bullet points

Answers should be in BULLET POINTS

Background:

You continue to follow KBO for the next 2 years. His A1c continues to improve but is still above goal (8.4% and most recently 7.9%, despite patient claims of improved diet and walking more outside. Patient denies any further changes in weight in the last 6 months. You address starting basal insulin, and patient states “I am not ready for that, isn’t there some other sugar pill you can give me that will help my weight and sugar?” You decide today to re-address diet. 

Vitals: 

· Blood pressure: 112/82 mmHg

· Pulse: 84 bpm

· Height: 5’10”

· Weight: 382 pounds 

PMH: 

· Morbid obesity

· Hypothyroidism 

· Depression 

· Mild intermittent asthma 

· Obstructive sleep apnea, with BiPAP

· Chronic venous insufficiency 

Current Medications: 

· Aspirin 81mg daily

· Cinnamon tablets

· Levothyroxine 150mcg daily

· Albuterol 1-2 puffs every 4-6h prn SOB

· Centrum One-a-day daily

· Diphendyramine 25mg daily prn

· Omega 3 Fish oil 3 caps daily

· Metformin XR 1g BID

· Trulicity 4.5mg weekly

Allergies: 

· NKDA

Fasting Labs:

	Today’s Value	Normal Range
Creatinine Level (CREAT)	1.0	0.5 - 1.0 mg/DL
Hemoglobin A1c	7.9	4.2 – 5.7%
eGFR	53	>59 mL/min

Diet

Breakfast (largest meal of the day): burrito wrap with chicken and cheese and dessert (coffee cake or pie (strawberry rhubarb pie and lemon meringue)), and orange juice (16 oz) Lunch: often does not eat lunch, denies any snacks Dinner (4-6pm): stir fry (one bowl), steak; or chicken (eats skin, leg and wing); does not like salads, or homemade chicken wings with Italian bread, or deep fried perch or soup Snacks:  Peanuts or pistachios (1-2 cup); occasionally popcorn; fruit (clementine 6 and banana); beets (once a week). Chips once a week.

Follow Up Visit

Background:

KBO returns to clinic for 3 month follow-up and states he is frustrated. Patient reports that he is drinking 8 glasses of water per day, as was advised at this last visit, and is going the bathroom all the time. At first, he thought it was the amount of water he was drinking, but then urination became associated with painful burning. He was seen at an urgent care 3 times in the last 2 months, on the initial visit he was diagnosed with a UTI, and on the last visits, he was diagnosis with yeast infections.  Moreover, he reports he has felt extremely fatigued and constipated over the last 2 months. Patient admits to doing research on WebMD and then recalled your warning about UTIs/yeast infections and empagliflozin. Upon learning of his A1c he states, he wants off the empagliflozin and is willing to start insulin. His home fasting readings averaged 233. He denies any episodes of hypoglycemia. 

Fasting Labs:

	Today’s Value	Normal Range
Creatinine Level (CREAT)	1.0	0.5 - 1.0 mg/DL
Hemoglobin A1c	9.9%	4.2 – 5.7%
TSH	6.42	0.30 - 5.50 mIU/L
Free T4	0.62	0.73-1.79 ng/DL

Answers should be in BULLET POINTS

1. What insulin and dose would you initiate?

2. How often will you instruct patient test his glucose and why?

3. You note that thyroid labs are not stable. What is your recommendation/explanation for the altered labs? Of note, patient denies any missed doses of medications.