Case Studies in T2DM A Comprehensive Management Approach

Transcription

1 Case Studies in T2DM A Comprehensive Management Approach John E. Anderson, MD The Frist Clinic Nashville, TN 43 yo Latina woman with 5 yrs T2DM. Originally diagnosed with PCOS and IGT by GYN at 32 yo. Begun on Metformin XR titrated to 2000 mg daily by GYN and subsequently T2DM. Completed comprehensive diabetes self management education at diagnosis, with A1C decreasing from 7.5 to 6.7%. Has had 2 outpatient walk in clinic visits for acute illnesses in the past year and GYN followup, but no visits to her primary care physician in 2 years. A1C at GYN visit 8.5% and referral back for diabetes care. Comorbidities: PCOS Hypertension Dyslipidemia Obesity Social History: Psychology professor at liberal arts college Lives with long term boyfriend No children, family nearby town Family History: both parents alive, mother with T2DM brother: recent hospitalization with angina, hx pre DM 1

2 Medications: Metformin XR Simvastatin Lisinopril/HCTZ 2000 mg/dl 20 mg daily 20 mg daily Physical Examination: Wt: 186 lb Ht: 63 BMI: 32.9 Normal Exam Laboratory Evaluation (within 30 days) gluc: 161 (fasting) A1C: 8.5% BP: 148/82 mmhg lipids: chol 199 HDL C 46 ms/dl LDL C 121 mg/dl egfr: > 90 She presents concerned about her overall health and wants to discuss ways to improve her health. States her brother s recent admission was a wake up call. Using the Comprehensive Assessment Tool, let s interview Alpina 2

3 Goals: CVD/CKD: A1C / blood glucose target and monitoring? BP goal New members of the care team? DSME? CV Assessment? CKD? Therapeutic Treatment Plan: Lifestyle Management? Pharmacologic Therapy? Referrals? Monitoring? Follow up? 60 yo White man with 8 year history of T2DM. A1C 7.6% at diagnosis prescribed lifestyle management with A1C achieved < 7%. Over the next 6 years A1Cs have ranged between 7.7% to 8.4% as medications have been added. Completed DSME after initial diagnosis. States to adherence with his medical regimen but is getting confused and light headed several times over the past month and 3 times last week. Monitors glucoses sporadically and occasional episodes of hypoglycemia (<70 mg/dl) noted. He treats the episodes with sugary drinks or candy. Comorbidities: Hypertension Obesity CKD PCI 2 years prior Hospitalized one week prior for CHF Social History: Retail clerk for an auto parts store Divorced father of two (adult children), lives alone Family History: father: deceased age 74 yo, T2DM, CVD, MI mother: living aged 82 yo, T2DM, HTN brother: living aged 58 yo, HTN sister: living aged 56 yo, T2DM, HTN 3

4 Medications: Metformin XR Sitagliptin Insulin glargine u 100 Atorvastatin Losartan/HCTZ ASA 2000 mg daily 100 mg daily 65 units daily 40 mg daily 100/25 mg daily 81 mg daily Physical Examination: Wt: 263 lbs Ht: 70 BMI: 37.7 BP: 144/82 EXTR: 1+ pedal edema bilaterally Laboratory Evaluation: gluc: 114 mg/dl (fasting) A1C: 8.3% lipids (fasting): chol 199 mg/dl HDL C 38 egfr: 57 ml/mm/1.73 m 2 LDL C 116 mg/dl He presents for follow up after hospitalization Using the Comprehensive Assessment Tool, let s interview Pete 4

5 Goals: CVD/CKD: A1C / blood glucose target and monitoring? BP goal New members of the care team? DSME? CV Assessment? CKD? Therapeutic Treatment Plan: Lifestyle Management? Pharmacologic Therapy? Referrals? Monitoring? Follow up? 77 yo black man with a 17 year hx of T2DM. Has progressed through multiple oral agents and is now on basal insulin but with poor glycemic control. He still drives but occasionally misses his follow up visits since he lives 30 miles from the office. Comorbidities: Advancing Parkinson s Disease Hypertension Dyslipidemia Obesity Major Depression ASCVD with hx CABG 10 years prior OA knees Social History: Widower in the past year, lives alone Retired machinist 3 adult children 2 daughters, 1 son Family History: both parents deceased brother: age 83 yo in a SNF 5

6 Medications: Metformin Empagliflozin Pioglitazone Sitagliptin Insulin glargine u 100 Metoprolol Lisinopril Spironolactone Rosuvastatin Levodopa/Carbidopa Ropinirole Wellbutrin XL Sertraline Trazodone ASA 1000 mg BID 25 mg BID 15 mg daily 100 mg daily 55 units daily 50 mg BID 40 mg daily 25 mg daily 20 mg daily 25/100 mg TID 2 mg QHS 300 mg daily 100 mg daily 50 mg QHS 81 mg daily Physical Examination: Wt: 223 lbs Ht: 69 BMI: BP: 132/76 Neuro: pill rolling tremor upper extremities shuffling gait Laboratory Evaluation: gluc (fasting): 187 A1C: 9.4% lipids: chol 187 mg/dl HDL C 34 LDL C 62 mg/dl TRIG: 370 mg/d egfr: 67 ml/mm/1.73 m 2 He presents today for a 3 month follow up of his T2DM. 6

7 Using the Comprehensive Assessment Tool, let s interview Pete Goals: CVD/CKD: A1C / blood glucose target and monitoring? BP goal New members of the care team? DSME? CV Assessment? CKD? Therapeutic Treatment Plan: Lifestyle Management? Pharmacologic Therapy? Referrals? Monitoring? Follow up? 7