Posted: October 3rd, 2023

A Week in Primary Care: Managing a Complex Patient Case

A Week in Primary Care: Managing a Complex Patient Case.

This week’s clinical experience in the primary care setting provided valuable insights into the multifaceted nature of family practice and reinforced the importance of a thorough and patient-centered approach. I encountered a diverse range of patient presentations, but one case, in particular, stands out due to its complexity and the learning opportunity it presented.

Patient Presentation and Assessment
A 45-year-old female patient presented to the clinic complaining of persistent fatigue, unintentional weight loss of approximately 10 pounds over the past two months, increased thirst, and frequent urination. She denied any fever, chills, or recent illness. Her medical history was significant for hypertension, managed with hydrochlorothiazide.

Physical examination revealed a well-developed, but fatigued-appearing female. Vital signs were within normal limits, except for a slightly elevated blood pressure of 140/90 mmHg. The cardiovascular and respiratory exams were unremarkable. Abdominal examination revealed no tenderness or masses. Neurological examination was grossly intact.

Differential Diagnoses and Rationale
Given the patient’s constellation of symptoms, several differential diagnoses were considered:

Type 2 Diabetes Mellitus: The patient’s symptoms of fatigue, weight loss, polydipsia (increased thirst), and polyuria (frequent urination) are classic signs of uncontrolled diabetes. Her existing hypertension further increases her risk for this condition (American Diabetes Association, 2022).

Hyperthyroidism: Fatigue, weight loss, and increased thirst can also be indicative of an overactive thyroid. However, the absence of other typical hyperthyroid symptoms, such as heat intolerance, tremors, and palpitations, makes this diagnosis less likely (Ross et al., 2019).

Chronic Kidney Disease: While less common, chronic kidney disease can sometimes present with fatigue and unintentional weight loss. The patient’s hypertension is a significant risk factor for kidney disease. Further investigation, including blood and urine tests, would be necessary to rule out this possibility (National Kidney Foundation, 2020).

Plan of Care
Given the high suspicion for diabetes, a point-of-care blood glucose test was performed, revealing a significantly elevated level of 250 mg/dL. A urinalysis was also conducted, which showed the presence of glucose and ketones, further supporting the diagnosis of diabetes.

The patient was educated about diabetes management, including lifestyle modifications such as dietary changes and regular exercise. Metformin was initiated at a low dose, with plans for titration based on subsequent blood glucose monitoring. She was also advised to closely monitor her blood pressure and follow up with the clinic for regular check-ups and laboratory assessments, including HbA1c and kidney function tests.

Health Promotion Intervention
A crucial aspect of the patient’s care involved comprehensive diabetes education. This included information on healthy eating habits, the importance of regular physical activity, and self-monitoring of blood glucose. The patient was also provided with resources for ongoing support and education.

Challenges and Successes
One challenge encountered was the patient’s initial apprehension about the diagnosis and its potential impact on her life. Addressing her concerns with empathy and providing clear, concise information helped alleviate her anxiety and fostered a collaborative approach to her care. The successful initiation of treatment and the patient’s demonstrated understanding of her condition were significant achievements.

Reflections and Learning
This clinical experience reinforced the importance of a comprehensive and patient-centered approach to care. It highlighted the need to consider multiple differential diagnoses and to tailor the plan of care to the individual patient’s needs and circumstances. As a future advanced practice nurse, this experience underscored the value of continuous learning and the importance of staying abreast of current research and guidelines to provide evidence-based care. The interaction also emphasized the significance of patient education and empowerment in promoting positive health outcomes. This case solidified my understanding of the diagnostic process and management of diabetes, which will undoubtedly be invaluable in my future practice.

References

American Diabetes Association. (2022). Standards of medical care in diabetes—2022. Diabetes Care, 45(Suppl. 1), S1–S264.

National Kidney Foundation. (2020). KDOQI clinical practice guideline for diabetes and chronic kidney disease. American Journal of Kidney Diseases, 75(6), S1-S266.

Ross, D. S., Burch, H. B., Cooper, D. S., Greenlee, M. C., Laurberg, P., Maia, A. L., … & Jonklaas, J. (2016). 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid, 26(10), 1343-1421.

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You are a Family Nurse Practitioner student doing clinical hours in a Primary Care Clinic.

Describe your clinical experience for this week.

Did you face any challenges, any success? If so, what were they?
Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
Mention the health promotion intervention for this patient.
What did you learn from this week’s clinical experience that can beneficial for you as an advanced practice nurse?
Support your plan of care with the current peer-reviewed research guideline.
Submission Instructions:

Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

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Tags: Primary Care, Patient education, Hypertension management, Evidence-Based Practice, Clinical Experience in Primary Care: Managing Hypertension