Posted: May 15th, 2023

You should respond to at least two of your peers by extending

D4cLR
• You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts.
• All replies must be constructive and use literature where possible cited in current APA style with support from at least 1 academic source for each response.

RESPONSE 1
My clinical experience this week was quite interesting. I learned a lot, especially about assessing individuals with various health conditions. With the assistance of a nurse practitioner, I was able to determine the primary diagnosis and design a treatment plan. I was successful in diagnosing a patient with type 2 diabetes and devising an excellent treatment plan. However, I encountered significant difficulties, particularly in distinguishing between health disorders with closely related symptoms. One of the more difficult situations I encountered was explaining the diagnosis to the patient.
This week a 75 y/o women was seen at the primary care office and stated that “I have been feeling very tired lately”. The patient reports feeling tired most of the time accompanied by unintended weight loss, increased hunger, increased thirst, and frequent urination. She reports experiencing the manifestations even when not engaging in any significant activity and notes no associated or relieving factors. To obtain the history of the present illness the acronym “OLDCARTS” was utilized.
-Onset – short memory loss started about a month ago.
–Location – General
–Duration – About 5 weeks ago
–Characteristics – Reports unplanned weight loss
–Associated factor – No associated factors
–Relieving factors – No relieving factor
–Treatment – No treatment obtained.
–Symptoms – Unintended weight loss, regular micturition, increased thirst, and increased hunger.
The list of differential diagnosis of diabetes mellitus consists of various conditions that would exhibit similar signs and symptoms: Drug-induced signs and symptoms due to corticosteroids, neuroleptics, pentamidine, Genetic aberrations in beta-cell function and insulin action Metabolic syndrome (syndrome X) Infection Endocrinopathies such as acromegaly, Cushing disease, pheochromocytoma, hypothyroidism, Complications of iron overload (hemochromatosis).
Plan- A thyroid function test as well as a Glycated hemoglobin (A1C) was completed . The A1C test results was 6.9 percent. The results were higher than the upper limit for normal blood sugar and prediabetes.Target glycated hemoglobin (A1C) levels in patients with type 2 diabetes should be tailored to the individual, balancing the anticipated reduction in microvascular complications over time with the immediate risks of hypoglycemia and other adverse effects of therapy. A reasonable goal of therapy is an A1C value of ≤7 percent (53.0 mmol/mol) for most patients. Glycemic targets are generally set somewhat higher for older adult patients and those with comorbidities or a limited life expectancy who may have little likelihood of benefit from intensive therapy.
Diagnostics – Serum glucagon test (SGT) and glucagon stimulation test (GST). –The SGT results were 121 pg/mL. –The GST results revealed decreased serum glucagon level (Yoshida, et al., 2020).
Therapeutic Plan – Initial dose: Metformin 500 mg PO bid. – Titrate by 500 mg weekly to a maintenance dose of 2000 mg PO divided in two doses. Refilled oral chlorothiazide 50mg daily dose for gore pressure control.
My clinical instructor educated me that patients with newly diagnosed diabetes should participate in a comprehensive diabetes self-management education program, which includes individualized instruction on nutrition, physical activity, optimizing metabolic control, and preventing complications. In clinical trials comparing diabetes education with usual care, there was a small but statistically significant reduction in A1C in patients receiving the diabetes education intervention. I also educated the patient to participate in regular physical activity, reduce intake of carbohydrates, fats, and sugar, eat a lot of vegetables, and drinking adequate fluids on a daily basis.

