Introduction
Evidence-based clinical practice is a derivation of evidence-based medicine. It involves conscious and judicious judgment based on existing evidence to come up with rational decisions regarding a particular case. This approach involves the collection, interpretation, and gathering of information which are relevant, valid and applicable to patient case scenario. The resulting report is based on clinician observed, tested and research driven information as evidence to the selected line of treatment. This method emphasizes on incorporation of particularized clinical expertise and external clinical evidence into interpretation and analysis of collected data in order to come up with relevant diagnosis (Buysse & Wesley, 2006).
In general, this practice is based on evidence and independent analysis of each patient case. It explicitly acknowledges the roe of evidence in assisting decision making with regard to patient case treatment (Buysse & Wesley, 2006). Clinical decisions are to a large extent based on the level of collected evidence. However, it is important to note that such evidence is evaluated against available research evidence (Duffy, Fisher & Munroe, 2008). The clinical cases study presented in this paper takes a step by step approach towards evidence based clinical practice.
Clinical Case
Clinical situation
The patient in this case is a 52 year old female with an educational level 8. She is a smoker and does not take alcohol. However, the patient takes heavy dosage of caffeine on daily basis. Additionally, the patient occasionally engages in exercises. The patient previously took up to 12 sodas per day and had been advised to cut down her soda intake take ice tea and sugar. Being in postmenopausal period, the patient has had no abortions/miscarriages during her life. She weighs 162lbs with a height of 5 ft 1, translating into a BMI of 30.6. Her pulse is 80.
The patient attends the clinic for follow-up previous visits medical tests. These included lab/imaging results, follow-up on unspecified hyperlipidemia, essential hypertension, and mood disorders. The patient complains of wanting to go through his blood work and discuss his medications. Indications show that the patient has been working out diets and has cut smoking to two to three cigarettes a day. She has lost weight though she does not report any kind of fatigue or fever. She complains of muscle pain but the joints have no pain.
A physical examination of the patient reveals no signs of illness, obesity, no signs of acute distress and she is wearing appropriate dress and is hygienically fine. His head shows a normal appearance with a stable midline posture. The eyelids are normal and the conjunctiva is clear. The patient’s pupils are equal, round, reactive to light and accommodation. The eye, nose, and throat are clear and non-tender. No inflammation is recorded and neither are lesions.
The neck appears normal and the lymph nodes show no signs of enlargement remains supple and show no tenderness. The respiratory system is unlabored, clear on auscultation and the patients do not cough. Cardiovascular inspection reveals no jugular venous distention and the carotid auscultation returns a normal verdict. Visual inspection of the gastrointestinal systems returns a normal verdict and active bowel sounds are recorded from all the four quadrants with no bruits.
Cranial nerves examination shows that they are all grossly intact. The Deep Tendon Reflex exam shows symmetry and 2+. Musculoskeletal shows no weakness, spasms, atrophy or any form of tenderness. The tone is normal. The pain shows no signs of pain on movement. Her skin is also normal. She experiences generalized warmth and normal turgor. Her speech is logical, relevant and organized.
The patients past medical history revealed that she has suffered allergies, high blood pressure, high cholesterol levels/hyperlipidemia, and asthma. The patient has also suffered emphysema, reflux, arthritis, several headaches, migraines, and insomnia. Family history also reveals that the patient’s father has suffered heart disease, while the mother has suffered breast cancer and diabetes while the sister was diagnosed for diabetes. The patient has also been previously reviewed for mood disorders, chronic airway obstruction, impaired fasting glucose and allergic arthritis in addition to the aforementioned conditions.
Hypothesis
Based on the collected evidence the investigation was narrowed down to three possible conditions. Having complained of muscle pains, a possibility of hyperlipidemia is considered for further evaluation and possible confirmation or disqualification (Project MATCH Research Group, 2007). Additionally, mood disorder is considered given her sudden visit to the hospital on the pretext of wanting to follow up on her medical condition.
Analysis of hyperlipidemia: Ideally, the patient’s history formed the basis for this analysis. She was noted as having not lost any significant weight and not suffering from any acute illness. In general, her state was steady. To come with a diagnosis, a number of tests were conducted. The patient is also tested for diabetes based on her medical history.
Diagnostic tests
To come with appropriate diagnosis, a number of tests were conducted which include a check in the level of glucose, urea nitrogen and creatinine among others. While most were found to be normal, interested areas include potassium which was found to be low, cholesterol levels which were found to high, triglycerides, which were found to be high, and LDL cholesterol which was found to be high. The results indicated that the levels of cholesterol total, HDL cholesterol, triglycerides and LDL cholesterol were 257, 50, 198, and 167 respectively. Another area of interest was hemoglobin with a value of 6.4 signaling increased diabetes risks.
