Patient is a 60 YO MALE seen in clinic for diabetes management follow-up. Allergies/ADEs: FLUNISOLIDE, PRIMIDONE, ALEVE CAPLET, CARBAMAZEPINE

Transcription

1 Patient is a 60 YO MALE seen in clinic for diabetes management follow-up. Allergies/ADEs: FLUNISOLIDE, PRIMIDONE, ALEVE CAPLET, CARBAMAZEPINE Dx/Hx: uncontrolled DM and HTN Lifestyle: Patient usually sleeps late so only eats 2 meals/day Diet: o Breakfast (11am-noon): sausage links, fried eggs, gravy o Lunch: usually skips o Supper (10-11pm): chili dogs, maybe just snack on crackers o Snacks: Ritz crackers, tv dinner Exercise: pain in hips, neck and lower back making walking and being active difficult. Alcohol: none Tobacco: none Wt. loss: 196 lbs (no change) Type 2 Diabetes: Current DM med regimen: Novolin 70/30 84 units BID (takes before breakfast 11am-12pm, before or after supper 10-11pm) Metformin 850mg PO BID (10-11am, 11pm) Self-Monitoring Blood Glucose: Date Morning Evening Before 2 hr. after before 6/21/ /23/ /23/ /24/ /25/ /26/ /27/ Average Hypoglycemia: Occurred about 2-3 times over the past month. He becomes shaky and sweats. If this occurs he usually does not check his BG levels and will eat a snack. He did say the few times he has checked his BG it has been anywhere from the 60s-120s.Reviewed s/sx and how to treat (rule of 15). HTN: Current HTN med regimen: Lisinopril 20mg PO BID Amlodipine 5mg PO BID

2 Metoprolol 50mg in the morning and 25mg in the evening Self-monitoring Blood Pressure: Patient is currently taking his blood pressure about twice a day, in the morning around 11am and at night around midnight. He takes it in the morning when he gets up before medications and at night, some times before medications and sometimes after. Date SBP DBP Pulse Notes 6/21/ Morning 6/22/ /23/ Midnight 6/23/ Morning 6/24/ Midnight 6/24/ Morning 6/25/ /26/ /27/ First thing in the morning (before meds) 6/27/ hours after medications 6/27/ At visit (left arm) Average Today patient reports that he does not feel well and the he feels "unstable". He reports these feelings a few times over the last week since increasing the dose on his medications. He also reports having about 3-4 "spells" over the past 6-7 weeks where his blood pressure has been high. During these spells he reports having a headache, face flushing, hard to read/see, and feeling like a "flashlight is shining in his face". He has taken his blood pressure during these "spells" and reports usually above 200s/100s. He states that these "spells" usually last hours. Medication adherence: Misses a dose "every now and then, mainly at night". Pt reports missing 1-2 doses/week for all medications. Tends to miss doses on nights he goes to bingo PMH: Active problems - Computerized Problem List is the source for the following: 1. Diabetes mellitus 2. Benign hypertension 3. Hyperlipidemia 4. Gastroesophageal reflux disease 5. Epilepsy 6. Benign prostatic hyperplasia 7. Cystoid macular edema (SCT ) - Cystoid macular degeneration of reti OS, noted 6/18/15 resolved 9/16/15 8. Pseudophakia s/p phaco os 4/16/15 9. Mild Nonprolf Db Retnoph - Mild nonproliferative diabetic retinopathy

