The Major Type 2 Diabetes Treatment Assignment

The 79-year-old patient, JJ, has had a past medical history of Diabetes Mellitus Type 2, making it the main reason why he was initially taking Metformin. According to Foretz et al. (2019), Metformin is the major Type 2 diabetes treatment, especially in reducing mortality rates and cardiovascular cases. Apart from its ability to lower glucose levels, Metformin also has other pleiotropic effects that are essential for critical conditions, including anti-thrombotic and inflammatory effects by reducing acute organ dysfunction development and progression. Hence, there is always a need to hold Metformin in the hospital to prevent adverse drug accumulation. However, in JJ’s case, Metformin needed to be discontinued before subjecting the patient to angiography. That would help in Metformin-associated lactic acidosis prevention The Major Type 2 Diabetes Treatment Assignment.

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Ethical principles are essential in healthcare since they guide hospitals and healthcare providers to acknowledge factors that negatively affect the patients. In that case, it was ethical for St. Mary Othordox to refer JJ to an ER since they aimed to prevent more patient harm. In that case, St. Mary Othordox was observing the nonmaleficence and beneficence ethical principles which help nurses to engage in activities that are beneficial to the patients and prevent any possible harm (McDermott-Levy et al., 2018)The Major Type 2 Diabetes Treatment Assignment. That is because tertiary care has more advanced expertise and equipment like the computerized tomography that easily helps the healthcare providers make informed decisions that lead to positive patient outcomes.

Apart from the pharmacological medications, it was essential for the patient to be introduced to non-pharmacological interventions, mainly dressing the affected area. According to Wheeland (2021), the most effective occlusive conventional dressing involves using Vaseline Petrolatum Gauze. Its main benefits are that it helps the affected area to remain moist, thus reducing dehydration. Also, the intervention is non-toxic and has no irritation effects, thus reducing trauma and pain

References

Foretz, M., Guigas, B., & Viollet, B. (2019). Understanding the glucoregulatory mechanisms of Metformin in type 2 diabetes mellitus. Nature Reviews Endocrinology, 15(10), 569-589. https://doi.org/10.1038/s41574-019-0242-2

McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical principles and guidelines of global health nursing practice. Nursing Outlook, 66(5), 473-481. https://doi.org/10.1016/j.outlook.2018.06.013 The Major Type 2 Diabetes Treatment Assignment

Wheeland, R. G. (2021). Dressings and Their Effects on Wound Healing. In Practical Dermatologic Surgery (pp. 79-88). CRC Press.

Focused SOAP Note Template
Patient Information:
Initials JJ, Age 79years old, Sex Male, Race Indian
S (subjective)
CC (chief complaint): “right leg pain and inability to walk.”

HPI (history of present illness): JJ is a 79 y.o. male, with PMH of CAD s/p CABG 10 years ago, HTN, DM type 2, b/l knee replacement 7 years ago, right ankle ORIF in 12/2021, right ankle skin graft 1/2022 who presents with right ankle graft area redness and drainage. The patient said he had the above surgery done in India. Then he came to the US to visit family in April. He had been doing fine till yesterday when he noticed the right ankle incision/graft area with redness and drainage. The patient could not bear weight on the right leg due to tenderness and pain. The patient said he went to see the Maryland Orthopedics association and was told to come to ER for further evaluation.
● Location: Right leg and ankle
● Onset: 1 day ago
● Character: oozing, pain, swelling, tenderness, redness.
● Associated signs and symptoms: chills, fevers, Purulent drainage, pain, swelling
● Timing: 5 months after his right ankle skin graft
● Exacerbating/relieving factors: Walking, bearing weight.
● Severity: 10/10 pain scale The Major Type 2 Diabetes Treatment Assignment

Current Medications:
● Ceftriaxone 2g IV Q24hrs
● Vancomycin 15mg/kg/dose IV Q12hrs
● Acetaminophen 650mg PO Q4hrs PRN
● Insulin Aspart 0-6 Units sub. ACHS
● Insulin glargine 30 Units Sub. Q24 hrs.
● Metoprolol Succinate 25mg PO Qdaily
● Ondansetron 4mg PO Q6hrs PRN
● Heparin (porcine) 5000units Sub. Q12hrs

Home Medications
● aspirin 81 MG EC tablet PO Qdaily
● metformin (JANUMET) 500 mg per tablet PO Qdaily

Allergies: NKDA, Denies any food or environmental allergies

PMHx:
● Coronary artery disease
● Diabetes mellitus type 2
● Hypertension (HTN)

Immunization: Declines Influenza and Covid vaccine. Last tetanus was 5 years ago, pneumococcal vaccine 5 years ago. Patient-reported Up to date on all immunizations.

