Discussion Peer/Participation Prompt Due Sunday by 11:59 pm
Instructions:
Please respond to two peers’ posts regarding their plan.
What did you find interesting about their response?
How did their plan compare to yours?
Do you agree with their plan and recommendations?
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with citations and references in APA format.
Estimated time to complete: 2 hours
I will provide both peers post for response please use updated references.
peer#1
Sarah
In this case study, we see a 14 year old female
Pertinent Positives
Symptoms started a week ago
Thirsty all the time
Voiding more than normal
Abdominal cramping
Nausea
Sick a few weeks ago
Maternal grandmother has diabetes
Some weight loss-about 10 lb
Dry, tacky mucous membranes
Sunken eyes
Looking tired
Skin tenting
Pertinent Negatives
No blood or burning/pain with urination
No vomiting, diarrhea, fever, chills
No allergies to medications, does not take medications
Not sexually active
No changes in appetite
No joint pain, swelling, muscle pain or cramps, neck pain or stiffness or changes in ROM
No acute distress
No bladder tenderness upon palpation
Other Information Needed
What was your illness? Did you see a doctor? Did you have a fever?
How many gatorades do you drink per day?
What Tanner stage is she in? She is 14 with no onset of menarche, however, as long as she has pubertal signs this is not a concern at this time (Garzon-Maaks et al., 2020). If she has no pubertal signs a workup may be needed for something such as Turner syndrome.
Do you have any visual changes?
Are there any signs of oral thrush or vaginal yeast?
Differentials
Type 1 Diabetes Mellitus with hyperglycemia E10.65 (priority diagnosis)
Diabetes Insipidus E23.2
Adrenalcortical insufficiency E27.40
Plan for Priority Diagnosis
I believe this patient is exhibiting signs and symptoms consistent with new onset type 1 diabetes mellitus. Her symptoms that line up with this as a priority diagnosis include polyuria, polydipsia, abdominal cramping, weight loss. A recent article shows that the most common presentation of juvenile onset type 1 diabetes mellitus is hyperglycemia with no ketoacidosis (Levitsky & Misra, 2022). The patient also recently was ill, which is a common onset for type 1 diabetes mellitus (Garzon-Maaks et al., 2020).
Diagnostics: urinalysis for glucose and ketones, serum glucose, pancreatic autoantibodies, A1C, CMP, BUN, creatinine. I would also order hypothyroid labs such as anti-TPO antibody, thyroglobulin antibody, and screen for celiac disease with tissues transglutaminase as these are common comorbid conditions (Garzon-Maaks et al., 2020; Levitsky & Misra, 2022)
Therapeutics
First, this patient would be admitted to the hospital for new onset diabetes and likely ketoacidosis and dehydration (Garzon-Maaks et al., 2020). This patient has abdominal pain and nausea which are common signs of accumulation of ketoacids (Garzon-Maaks et al., 2020). The patient will be started on insulin and IV hydration to stabilize her and prevent complications (Garzon-Maaks et al., 2020). The dosing will be individualized and a plan will be made with the family based on her needs (Garzon-Maaks et al., 2020). It is possible to manage a new onset diabetic on an outpatient basis, however with the signs of dehydration she has and the likelihood of ketoacidosis, I would recommend she go to the hospital. Before discharge, the patient and family must be comfortable with glucose testing, insulin injections and/or use of an insulin pump, and potentially use of a continuous glucose monitor.
Education
Education for this patient and her family would include monitoring of blood glucose levels, signs and symptoms of hyper and hypoglycemia, meal planning, insulin types and actions, sliding scale insulin boluses, use of insulin pump if applicable and safe injection tactics, a treatment plan for her school, necessity of carrying glucose tablets, the impact of exercise on glucose levels, and preventing complications such as wound infections (Garzon-Maaks et al., 2020). It would also be important to have child-life involved as well as child psych to have a discussion regarding increased likelihood of anxiety and depression as well as how to cope with a new onset illness (Garzon-Maaks et al., 2020). I would also encourage them to use online resources such as the American Diabetes Association, there they can find nutrition information, support groups, tips for managing medications, and even connections through camps for diabetic kids and teens (American Diabetes Association, 2022).
Collaboration/Consultation
If possible, I would recommend that this patient be followed by a pediatric diabetes center if possible or pediatric endocrinologist (Garzon-Maaks et al., 2020). I would anticipate collaborating with school faculty, school nurses, nutritionists, and either having her see pediatric endocrinology for follow ups or consult with them for recommendations (Garzon-Maaks et al., 2020).
References
American Diabetes Association. (2022). Type 1 diabetes – symptoms, causes, treatment. https://www.diabetes.org/diabetes/type-1Links to an external site.
Garzon-Maaks, D. L., Starr, N. B., Brady, M. A., Gaylord, N. M., Driessnack, M., & Duderstadt, K. (2020). Burns’ pediatric primary care (7th ed.). Elsevier.
