PCOS Peer Response

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QUESTION

Peer Responses – Pratiksha

Length: A minimum of 170 words per post, not including references

Citations: At least two high-level scholarly reference in APA per post from within the last 5 years

  • Relate to another journal readingFor peer posts and subsequent posts under the initial discussion board thread add in second and third line treatments and additional considerations (250 word maximum for responses). Example requirement, only evidence-based sources, such as AAFP, CDC, IDSA, ADA, JNC 8 etc. (textbook resources and internet sites affiliated with medical associations are considered credible sources to obtain the information on the most up to date guidelines). Add in the link to the guideline(s) within the discussion board for further reading by your peers.
  • Polycystic ovary syndrome, also known as PCOS or Stein Leventhal syndrome is a disorder that primarily affects women in their childbearing years. It is a condition characterized by periods, difficulty getting pregnant, excessive hair growth, acne and weight gain. The causes of PCOS are varied. Include factors, insulin resistance and environmental influences. Factors such as levels of hormones disruptions in hormone release from the brain and irregular development of ovarian follicles play a role in the development of this syndrome. (Singh et al 2023) 
  • Epidemiology 

Globally Polycystic Ovary Syndrome (PCOS) affects around 8% to 20% of women during their years according to diagnostic criteria (Singh et al., 2023). The prevalence varies across populations due, to environmental factors. 

Pathophysiology 

The underlying mechanisms of PCOS involve metabolic disruptions mainly characterized by levels of androgens and insulin. Increased androgen levels originating from the ovaries and adrenal glands result in symptoms such as hair growth (hirsutism) and acne while disturbing ovarian function (Witchel et al., 2019). Imbalances in the ovarian axis worsen excess androgen production, influenced by genetic factors affecting steroid production. Additionally, insulin resistance contributes to insulin levels, which in turn stimulate androgen production and lower sex hormone binding globulin levels intensifying the effects of androgens. 

Clinical Presentation 

Common symptoms include cycles, hirsutism, acne, weight gain and difficulty conceiving. Long term implications involve metabolic issues, like diabetes, abnormal lipid levels and cardiovascular problems (Bulsara et al., 2021). 

Diagnostic Criteria 

To diagnose syndrome (PCOS) healthcare providers consider various criteria outlined by the Rotterdam ESHRE/ASRM Sponsored PCOS Consensus Workshop Group in 2004. These criteria involve the presence of two out of three key features; hyperandrogenism (HA) ovulatory dysfunction (OD) and polycystic ovarian morphology (PCOM) observable on ultrasound scans. The Androgen Excess and PCOS Society (AE PCOS) criteria also consider hyperandrogenism and ovarian dysfunction for diagnosis. Anti Mullerian hormone (AMH) plays a role as an indicator in PCOS reflecting the maturation and development of ovarian follicles. Elevated levels of AMH can hinder development contributing to the dysfunction commonly seen in PCOS cases. 

Non-Drug Treatment Approaches 

For women with PCOS lifestyle modifications are fundamental in managing the condition alongside medication. Engaging in activity is vital as it improves insulin sensitivity and overall metabolic health. Including both aerobic exercise and resistance training in routines has been shown to enhance insulin sensitivity and regulate androgen levels. Following glycemic index (LGI) diets that’re high in fiber and plant-based fats can provide metabolic benefits by helping to regulate glucose levels and hormones that control appetite. 

It’s important to steer diets that’re high in calories, sugar and saturated fats to help reduce inflammation and insulin resistance linked to PCOS (Singh et al., 2023). 

Pharmacological Management 

Oral contraceptives (OCPs), including both progesterone-only pills and combined estrogen-progesterone pills, serve as first-line therapy for menstrual irregularities and ovulation suppression (Bulsara et al., 2021). Antiandrogens such as spironolactone, flutamide, and cyproterone acetate are preferred for managing hirsutism. Insulin sensitizers like metformin improve insulin resistance and restore menstrual regularity, while thiazolidinediones (TZDs) offer additional benefits in improving ovulation and reducing androgen levels (Bulsara et al., 2021). 

Education

Patient education on lifestyle modifications, contraception, and long-term health risks is crucial. Encourage adherence to treatment and regular follow-ups. 

Follow-up 

Regular monitoring of menstrual cycles, androgen levels, and metabolic parameters is essential. Adjust management strategies based on patient response and goals. 

focused soap note: complex case

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QUESTION

TO PREPARE: 

Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.

