LadyGrad
Diabetic Case Study Mr. Brown a 47-year-old white male presents to…
Diabetic Case Study
Mr. Brown a 47-year-old white male presents to your office for a follow-up visit. He was
seen 2 weeks ago for an upper respiratory infection and noted incidentally to
have a blood pressure of 164/98. He vaguely remembered told in the past that his
B/P was “borderline”. Labs were also done last visit and you are going over the
results with him today. He brings his B/P diary in and it is showing elevated
pressures from 144/94 to 176/96
Today: V/S: Right arm: 172/98; Left arm: 170/96; P 76; resp 16; 70 inches tall
weighs 210
DOB: 3-12-7
Labs from last week: CBC normal; CMP normal; A1C 7.4; TSH normal; Lipids: Total
cholesterol is 250; LDL is 190; HDL 35; Trigs 170
He feels fine, has no complaints.
PMH
Broken arm at age 12.
Hernia repair 10 years ago
No eye examination for about 1.5 years
Meds: zero
Allergies: NKDA
Fam hx:
Father died of stroke at age 69; diabetic
Mother alive at age 69 with HTN, DM
2 sisters ages 45 and 43; the older sister has DM
Social hx: Married. Son age 22 and daughter 20 both healthy. Sedentary job
(Accountant) does not exercise. Smokes 1ppd for 10 years. Has “a couple of beers
every weekend”
ROS:
Unremarkable except for above
Physical examination
No thyromegaly or lymphadenopathy
Fundoscopic exam is within normal limits
Cardiac exam: S1 and S2 are normal and no murmurs are auscultated
Lung and abdominal examinations are normal.
EKG shows nonspecific T wave changes; no acute ischemic changes
Assessment
Stage 2 HTN
Obesity
DM type 2
Hyperlipidemia
Tobacco abuse
Plan- six page
Should plug data in cardiac risk into ASCVD risk calculator:
https://tools.acc.org/ASCVD-Risk-Estimator-Plus/ use today’s b/p; he now has
past hx of diabetes; go to view advice
Use AACE/ACE Guidelines and ADA guidelines.
Also read the attached article
What is the treatment plan for Jack today? Must provide rationale. This is your
medical decision making. Think of how you would answer the patient if they
asked why you were recommending this. Must use evidence-based reference with
citations on all questions
? Pharmacologic? This should include any OTC medications
o Use blank prescription document to write prescriptions for your
pharmacologic treatments
? Nonpharmacologic? This should also include any patient education
? Follow up and Referral? If patient needs referral, you need to include this
here and why you are referring.
? write two pages for his treatment plan
Cite any lab/diagnostic testing needed for before prescribing that are required
and any needed for monitoring or that need to be done now or for follow up.
The following should be done once treatment plan is complete and separate
from the treatment plan:
State MOA of drug/drug class, ADME of each medication (short summation),Note pertinent drug-drug interactions and side effects (do not list
every drug interaction. Can state CYP450 inhibitor etc. Or if the patient is already
taking a medication that could be an issue), Black Box warnings and life span
considerations?
