B.A 60yrs old,female full code, admitted may 6 for lower abdominal pain(9month), secondary diagnose, hyperkalemia, history diabetes,hypertension, hyperlipidemia,migraines,bipolar,anxiety. first vital signs was 132/72, HR 76, TEMP. 98.2, SPO2 98, RESP R.17, BLOOD glucose 282 was high after an 1hour vital and also after the medication 118/70 spo 95, Hr 78, Temp 97.6, rr, 17 blood glucose 242. pottassium level was high 7.1, doctors order Glucose AC& HS, Diabetic diet, Diabetic teaching, SCD. medication topamax,insulin lispro, gabapentin,seroquel,amlodipine,sodium bicarbonate,inslin aspart 70/30& protamine.metoprolol, oxycodene actemapohine.
Introduction:
In this case study, we will analyze the medical history and current condition of a 60-year-old female patient, B.A., who was admitted for lower abdominal pain. Along with the primary diagnosis, secondary diagnoses include hyperkalemia, diabetes, hypertension, hyperlipidemia, migraines, bipolar disorder, and anxiety. The patient’s vital signs, blood glucose levels, and potassium levels will be examined, along with the prescribed medications and treatment plan.
Medical History:
B.A. has a history of diabetes, hypertension, hyperlipidemia, migraines, bipolar disorder, and anxiety. These underlying conditions play a crucial role in assessing her overall health and potential complications. Diabetes, hypertension, and hyperlipidemia are chronic diseases that require long-term management to control blood sugar, blood pressure, and cholesterol levels. Migraines, bipolar disorder, and anxiety are neurological and mental health conditions that also need appropriate treatment.
Vital signs assessment:
Upon admission, B.A.’s initial vital signs were recorded as follows: blood pressure (BP) of 132/72 mmHg, heart rate (HR) of 76 beats per minute (bpm), temperature of 98.2°F, oxygen saturation (SPO2) of 98%, respiratory rate (RR) of 17 breaths per minute (bpm). These vital signs indicate stable cardiovascular and respiratory function.
Blood glucose assessment:
The patient’s blood glucose level upon admission was measured as 282 mg/dL, which indicates a high blood sugar level. This elevated value can be attributed to her underlying diabetes and poor glycemic control. After one hour, B.A.’s blood glucose level decreased to 118 mg/dL, indicating a response to the administered medication. However, it is important to note that the blood glucose level remains above the recommended target range of 80-130 mg/dL for a fasting glucose level.
Potassium assessment:
B.A.’s potassium level was measured at 7.1 mmol/L, which is significantly higher than the normal range of 3.5-5.0 mmol/L. Hyperkalemia, or high potassium levels, can have serious implications on cardiac and renal function. It is necessary to monitor and manage potassium levels closely to prevent potential complications.
Prescribed Medications and Treatment Plan:
Based on the provided information, B.A.’s prescribed medications include topamax, insulin lispro, gabapentin, seroquel, amlodipine, sodium bicarbonate, insulin aspart 70/30, and protamine, metoprolol, oxycodone, and actemapohine.
Topamax is an anticonvulsant medication often used for the management of migraines. Insulin lispro and insulin aspart 70/30 are types of insulin used to control blood sugar levels in patients with diabetes. Gabapentin is primarily used to treat neuropathic pain. Seroquel is an antipsychotic medication commonly prescribed for bipolar disorder and schizophrenia. Amlodipine is a calcium channel blocker used to manage hypertension. Sodium bicarbonate is given to patients with acidosis or high levels of acidity in the body.
Metoprolol is a beta-blocker used to control heart rate and blood pressure. Oxycodone is a narcotic analgesic used for pain management. Lastly, actemapohine is an oral anticoagulant often prescribed for patients at risk of blood clot formation.
Treatment plan:
In addition to the prescribed medications, B.A.’s treatment plan includes glucose AC&HS (before meals and at bedtime), a diabetic diet, diabetic teaching, and SCD (sequential compression devices). Monitoring blood glucose levels and adhering to a diabetic diet are crucial for maintaining glycemic control. Diabetic teaching likely includes education on proper insulin administration, blood glucose monitoring, dietary management, and recognizing signs of hyperglycemia and hypoglycemia. Sequential compression devices are an adjunctive treatment used to prevent deep vein thrombosis and promote venous circulation in immobilized patients.
Conclusion:
In conclusion, B.A.’s case demonstrates a complex medical history with multiple underlying conditions. Diabetes, hypertension, hyperlipidemia, migraines, bipolar disorder, and anxiety require careful management and treatment. The assessment of vital signs, blood glucose levels, and potassium levels provides insight into the patient’s current condition and guides appropriate interventions. The prescribed medications and treatment plan aim to control blood sugar levels, address neurological and mental health conditions, manage hypertension, and prevent potential complications. Continuous monitoring and thorough patient education are essential for optimizing B.A.’s overall health and well-being.