Medication Regimen

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.

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

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

1. Pertinent Positive and Negative Findings:

Positive Findings:

• Dizziness and nausea lasting for 4 days, exacerbated upon standing.
• Increased thirst and urination.
• Elevated blood sugar (405 mg/dL).
• Hypertension (190/101 mmHg).
• Tachycardia (HR 102 bpm).
• Respiratory rate within normal range.
• Reported inability to afford medication refill.

Negative Findings:

• Absence of headaches or blurry vision.
• No reported recent trauma or injury.
• No specific gastrointestinal symptoms apart from nausea.

2. List of Differentials with Rationales:

1. Diabetic Ketoacidosis (DKA): Given the elevated blood sugar, polyuria, and increased thirst, DKA is a significant concern in uncontrolled diabetes.
2. Hyperosmolar Hyperglycemic State (HHS): Similar to DKA but typically seen in type 2 diabetes, characterized by severe hyperglycemia without significant ketosis.
3. Dehydration: Elevated thirst and polyuria can result in dehydration, leading to dizziness and weakness.
4. Orthostatic Hypotension: Symptoms worsen upon standing, indicating possible orthostatic hypotension.
5. Hypertensive Crisis: Elevated blood pressure requires consideration for hypertensive urgency or emergency.
6. Renal Insufficiency: Considering the patient’s history of diabetes and hypertension, renal insufficiency could be contributing to his symptoms.

3. Medication Regimen:

Considering the patient’s financial constraints, it’s essential to prioritize cost-effective options:

• Insulin: Lantus may be expensive, but alternatives such as NPH insulin or Regular insulin can be considered due to their lower cost.
• Metformin: A generic version of metformin can be prescribed, which is more affordable.
• Hypertension Management: ACE inhibitors or ARBs are first-line agents and are generally affordable. Options like lisinopril or losartan can be prescribed.
• Blood Sugar Management: Affordable options like sulfonylureas (e.g., glipizide) or generic formulations of DPP-4 inhibitors (e.g., sitagliptin) can be considered.

4. Priority Concern:

The priority concern for this patient is addressing the acute hyperglycemia and potential complications such as DKA or HHS, given the significantly elevated blood sugar level.

5. Impact of Comorbid Diagnoses:

The patient’s comorbid diagnoses of diabetes, hypertension, and CAD contribute significantly to his current symptoms and health status. Uncontrolled diabetes can exacerbate cardiovascular risks, leading to complications such as stroke (as seen in his medical history) and peripheral vascular disease, further complicating his ability to ambulate.

6. Impact of Health Beliefs, Culture, and Behaviors:

• Financial Constraints: The patient’s inability to afford medication reflects socioeconomic barriers to healthcare access, which may impact medication adherence and disease management.
• Health Literacy: Understanding the importance of medication adherence, dietary modifications, and lifestyle changes is crucial. Tailoring education to the patient’s level of health literacy is essential for successful management.
• Cultural Beliefs: Cultural beliefs regarding illness, treatment, and healthcare providers may influence the patient’s willingness to adhere to medical recommendations. Building trust and rapport with the patient while respecting cultural preferences can enhance patient outcomes.

In conclusion, addressing the patient’s acute hyperglycemia, optimizing his medication regimen considering financial constraints, and addressing potential complications are crucial for improving his health outcomes and quality of life. Additionally, considering the patient’s health beliefs, culture, and behaviors is essential for developing a holistic and patient-centered approach to care.