Focused Exam: Hypertension and Type 2 Diabetes, Exams of Nursing

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 Hello Mr Patel, my name is an FNP student and I will be taking care of you today Hey. what brings you in today? Greet 06/18/20 10:15 PM CDT Question 06/18/ 10:15 PM CDT I'm here to check up on some numbers that I have for my diabetes and my hypertension. Guess they're not looking too hot. i'm glad you followed up on the numbers, we can plan a better regimen to help improve the numbers Alright. I get it. Can you please tell your medical history? I've had hypertension and diabetes for some time now, but recently I've had some new stuff going on, or I guess it could be related. I've gained some weight over the past three months or so, and I've just been all around tired and uncomfortable. I've also had to pee pretty frequently, and I've been ridiculously thirsty. Educate 06/18/ 10:16 PM CDT Question 06/18/ 10:17 PM CDT

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 I am sorry to hear that, that must have been challenf=ging Well, gee. Thanks. your symptoms are related to diabetes and hypertension I don't have any allergies that I know of. Any other symptom apart from the ones you mentioned? I've had hypertension and diabetes for some time now, but recently I've had some new stuff going on, or I guess it could be related. I've gained some weight over the past three months or so, and I've just been all around tired and uncomfortable. I've also had to pee pretty frequently, and I've been ridiculously thirsty. Do you have any pain? I'm not in any pain. [AUDIO COMING SOON] Empathize 06/18/ 10:19 PM CDT Question 06/18/ 10:20 PM CDT Question 06/18/ 10:22 PM CDT Question 06/18/ 10:22 PM CDT

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 Any recent hospitalizations? I haven't ever been hospitalized in that sense of the word. But I have seen a doctor before, about my hypertension and diabetes numbers, and I'm here to check in about them. What medication are you taking? Hydrochlorothiazide for my hypertension, metformin for diabetes, and escitalopram for anxiety. Do you take any other non prescription medication? (Clarified to Are there other prescriptions you are taking that we haven't discussed?.) Nothing besides hydrochlorothiazide, metformin, and escitalopram. (Clarified to if I am taking other prescriptions.) How often do you take your medications I take all my meds every day... the metformin is three times a day, and the water one and the anxiety one are both once a day. Question 06/18/ 10:23 PM CDT Question 06/18/ 10:23 PM CDT Question 06/18/ 10:25 PM CDT Question 06/18/ 10:25 PM CDT

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 Do you have any reaction from tis meds (No matching questions found.) Do you have any reaction from taking these medications I don't have any allergies to anything. when were you diagnosed with diabetes? I was diagnosed with type two diabetes about five years ago. That was a great day. When were you diagnosed with hypertension? I was diagnosed with high blood pressure a year ago. When was the last time you visited the doctor? Question 06/18/ 10:26 PM CDT Question 06/18/ 10:27 PM CDT Question 06/18/ 10:29 PM CDT Question 06/18/ 10:29 PM CDT Question 06/18/ 10:30 PM CDT

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 My last checkup was about 6 months ago. I was supposed to come in sooner, but I've been so busy that I just forgot. A week ago I had some labs done to prepare for this visit. [AUDIO COMING SOON] Do you smoke? I don't use any tobacco. Do you use any illegal drugs? I smoked pot a little bit in undergrad, but it's been years. do you drink alcohol? I never drink. Tell me you your family past medical history? (Clarified to Can you tell me about your family medical history?.) Question 06/18/ 10:31 PM CDT Question 06/18/ 10:31 PM CDT Question 06/18/ 10:31 PM CDT Question 06/18/ 10:32 PM CDT

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 My folks have some stuff going on, which is probably why I've got some stuff going on. My dad has hypertension like me, and my mom has diabetes like me. She has high cholesterol, too. (Clarified to to tell you about my family medical history.) That's good to know, we probably need to check your cholesterol levels to make sure it is within normal limit I hadn't thought of that. Do you live alone or with your family? Miranda and I just moved in together. Who is Miranda if I may Ask? My girlfriend! You'll meet her at some point, I'm sure. [AUDIO COMING SOON] I would love to meet her (No matching questions found.) Educate 06/18/ 10:33 PM CDT Question 06/18/ 10:33 PM CDT Question 06/18/ 10:34 PM CDT Question 06/18/ 10:35 PM CDT

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 How is it going with your parents? (Clarified to How do you get along with your parents?.) My family relationships are a little strained right now because of my decision to go back to school, to study film. I had a good job as an engineer, and my parents thought that I should stick with that, instead of taking a risk. We disagree, but our relationship seems to be getting a little better lately. (Clarified to how I get along with my parents.) I'm sorry to hear that, I hope everything gets better soon I appreciate that. Do you feel overweight? I'm definitely not at a healthy weight. I don't know what a healthy weight is number-wise, but I'm not there yet. A healthy weight is a BMI less than 25, which takes into consideration your weight and your height Question 06/18/ 10:35 PM CDT Empathize 06/18/ 10:36 PM CDT Question 06/18/ 10:37 PM CDT Educate 06/18/ 10:38 PM CDT

