Evidence Based Practice in Primary Care

Include an exemplar of a scholarly paper (3 to 5 pages in APA format) on the relevance of evidence based practice in primary care

56 y/o Caucasian male presents to the primary care clinic with complains 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 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 his 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.

Using Evidence Based practice, answer the following questions thoroughly. Be sure to use APA formatting.

What is 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.

SAMPLE ANSWER

Evidence Based Practice in Primary Care

Pertinent Positive and Negative Findings in Patient Assessment

Results from the patient assessment indicate that there are both pertinent positive and negative findings. Pertinent positives, in this case, include complaints of dizziness and nausea, which he has been experiencing for four days. Further, from the patient’s reports, his symptoms are worsened by standing, and as such, he is not able to get out of bed. Other complaints aired by the patient include increased urination and thirst during the preceding days. Apart from the reports provided, tests conducted upon arrival in the health facility and his medical history indicate that he has signs of hypertension, diabetes mellitus, and coronary artery disease.

Another important positive finding that may aid in explaining the recent deterioration in the patient’s health is the report on his inability to refill his medication as required to manage his chronic condition. Besides the pertinent positives, some of the negatives declined include headache and blurry vision. Examination of the patient’s vital signs also yielded important positives that shed light on the patient’s condition, including a high blood glucose level, increased blood pressure, particularly a very elevated systolic blood pressure and widened pulse pressure, and an elevated heart rate.

Differential Diagnoses for the Chronic Condition

Meniere’s disease and peripheral causes of vertigo; one of the reasonable differential diagnoses to explain the acute onset of dizziness and nausea in the patient, are the peripheral causes of vertigo since they also show an acute onset. Among the different causes of peripheral vertigo, Meniere’s disease can be identified as the most plausible differential diagnosis that should be considered in this case. According to (Kerner & Brückel (2014), the condition mostly affects individuals who are more than 50 years old and presents with a triad of intermittent vertigo, ringing in the ears and progressive deafness. Other likely differentials include inflammation of the inner ear, including labyrinthitis and vestibular neuronitis, both of which will produce persistent vertigo of acute onset, though only the former is associated with concurrent hearing loss (Muncie, Sirmans & James, 2017). These conditions are more likely to have arisen in the patient complained of a recent viral illness (Kerner & Brückel, 2014). However, none of these symptoms explain the increase in thirst and urine output.

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Vertebrobasilar ischemia (Cerebrovascular disease); from the patient’s reports, major complaints include dizziness and nausea, which increase when he stands. According to Muncie, Sirmans, and James (2017), such symptoms are consistent with vertigo, a condition that occurs once the vestibular system is affected. In this case, various diseases may affect the vestibular system’s peripheral or central parts and hence lead to vertigo (Reusch & Manson, 2018). For the patient under examination, the rapid development of signs and symptoms seem to suggest a condition that is originating from vascular. A cerebrovascular disease affecting the vertebrobasilar part of the circulation, which supplies the posterior aspects of the brain, may present with acute vertigo, thereby explaining the symptoms in this patient (Muncie, Sirmans & James, 2017).

Intracranial tumor; is another condition that can be related to the symptoms of dizziness and nausea that the patient is experiencing. The existence of a tumor would compress the vestibular centers in the brain or the nerves connecting it to the peripheral part in the inner ear, hence resulting in dizziness or nausea, as in the patient’s case. Further, for other symptoms like the frequent need to urinate and to be thirsty may be a result of a tumor compressing the pituitary gland hence preventing the release of antidiuretic hormone (Muncie, Sirmans & James, 2017).

The Patient’s Medication Regimen and Priority Concerns

From the symptoms, patient reports, and family history, the patient is likely to have been diagnosed with type 2 diabetes. The condition was previously known as a non-insulin dependent diabetes that affects sugar metabolism in the body (Kerner & Brückel, 2014). The medication regimen, in this case, would consist of low-dose sulfonylurea and metformin to reduce the high concentration of blood sugar levels. Further, to control sugar levels, other options will involve administering thiazide diuretic like hydrochlorothiazide and calcium channel blockers like nifedipine (Muncie, Sirmans & James, 2017). However, taking into consideration the financial position of the patient, he can also access generic forms of drugs to reduce the potential cost.

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The major priority concerns for the patient in question is controlling blood sugar levels as well as reducing high blood pressure. In this case, other conditions like a causative stroke would not be considered due to delayed presentation. But, by maintaining low levels of sugar and pressure levels, the risk factors for the development of subsequently severe stroke is equally reduced (Kerner & Brückel, 2014).

The Relationship between Comorbid Diagnosis with Current Symptoms.

The patient’s diagnosis is based on the fact that his comorbid diagnoses are major risk factors for cerebrovascular disease. The first aspect to consider is his medical history, which indicates that he has a history of hypertension; further, from the medical evaluation and patient reports, the high blood pressure is an indication of poorly managed hypertension. As Kerner and Brückel (2014) note, one of the major long-term complications of diabetes is the high risk of vascular diseases associated with atherosclerosis, including cerebrovascular conditions and myocardial infarction. Further, the said patient’s age is a serious factor that increases their risk for cardiovascular condition. From the patient’s history, he has previous sessions of stroke, which have left him disabled and with generalized weakness. Further, it is clear the blood sugar management is done poorly since he is unable to get the required medication. The patient reports that he is out of his Lantus and metformin because he cannot afford the refill until he gets his disability check. Clearly, this patient has a very high risk of having another cerebrovascular accident. The patient’s increased thirst and increase in urine output are an indicator of the poorly controlled blood sugars as these are some of the primary symptoms of diabetes (Reusch & Manson, 2018).

Evidence Based Practice in Primary Care

Effects of Patient’s Health Beliefs, Culture, and Behavior on Potential Outcomes

The patient’s health beliefs, culture, and behavior are undeniably crucial determinants of the outcomes of illness and treatment (Reusch & Manson, 2018). Since he suffers from a chronic condition, it is important that patient understands the nature of their illness and the need to remain compliant to medication as instructed by medical professionals as well as the recommended lifestyle changes to improve the outcomes of treatment. Conversely, the patient’s condition is likely to deteriorate further if he is negligent towards the treatment guidelines.

References

Kerner, W., & Brückel, J. (2014). Definition, classification, and diagnosis of diabetes mellitus.

Experimental and Clinical Endocrinology & Diabetes, 122(07), 384-386.

Muncie, H. L., Sirmans, S. M., & James, E. (2017). Dizziness: Approach to evaluation and

management. American Family Physician, 95(3), 154-162.

Reusch, J. E., & Manson, J. E. (2018). Management of type 2 diabetes in 2017. JAMA, 317(10),

1015-1016. Doi:10.1001/jama.2017.0241

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