Levitsky, L. L., & Misra, M. (2022). Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents (J. I. Wolfsdorf & A. G. Hoppin, Eds.). UpToDate. Retrieved August 1, 2022, from https://www.uptodate.com/contents/epidemiology-presentation-and-diagnosis-of-type-1-diabetes-mellitus-in-children-and-adolescents?search=type%201%20diabetes%20in%20children%26source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1Links to an external site.
Reply
Unit 12 Discussion – Care Management
Pertinent Positives:
C.C. “I’m so thirst all the time.”
HPI: 14 y.o. F presents to clinic with grandfather for what she believes is dehydration.
She reports symptoms started a week ago with constantly being thirst and urinary frequency
She noticed that she was going to the bathroom more than normal too, but she thought it was because she was drinking more.
She is having some abdominal pain but reports more like cramping.
She has also been experiencing some nausea but no vomiting.
She is currently drinking a bottle of Gatorade in office.
Grandfather reports her being sick a few weeks ago but she hasn’t gotten better since then.
He reports her looking tired.
Family History: Mother – HTN, diabetes. Maternal grandfather deceased at 61 due to heart attack and maternal grandmother has diabetes and HTN. Paternal grandfather HTN, CAD.
ROS
Reported weight loss (10 pounds)
Increased thirst
Positive abdominal cramping with nausea
Physical Exam
Skin tenting
Sunken eyes
Pertinent Negatives:
Denies visual changes, diplopia, and dry eyes.
Denies neck pain or stiffness.
Denies any history of a heart murmur, chest pain, palpitations, dyspnea, activity intolerance.
Denies cough, SOB on exertion, difficulty breathing, wheezing.
Denies vomiting, dysphagia, loss of appetite, bloating, diarrhea, or change in bowel habits.
Denies sexually active.
Denies dysuria
Denies weakness, numbness, tingling, memory difficulties, involuntary movements or tremors
Denies cold or heat intolerance
Missing Information:
What were your initial symptoms?
How does your urine smell?
How does your breath smell?
Experiencing bed wetting?
What liquids are you consuming? Water? Soda? Juice?
How often are you exercising?
What does your diet consist of?
Is your diet high in carbohydrates? Sugar? Fats?
How often are you urinating?
How often are you drinking?
Any skin rashes, especially on the back of your neck?
Differential Diagnosis:
Type 1 Diabetes Mellitus
Diabetic Ketoacidosis
Hyperglycemia
Priority Diagnosis: Type 1 Diabetes Mellitus
The onset of T1DM may be varied. The classic presentation is one where the children present to the pediatrician or PCP’s office because parents have noticed increased frequency of urination, increased thirst, or even nocturia in those who have been previously toilet trained. Parents may also notice weight loss over a period of several weeks. These children/adolescents are not decompensated enough physiologically to be clinically sick.
Plan of Care
Diagnostics: Urine sample to check for glucose and ketones, fasting blood sugar, CMP, HgA1c
Therapeutics: Management of Type 1 Diabetes Mellitus will depend on the initial presentation. Insulin is the only specific therapeutic agent for the treatment of Type 1 Diabetes Mellitus. Successful management of Type 1 Diabetes Mellitus in children and adolescents involves not only adequate insulin management: but also, comprehensive management strategies including individualized treatment options for each child/adolescent in relation to the whole family dynamics (Kamboj and Henry, 2017). The child’s age, maturity, and developmental level are important considerations, in addition to the level of family involvement, interest, and dedication to implementation of a management plan. The overall aim is to set realistic glycemic goals which can be practically followed to achieve a good balance between maintaining the strictest glycemic control, to minimize the risk of long-term complications while avoiding short-term complications, mainly hypoglycemia (Kamboj and Henry, 2017).
Education: Learning of the survival skills is the initial aim of diabetes education. The patient and her family should be educated on the basic technical skills required to start testing blood glucoses and to do insulin administration (Kamboj and Henry, 2017). The patient will learn how to use her glucose testing meter; how to poke herself for blood glucose (BG) testing; and will also learn techniques for drawing up insulin and administering it. With this patient, she will be educated on the use of an insulin pen instead of using insulin vials and syringes. The patient will be taught how to keep track of her blood glucose through log sheets that will include a record of self-monitored blood glucose levels, insulin given, carbohydrate consumed, and any other special or unusual circumstances noted. The patient will be advised on the importance of keeping track as it is very useful in monitoring, evaluating, discussing, and make appropriate changes to the insulin regimen in close communication with her health care team. The patient will be asked to participate in an educational session where she can get a better understanding of her new chronic health condition. The patient will be advised to contact the clinic with any questions and seek medical treatment if symptoms worsen. Patient will be educated on the signs and symptoms of high and low blood glucose levels and what to do.
Collaboration/Consultation: Adolescent Endocrinology, Social Worker, Dietician
Reference:
Kamboj, M.K, Henry, R.K. (2017). Children and adolescents and diabetes Links to an external site.. International Journal of Child and Adolescent Health, 10(4), 407-419.
Reply
please leave favorable replies! Thanks
peer#2
Tashanda
