PatientInitials: ANG Age:27 years Gender:Female
ChiefComplaint (CC):complains of having escalated hypertension
History ofPresent Illness (HPI):27-year-oldfemalehasbeen having severe hypertension after being in a diabeticketoacidosis medication for 14 years. Her medical history unravelsthat she contracted diabetic ketoacidosis aged fourteen years. Thepresence of hyaline and blood in her urine coupled with the severehypertension prompted her to visit the clinic.
Medications:Currently under 25 mg daily Hydrochlorothiazide medication.
Allergies:No specific allergies.
PastMedical History:The patient has been diabetic for 14 years. No history ofhospitalization.
Sexual/ReproductiveHistory:No highlighted key sexual or reproductive aspects.
General:Thepatient confides of weight gain
Skin:The patient affirms that no rashes or skin sores that have beenexhibited during the ailing period.
Key Signs:Blood pressure of 172/108 mmHg
General:A27-year-old female who appears energetic, healthy and in excellentposture. General body weakness
Eyes-theeyes have a completely transparent cornea coupled by a white sclera.
Ears-appear to be in the right posture and no lesions or visible palpablemasses.
Nose:her nose appears symmetrical with no evidence of nasal discharges orvisible lesions.
Tongue:The patients tongue appears centrally positioned.
Neck: No physical evidence of trauma.
Breasts:No pain or discharge.
Respiratory:No evidence of respiratory disorders or cough.
Cardiovascular/PeripheralVascular:No evidence of chest pain.
Genitourinary: No change in frequency.
Musculoskeletal:No symptoms of musculoskeletal complications.
Psychiatric:No evidence of psychiatric ailments.
Neurological:No evidence of neurological ailments.
Skin:No evidence of lumps or skin rashes.
Hematologic:No evidence ofhematologic ailments or complications.
Endocrine:Normal endocrine system.
The primarydiagnosis is accelerated hypertension. However, the assessment issubject to further analysis so as to ascertain the diagnosis.
The optimumobjective is to cut down the rate of hypertension and leverage thesymptoms of diabetic ketoacidosis.
TreatmentPlan:The patient can undergo a fluidreplacement either orally or intravenously. The patient can undergoan electrolyte replacement as well (electrolytes may encompasschlorides and potassium). Lastly, the patient can undertake anInsulin therapy.
HealthPromotion:take part in regular exercise and take balanced diet with extremelyminimal fat and cholesterol
DiseasePrevention:Maintain a steady daily diet.
From aclinical perspective, I’m now furnished with the information thatpatients ailing from diabetes ketoacidosis have intricate symptomswhich jeopardize their general health and wellbeing. Faced with acongruent scenario, I’ll screen the patients’ medical history ata deeper scrutiny level. I would also enquire concerning the patientsfamily history. I concur with the preceptor based evidence.
Gosmanov, A.,Gosmanova, E., & Dillard-Cannon, E. (2014). Management of adult diabetic ketoacidosis. Diabetes, Metabolic Syndrome And Obesity:Targets And Therapy, 255. http://dx.doi.org/10.2147/dmso.s50516
Westerberg, D.(2016). Diabetic Ketoacidosis: Evaluation and Treatment – American Family Physician. Aafp.org. Retrieved 12 May 2016, from http://www.aafp.org/afp/2013/0301/p337.html
Diabeticketoacidosis – Treatment – NHS Choices. (2016). Nhs.uk. Retrieved 12May 2016, fromhttp://www.nhs.uk/conditions/diabetic-ketoacidosis/pages/treatment.aspx
Type 1diabetes in adults: diagnosis and management | diabetic-ketoacidosis| Information for the public | NICE. (2015). Nice.org.uk. Retrieved12 May 2016, from https://www.nice.org.uk/guidance/ng17/ifp/chapter/diabetic-ketoacidosis