Select a child/adolescent or adult patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of completed assignment signed by your Preceptor. You must submit your SOAP Note using Turnitin.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.

  • Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice what you will say beforehand, and ensure that you have the appropriate lighting and equipment to record the presentation.
  • Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.

Video assignment for this week’s presenters:

Record yourself presenting the complex case study for your clinical patient. In your presentation:

  • Dress professionally and present yourself in a professional manner.
  • Display your photo ID at the start of the video when you introduce yourself.

Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).

State objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.

Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.

Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value. 

Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.

  • Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment? 
  • Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.

Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.  Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).

  • Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.

response.

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QUESTION

During my recent clinical rotation, I encountered a multitude of cases that underscored the importance of conducting thorough assessments and exercising critical thinking skills. Navigating through a clinic that predominantly serves older patients with a plethora of comorbidities posed initial challenges, as the signs and symptoms they presented with often pointed towards a myriad of potential disease processes. However, with the invaluable guidance of my preceptor, I quickly acclimated to the fast-paced environment and was able to adeptly manage the complexities inherent in such patient demographics.

    One particularly memorable case involved an 82-year-old African American female with an extensive medical history including type 2 diabetes, stage 3 chronic kidney disease, hyperthyroidism, and hypertension. She presented with complaints of sharp, tingling lower back pain that had been radiating to her hips for the past six months, accompanied by mild difficulty in ambulation due to the discomfort. Both my preceptor and I suspected sciatic nerve involvement based on her clinical presentation. However, abnormal results in her blood work, specifically elevated levels of creatinine, BUN, and calcium, prompted us to delve deeper into the diagnostic process. Consequently, we decided to refer her for spinal X-rays to confirm our preliminary diagnosis. To manage her pain, she was prescribed meloxicam 5mg PO BID and educated on the importance of adhering to the prescribed medication regimen, as well as utilizing a heating pad to alleviate inflammation. Given the complexity of her medical history, we also considered alternative diagnoses such as spinal stenosis, which could exacerbate her symptoms due to spinal degeneration (Goldsmith et al., 2019). Diabetic Neuropathy was another plausible explanation, given her history of type 2 diabetes, which could manifest as radiating pain in the lower limbs (Nordheim & Jenssen, 2021). Additionally, peripheral vascular disease was considered, given her advanced age and history of hypertension, potentially contributing to her ambulatory difficulties (Jaul & Barron, 2017).

    In light of her multifaceted medical conditions and associated risk factors, we prioritized implementing various health promotion strategies to optimize her overall well-being. These strategies encompassed educating her on the importance of glycemic control through medication adherence, regular blood glucose monitoring, and adhering to a balanced diet. Furthermore, we emphasized the significance of managing blood pressure and blood sugar levels to decelerate the progression of kidney disease, alongside advocating for regular kidney function tests to monitor renal health. In addition, we tailored a safe and feasible exercise regimen to her individual capabilities, advocating for gentle activities such as walking and stretching to enhance mobility and mitigate the risk of complications associated with her myriad of conditions.

    This clinical encounter served as a poignant reminder of the indispensable role of interdisciplinary collaboration in delivering comprehensive patient care. Engaging with other healthcare professionals, consulting specialists, and fostering collaboration within a multidisciplinary team framework proved instrumental in navigating the complexities of managing patients with multiple chronic conditions. Also, addressing medication management in such patients necessitates a nuanced understanding of potential drug interactions, side effects, and contraindications, further underscoring the importance of effective communication and coordination among healthcare providers.

    Drawing from evidence-based guidelines and recommendations, such as those provided by the American Diabetes Association (ADA) for glycemic control and the Kidney Disease: Improving Global Outcomes (KDIGO) guideline for blood pressure management in chronic kidney disease patients, informed our approach to patient care (Reynolds et al., 2018). Additionally, leveraging evidence-based dietary guidelines from the Academy of Nutrition and Dietetics facilitated tailored dietary recommendations to effectively manage the patient’s complex medical conditions (Reynolds et al., 2018).

    This clinical experience exemplified the intricate interplay between comprehensive assessment, critical thinking, and interdisciplinary collaboration in providing optimal care for patients with complex medical histories and multiple comorbidities. By prioritizing patient education, implementing tailored health promotion strategies, and leveraging evidence-based guidelines, advanced practice nurses can empower patients to actively participate in their care and achieve improved health outcomes amidst the intricate tapestry of chronic disease management.