It is important that in such situations the suspected ailments are weighed against the existing literature to come up with the best diagnosis. Conducted test include the following: Lipid profiles testing in the laboratory: the test conducted here include cholesterol screen HDL as well as triglycerides testing. VLDL is also calculated by division of the obtained value for triglyceride by 5 (Project MATCH Research Group, 2007). Subtraction of HDL cholesterol and VLDL gives the LDL value. It is often desirable that cholesterol levels are kept at levels below 200mg/dL (Smith, 2009). Between 200 and 239 mg/dL are termed as high concentration borderlines.
At eves greater than 240mg/dL. Hypercholesterolemia is said to be present. As total cholesterol levels fall, cardiac occurrence risk is greatly minimized. Values less than 150mg/dL are said to be normal triglyceride values. Borderline concentrations range from 150 to 199mg/dL while values of between 200 to 499mg/dL are considered high (Smith, 2009). Values greater than 500 are extremely high. For HDL concentration, 60mg/dL are considered high. Values below 40mg/dL pose a greater risk of the patient suffering coronary attack. For women though the value is marginally set at a value of less than 50.3 mg/dL. Given its interpretation on the basis of total cholesterol as well as LDL, the value of HDL may prove insignificant in those incidences where the value of LDL is very low.
For less than 100mg/dL cholesterol levels, the situation is considered optimal. Between 100 to 129 and between 130-159 mg/dL are considered near optimal and borderline respectively. Values ranging form 160 to 189 are considered high. Emerging evidence however, indicate that normal human LDL cholesterol concentration may be as low as 70mg/dl. Coronary heart disease risk is believed to decrease as the concentration of LDL cholesterol also decreases.
Diabetes is related to blood glucose levels. A number of tests are useful in order to come up with conclusive evidence that a patient is diabetic (Cooke & Plotnick, 2008). Fasting plasma glucose (FPG) test is useful in measurement of a person blood glucose level if the person ahs not eaten within the previous 8 hours. Oral glucose tolerance test (OGTT) on the other hand provides a measure of an individual glucose levels after the individual has fasted for at least a period of 8 hours or has drank a beverage containing glucose 2 hours prior to the test. Another test performed in testing diabetes is the random plasma glucose test which test blood sugar levels regardless of the time the person being tested last ate.
All these tests are useful in diagnosis of both pre-diabetes condition as well as the condition itself. For persons recording positive diabetes test results, a similar test should be repeated on another day to confirm the test results.
FPG is the preferential testing method given its low cost and increased convenience. It’s however less precise as compared to OGTT and can easily miss some cases which are detected by the latter. It is more reliable when conducted in the morning hours. Its results are as summarized in the table below:
Table 1: FPG test.
Compared to FPG, OGTT is more sensitive in re-diabetes diagnosis. It is however, less convenient. Like FPG it is subject to at least 8hours of fasting prior to the test. The level of plasma glucose is then measured 2 hours after the person being tested has drunk 75gms glucose content liquid dissolved in water. Table 2 illustrates the results of this test in a better light.
Table 2: OGTT.
Pre-diabetes, also referred to as impaired glucose tolerance, indicated that the individual in question suffer elevated risk of developing diabetes though at the time of test he/she has not actually developed the condition. Like the case of FPG, once levels found to be beyond 200mg/dl, the test is repeated another day to confirm if indeed the person has the condition or it was just a case of spontaneous blood glucose elevation.
Random plasma glucose tests concludes diabetic condition of an individual if a 200mg/dl, glucose level is recorded and accompanied by a number of symptoms including increased urination, high thirst rates and loss of weight that is not accounted for. Other possible symptoms associated with diabetes include general fatigue, allured vision, high rates of hunger and non-healing sores (Cooke & Plotnick, 2008). The results are confirmed on a different using the other testing techniques.
The basis for testing the patient for diabetes was drawn from his obese condition, more so with regard to age. Additionally, the patient’s family history indicated that both the mother and the sister had previously suffered diabetic condition. The patient’s history also indicated that she had previously been diagnosed with high blood pressure. The father has also previously suffered a cardiovascular disease. These factors informed the decision to consider diabetes as one of the possible ailments that the patient could be suffering.
As earlier mentioned, another possible condition investigated if the patient could be suffering from was mood disorders or depressions. Depression is often characterized with a number of functional disabilities that that of a normal person. Depression was considered due to a number of factors that the patient had recorded based on his medical history. These include obese condition, previous suspected cases of arthritis, hypertensions and diabetes.
All of which are related to depressions. Diagnosis of depression includes both physical and psychological evaluation. Its possibility can only be ruled out based on physical examination, patient-physician interviews and tests conducted in the laboratory. Screening is a common too used for its diagnosis. A through diagnostic evaluation traces the patient’s history from the time the earliest signals were observed, their severity, to the mode of occurrence. Drug abuse is an important factor considered in diagnosis of depression. It is also worth establishing if other family members have previously suffered from similar conditions.
