Question

Reason for Visit: 3 month follow up

History of Present Illness

A 45-year-old woman with type 2 diabetes arrives for a follow-up visit 1 week after her HbA1c was determined. She has been compliant with metformin 1000 mg twice daily. She reports that her home blood sugar readings have improved slightly but are still high. She admits to a few dietary indiscretions, such as having multiple servings of dessert when going out with friends. For exercise, she has been walking 10 to 15 minutes a day.

She denies polyuria, polydipsia, or blurry vision. The review of systems is unremarkable.

Past Medical History/Current Meds

• Type 2 diabetes, diagnosed 6 months ago when she presented with polyuria, blurry vision, and a random glucose level of 276mg/dl. Her HbA1c at the time was 8.0%. She was started on metformin 500mg twice daily and within 3 months her HbA1c dropped to 7.6%. The metformin was increased to 1000mg twice daily at that time. She has not had any significant hypoglycemic episodes.

• Hypertension treated with Lisinopril 40mg daily

• Dylipidemia, treated with atorvastatin 20 mg daily.

Physical Examination

Vital signs are blood pressure 122/76 mm Hg, heart rate 82, respiratory rate 18, temperature 98.1 °F, height 5’5”, weight 196 pounds, and BMI 32.6. She has not gained or lost significant weight since she started treatment for diabetes.

On exam, the lungs are clear to auscultation, the heart has a regular rate and rhythm without any murmurs, and the abdomen is non-tender. Peripheral pulses are normal, and there is no lower extremity edema. The foot exam shows normal sensation to light touch and no skin or toenail lesions.

Labs:

HbA1c level, determined last week, is 7.3%.

Patient’s blood glucose log shows morning fasting glucose ranging from 120 mg/dL to 150 mg/dL, and postprandial readings at 190 mg/dL to 220 mg/dL.

Case Study Discussion Questions

What are the targets for diabetes Control?

Is this patient meeting those goals?

Using the goals for treatment, formulate a plan of care and support it by incorporating evidence based rationale. What pharmacologic treatments should be considered and why? If the patient needed to be started on insulin how does the primary care provider initiate insulin therapy. Be sure to include important patient education and behavior modifications in the patient’s plan of care. Does this patient need to be referred to anyone?

Answer 1

The main target for diabetes control is to maintain the HbA1c level less than 7% to prevent microvascular complication (Retinopathy, neuropathy, nephropathy)

As she us overweight or severe obsese a management of it is necessary

By this time the patient should have reached the level less than 7% but her levels are at 7.3%. The patient has to meet this goal.

The following plan of care can be incorporated

• A brisk walking for at least 30 minutes a day is a must everyday
• Avoid fast foods
• Follow a diet low in calorie
• If insulin to be started long acting insulin (mixtard) will work for the patient ,along with metformin twice a day
• Patient strictly to be health educated on insulin therapy, monitoring blood glucose level regularly, watch for hypoglycemia signs

The patient can be referred to a Bariatric physician to maintain weight and for dietary modifications,