WCU Payment Disparities for APRNs vs Physicians Discussion

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Question

Jalil D Response 1

Medicare, Medicaid, private insurers, and HMOs are reimbursement mechanisms designed to make payments to APRNs for services rendered. Notably, most billing regulations for insurers follow the Medicare guidelines. Payments to APRNs are only made on an assignment basis that follows the Medicare-allowed amount. Consequently, APRNS are not allowed to collect or bill the beneficiary any amount apart from unmet copayments, coinsurance, and deductibles. However, payment is made to APRNs unbundled when inpatient and outpatient hospital services are billed directly. 

Differences exist between physicians and non-physician providers. For instance, while the reimbursement for non-physician providers tends to be based on direct diagnosis-related groups, provider services are made independently from the respective system. It is also important to note that payment for nursing services is equivalent to 85% of the doctor’s payment plan. The reimbursement of provider services is done independently from other services offered in healthcare facilities. On the one hand, payments for provider services are made through Part B of Medicare, which includes surgery, therapy, diagnosis, care plan oversight, consultations, and institutional and home visits. Billing done for inpatient services for physician services uses the Current Procedural Terminology (CPT) code system. On the other hand, non-physician services use the Evaluation and Management (E&M) service, which includes coordination of care, counseling, diagnosis, history taking, and examination.

Previously, APRNs were not allowed to have their practice in California. However, from the beginning of 2023, APRNs in California State could apply for licenses to operate their practice (Haney, 2023). The main reason for this authorization is that NPs are essential leaders in healthcare teams where standardized procedures are needed to ensure that they function within their area of practice to meet patients’ primary healthcare needs.

Rocio R Response 2

Reimbursement mechanisms for Advanced Practice Registered Nurses (APRNs) vary depending on the payer, whether it’s Medicare, Medicaid, private insurers, or Health Maintenance Organizations (HMOs). In the case of Medicare, it reimburses APRNs for services provided under certain conditions. For example, nurse practitioners, clinical nurse specialists, and certified nurse-midwives can be reimbursed for services they independently provided within their scope of practice and state laws (Harrison et al., 2023). However, certified registered nurse anesthetists typically receive reimbursement under physician supervision rules (Harrison et al., 2023). In addition, Medicaid reimbursement for APRNs also varies by state regulations and scope of practice laws. While some states allow APRNs full practice authority, enabling them to bill Medicaid directly for their services without physician oversight, other states require that APRNs collaborate with physicians to receive reimbursement (Harrison et al., 2023).

Private insurers typically follow Medicare guidelines but may have their reimbursement policies regarding APRN services. Many private insurers reimburse APRNs for services within their scope of practice, although the rates may vary (Leger & Vanhook, 2021). On the other hand, Health Maintenance Organizations (HMOs) often have reimbursement policies for APRNs that may reimburse APRNs depending on the specific HMO and its contract agreements with healthcare providers (Leger & Vanhook, 2021).

Regarding fee schedules, there are often differences between physicians and non-physician providers (NPPs) such as APRNs. 

According to Bischof & Greenberg (2021), Medicare generally pays APRNs at 80 percent of the lesser of the actual charge or 85 percent of physician payment under the Medicaid Physician Fee Schedule. Those reimbursement rates differ due to the scope of practice between physicians and NPs, billing rules and market dynamics, that include negotiations between healthcare providers, insurers, and government agencies (Razavi et al., 2021).

Finally, Advanced Practice Registered Nurses (APRNs) can own their practices in Florida in primary care, including family medicine, general pediatrics, and general internal medicine (APRN, 2024). Florida is one of the states that allows APRNs to practice independently without physician supervision under certain conditions. The ability of APRNs to own their practices in Florida is influenced by factors such as the scope of practice laws, state licensing requirements, and business regulations (APRN, 2024). 

Discussion 2 1st reply

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QUESTION

Primary Care NP Role vs. APN Roles

  • Thaiz 
  •     Advanced Practice Nurses (APNs) play crucial roles in healthcare, providing specialized care, improving access to healthcare services, and promoting health outcomes (American Association of Nurse Practitioners, n.d). Among APNs, Nurse Practitioners (NPs) hold a significant position, with various specialties such as primary care, acute care, pediatric care, and more. This paper compares the primary care NP role with other APN roles, highlighting their similarities, differences, and methods of communication to healthcare providers and consumers.
  • Similarities among APN Roles

    All APN roles share several core similarities like advanced education and training. All APNs possess advanced degrees such as Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP), which equip them with advanced clinical knowledge and skills (Chan et al, 2020).