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 Yeah, youre probably right. What doses are your medications? Let's see... the water pill is a 50 milligram... the anxiety pill is a 20 milligram... and the metformin is an 850 milligram tablet. What does your diet look like? My diet could be better, to be honest. I eat a lot of carbs and fried foods, and I tend to go for pizza when I've had a really bad day. I don't feel like my diet is out of control exactly, but I've been thinking about cutting down. Its a good step when you acknowledge a need for a better diet Ok, got it. I can help you with some materials on how to count your carbs that can help with eating right Question 06/18/ 10:39 PM CDT Question 06/18/ 10:40 PM CDT Educate 06/18/ 10:41 PM CDT Educate 06/18/ 10:43 PM CDT

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 Good to know. Do you do exercise? I don't exercise. I just don't have the time. Do you have a support system? My girlfriend gives me a lot of support, but I don't want to to stress her out with all my problems. It's hard going to anyone else, thoughI feel like my friends from the film program don't like to get too personal, and my family isn't always the best to go to. I am sorry you feel this way, would you like referral to a support group? Thank you. Do you work? Question 06/18/ 10:43 PM CDT Question 06/18/ 10:43 PM CDT Empathize 06/18/ 10:44 PM CDT Question 06/18/ 10:44 PM CDT

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 I teach film courses at Shadowville University. You said you were in school? (No matching questions found.) Where do you live? (Clarified to Where do you work?.) I teach film courses at Shadowville University. (Clarified to where I work.) Do you have any financial challenges? (Clarified to What is your financial situation?.) I do OK. I don't make a lot of money off of my graduate school stipend, but I manage to make it work. I just have to be careful about how I spend my money. (Clarified to what my financial situation is like.) When last did you take your medications Took them all this morning. Don't remember the exact time. Question 06/18/ 10:45 PM CDT Question 06/18/ 10:45 PM CDT Question 06/18/ 10:45 PM CDT Question 06/18/ 10:46 PM CDT

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 DO YOU HAVE ANXIETY? I was diagnosed with generalized anxiety disorder when I was 25. I was having a lot of panic attacksthat's when I was really struggling with being in aerospace. The escitalopram helps a lot, though. My panic attacks don't happen nearly as much anymore, but I still worry a lot. More than I should, I think, especially recently. WHAT MAKES YOU WORRY RECENTLY? (Clarified to What are some of your worries?.) I just try really hard to take things a day at a time. School is so much and teaching is really demanding. I'm trying to write a screenplay on top of it. It feels like I don't have very much control of my life. I'm always trying to fit everything I have to do into my schedule, and I don't always feel sure I can do it. I know I can now, but things just get so hard. (Clarified to what I am worried about.) I'm sorry you feel this way, is there anything that helps you relax during stressful times? Ha, thanks. Question 06/18/ 10:46 PM CDT Question 06/18/ 10:47 PM CDT Empathize 06/18/ 10:48 PM CDT

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 How much water are you drinking? The past month or so, I've been drinking multiple glasses a day. Don't know the exact number. I've just been really thirsty. How often do you pee I don't know the number... six or seven times, maybe? It's a lot. It doesn't hurt, but it's a lot. And I'm thirsty as all heck, too. How bad are your symptoms I wouldn't call any of these symptoms severe. It's more just annoying and uncomfortable. What makes your symptoms worse or better? I'm not really triggered or exacerbated by anything in particular. It's just been more general stuff. Question 06/18/ 10:49 PM CDT Question 06/18/ 10:50 PM CDT Question 06/18/ 10:50 PM CDT Question 06/18/ 10:51 PM CDT

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 Do you have headaches? I don't really get headaches. WHAT ARE THE NUMBERS THAT BROUGHT YOU IN TODAY? I'm here to check up on some numbers that I have for my diabetes and my hypertension. Guess they're not looking too hot. What was your last checked blood pressure? (Clarified to What was your blood pressure measurement?.) I last checked my blood pressure two weeks ago. It was 144/92. Not so good, I guess. (Clarified to what my last blood pressure reading was.) Yeah, we need to keep it below 130/ Alright. I get it. Question 06/18/ 10:51 PM CDT Question 06/18/ 10:52 PM CDT Question 06/18/ 10:52 PM CDT Educate 06/18/ 10:53 PM CDT