Soc and Substance Hx: JJ is a 79-year-old Indian widower living in India and a retired accountant. JJ loves to spend time with family. Denies tobacco, alcohol, and illicit drugs use. JJ reports wearing his seat belt while riding and not using his cell phone when driving. JJ has a great support system both here and in India.

Fam Hx: Mother deceased. Died at 82yrs with diabetes complications. Father, deceased. Died at 85 years old with stroke. Son, 52 years old, living. HTN, Daughter, 48 years old, Living, no medical history, Son 44years old, living, no medical history, granddaughter 20 years, living, no medical history, grandson 18years living, no medical condition, granddaughter, 15 years old, living, no medical condition. The Major Type 2 Diabetes Treatment Assignment

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Surgical Hx:
● CORONARY ARTERY BYPASS (CABG) 2012
● Right Ankle skin graft (1/2022).
● JOINT REPLACEMENT- Bilat Knee replacement (2015).

Mental Hx: Denies anxiety, depression, suicidal or homicidal ideations.

Violence Hx: Denies any safety issues at home or in the community.

ROS (Review of Systems)

Constitutional: Negative for chills, diaphoresis, fever, malaise/fatigue, and weight loss.

HENT: Negative for congestion, ear discharge, ear pain, hearing loss, nosebleeds, sinus pain, sore throat, and tinnitus.

Eyes: Negative for blurred vision, double vision, photophobia, pain, discharge, and redness.

Respiratory: Negative for cough, hemoptysis, sputum production, shortness of breath, wheezing, and stridor.

Cardiovascular: Positive for leg swelling. Negative for chest pain, palpitations, orthopnea, claudication and PND.

Gastrointestinal: Negative for abdominal pain, blood in stool, constipation, diarrhea, heartburn, melena, nausea, and vomiting.

Genitourinary: Negative for dysuria, flank pain, frequency, hematuria, and urgency.

Musculoskeletal: Negative for back pain, falls, joint pain, myalgias, and neck pain.

Skin: Negative for itching and rash.

Neurological: Negative for dizziness, tingling, tremors, sensory change, speech change, focal weakness, seizures, loss of consciousness, weakness, and headaches.

Endo/Heme/Allergies: Negative for environmental allergies and polydipsia. Does not bruise/bleed easily.

Psychiatric/Behavioral: Negative for depression, hallucinations, memory loss, substance abuse, and suicidal ideas. The patient is not nervous/anxious and does not have insomnia.

Physical exam:
Constitutional:
General: The patient is lying in bed and is not in acute distress.
Appearance: Normal appearance. He is of average weight. He is not ill-appearing or toxic appearing. The Major Type 2 Diabetes Treatment Assignment

HEENT:
Head: Normocephalic and atraumatic.

Right Ear: External ear normal. There is no impacted cerumen.

Left Ear: External ear normal. There is no impacted cerumen.

Nose: Nose normal. No congestion or rhinorrhea.

Mouth: Mucous membranes are moist and intact.

Pharynx: Oropharynx is clear. No oropharyngeal exudate or posterior oropharyngeal erythema.

Eyes:
General: No scleral icterus.
Right eye: No discharge.
Left eye: No discharge.
Extraocular Movements: Extraocular movements intact.
Conjunctiva/sclera: Conjunctivae normal.
Pupils: Pupils are equal, round, and reactive to light.

Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm (sinus rhythm)The Major Type 2 Diabetes Treatment Assignment.
Pulses: Normal pulses.
Heart sounds: Normal heart sounds in all quadrants.

Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds. No wheezing or rhonchi was heard during auscultation.