    The scope of practice for APNs is more expanded scope of practice compared to registered nurses, including assessing, diagnosing, prescribing medications, and providing treatments independently or collaboratively with physicians (Chan et al., 2020).

    The APNs prioritize holistic, patient-centered care, emphasizing health promotion, disease prevention, and patient education to improve health outcomes (American Association of Nurse Practitioners, n.d).

    APNs often work in collaboration with physicians, other healthcare professionals, and interdisciplinary teams to deliver comprehensive care to patients (Pulcini et al., 2019).

Differences among APN Roles

    APN roles exhibit distinct differences, primarily in their scope of practice, patient population, and settings. Primary Care NPs focus on providing comprehensive care to patients across the lifespan, emphasizing health promotion, disease prevention, and management of common acute and chronic conditions in various primary care settings, including clinics, community health centers, and private practices (American Association of Nurse Practitioners, n.d).

    Acute Care NPs specialize in managing complex acute and critical conditions in settings such as hospitals, emergency departments, and specialty clinics. They often work with acutely ill or injured patients, conducting assessments, ordering diagnostic tests, and coordinating care in fast-paced environments (Pulcini et al., 2019).

    Pediatric NPs specialize in providing primary and acute care to infants, children, and adolescents, addressing their unique physical, developmental, and psychosocial needs. They work in pediatric clinics, hospitals, schools, and specialty practices, collaborating with pediatricians and other healthcare providers (Pulcini et al., 2019).

    Psychiatric-Mental Health NPs focus on assessing, diagnosing, and managing mental health disorders across the lifespan. They provide psychiatric evaluations, psychotherapy, medication management, and crisis intervention in various settings, including psychiatric hospitals, community mental health centers, and outpatient clinics (American Association of Nurse Practitioners, n.d).

Communication of APN Roles to Healthcare Providers

    To effectively communicate the roles of APNs to healthcare providers, it is essential to emphasize their advanced education, specialized training, and contributions to patient care. Healthcare providers should be informed about the specific responsibilities, scope of practice, and collaboration opportunities with APNs in different settings. Utilizing professional presentations, workshops, and informational materials can help raise awareness and foster collaborative relationships among healthcare teams (Chan et al., 2020).

Communication of APN Roles to Consumers

    Communicating APN roles to consumers requires clear and accessible language to transfer the benefits of receiving care from APNs. Consumer education efforts should focus on highlighting APNs’ expertise, personalized approach to care, and ability to address a wide range of health needs. Strategies such as pamphlets, websites, and community outreach events can be employed to educate consumers about the role of APNs in delivering high-quality, patient-centered care across various healthcare settings (Chan et al., 2020).

    In conclusion, while APN roles share commonalities such as advanced education and patient-centered care, they differ in scope of practice, patient population, and practice settings. Primary care NPs, along with other APNs, play integral roles in improving access to healthcare services and promoting positive health outcomes. Effective communication of APN roles to healthcare providers and consumers is essential for fostering collaboration, increasing awareness, and enhancing the delivery of healthcare services. By highlighting the unique contributions of APNs, healthcare teams can work together to meet the diverse needs of patients and communities.

CASE STUDIES

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QUESTION

Case studies are a useful way for you to apply your knowledge of pharmacokinetics and pharmacodynamic aspects of pharmacology to specific patient cases and health histories.

For this Assignment, you evaluate drug treatment plans for patients with various disorders and justify drug therapy plans based on patient history and diagnosis.

To Prepare:

  • Review the case study posted in “Announcements” by your Instructor for this Assignment
  • Review the information provided and answer questions posed in the case study
  • When recommending a medication, write out a complete prescription for the medication
  • Whenever possible, use clinical practice guidelines in developing your answers when possible
  • Include at least three references to support your answer and cite them in APA format.

For this Assignment, you evaluate drug treatment plans for patients with various disorders and justify drug therapy plans based on patient history and diagnosis.

Do Not place the references at the end of the assignment post, place the references after each individual scenario.

Below are the scenario cases:

Directions: For each of the scenarios below, answer the questions below using clinical
practice guideline where applicable. Explain the problem and explain how you would
address the problem. If prescribing a new drug, write out a complete medication order
just as you would if you were completing a prescription. Use at least 3 sources for each
scenario and cite sources using APA format.

