Chief Complaint
“Lately I feel extremely tired and now my vision is blurred.”
HPI
Joe Perez is a 66 y/o Hispanic male who presents to the family medicine clinic complaining of periodic blurred vision for the past 3 weeks. He further complains of severe fatigue and lack of energy; which limits his daily activities. He states that he started taking a multiple vitamin 1 week ago but has not noticed any improvement in his energy level.
PMH
HTN x 7 yrs
Hyperlipidemia x 5 yrs
FH
Diabetes present in both father and paternal grandfather. Father died suddenly of a massive stroke at age 62; mother died of breast cancer at age 49; 2 younger siblings are alive and apparently well.
SH
Married x 43 years with 2 children. Works full time as parking lot attendant. No alcohol or tobacco use. Rarely exercises and admits to trying fad diets for weight loss with little success.
Meds ALL
Propranolol LA 80 mg p once daily NKA
MVI po once daily
Labs
Na 141
K 4.0
Cl 96
Co2 22
BUN 24
Cr 1.6
Random glucose 260
Ca 9.9
Phos 3.2
AST 21
ALT 15
Alk Phos 45
- bili 0.9
- chol 285
UA (-) ketones
(-) Microalbuminuria
Assessment
Elevated random glucose
Elevated total cholesterol
Questions
1& 2 Problem Identification & Desired Outcomes
– What risk factors for type 2 DM are present in this patient?
– What information (signs, symptoms, laboratory values) support the diagnosis
of type 2 DM?
-what information presented indicates the presence of insulin resistance?
-what is the therapeutic objective for treating this patient?
-what are the goals of this patient’s diabetes?
-considering his other medical problems, what other treatment goals should be
established?
3& 4 Therapeutic Alternatives Optimal Plan
-what nonpharmacologic therapies might be useful in the management of this patient?
-what feasible pharmacotherapeutic alternatives are available for the treatment of
this patient’s DM? -identify the factors that will influence your choice of initial therapy?
-outline a complete pharmacotherapeutic plan to manage this patient’s current
problems including
- Drug name, dose & dosage, form, route, frequency, duration and purpose.
- Identify the medication classification
- Mechanism of action
- Major adverse effects and side effects
- Contraindications
- Safety alerts and precautions
- Determination of clinical efficacy
What clinical guideline/standard of practice guidelines support your medication selection? State the specific clinical guideline used. How do these guidelines relate to your patient? Include dosage, patient variables, follow up, diagnostic tests, and maintenance regimens.
What changes in therapy would you recommend if your initial plan fails to
achieve adequate glycemic control?
Outcome Evaluation
5 -what clinical and laboratory parameters will you monitor to evaluate glycemic efficacy and to detect or prevent adverse effects?
– The patient’s physician suggested that he obtain a blood glucose meter for self testing. What are the health care provider’s responsibilities with respect to patients and self monitoring of blood glucose (SMBG)?
-identify at least four potential situations in which the information provided by SMBG would be useful to patients and healthcare provoders.
-what factors should be considered in the selection of appropriate blood glucose
meter?
Patient Education
6. What information should be provided to this patient about diabetes and its treatment to enhance compliance, ensure successful therapy, minimize adverse and prevent future complications?
-how would you educate the patient regarding how and when to check his blood
glucose?
-what over the counter products could be recommended for patient to use in treating hypoglycemic episodes?
-list several potential sources of error in SMBG?
- Follow Up questions
-when starting a patient on insulin, the use of combination oral
antihyperglycemics agents and insulin affords several advantages over switching entirely to insulin.
- what are the advantages of adding insulin to existing therapies with oral agents?
- list an appropriate method of starting insulin therapy to adequately control
fasting hyperglycemia in patients on combination agents.
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