Abdominal:
General: Abdomen is flat. Bowel sounds are present in all quadrants. There is no distension.
Palpations: Abdomen is soft.
Tenderness: There is no abdominal tenderness.

Musculoskeletal:
Cervical back: Normal range of motion and neck supple.
B/l feet mild edema + 3, right ankle medial aspect skin graft area mild erythema, the small open area below skin graft with active yellowish drainage. Patient able to move ankle b/l. The distal sensation is intact. B/l Knee no erythema or effusion noted. The Major Type 2 Diabetes Treatment Assignment

Skin:
Capillary Refill: Capillary refill takes 2 to 3 seconds.

Neurological:
General: No focal deficit present.
Mental Status: He is alert and oriented to person, place, time, and situation
Cranial Nerves: No cranial nerve deficit.
Sensory: No sensory deficit.
Motor: No weakness.
Coordination: Coordination normal.
Gait: Gait normal.
Deep Tendon Reflexes: Reflexes normal.

Psychiatric:
Mood and Affect: Mood normal.
Behavior: Behavior normal.
Thought Content: Thought content is normal.
Judgment: Judgment normal.

A (assessment)
Differential diagnoses:
● Right ankle cellulitis with potential graft infection is an acute skin infection affecting the dermis and subcutaneous regions. The hallmarks of cellulitis include rubor (redness), polor (pain), tumor (swelling), and calor (heat). The severity of the condition can range from localized erythema in a patient who is otherwise healthy to fulminant sepsis and quickly spreading erythema in necrotizing fasciitis. A thorough clinical examination may show an entry point such as an ulcer, a wound, eczema, or cutaneous mycosis. Although blood cultures and microscopic analysis of cutaneous aspirates, biopsies, or swabs should be considered for some patients, especially those immunocompromised, cellulitis may typically be diagnosed solely based on a patient’s medical history and physical examination. Patient JJ had a poor wound healing wound on his right ankle from his previous ORIF surgical incision and subsequently had a skin graft in January. His history of diabetes type 2 predisposed him to cellulitis. The patient JJ presented with all the classic symptoms of cellulitis. Although blood cultures are pending, all evidence suggests that patient JJ has cellulitis of the right ankle (Sullivan & de Barra, 2018)The Major Type 2 Diabetes Treatment Assignment.

● Osteomyelitis is a severe bone infection that can be acute or chronic. It is an inflammatory process of the bone and bone marrow that causes localized bone loss, necrosis, and the formation of new bone. Although any creature, including bacteria, viruses, parasites, and fungi, can cause osteomyelitis, pyogenic bacteria and mycobacteria usually cause bone infections. Some signs and symptoms are fever, pain, tenderness, swelling, redness, and warmth of the affected area. The patient presented with all the signs and symptoms. To establish whether a skin abscess is present and to differentiate between cellulitis and osteomyelitis, radiographic evaluation can be helpful. An MRI or a CT scan can also be ordered to support the definitive diagnosis (Birt et al., 2016)The Major Type 2 Diabetes Treatment Assignment.

● Deep Vein thromboses (DVT): Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT), is a leading global cause of morbidity and mortality that can be easily avoided. DVT is the formation of a blood clot in a vein that is deep into the planes of the muscle. DVT typically affects the legs but can also happen in other parts of the body, including the arms. Risk factors such as cancer, trauma, major surgery, hospitalization, immobilization, pregnancy, or oral contraceptive use can cause DVT. Patient JJ recently traveled from India, and that could be a cause for his DVT. The patient had Leukocytosis, his WBC at 17kand presented with a fever. An ultrasound should be obtained to confirm an actual diagnosis of DVT. Even though symptoms are similar, it is not likely that the patient had DVT, and that cannot be the primary diagnosis. The distinguishing duplex ultrasonography will have the presence of a thrombus within the vein. (Stone et al., 2017)The Major Type 2 Diabetes Treatment Assignment.