RESPOSE 2
Challenges and Success during Clinical Experience
During my clinical experience, I encountered both success and challenges. One major challenge I experienced was discussing advance directives and Do Not
Resuscitate (DNR) orders with the patients and their families. In addition, my receptor and I emphasized the significance of having these discussions in advance to
ensure we respected the patient’s wishes. The major challenge when conducting these discussions is that, in one case, some families became upset and were
resistant to the idea since they believed their 90-year-old family member would live forever. This challenge outlined the sensitive nature of end-of-life discussion and
the need for empathy and effective communication when addressing these topics. In contrast, one success I experienced during my clinical rotation was effectively
evaluating my patient and offering them appropriate care. During the experience, I had the opportunity to assess an 80-year-old female with a complex medical
history. The patient has a known diagnosis of diabetes since the patient was a current smoker and had chronic obstructive pulmonary disease (COPD). In addition, the
female patient presented with a non-healing ulcer on her right leg. Also, the female patient reported a new wound on her left leg and experienced a cramping pain in
her leg during exercise.
Assessment of the Patient
Moreover, in assessing the 80-year-old female, I conducted a comprehensive examination. Some of the symptoms I observed include; a chronic ulcer on the
right leg; this illustrated the possibility of a venous stasis ulcer, typically linked with impaired venous circulation. In addition, a new wound on the left leg; indicated
the possibility of arterial insufficiency or additional vasculitis illness. Lastly, claudication indicated compromised blood flow to legs associated with arterial
insufficiency.
Differential Diagnoses
Following the patient’s presentation, the three differential diagnoses I generated include the following; Venous stasis ulceration. This is linked with the patient’s
history of chronic leg ulceration, the presence of venous insufficiency signs, and risk factors like diabetes; hence the possible primary diagnosis is venous stasis
ulceration (Nicolaides, 2020). Vasculitis ulceration due to arterial insufficiency; The patient’s claudication symptoms, new wound, and smoking history raise issues
about arterial insufficiency. It also raises issues with possible vasculitic illness affecting the blood supply to the legs. Studies reveal that arterial insufficiency
originating from atherosclerosis can impair wound healing and ulceration (Bekeny et al.,2019). Granulomatous disease: based on the non-healing nature of the ulcers
and the likelihood of inflammatory etiologies, it is significant to consider granulomatous diseases linked with vasculitis, like infectious diseases of the leg or
granulomatosis with polyangiitis (GPA) (Bangalore Kumar et al., 2022).
Plan of Care
Following the assessment findings, I developed a care plan for my 80-year-old female patient. The component of the plan of care comprised of; Referring the
patient to a vascular specialist to assess and manage the underlying vascular issues since the patient had a history of diabetes, COPD, and the presence of non-
healing wounds (Bangalore Kumar et al., 2022). I also collaborated with the wound clinic to offer the 80-year-old female patient appropriate wound care, dressings,
debridement, and infection control measures (Bekeny et al.,2019). As the healthcare provider, I recognized the patient’s current smoking status, proposed integrating
a smoking cessation program, and offered her support and resources to aid her in quitting smoking. Smoking harms the patient since it impairs her wound healing and
worsens vascular complications (Nicolaides, 2020).
This week’s clinical experience taught me the importance of effective communication when discussing end-of-life decisions with patients and their families.
Having first-hand experience reinforced the need for patience, empathy, and profound understanding since the discussions were emotionally charged. In addition, I
gained vital insight into evaluating and managing complex wounds and the significance of considering different differential diagnoses depending on the patient’s
symptoms and history.

ChatGPT
Response 1:

Your clinical experience and the case of diagnosing a patient with type 2 diabetes and designing a treatment plan is a great example of the challenges and successes healthcare professionals encounter. It’s important to carefully consider the differential diagnoses and perform relevant diagnostic tests to arrive at an accurate diagnosis. You mentioned using the A1C test to assess blood sugar levels in the patient, which is a common and reliable method for diagnosing and monitoring diabetes.

In terms of therapeutic management, initiating treatment with metformin and titrating the dose gradually is in line with current recommendations. It’s worth noting that individualized care is crucial in determining glycemic targets, especially considering factors such as age, comorbidities, and life expectancy. Setting a goal of ≤7 percent for most patients is a reasonable approach, as mentioned in your response. However, it would be beneficial to support your statements with literature or guidelines from authoritative sources, such as the American Diabetes Association (ADA) or the Endocrine Society.

Additionally, you mentioned the importance of comprehensive diabetes self-management education programs for patients with newly diagnosed diabetes. This is a crucial aspect of care to help patients understand their condition, adopt healthy lifestyle behaviors, and prevent complications. You might consider referencing studies or guidelines that highlight the positive impact of diabetes education on patient outcomes and glycemic control.

Overall, your response provides a comprehensive overview of your clinical experience and showcases your understanding of the diagnostic and therapeutic aspects of managing type 2 diabetes. Adding references to support your statements would further enhance the credibility of your response.

Response 2:

Your experience in discussing advance directives and Do Not Resuscitate (DNR) orders with patients and their families highlights an important aspect of end-of-life care. Effective communication and empathy are indeed crucial in navigating these sensitive conversations. The resistance from families, as you mentioned, is not uncommon and underscores the need for healthcare professionals to approach these discussions with understanding and patience. It may be helpful to provide resources or references that address strategies for effective communication and overcoming challenges in discussing advance directives.

Regarding the assessment and care of the 80-year-old female patient with complex wounds, your differential diagnoses and plan of care demonstrate a systematic approach to managing the patient’s condition. Referring the patient to a vascular specialist and collaborating with the wound clinic align with a multidisciplinary approach to wound care, which is essential for optimizing outcomes. Incorporating smoking cessation interventions is also crucial, as smoking can significantly impede wound healing and exacerbate vascular complications.

To strengthen your response, it would be beneficial to include references that support your statements about differential diagnoses and the plan of care for complex wounds. Research articles or clinical guidelines that discuss the management of venous stasis ulcers, arterial insufficiency, and granulomatous diseases can provide additional support to your insights.

Overall, your response effectively addresses the challenges and successes encountered during your clinical experience. Expanding on the evidence-based management strategies with appropriate references would further enhance the depth and credibility of your response.