1. Sara is a 45-year-old female presenting for her annual exam. Her blood pressure
today is 160/90 HR 84 RR 16. Her height is 64 inches and her weight is 195. Her
last visit to the clinic 3 months ago shows a BP of 156/92. She is currently taking
ibuprofen 600 mg tid for back pain. She has no known allergies. What is the goal
for her blood pressure? What medication would you prescribe to treat her blood
pressure? What education would you prescribe?

2. Monty is a 52-year-old male following up on his labs that were drawn last week.
He smokes 1 pack per day. He is currently on Lisinopril 20 mg po daily. He is
allergic to penicillin. Fasting lipid profile shows total cholesterol 266, LDL
cholesterol 180, HDL cholesterol 40, and Triglycerides 185. What treatment plan
would you implement for Monty’s lipid profile? What is the goal Total Cholesterol
(TC), HDL-C, and LDL-C level for Monty? How would you monitor the
effectiveness of your treatment plan? How many risk factors for coronary artery
disease does this patient have? Identify them specifically.

3. Beatrice is a 17-year-old female diagnosed with mild persistent asthma since age
7. During her visit today, she reports having to use her albuterol MDI 3 to 4 days
per week over the past 2 months. Over the past week she has been using
albuterol at least once per day. She reports being awakened by a cough three
nights during the last month. She is becoming more short of breath with exercise.
She also has a fluticasone MDI, which she uses “most days of the week.” Her
current medications include: Flovent HFA 44 mcg, two puffs BID, Proventil HFA
two puffs Q 4–6 H PRN shortness of breath, Yaz one PO daily, Propranolol 80
mg PO BID. What treatment plan would you implement for this patient? What
medication changes would you make? How would you monitor the effectiveness
of this plan?

4. Daute is a 56-year-old man seeking evaluation for increasing shortness of
breath. He noticed difficulty catching his breath about 3 years ago. Physical
activity increases his symptoms. He avoids activity as much as possible to
prevent any SOB. His previous physician had placed him on
salmeterol/fluticasone (Advair Diskus) one inhalation twice daily 2 years ago. He
thinks his physician initiated the medication for the shortness of breath, but he is
not entirely sure. He did not refill the prescription and has not been taking it.
Pertinent history Chronic bronchitis X 8 years with one exacerbation in last 12
months of treatment with oral antibiotics. He has a 40-pack-year smoking history.

What treatment plan would you implement for this patient? What medication(s)would you monitor the effectiveness of this plan?

poster presentation to communicate implementation plan to bridge gap between evidence research and clinical practice

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Question

Create a poster presentation to communicate an implementation plan to bridge the gap between the evidence you will research and clinical practice. You will then record audio of no more than five minutes presenting your poster.

Master’s-level nurses need to be able to think critically about the evidence, outcomes data, and other relevant information they encounter throughout their daily practice. Often the evidence or information that a nurse encounters, researches, or studies is not presented in the exact context of that nurse’s practice. A key skill of the master’s-level nurse is to transfer evidence from the context in which it was presented and apply it to a different context in order to maximize the benefit to patients in that new context.

Master’s-level nurses understand the importance of utilizing evidence-based practice in their health care setting. The challenge is bridging the gap between the evidence and clinical practice. “This is the way we’ve always done it,” is a common response and may not indicate evidence-based practice is being utilized. Furthermore, when a practice problem is identified, what are the steps to communicate the need for change with the interprofessional team?

One way to communicate the need for quality improvements, as well as your plans for achieving specific changes, is through a presentation poster. This type of communication tool is used in workplaces as well as professional and academic conferences. Being able to convey the essence and value of a project in a compelling and succinct way is a valuable skill, and it is vital within the constraints of a single poster.

You have been asked to give a poster presentation based on your work and research on a clinical problem in your practice setting. The purpose is to lay out the evidence and a potential implementation plan to your colleagues in order to bridge the gap between the evidence and the practice and improve the quality and outcomes of care.

Identify a clinical problem in your work setting and develop an implementation plan to carry out your evidence-based practice proposal using a poster presentation. You may use the Poster Presentation Template [PPTX] Download Poster Presentation Template [PPTX]to help structure and organize your assessment submission.

Your Implementation Plan should include the following:

Background on the clinical problem.

PICOT question.

Stakeholders that will be impacted.

Action plan for implementation.

Potential barriers to project implementation.

Baseline data that will be needed to evaluate outcomes.

Search strategy and databases used.

Summary of the evidence with a critical appraisal of its quality.

The bullet points below correspond to the grading criteria in the scoring guide. Be sure that your poster presentation addresses all of them.