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 What was you last checked blood glucose? (Clarified to What is your latest blood sugar number?.) It was 210 last week when I had labwork done and 220 two weeks ago. I'm not great about checking it regularly. But I did manage to take down some numbers. [AUDIO COMING SOON] (Clarified to what my latest blood sugar number is.) Any chest pain? I never really have chest pain. any visual changes My vision's fine. Do you take any over the counter medications? All my medications are prescriptions. Question 06/18/ 10:53 PM CDT Question 06/18/ 10:54 PM CDT Question 06/18/ 10:54 PM CDT Question 06/18/ 10:55 PM CDT

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 Do you always take your medications? I'm good about taking all my doses. I just take my metformin with breakfast, lunch, and dinner. And I take the water pill and the anxiety pill just with breakfast. I've been on metformin for 5 years, and I don't think I've missed a dose. That's good to know Yeah, youre probably right. Mr Patel, I know you have a lot going on but I will be changing some of your medication to help improve your outcomes Good to know. I understand it is challenging to manage diabetes and hypertension with life stressors but I will work with you towards a goal and a better outcome Thanks for saying that. Question 06/18/ 10:56 PM CDT Educate 06/18/ 10:56 PM CDT Educate 06/18/ 10:57 PM CDT Empathize 06/18/ 11:00 PM CDT

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 Hello Mr Patel, I'm changing and prescribing new medication that i will be reviewing with you I appreciate it. Be sure to take your glipizidemetformin at the same time everyday Yeah. Got it. Do not continue your previous metformin of 850mg do not use it with the new prescription of glipizide/metformin Alright. I'll stop taking my other medication. Please avoid alcohol, alcohol increases the risk of hypoglycemia and can also cause lactic acidosis OK, no drinking. Got it. Question 06/18/ 11:04 PM CDT Question 06/18/ 11:06 PM CDT Question 06/18/ 11:07 PM CDT Question 06/18/ 11:09 PM CDT

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 Signs of low blood sugar include fast heartbeat, sweating, shakiness, hunger, confusion and lightheadedness. Take a snack with you at all times I'll start keeping snacks in my school bag. It is important you check your blood glucose regularly and it is of utmost importance to make an appointment for follow up to let us know the medication regime is working for you Oh, alright. I will also be changing you blood pressure medication, make sure when you miss a dose, take it as soon as you remember, if its close to the next dose, skip and take the next dose OK. Yeah, that's pretty important. Will do. common expected adverse effect of this medication include fatigue, cough and headache, take the medication with food o avoid GI upset, If the cough gets really bothersome, contact your provider immediately Thanks for the heads up. Question 06/18/ 11:16 PM CDT Question 06/18/ 11:17 PM CDT Question 06/18/ 11:19 PM CDT Question 06/18/ 11:20 PM CDT

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 If there is any allergic reaction like shortness of breathe or swelling in your throat or rashes hives call 911 or contact an emergency room immediately You're scaring me. Contact your healthcare provider if you have any form of swelling in your throat Ah. Alright. Avoid standing too quickly to avoid dizziness and falls Hmm. Alright. I hope the medication helps you feel better and better manage your symptoms. Don't forget to make an appointment for follow up, Continue taking your anti anxiety medication, I did not make any changes to that, try to also incorporate a 30 - 45 minute brisk walk daily into your routine. I wish your the best Mr. Patel and I hope to see you soon at your next appointment.Have a nice day Ok. See you later. Question 06/18/ 11:21 PM CDT Question 06/18/ 11:22 PM CDT Question 06/18/ 11:23 PM CDT Question 06/18/ 11:26 PM CDT

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1. Assessment Patient's hypertension and diabetes are not well managed, he needs to lose weight and also have regular follow up to know if the treatment plan is working for him. Consideration should also be given to his support system which might affect how he follows the treatment regimen.Patient has a strong side in that he understands the disease process and knows what his numbers should be. Patient family history provides a baseline for further follow up with the patient. Model Note Arun Patel is a 38 - year-old Indian American man with hypertension and type 2 diabetes mellitus who came to the clinic for a check-up. He has not been regularly monitoring his blood pressure or glucose levels at home. He is under financial stress, which has contributed to his health issues. He has gained 15 pounds in the last three months. Reccomendations Provide resources that can help patient pay for his drugs Patient reports having a lot of stressors, recommending relaxation techniques and referral to appropriate support group might help. Encourage patient to follow up by ensuring an appointment is made before leaving. Prescribe the most affordable and boiavailable drug Educate patient on the new medications prescribed Encourage exercise and weight loss Educate patient on healthy weight Introduce patient to the DASH diet Educate patient on how to count carbs Model Note I prescribed Mr. Patel a combination lisinopril / hydrochlorothiazide to treat his hypertension, and a combination glyburide / metformin to treat his type 2 DM. I have recommended that he begin regularly monitoring his blood pressure numbers and glucose levels, and keeping a log at home. I recommend that Mr. Patel consult with a nutritionist and come back for a check-up in three months. Model Plan ( Medication) - (1 point) Take with meals to avoid GI upset - (1 point) Take at the same time daily - (1 point) Discontinue previous medication - (1 point) The signs of lactic acidosis - (1 point) The signs of low blood sugar Topics priorized for patient teaching Education Items - (1 point) Take at the same time daily - (1 point) Discontinue previous medication

