04 Nov In the United States, diabetes is the primary cause of kidney failure a

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 In the United States, diabetes is the primary cause of kidney failure and new cases of blindness in adults (Davidson et al., 2021). In addition, it is linked to elevated risks of cardiovascular disease (CVD), nonalcoholic fatty liver disease, and nonalcoholic steatohepatitis (Davidson et al., 2021). Therefore, screening asymptomatic persons for prediabetes and type 2 diabetes may permit earlier detection, diagnosis, and treatment to enhance health outcomes.

          The US Preventive Services Task Force (USPSTF) concludes with intermediate certainty that screening for prediabetes and type 2 diabetes and giving or referring prediabetic patients to effective preventive therapies offers a moderate net benefit (Davidson et al., 2021). Clinicians should consider screening at a younger age in individuals from populations with disproportionately high incidence and prevalence, in those with a family history of diabetes, a history of gestational diabetes, or a history of polycystic ovary syndrome, and Asian Americans with a lower BMI (Davidson et al., 2021). This advice applies to nonpregnant persons aged 35 to 70 seen in primary care settings who are overweight or obese (BMI of 25 and more) and have no signs of diabetes (Davidson et al., 2021).

          Screening tests for diabetes are initiated by measuring fasting plasma glucose or oral glucose tolerance test and hemoglobin A1C (U.S. Preventive Services Task Force, 2022). Studies suggest that screening takes place every three years for adults with normal blood glucose levels (U.S. Preventive Services Task Force, 2022).

Diagnosis	Fasting Plasma Glucose	Oral Glucose Tolerance Test	HbgA1C
Type 2 Diabetes	126mg/dL or greater	200 mg/dL or greater	6.5% or greater
Pre Diabetes	100-125 mg/dL	140-199 mg/dL	5.7-6.4%

           Multiple studies have shown that lifestyle intervention was more effective than metformin in preventing or delaying diabetes in the Diabetes Prevention Program (DPP) research (Davidson et al., 2021). In addition to reducing the development of diabetes, lifestyle interventions positively impact body mass index, blood pressure, increasing high-density lipoprotein cholesterol levels and lowering triglyceride levels (Davidson et al., 2021).

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  Diabetes is a disease that effects patients all over the world but has hit the citizens of the United States in large numbers. Type two diabetes effects and estimated 30 million people in the United States. This condition is a common condition that we must be aware of and familiar with proper screening once symptoms of diabetes are identified to provide our patients with the best treatment plan. Screening aims at early detection of diabetes to treat and prevent complications from diabetes. Screening tools for diabetes include a fasting glucose, A1c, and glucose tolerance testing. It is important to ensure patients understand the risk factors for diabetes and prevention steps they can take to avoid diabetes. If a patient is diagnosed with diabetes, it is an excellent opportunity for patient education and a chance for the practitioner to implement changes that can improve diabetes type two and even possible with the right interventions reverse a diabetes diagnosis (Vasavada & Taub, 2021).

            The goal of treatment of diabetes type 2 is to control diabetes to avoid complications of diabetes such as organ damage or other morbidities. The US Preventative Services Task Force recommends screening for diabetes for patients 40-70 years old, and or overweight. Risk factors for diabetes include hypertension, coronary vascular disease, obesity, first-degree relative with diabetes, and high-risk ethnicity-African American, Latino, Native American, Asian American, Pacific Islander. Other patient factors to include would be history of gestational diabetes or Poly Cystic Ovarian Syndrome. It is essential to identify diabetes type two early on to aid the patient in making changes to irradiate the diabetes or to prevent the complications that can arise from diabetes (Vasavada & Taub, 2021).

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A ten-year-old patient presents in the clinic with soft-tissue swelling around the left eye. The parent reports that the child has had a cold with copious amounts of nasal drainage for approximately a week. The parent thought the child was getting better, but this morning the child awoke with a red eye and a fever of 102.1°F. The child has no complaint of headache, vomiting or visual disturbances.

Describe how the FNP would clinically manage and follow up this patient. List the pharmacological and non-pharmacological interventions. Describe how the treatment plan might be different for a 35-year-old patient as well as a 65+ year old patient.

Diagnosis

When a patient exhibits soft tissue swelling around the left eye, along with concomitant eye redness and fever, and there has been nasal discharge for a week due to a cold, the patient may be experiencing conjunctival chemosis.

What is Conjunctival chemosis?