  • Develop a PICOT question for a chosen clinical problem.
  • Include a graphic that is relevant to the clinical problem.
  • Provide a background on the clinical problem identified.
  • Outline an action plan to implement the evidence-based project that includes:
  • The recommended practice change.
  • Proposed timeline for implementation.
  • The tools or resources that will be needed to support the project.
  • Identify the stakeholders, opportunities for innovation, and potential barriers to the practice change needed for project implementation.

Who are the stakeholders who will be impacted?

What are areas of the project that present opportunities for innovation?

  • What are the potential barriers, such as a lack of knowledge, time, skill level, motivation, or resources that could impact project implementation?

Propose outcome criteria to evaluate the evidence-based practice project and how they will be measured.

  • How will outcomes be measured?
  • How do your outcomes align with the Quadruple Aim?
  • How will your outcome measures inform evidence-based practice, guidelines, or policies?

Evaluate the evidence that supports the need for practice change.

  • In the notes section of your poster presentation:
  • Describe your search strategy and databases that were used.
  • Summarize your findings with a critical appraisal of the quality and relevance of your resources.
  • Convey purpose of the poster presentation, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly communication standards.

Week 6 Case Study.

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QUESTION

Directions

All students should complete the two (2) case studies below.  Note: All case studies are provided as a learning tool for students who wish to have them. 

Case 1 

See Thyroid Function Panel Reference Range on page 478. 

Review the following case and answer the questions.  

Ms. Jefferson is a 50-year-old woman who comes into the clinic to review her laboratory results from 2 weeks prior. She is in good health and has no complaints.  

Her laboratory values are normal except for the following: 

TSH = 30 mU/L; T4 = 3.0 mcg/dL 

free T4 = 0.5 mcg/dL 

free thyroxine index = 3.0 

T3 = 90 ng/dL 

Answer the following questions. 

  • Based on these lab findings Ms. Jefferson is diagnosed with which thyroid disorder? 
  • Hyperthyroidism 
  • Subclinical hyperthyroidism 
  • Hypothyroidism 

Subclinical hypothyroidism

The lack of symptoms in the type of thyroid disorder Ms. Jefferson has is uncommon.

  1. 2. The lack of symptoms in the type of thyroid disorder Ms. Jefferson has is uncommon. True or False 

3. Ms. Jefferson’s thyroid disorder is most likely caused by what? 

A pituitary adenoma (i.e., thyrotroph) 

  • Chronic autoimmune thyroiditis (i.e., Hashimoto thyroiditis) 
  • Autoimmune Graves disease 
  • Iodine deficiency 
  • 4. Ms. Jefferson asks when she should return to evaluate her thyroid disorder. You should respond: 
  • An annual evaluation should be sufficient. 

Return to have a TSH level done 6 weeks after starting therapy. 

Six months from now. 

5. Ms. Jefferson asks what are some possible symptoms of her thyroid disorder? Indicate all that apply.  

Weight gain 

  • Diarrhea 
  • Anxiety 
  • Palpitations 
  • Fatigue 

Cold intolerance

Case Study 2

A 50-year-old woman with an 8-year history of diabetes mellitus presents with difficulty controlling her blood sugars for the past 2 weeks. Her self-monitoring blood glucose readings have been in the 200s–300s for 2 weeks. She has managed her type 2 DM with diet, exercise, and metformin 1,000 mg twice a day. Her last glycosylated hemoglobin (HgbA1c) level, which was measured 2 months ago, was 6.8%.  

  • She has had asthma since age 18. She felt her asthma was getting worse for the past 6 months as she was having increased dyspnea and dry cough. She has managed her asthma with a daily combined long-acting beta-2 adrenergic agonist, an inhaled corticosteroid, and montelukast. She also uses her short-acting beta-2 adrenergic agonist, albuterol, about once a day. She went to her pulmonologist about 2 months ago and was diagnosed with severe asthma. A decision was made to start her on oral prednisone (corticosteroid). The first month she took 5 mg a day with some relief, but the symptoms returned, so her prednisone dose was increased to 10 mg a day. She has been taking the 10 mg dose for 3 weeks. She says her breathing is better, but she feels increasingly tired and like she is gaining weight.  
  • Physical examination reveals an anxious woman with blood pressure of 144/92 mmHg; pulse of 90 beats per minute; respirations 20 per minute; and weight of 190 pounds. She is talking in full sentences. Lung sounds are clear bilaterally. No accessory muscles are being used. No cyanosis is present. 
  • Answer the following questions.