● Necrotizing fasciitis: It is a group of rare but deadly skin infections, muscles, and soft tissues that tend to spread quickly across the fascia planes and gradually erode the fascia at a pace of up to 2-3 cm/h. The most specific etiology that can be identified is trauma. Because the infection spreads quickly and septic shock can occur, the death rate is significant. The Initial findings are nonspecific and can be like those of cellulitis. An MRI needs to be obtained to get a definitive diagnosis, and a surgical consult should be considered in the initial stages. This could not be the primary diagnosis for this patient (Misiakos et al., 2014)The Major Type 2 Diabetes Treatment Assignment.

P (plan)
Diagnostic Studies
Labs-Heme
17.00* \ 11.1* / 267
/ 33.6* \

Blood Culture-Pending
Chem 7
131* 99 13 / 144*
— 23 0.9 \
Metabolic Panel:
BILITOT 0.4
AST 24
ALT 19
ALKPHOS 72
PROT 7.0
ALBUMIN 4.1

Lactate Whole Blood 2.2
URINALYSIS – Abnormal; Notable for the following components:
Glucose, Urine, Semiquant >=500 (*)
Ketones, Urine, Qualitative Small (*)
Imaging
XR Ankle Right Minimum 3 VWS- Distal right tibia and fibular shaft fracture deformities are seen status post hardware fixation. There are overlying soft tissue defects.

XR Tibia Fibula Right 2 VWS- Distal right tibia and fibular shaft fracture deformities are seen status post hardware fixation. There are overlying soft tissue defects.

Assessment/Plan
Right ankle cellulitis with potential graft infection:
I consulted ID, the patient started on broad-spectrum antibiotics Vancomycin 15mg/kg/dose and Ceftriaxone 2g IV. Pending blood and wound cultures.
Orthopedics consulted. Recommend transfer to a tertiary institution (JHH) for surgery.

SIRS/Sepsis:
Presents with lactate elevate 2.2
Resolved with IVF and IV antibiotics.
Blood culture sent.
Vital signs stable.

History of CAD s/p CABG: hold ASA for possible surgery.
Continue BB.
Clinical stable.
Will obtain EKG for pre-op.

DM: patient takes oral agents and basal insulin 30 units in AM and 20 units at night.
Will hold oral agent. (metformin)
Continue home dose of basal insulin.
Add SSI.
Check A1c.

Patient Education
● Educated patient on poor diabetes control and referred patient for outpatient diabetes educator The Major Type 2 Diabetes Treatment Assignment

Reflection
This patient is a learning experience type as his presenting symptoms connect to his past medical illnesses. The patient’s presenting symptoms and past medical history are aligned, and it was very educative research about poor healing of diabetic wounds and another disease such as cellulitis. I encouraged the patient to participate in examining his feet daily, report any non-healing wounds as soon as possible to his provider, and to work on controlling his diabetes to prevent this in the future.
CLASS QUESTION
● Why do you think patient JJ’s metformin was held during his hospitalization?
● Considering the patient’s situation, do you think it was ethical to transfer the patient to a tertiary institution or ortho could have stepped in?
● What other treatment plan would you add to what was initiated?

References
Birt, M. C., Anderson, D. W., Bruce Toby, E., & Wang, J. (2016). Osteomyelitis: Recent advances in pathophysiology and therapeutic strategies. Journal of orthopedics, 14(1), 45–52. https://doi.org/10.1016/j.jor.2016.10.004

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Misiakos, E. P., Bagias, G., Patapis, P., Sotiropoulos, D., Kanavidis, P., & Machairas, A. (2014). Current concepts in the management of necrotizing fasciitis. Frontiers in surgery, 1, 36. https://doi.org/10.3389/fsurg.2014.00036

Stone, J., Hangge, P., Albadawi, H., Wallace, A., Shamoun, F., Knuttien, M. G., Naidu, S., & Oklu, R. (2017). Deep vein thrombosis: pathogenesis, diagnosis, and medical management. Cardiovascular diagnosis and therapy, 7(Suppl 3), S276–S284. https://doi.org/10.21037/cdt.2017.09.01
Sullivan, T., & de Barra, E. (2018). Diagnosis and management of cellulitis. Clinical medicine (London, England), 18(2), 160–163. https://doi.org/10.7861/clinmedicine.18-2-160 The Major Type 2 Diabetes Treatment Assignment