ASSESSING, DIAGNOSING, AND TREATING ENDOCRINE, METABOLIC, AND NUTRITIONAL DISORDERS

ASSESSING, DIAGNOSING, AND TREATING ENDOCRINE, METABOLIC, AND NUTRITIONAL DISORDERS

Nutritional disorders in older adults may present in many different ways and be caused or affected by a number of patient factors and comorbidities. Consider a patient with decreased cognitive function and mobility who may experience undernutrition because of low variety and quantity of food consumed. Another patient suffering from obesity may experience fatty liver, diabetes, or colon cancer due to dietary fat intake. Issues such as food scarcity and cost also play a role in nutritional disorders for this population.

Like many disorders affecting other systems, those related to endocrine, metabolic and nutritional concerns have specific considerations for geriatric populations. Accurate history taking of symptoms associated with these disorders is essential for completing an assessment of the older adult, since onset of symptoms (for example, with some endocrine disorders) may appear more subtly than those in younger patients. It can also be difficult to determine onset and severity of illness in older adults. Keep in mind special considerations for older adults as you complete your case analysis and SOAP note on endocrine, metabolic, and nutritional disorders.

You explore geriatric patient presentations nutritional disorders, as well as endocrine and metabolic disorders. You also examine assessment, diagnosis, and treatment for these disorders and complete a SOAP note.

To prepare:

Review the case study provided.
Reflect on the patients symptoms and aspects of disorders that may be present.
Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
Access the Focused SOAP Note Template in this weeks Resources.
The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

Subjective: What was the patients subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria, and consider alternative drugs if appropriate. Provide a review of systems.

Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?

Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.

Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.

Case Study:
Case 1: Low Blood Sugar

HPI: Ms. Lewis is a 63-year-old female, who comes into your office with concerns of low blood sugar in the morning, fasting. She reports seeing blood sugar as low as 50 fasting in the mornings for the last few weeks. She has a known history of Diabetes, Hypertension, Hyperlipidemia, and Chronic Osteoarthritis. She also reports elevated blood pressures. Her blood pressure at presentation is 165/90.

RESOURCE FOR THIS WEEK: Review endocrine-related Evidence Based Practice Guidelines and your required readings for this week.

Ms. Lewis is a 63 y/o female who is alert awake oriented to time, place, situation. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls, denies any pain.

(All other Review of System and Physical Exam findings are negative other than stated. Please document negative findings as you would with a real patient instead of writing normal or negative) Write this as a focused soap note for : CC: morning hypoglycemia. Base your HPI, ROS, and PE on this CC.

Vital Signs: BP 165/90, HR 89, RR 20, Temp 98.1 Weight:____BMI:___

PMH: Hypertension, Hyperlipidemia, Diabetes, Chronic Osteoarthritis

Allergies: Penicillin, lisinopril: list reactions

Medications: list by name, dose, frequency.

Womens One A Day-Multivitamin daily

Chlorthalidone 25mg daily

Fish Oil 1 tablet daily

Amlodipine 5mg p.o. daily

Atorvastatin 40mg p.o. at bedtime daily

Novolog 10 units with meals TID

Aspirin 81mg p.o. daily

Lantus 25 units Subcutaneous nightly

Ergocalciferol 50,000 units PO once a month

Social History: as stated in Case Study. Please be succinct, be sure to include anything that helps the case evaluation.

ROS: which ROS would you ask the patient about for this CC?

Diagnostics/Assessments done:

CXR- Last CXR showed no cardiopulmonary findings. Within normal limits.
Basic Metabolic Panel and CBC as shown below.
Vitamin D Level- as noted below in lab results.
TEST

RESULT

REFERENCE RANGE

GLUCOSE

85

65-99

SODIUM

134

135-146

POTASSIUM

4.2

3.5-5.3

CHLORIDE

104

98-110

CARBON DIOXIDE

29

19-30

CALCIUM

9.0

8.6- 10.3

BUN

20

7-25

CREATININE

1.01

0.70-1.25

GLOMERULAR FILTRATION RATE (eGFR)

76

>or=60 mL/min/1.73m2

TEST

RESULT

REFERENCE RANGE

Vitamin D 1,25 OH

58

36-144

TEST

RESULT

REFERENCE RANGE

WBC

7.3

3.4- 10.8

RBC

4.31

135-146

HEMOGLOBIN

14

13-17.2

HEMATOCRIT

42%

36-50

MCV

90

80-100

MCHC

34

32-36

PLATELET

272

150-400

(All other Review of System and Physical Exam findings are negative other than stated.

Please describe what your negative ROS and PE findings would be rather than writing negative or normal)

Remember to include the following:

Three Ddx With Your Rationale (One Paragraph Only For Each Dx With Citations & References)

Your Primary Dx (One Of The 3) And Why You Chose This

Your Treatment Plan: Prescriptions, Referrals, Testing, Follow Up (**If you are the primary care NP, do not write : refer to PCP

Education

Reflection

References

Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Endocrine, metabolic, and nutritional disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 361406). F. A. Davis.

American Diabetes Association. (2020). Glycemic targets: Standards of medical care in diabetes2020 Links to an external site.. Diabetes Care, 43(Suppl. 1), S66S76. https://doi.org/10.2337/dc20-S006

Munshi, M., Nathan, D. M., Schmader, K. E., Mulder, J. E., & Givens, J. (2019). Treatment of type 2 diabetes mellitus in the older patient Links to an external site.. UpToDate. Retrieved June 8, 2020, from https://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient

NIH National Institute on Aging. (2017). Basics of Alzheimers disease and dementia: What is Alzheimer’s disease? Links to an external site.[Multimedia file]. https://www.nia.nih.gov/health/what-alzheimers-disease