1. Though this item involves pharmacology, it is still important. Which is the most likely cause of this patient’s loss of glucose control?  

Inhaled corticosteroid 

Prednisone therapy 

  • Asthma exacerbation 
  • Albuterol 
  • 2. All of the following actions are important for this patient to learn regarding glucocorticoid therapy, but which is the most important?  
  • Monitor cuts for healing 
  • Take the medication with food 
  • Do not stop taking the medication abruptly 

Contact her healthcare provider if she has any manifestations of infection 

3. Which endocrine condition is this patient at risk of developing?  

Hyperthyroidism 

Pheochromocytoma 

Addison disease 

Cushing syndrome 

4. Given this patient’s acute loss of glucose control, which of the following interventions would be ordered for this patient?  

Insulin as needed per routine sliding scale (dosing based on blood glucose levels) 

Increase exercise 

  • Decrease caloric intake 
  • Decrease prednisone dose 
  • SUBMISSION DETAILS:
  • Please make sure you are using scholarly references and they should not be older than 5 years. Your posts/references must be in APA format.

response

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Question

Please respond to discussion below

Atopic dermatitis, sometimes referred to as atopic eczema, is a chronic inflammatory dermatologic disorder that is typified by scaly, erythematous, and pruritic skin lesions that are normally restricted to the body’s flexural surfaces. As part of the allergic triad, which also include asthma and allergic rhinitis. As a result, 30% of children with atopic dermatitis go on to acquire asthma in their later years. Only 10% of instances of atopic dermatitis are detected beyond the age of five, as it often manifests before the age of two. According to a research by Frazier and Bhardwaj (2020), which polled pediatric patients across the United States, the incidence among children was as high as 19% in some places and roughly 11% nationwide. Significant morbidity from sleep disturbances, chronic postinflammatory dermatological changes, scarring formation from scratching and picking, and the development of subsequent skin infections with such pathogens as herpes viruses, Streptococcus, and Staphylococcus, may be avoided with early diagnosis and treatment.

         However, atopic dermatitis has no known cure, as much as there exist some medications that can be helpful in managing the symptoms. In actuality, an unparalleled quantity of novel atopic dermatitis treatments are presently under development. In many cases of atopic dermatitis, xerosis is present, and patients report that managing their dry skin is akin to managing their dermatitis. Therefore, whether or not they have active symptoms, people with atopic dermatitis ought to generously apply emollients to their whole body. According to a study by Frazier and Bhardwaj (2020),  regular use of emollients decreased the necessity for using topical corticosteroid and help ensure improved symptoms in infants with moderate to severe atopic dermatitis.

         Comparable to emollients, moisturizers aid in preserving and restoring skin moisture. All emollients are not created equal, though. Emollients with a high oil content and a low water content are often advised. Preferred are thick creams with minimal water content, such Cetaphil and Eucerin, or ointments, like Petroleum Jelly or Aquaphor (Puar et al., 2021). The latest batch of barrier-repair moisturizers has emerged, such Cerave and Restoraderm, that are intended to provide skin with ceramide lipids in addition to moisture, albeit their superiority over traditional emollients is not well established. Doctors should advise patients to take warm showers rather than hot ones and to use an emollient wash while doing so to prevent xerosis.

         For flare-ups of atopic dermatitis, topical corticosteroids are the primary line of treatment. Group VII has the least potent medications, such as 1% hydrocortisone, and group I, which is the most potent and includes clobetasol (Temovate). Generally speaking, the potency ought to be adjusted according to the disease’s severity. Longer courses of higher-potency corticosteroids are frequently required for individuals with lichenified plaques indicative of chronic eczema (such as lichen simplex chronicus), and occlusive therapy may also be beneficial (Sroka-Tomaszewska & Trzeciak, 2021). Mild-potency corticosteroids are recommended for the axillary regions, groin, neck, face, and surfaces of flexor muscles in order to prevent atrophy. For short periods (two weeks or less), moderate potencies can be used in these areas if the patient is experiencing a significant flare-up.

         Topical calcineurin inhibitors, which are immunomodulators and regarded as second-line therapy, include pimecrolimus (Elidel) and tacrolimus (Protopic). In patients with moderate to severe atopic dermatitis, they are typically only used temporarily or sporadically for long-term therapy. This is particularly the case when there is worry that continuous topical corticosteroid administration may have unfavorable side effects, like atrophy (Sroka-Tomaszewska & Trzeciak, 2021). These medicines are especially helpful for areas of thinner skin on the face, neck, and skin folds because they do not produce skin atrophy. Another advantage is that even after extended treatment, they do not exhibit tachyphylaxis, which is a reduction in reaction to a medication when it is taken frequently.

