

going to go to Medscape. And you’re going to be

able to see that table. If you could just

remember two things hyper is accelerating metabolism. Hypo is under

established metabolism. He’s always sleepy. Hypo just wants to sleep. He doesn’t want to do

anything He just wants to have just one of those

lazy days, sedentary days, doesn’t really want to

add, to do anything. His energy release

is pretty much zero. His cell turnover

is pretty much zero. I mean think about it. Your lethargic. You have no interest. You have memory problems. You have a coldness to you. Your hair is coarse. There’s no vitamins,

no minerals going anywhere, your constipation. Think of all the things

that are a drying effect. Your eyes are dry. You have greater cardio. Your heart slows down

because the thyroid drives laziness in all of our system. So hypothyroidism is

going to drive laziness. Hyperthyroidism is going

to have an acceleration. It’s going to be very active. He doesn’t know when to sleep. He’s up. He’s down. Your heart’s tachycardic. It’s going to be racing. You’ve got some

hyper-reflections. You might not have

any type of menses. Your nails are thin. Your hair is fine. You have frequent loss of hair. You have a heat intolerance. Your weight loss could be

pretty modest about 50% whereas in hypothyroidism

you’ve got a weight gain. So he doesn’t do anything

he’s just growing your adipose tissue in a sense. So hyper and hype

need a balance. So your thyroid needs

a balance in order to communicate with everybody. And therefore you

have the medications that are available for that. We do like to check the

thyroid profile test. We like to feel for goiters. You can have a normal lab. But you can have goiters. Don’t forget that. So ultrasound those goiters. Normally a lot of times

are those nodules. A lot of times you’re going

to find incidentals on CT scans when it comes to thyroid. Patient hasn’t palpated them. You haven’t palpated them. There is no sign, no inkling of. Thyroid tests come back normal. The time when you actually see

those nodules on those thyroids is when those patients

end up with a CT scan. And it’s found as an

incidental finding. Then they can do biopsies

on it fine needle biopsy. A lot of times

they are negative. They’re benign. There’s nothing going on. However, think about something

pressuring that thyroid. It could most

definitely cause it to be hypo and sluggish

even those labs tests are negating that. So just keep that in

mind with somebody that has multinodular goiter

or goiters in general. Endocrinologists are wonderful

for questions on that. Endocrinology website

is wonderful as well. Make sure you check vitamin

D levels, thyroid levels, B vitamin levels,

things of that nature. So let’s go on real briefly

to the pheochromocytoma or chromocytosis. When you look at

this, you’re looking at a rare tumor that

usually starts on top of one of the adrenal glands. And it’s usually benign. However the problem is it

makes too many hormones. So it raises your blood

pressure causes tachycardia. Does a lot of things. It causes you to

sweat, headaches. So we have to treat

all of these symptoms. And normally to be honest

the adrenal tumors are found incidental as well

normally during an abdominal or a CT scan. Sometimes of the

back or the spine. So just as an FYI a lot

of times those tumors on the adrenal glands

are found in that realm. Normally they’ll remove them. We can treat them

with medication. For most of my patients I think

I’ve found that most of them have them removed

at some given point. They don’t really remove

the tumors to be honest. They will remove

an adrenal gland. And then the patient has

to be conscientious of that going forward

because he did have a major significant part of

their body taken away that regulates. So they have to make sure

every single person knows that adrenal gland is no longer

there, especially when it comes to steroid taking. Diabetes insipidus,

a very rare disease. And since it is an

uncommon disorder that is an imbalance of fluids

when we talk about the checks and balances. The imbalance makes you thirsty. It leads one to think

they have diabetes. The difference is a lot of

times it causes your kidneys to make too much urine. So basically what they’ll

do is a 24 hour urine catch. You take the little

red container home or you tell your patients. And for 24 hours they are

urinating in a red container. And then they take it back. So that’s one of the

things that they’re doing. So when you look at

pheochromocytosis and diabetes insipidus, sometimes

they’ll marry those two trying to

do a differential diagnosis on those. When you monitor

homeostasis, you’re looking at body temperature. You’re looking at glucose. You’re looking at

toxins that can disrupt the body’s homeostasis. blood pressure that needs to be

maintained for healthy levels of blood pressure. So when cells

maintain homeostasis, they control the movement of

substances across the cell membrane. So that’s a good thing. There’s a balance. That’s that check and balance. The problem is when

you have a negative. So there is too

much of something such as your thyroid,

too much of or not enough of something else. So always those

checks and balances are important that you

check those, know those. And again when

you draw labs, you make sure you know what you’re

drawing when they come back. Don’t just initial data or

look at them in the computer and sign off on him. Make sure that you

know what you ordered and can treat what you ordered. So let’s talk about as far

as the rest of the topics in this discussion. The one thing that you

want to remember is– I’m sorry we forgot about

the hyperparathyroidism. How could we forget

about that guy? Hyperparathyroidism

when you look at it is too much apparent

thyroid hormone. What causes the two types

of hyperparathyroidism is an enlargement of one or

more of the parathyroid glands. They cause a high calcium

level in the blood. And when this happens, surgery

is almost eminent for that as far as the most

common treatment for the primary for

hyperparathyroidism is surgical. Secondary is due

to another disease that causes those low calcium. It could be renal failure. It can be osteoporosis. It could be depression,

the symptoms of it. So basically when you look

at hyperparathyroidism, how we diagnose it, is

multiple means of the disorder. The result of the damage or

the dysfunction in these glands is too much calcium levels

in the blood and urine or too little calcium in

the bones which can lead to the osteoporosis,

tiring, depression, forgetfulness, bone and joint

pain, complaints of an illness but you really can’t

put your finger on it type of thing, nausea,

vomiting, loss of appetite. So definitely look

at these labs. Make sure you check them. And again, the

endocrinologist or one of the best people

that you can talk to If you have any questions

on any of these the one thing that I would suggest on all

of these is your testing. So on secondary

hyperparathyroidism the result of another

condition that can lower those calcium levels. The causes of in your

parathyroid glands to overwork can be multiple things. It can be severe

calcium deficiency, vitamin D deficiency, CKD. Normally you’re going to see

the parathyroidism altered based on CKD. What is CKD? Chronic Kidney Disease. Make sure you know

the person’s EGFR. If you don’t have the

lab value that shows it, do your creatinine equation. You can find those

online as well. All right everyone,

I think that’s it. If you have any questions,

make sure you reach out to any of your instructors. And if you have any

questions, please read the resources that are there. Good luck on your

midterm exam this week. I’m sure you all

will do very well. Just study your knowledge points

and reach out with questions.

Optional Resources

The following source provides various tutorials related to maximizing your time management and managing stress. Feel free to access this resource to support you as you move through this course.

Also Read: Academic and Professional Success Plan Paper