What are the pertinent positive and negative findings in this patient assessment? -

56 y/o Caucasian male presents to the primary care clinic with complaints of dizziness and nausea x 4 days. The patient reports he has not been able to get out of bed since the symptoms started. The patient reports symptoms are worse when he tries to get out of bed to stand. He denies any headaches or blurry vision. He states he is urinating more over the last few days and he has noticed an increase in thirst. He reports he just drank a large sweet tea before he came into the clinic.
The patient reports that he is out of his Lantus and metformin because he cannot afford the refill until he gets his disability check. He is disabled after his second CVA that left him with generalized weakness. His medical history includes DM, HTN, CAD.
Upon arrival at the clinic, the patient’s vital signs are as follows- Blood sugar 405, B/P 190/101, HR 102, R-20, T- 98.5.

What are the pertinent positive and negative findings in this patient assessment?
Create a list of differentials with rationales for this patient?
Discuss a medication regimen for this patient considering his financial status?
What is the priority concern for this patient?
How does this patient’s comorbid diagnosis impact his current symptoms?
Discuss how the patient’s health beliefs, culture and behaviors impact the potential outcomes for the patient.

Answer & Explanation

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The pertinent positive and negative findings in this patient assessment are as follows:The pertinent positive findings are that the patient has a history of DM, HTN, and CAD. The patient also reports that he is out of his Lantus and metformin because he cannot afford the refill until he gets his disability check. The patient’s vital signs are as follows- Blood sugar 405, B/P 190/101, HR 102, R-20, T- 98.5.The pertinent negative findings are that the patient denies any headaches or blurry vision. He states he is urinating more over the last few days and he has noticed an increase in thirst. He reports he just drank a large sweet tea before he came into the clinic.Differ

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Step-by-step explanation

entials with rationales for this patient include:1. Dehydration- The patient’s increased thirst and urination could be indicative of dehydration.2. DKA- The patient’s high blood sugar, increased thirst and urination, and general malaise could be indicative of DKA.3. Hypoglycemia- The patient’s low blood sugar could be indicative of hypoglycemia.4. Infection- The patient’s general malaise and increased urination could be indicative of an infection.5. CVA- The patient’s history of CVA and current symptoms of dizziness and nausea could be indicative of another CVA.A medication regimen for this patient considering his financial status could include:1. Lantus- to help control the patient’s blood sugar2. Metformin- to help control the patient’s blood sugar3. Insulin- to help control the patient’s blood sugar4. Hydrochlorothiazide- to help control the patient’s blood pressure5. Lisinopril- to help control the patient’s blood pressureThe priority concern for this patient is his blood sugar. The patient’s high blood sugar could be indicative of DKA. The patient’s comorbid diagnosis of DM, HTN, and CAD impact his current symptoms because they can all contribute to high blood sugar. The patient’s health beliefs, culture, and behaviors impact the potential outcomes for the patient because they can all contribute to poor compliance with treatment.

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