PCOS 2 – Peer Response

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QUESTION

Peer Responses – Pratiksha

Relate to another journal readingFor peer posts and subsequent posts under the initial discussion board thread add in second and third line treatments and additional considerations (250 word maximum for responses). Example requirement, only evidence-based sources, such as AAFP, CDC, IDSA, ADA, JNC 8 etc. (textbook resources and internet sites affiliated with medical associations are considered credible sources to obtain the information on the most up to date guidelines). Add in the link to the guideline(s) within the discussion board for further reading by your peers.

  • Polycystic ovary syndrome, also known as PCOS or Stein Leventhal syndrome is a disorder that primarily affects women in their childbearing years. It is a condition characterized by periods, difficulty getting pregnant, excessive hair growth, acne and weight gain. The causes of PCOS are varied. Include factors, insulin resistance and environmental influences. Factors such as levels of hormones disruptions in hormone release from the brain and irregular development of ovarian follicles play a role in the development of this syndrome. (Singh et al 2023) 
  • Epidemiology 

Globally Polycystic Ovary Syndrome (PCOS) affects around 8% to 20% of women during their years according to diagnostic criteria (Singh et al., 2023). The prevalence varies across populations due, to environmental factors. 

Pathophysiology 

The underlying mechanisms of PCOS involve metabolic disruptions mainly characterized by levels of androgens and insulin. Increased androgen levels originating from the ovaries and adrenal glands result in symptoms such as hair growth (hirsutism) and acne while disturbing ovarian function (Witchel et al., 2019). Imbalances in the ovarian axis worsen excess androgen production, influenced by genetic factors affecting steroid production. Additionally, insulin resistance contributes to insulin levels, which in turn stimulate androgen production and lower sex hormone binding globulin levels intensifying the effects of androgens. 

Clinical Presentation 

Common symptoms include cycles, hirsutism, acne, weight gain and difficulty conceiving. Long term implications involve metabolic issues, like diabetes, abnormal lipid levels and cardiovascular problems (Bulsara et al., 2021). 

Diagnostic Criteria 

To diagnose syndrome (PCOS) healthcare providers consider various criteria outlined by the Rotterdam ESHRE/ASRM Sponsored PCOS Consensus Workshop Group in 2004. These criteria involve the presence of two out of three key features; hyperandrogenism (HA) ovulatory dysfunction (OD) and polycystic ovarian morphology (PCOM) observable on ultrasound scans. The Androgen Excess and PCOS Society (AE PCOS) criteria also consider hyperandrogenism and ovarian dysfunction for diagnosis. Anti Mullerian hormone (AMH) plays a role as an indicator in PCOS reflecting the maturation and development of ovarian follicles. Elevated levels of AMH can hinder development contributing to the dysfunction commonly seen in PCOS cases. 

Non-Drug Treatment Approaches 

For women with PCOS lifestyle modifications are fundamental in managing the condition alongside medication. Engaging in activity is vital as it improves insulin sensitivity and overall metabolic health. Including both aerobic exercise and resistance training in routines has been shown to enhance insulin sensitivity and regulate androgen levels. Following glycemic index (LGI) diets that’re high in fiber and plant-based fats can provide metabolic benefits by helping to regulate glucose levels and hormones that control appetite. 

It’s important to steer diets that’re high in calories, sugar and saturated fats to help reduce inflammation and insulin resistance linked to PCOS (Singh et al., 2023). 

Pharmacological Management 

Oral contraceptives (OCPs), including both progesterone-only pills and combined estrogen-progesterone pills, serve as first-line therapy for menstrual irregularities and ovulation suppression (Bulsara et al., 2021). Antiandrogens such as spironolactone, flutamide, and cyproterone acetate are preferred for managing hirsutism. Insulin sensitizers like metformin improve insulin resistance and restore menstrual regularity, while thiazolidinediones (TZDs) offer additional benefits in improving ovulation and reducing androgen levels (Bulsara et al., 2021). 

Education

Patient education on lifestyle modifications, contraception, and long-term health risks is crucial. Encourage adherence to treatment and regular follow-ups. 

Follow-up 

Regular monitoring of menstrual cycles, androgen levels, and metabolic parameters is essential. Adjust management strategies based on patient response and goals.