Conjunctival chemosis is a medical disorder that typically results from an allergy or cold. It causes positive eye inflammation or edema, mainly in the patient's conjunctiva (Azari & Arabi, 2020). Conjunctival chemosis or excessive rubbing of the eyes can also result from other eye illnesses including viral or bacterial conjunctivitis and irritate your eyes. Conjunctival chemosis, or the presence of extra fluid in the conjunctival interstitium, can be brought on by a number of circumstances, such as exposure, trauma, infection, allergies, blockage of the lymphatic and venous drainage, and inflammation of the conjunctiva and surrounding tissues (Azari & Arabi, 2020).

Assessment

An essential assessment technique for identifying the reason of conjunctival chemosis is an eye examination in conjunction with a thorough patient history. From there, the doctor may be able to make a diagnosis and adopt the best possible course of action for the patient's therapy.

Interventions

The treatment approach includes reducing swelling in the afflicted eye and treating it with antibiotics, eye drops, and antihistamines to prevent complications like cellulitis, encephalitis, or even meningitis which might be fatal for the patient. These drugs are a component of the therapy for reducing edema. Inflammatory episodes can be reduced by treating the underlying causes, such as the cold and other allergies (Kwong & Joshi, 2020).

Artificial tears, saline solution to lower antigen load and inflammation-causing mediators, and cold compresses are examples of non-pharmacologic therapy that may help soothe eye irritation and temporarily reduce redness. Interventions that target one or more phases in the inflammatory response cascade will be required in order to reduce the inflammation that is the underlying cause of conjunctival chemosis symptoms (Kwong & Joshi, 2020). The majority of patients who have active conjunctival chemosis are managed with a combination of non-pharmacologic treatments (such as cold compresses or artificial tears to provide temporary symptomatic relief) and topical pharmacologic drugs (such as a dual-acting antihistamine-mast cell stabilizer agent) to reduce inflammation. Non-pharmacologic treatments include artificial tears and cold compresses.

Treatment plan for conjunctival chemosis does not vary on the basis of age difference but maybe the risk factors causing conjunctival chemosis can be different as per age difference as when the age increases immunity decreases which causes many opportunistic pathogens to cause opportunistic infections which can resemble other infections.

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Complaint:

For the last 5 days a 52-year-old male has had a productive cough.

Questions for health history:  

1. How would you describe the cough?

2. Is there anything that you notice that makes your cough worst?

3. Is there anything that you notice that makes your cough better?

4. Have you tried any treatments for your cough, and did they work?

5. Is there any pain in your throat and what number 0-10 would you give it?

6. Are you coughing up any sputum?

7. When you start coughing, how long does it last?

Differential diagnosis:

1. B34.8 Rhinovirus disease:

Education about how to prevent spreading the virus. Making sure to wash hands, wipe down high touch surfaces. Stay home when sick. Drink lots of fluids and get plenty of rest. This is a virus, and it is not recommended to treat a virus with an antibiotic (U.S. Department of Health & Human Services, 2022).

2. B95 Streptococcus:

Education about how to prevent spreading the virus. Making sure to wash hands, wipe down high touch surfaces. Stay home when sick. Drink lots of fluids and get plenty of rest. Treat with 500 mg of Amoxicillin for 10 days (UpToDate, 2022).

3. J30.2 Seasonal allergic rhinitis: (Morice et al., 2020).

There are many over the counter medications that can be used for seasonal allergic rhinitis. Some medications are decongestants, antihistamines, oral leukotriene receptor antagonists, intranasal cromolyn, corticosteroids, and intranasal anticholinergics (American Academy of Family Physicians, 2022).

4. Reflux Cough (Morice et al., 2020), K21.0 Gastro-esophageal reflux disease with esophagitis:

There is both medications that can be taken, as well as lifestyle changes. It is recommended to us a proton pump inhibor 30 to 60 minutes before breakfast and some lifestyle changes such as smaller meals, and elevating the head of the bed (American Academy of Family Physicians, 2003)

5. 493.90 Unspecified Asthma: chronic cough (Morice et al., 2020)

It is recommended to start treatment of asthma with inhaled corticosteroids (Edward, 2021).

6. R09.82 Postnasal drip syndrome

Recommendation includes nasal rinsing and irrigation, avoid triggers, and using medications such as an antihistamine like Astepro or azelastine, a nasal glucocorticoid such as Flonase, ipratropium, or a combination nasal glucocorticoid/antihistamine, such as fluticasone (Lieberman, 2022).

7. J18.9 Pneumonia: Cough, fever chest pain, loss of appetite and fever are symptoms of pneumonia (Grief & Loza, 2018).

Pneumonia can be caused by different organism, which depending on the organism will depend on treatment choice. Pneumonia can be treated with an antifungal, antibiotic, or an antiviral medication (National Heart, Lung, and Blood Institute, 2022).