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• (0.5 points) Avoid drinking alcohol

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• (1 point) The signs of low blood sugar
• (0.5 points) The importance of routine follow-ups Take at the same time daily Be sure to take your glipizidemetformin at the same time everyday Yeah. Got it. Statement 19/6/2020 4:06:11 AM Discontinue previous medication Do not continue your previous metformin of 850mg do not use it with the new prescription of glipizide/metformin Alright. I'll stop taking my other medication. Avoid drinking alcohol Please avoid alcohol, alcohol increases the risk of hypoglycemia and can also cause lactic acidosis OK, no drinking. Got it. The signs of low blood sugar Statement 19/6/2020 4:07:43 AM Statement 19/6/2020 4:09:08 AM Model Statement: Taking medication at the same time every day ensures that the medication is in your system for the same amount of time, which makes it the most effective. Model Statement: Avoid drinking alcohol while taking this medication to avoid increasing the chance of adverse effects. Model Statement: Stop taking your previous medication when you begin this new regimen.

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 Signs of low blood sugar include fast heartbeat, sweating, shakiness, hunger, confusion and lightheadedness. Take a snack with you at all times I'll start keeping snacks in my school bag. Statement 19/6/2020 4:16:38 AM The importance of routine follow-ups Model Plan It is important you check your blood glucose regularly and it is of utmost importance to make an appointment for follow up to let us know the medication regime is working for you Oh, alright. Statement 19/6/2020 4:17:40 AM

• (1 point) Take the next dose immediately if you miss a dose
• (1 point) Discontinue previous medication
• (1 point) Seek emergency help if you show signs of a severe allergic reaction
• (1 point) Contact your healthcare provider if you experience signs of low blood pressure
• (1 point) Contact your healthcare provider if you experience signs of angioedema Topics priorized for patient teaching Education Items
• (1 point) Take the next dose immediately if you miss a dose Model Statement: This medication is designed to treat high blood sugar, so it is important to watch out for signs of your blood sugar getting too low. Signs of hypoglycemia include headaches, irritability, dizziness, confusion, hunger, and shakiness. Make sure to keep something with sugar in it on hand in case you experience these symptoms. Model Statement: Beginning any new medication requires routine follow-ups to monitor potential adverse effects and to ensure the medication is working. lisinopril / hydrochlorothiazide 4.5 out of 5

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• (0.5 points) Common adverse effects include cough, fatigue, and headache
• (1 point) Seek emergency help if you show signs of a severe allergic reaction
• (1 point) Contact your healthcare provider if you experience signs of angioedema
• (1 point) Avoid standing too quickly Take the next dose immediately if you miss a dose I will also be changing you blood pressure medication, make sure when you miss a dose, take it as soon as you remember, if its close to the next dose, skip and take the next dose OK. Yeah, that's pretty important. Will do. Common adverse effects include cough, fatigue, and headache common expected adverse effect of this medication include fatigue, cough and headache, take the medication with food o avoid GI upset, If the cough gets really bothersome, contact your provider immediately Thanks for the heads up. Seek emergency help if you show signs of a severe allergic reaction If there is any allergic reaction like shortness of breathe or swelling in your throat or rashes hives call 911 or contact an emergency room immediately You're scaring me. Statement 19/6/2020 4:19:01 AM Statement 19/6/2020 4:20:53 AM Statement 19/6/2020 4:21:49 AM Model Statement: Common adverse effects of this medication include cough, fatigue, and headache. Model Statement: If you miss a dose, take the next dose immediately unless it is almost time for your next scheduled dose.

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 Model Statement: Seek emergency help immediately if you show signs of a severe allergic reaction such as swelling in your face and throat, hives, stomach pain, and difficulty breathing.

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 Contact your healthcare provider if you experience signs of angioedema Contact your healthcare provider if you have any form of swelling in your throat Ah. Alright. Avoid standing too quickly Statement 19/6/2020 4:22:38 AM Avoid standing too quickly to avoid dizziness and falls Statement 19/6/2020 4:23:00 AM Hmm. Alright. Model Statement: Contact your healthcare provider if you experience signs of angioedema. Model Statement: Avoid standing too quickly from a prone position, as this may cause dizziness. Brace yourself and stand gradually.