SOAPE NOTE (Diabetes Case 2) Subjective: 1. Chief Complaint: CT is a 77 year old African American woman who comes into the clinic for her diabetes. 2. History of Present Illness: CT is coming to clinic today to seek help in controlling her diabetes.
Objective: 1. Past Medical History: • Diabetes Mellitus Type 2 for the past 40 years • Hypertension for the past 45 years • Chronic Kidney Disease for the past ten years with neuropathy • Myocardial Infarction in the year 2010 2. Family History: N/A (Not Available) 3. Social History: Patient said she had never smoked and does not drink alcoholic beverages. 4. Allergies/Reactions: N/A (Not Available) 5. Current Medications and Indications: • Lisinopril 20mg daily • hydrochlorothiazide 25mg daily • carvedilol 25mg BID • furosemide 40mg daily • simvastatin 20mg daily • piglitazone 30mg daily • insulin glargine 60 units QHS and insulin glulisine 15 units with each meal, gabapentin 300mg TID 6.
Pertinent Physical Examination/Review of System: N/A 7. Vital Signs (Height and Weight): : BP: 132/86, Pulse: 58, weight: 160lbs, height: 5’2”, RR: 18 8. Lab Tests: (The lab results are from last week with fasting) Glucose: FBG: 180mg/dl, A1C: 9%, SrCr: 1.7, other BMP: WNL 9. Diagnostic Tests: N/A Assessments: • Diabetes Mellitus Type 2- Patient has DM 2 that is not controlled • Hypertension- Blood pressure is a little high • Chronic Kidney Disease- Patient has CKD for 10 years with damage to the nerves • Myocardial Infarction- Patient had a heart attack back in 2010
Plan: • Diabetes Mellitus Type 2- Continue with current medications and increase insulin as needed to control the high FPG. • Hypertension- Continue on current medications to lower the blood pressure • Chronic Kidney Disease- Continue with lisinopril to help lessen the burden of the kidney function • Myocardial Infarction- Add aspirin to the patient medication list due to previous heart attack Education: Counsel patient on taking her medications regular and check her blood sugar. Advise on exercising and do some physical activities to lower the blood pressure and improve her glucose level.
Case Discussion (Diabetes Case 2)
1. What adjustments would you make to the patient’s insulin regimen? The patient’s fasting plasma glucose is very high in all seven reading; therefore, I would increase her basal insulin dose, so increase the insulin glargine from 60 units to maybe around 70 units every time before bedtime. Also, the patient needs to continue taking the bolus insulin with her food.
2. What is the best patient’s A1C goal for this patient? Why? 8% is a good A1C goal for this patient because of the neuropathy and the heart attack in 2010 and life expectancy because of her advanced age. 3. What intervention to the patient’s diabetes management do you recommend? Increasing the long acting insulin to help the patient with her fasting plasma glucose level while still continue using the rapid acting for when she is eating.
4. What lifestyle recommendations would you provide? I would recommend a brisk walking around the neighborhood everyday if possible, if not then at least 3 times a week. Do the nine inch plate meal choice by filling half the plate with non-starch vegetable, add a quarter of high protein meat, and a quarter of whole wheat or grain carbohydrate like brown rice or wheat paste. Also, reduced salt intake as this can lower her blood pressure. 5. Is aspirin daily recommended? Yes, because she had a previous heart attack back in the year 2010. 6. What else would you do with this patient? I would also recommend a higher potency statin like atorvastatin for this patient due to the previous heart attack.
7. What is the monitoring criteria? What is the appropriate follow up? Check for lipid level with the statin, kidney function for her Chronic Kidney Disease hypoglycemia because of the insulin she is taking basal and bolus, blood glucose because she is diabetic, electrolytes due to the diuretic and ACEI she is taking. Have the patient come back in three months for her follow up at the clinic at the same time. After your intervention and selected follow up time, the patient returns with the following BG log 8. What intervention would you make? The fasting plasma glucose is still very high especially before she have lunch, so I would recommend adding around a 10 units to her current 15 units for her bolus insulin.