Other laboratory test may be performed which include CT, MRI, SPECT among others though not yet widely used. It is however, important to note that though the laboratory test are more efficient and reliable, they have high costs attached which limits their usage to only sever cases. Unlike physical examination and oral interviews which are less costly they increased the patient’s medical bill enormously. It is on this basis that in this case, laboratory test received little focus.
Diagnostic and treatment plan
After a thorough and careful analysis of the possible diagnosis, hyperlipidemia was chosen as the diagnostic problem that the patient was suffering from. This was after it was established that the patient’s glucose level was normal and hence she was not diabetic. However it is important to note that the patient suffers increased risk of diabetes based on the result obtained from hemoglobin test. This is considered as an under factor that could further increase the effect of hyperlipidemia. Additionally, the patient experiences logical and appropriate decision making. He presents logical and relevant thoughts as well as perceptions.
This is in addition to giving organized speech ruling out the possibility of depression. However, all indication point towards hyperlipidemia with lots of discrepancies recorded in cholesterol levels. A treatment plan is therefore developed for hyperlipidemia as shown below:
- Step 1: obtaining of complete and fasting lipids: This step involves obtaining laboratory information of lipids with regard to the patients. In this case the obtained results are that the levels of cholesterol total, HDL cholesterol, triglycerides and LDL cholesterol were 257, 50, 198, and 167 respectively. LDL recorded is 167 which is high. Likewise is the total cholesterol level as well as triglycerides.
- Step 2: CAD identification in patients: Coronary heart disease is associated with hyperlipidemia. It poses an unfavorable prognosis and the need for early identification cannot be overstated.
- Step 3: assessment of risk factors: This is fundamental steps which involves identification of possible risk that patients are subjected to. Based on identified condition, medical intervention measures which may pose risks to the customers are identified to ensure that the treatment approach employed does pose risks to the client.
- Step 4 assessment of increased number of risks
Table 3: Framingham Ten Year Risk.
- Step 5: therapeutic lifestyle changing initiatives undertaken: These include dietary changes, consumption of soluble fibers (10-25gm/day), plant sterols for lower LDL, increased exercise by the patient, and weight management initiatives.
- Step 6: drug therapy alongside therapeutic lifestyle changes. After three months and TLS fails to yield changes, introduce a drug regime. As mentioned earlier, drugs vcan either be administered independently or jointly depending on the diagnosis. Based on this case, the patient showed increased signs of hyperlipidemia while at the same time showed increased risk of diabetes. She is therefore to be started with pravastatin and metformin. Other possible drugs in case of unsuccessful results are indicated below:
- Atorvastatin – Lowers LDL and TG to a great level.
- Lovastatin: Allows one to take whole foods
- Pravastatin: Has least interaction with the pathway used in elimination, its taken on empty stomach.
- Simvastatin: potent and requires lots of prevention data.
- Fluvastatin: has lesser potency and reduced prevention data.
- Rosuvastatin: increasingly potent. Raises HDL and lowers TG.
- Step 8: metabolic syndrome identification: Underlying cause of obese are treated as well as inactivity physically.
- Step 9: treatment of elevated TG >150: After lowering LDL, if TG remains higher than 200, drug therapy is increased. For TG greater than 200, initially lower triglycerides t eliminate possibilities of pancreatitis. Once maintained at below 5000, LDL treatment is resumed.HDL<40 is treated after LDL is lowered.
Legal and/or ethical concerns
Physicians owe a legal duty to the patients with regard to provision of healthcare and confidentiality of information. Under no circumstances is a physician allowed to divulge patient information except is such circumstances are aimed at improving the patients welfare. Additionally, the physicians have a legal mandate to ensure that the diagnosis they come up with and its relevant treatments are as accurate and precise as possible. The medication prescribed to a client should not be detrimental to that client.
Conclusion: In general, it may be concluded that evidence bas nursing practice is time intensive and requires a lot of dedication. However, its success has seen a number of organizations adopting it and incorporating it into its medical practice. It popularity continues to grow by the day. Patients are treated based on a number of factors that may contribute to the ailments they suffer there by making it a wholesome treatment approach as compared to the other techniques available in nursing practice.
References
Buysse, V. & Wesley, P. W. (2006). Evidence-based practice: How did it emerge and what does it really mean for the early childhood field? Zero to Three, 27(2), 50-55.
Cooke D. W. & Plotnick, L. (2008). “Type 1 diabetes mellitus in pediatrics”. Pediatr Rev 29 (11): 374–84.
Duffy, P., Fisher, C. & Munroe, D. (2008). “Nursing knowledge, skill, and attitudes related to evidenced based practice: Before or After Organizational Supports”. MEDSURG Nursing 17 (1): 55–60.
Project MATCH Research Group. (2007). Matching Alcoholism treatments to client heterogeneity: Project MATCH post treatment drinking outcomes. Journal of Studies in Alcoholism, 58(12): 7-29.
Smith, L. L. (2009). “Another cholesterol hypothesis: cholesterol as antioxidant”. Free Radic. Biol. Med. 11 (1): 47–61.