3 10. Benign prostatic hyperplasia 11. Ocular Hypertension * 12. Cataract, Unspecified 13. Spondylosis 14. Splitting of Urinary Stream 15. ACCRETIONS ON TEETH 16. Hypertension, Benign 17. Impotence of organic origin 18. Bereavement * 19. Pain in joint involving shoulder region 20. Hip: arthralgia (pain on rotation, pain in groin) * 21. Seizure Disorder 22. DYSTHYMIC DISORDER 23. HYPERLIPIDEMIA 24. Diabetes Mellitus Type II or unspecified 25. Esophageal Reflux 26. PROLONG POSTTRAUM STRESS ACTIVE OUTPATIENT AND NON-VA MEDICATIONS: Medication Directions Qty Last filled Gemfibrozil 600mg Take 1 tablet by mouth twice daily 180 2/8/16 Sertraline 100mg Take 1 tablet by mouth daily 90 2/6/16 Lisinopril 40mg Take ½ tablet by mouth twice daily 180 6/21/16 Omeprazole 20mg Take 1 capsule by mouth twice daily 180 6/21/16 Tamsulosin 0.4mg Take 1 capsule by mouth every evening 90 6/21/16 Divalproex 250mg ER Take 1 tablet by mouth twice daily 180 6/21/16 Gabapentin 300mg Take 1 capsule by mouth at bedtime 90 4/19/16 Nitroglycerin 400mcg SL Dissolve one tablet under tongue every 5 minutes up to 3 1 5/26/16 doses Insulin Novolin 70/30 Inject 84 units under skin twice daily 16 6/23/16 Metformin 850mg Take 1 tablet by mouth twice daily 180 6/23/16 Metoprolol Tartrate 50mg Take 1 tablet by mouth in the morning and ½ tablet in the evening Amlodipine 5mg Take 1 tablet by mouth twice daily 90 2/19/16 Tramadol 100mg Take 1 tablet by mouth twice daily as needed Non-VA med Labs: Panel 1 Coll. Date Glucose BUN CREAT Sodium K CHLOR CO2 6/21/ H 27 H /9/ H 24 H L 5.2 H 99 28

4 SLT - Lab Tests Selected Collection Specimen Test Name Result 2/9/16 Plasma Cholesterol 298 H 2/9/16 Plasma Triglyceride 577 H 2/9/16 Plasma HDL 44 2/9/16 Plasma LDL 138 H Microalbumin screen: mg/l H (02/09/2016) GLYCOHEMOGLOBIN: 13.4 H (02/09/2016) Patient-specific A1c target (per VA/DoD guidelines): (?) <8% - due to long duration of DM (>10 years), multiple comorbidities, and requiring medication regimens including insulin (X) 8-9% - advanced microvascular complications, major comorbidities or life expectancy <5 years; unlikely to benefit from aggressive glucose lowering Assesment/Plan: Type 2 Diabetes: - A1c above goal of <8-9. SMBG above "ideal goal" of before meals and above "short term goal" of <200 before meals. - DM Standards Of Care: (+) ASA 81mg- will send patient prescription (+) ACEI/ARB- Lisinopril 20mg twice daily (+) Statin (high-intensity)- starting Atorvastatin 10mg daily and D/C gemfibrozil, will increase dose if patient tolerates initial dose (-) Foot exam- due now, will alert PCP to complete in August (+) Dilated eye exam- going to optometry today (+) Flu vaccine- 2/2016 (+) Pneumococcal vaccine- per patient report, received a few years ago at outside MD - Blood Glucose Monitoring: SMBG BID AC meals, occasionally 2 hr. PP - Other: Reviewed proper management of hypoglycemia. Patient eats a snack to treat. INCREASE to Novolin 70/30 86 units BID AC CONTINUE Metformin 850 mg BID

5 HTN: - BP goal is <140/90, but patient does report symptoms around /70. Goal would be to keep his BP around 140/90. - Monitoring: Take blood pressure in the morning 2 hours after taking medications and 30 minutes after caffeine or exercise. Make sure feet are flat on the ground, sitting upright with arm relaxed. CONTINUE Lisinopril 20mg PO BID CONTINUE Amlodipine 5mg PO BID CONTINUE Metoprolol 50mg in the morning and 25mg in the evening *waiting to see new BP logs before changing (with pt monitoring 2 hrs after HTN medications) HLD: - ASCVD risk = 44%, ACC/AHA guidelines recommend high-intensity statin. - Discussed starting a statin with the patient and informed him of common adverse effects. Patient has taken several statins in the past and does not report any adverse effects. INITIATE Atorvastatin 10mg daily INITIATE Aspirin 81mg daily DISCONTINUE Gemfibrozil *Plan to titrate atorvastatin dose as tolerated Refill requests: Alcohol swabs, test strips, gabapentin (not yet due, will clarify dose) Veteran verbalized understanding and agreed with plan above. Advised to call if assistance needed prior to next f/u. To be addressed at next phone f/u: Clarify gabapentin dose Ask if he is going to follow up with neurology, would like a repeat valproic acid dose after initiation of ASA Reinforce medication adherence Will discuss increasing metformin dose to 1000 mg BID Alexandria Rydz, PharmD Candidate 2017