Visit 1 - Roger A 46 yo male, Roger, who works as an ecologist for the State, presents to your office to establish care. He has not seen a physician since starting college. His only concern is that of fatigue. He sleeps well at night, denies any particular stressors, but just can’t seem to get through his day like he used to. He is wondering about the safety of energy pills or drinks.
Roger is the single parent of three children, having lost his wife in an airplane accident several years ago. He works full time and completes most of the household chores. His mother-in-law, a widow, also resides with the family; she watches the children after school and does some of the cooking. He has a past history of smoking in his 20s, drinks beer occasionally, and denies history of drug use. He is not presently sexually active.
The patient has no past surgical history and has never been hospitalized. He was seen in the ER for abdominal pain about a year ago which was diagnosed as GERD. Labs at that time were notable for normal liver and kidney function, normal blood counts, and a blood glucose of 189. He was given antacids at that time, but did not continue them. He takes no other medicines and has no known allergies.
Question Block 1 - Roge r
This is not a comprehensive visit. What additional history or ROS questions would you ask at this time?
This is not a comprehensive visit. What focused physical exam would you perform?
Visit 1 continued - Roger The remainder of the patient’s ROS was negative and exam was unremarkable except for a blood pressure of 146/89 and BMI 32.
Question Block 2 - Roger
Would you order any labs? Please state reason for ordering each one.
Please remember that the patient had a random blood glucose of 189 one year ago. Does this qualify as diabetes?
Visit 2 - Roger The patient returns to see you in follow-up. He had fasting labs a couple days ago.
He is still feeling tired. He tried a couple different energy drinks and they made him feel worse.
He has no new additional concerns, but is accompanied by two of his kids today who are running around the room. His blood pressure is 152/92 and BMI is unchanged
Question Block 3 - Roger
Name two resources (other than you) in the clinic or the community that can help him to learn more about diabetes and improve his blood sugars.
Management goals for diabetes include prevention and detection of micro- and macro-vascular complications. Please list six “end-organ” diseases or conditions that can result from poor diabetic control.
At each visit for DM, one of your goals is to screen for this end-organ damage. For each complication you listed above, please now list the ROS questions, physical exam and screening labs you would order.
Visit 2 continued - Roger Today, the patient denies CP, DOE, polyuria, polydypsia, tingling or numbness in his feet.
Question Block 4 - Roger
What additional testing would you do at this visit and why?
As you write your note and bill for this visit, please list the problems you would add to the patient’s active problem list.
Would you prescribe any medications at this visit? If so, please include name, dose and rationale for prescribing.
Would you make any referrals at this visit? To whom and why?
Visit 2 Ending - Roger The patient is interested to know more about diabetes and how changes in his diet and exercise might help him to feel better. He does not like to take pills and would like to avoid as many medicines as he can. He leaves with a referral to the diabetes and nutrition center and will have the labs done that you ordered.
A few days later you get his lab results:
Question Block 5 - Roger
True – False Questions:
Weight loss will improve glycemic control.
150 minutes of aerobic physical exercise weekly will improve glycemic control.
Structured diabetes education & nutrition counseling improves glycemic control .
Daily aspirin will prevent retinopathy .
In patients with type 2 DM, HTN and microalbuminuria, ACE-I and ARBs will delay progression to macroalbuminuria.
Phone Call 1 - Roger The patient attends appointments with the dietician and the nurse at the Diabetes Center.
He calls you to review what he learned there and discuss his lab results again.
Question Block 6 - Roger
He has been taught to check his blood sugars twice daily. What should his fasting blood sugar be?
What should his 2 hour post-prandial be?
He has looked again at his cholesterol and wants to know about his cholesterol goals. What is his target LDL, HDL and triglycerides?
He has been checking his blood pressure at home – what should this be?
Roger is thinking about starting an exercise program. He wants to know if he needs a stress test first. What do you think?
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