see below

You are seeing a 64-year-old Hispanic male for his diabetes management. He reports that his morning

capillary blood sugar readings are ranging in the 150 to 190 range.

Last month his Hgb A1C was 7.4

He is on Metformin 1000mg twice a day and Glipizide 5mg daily.

He walks a couple miles three to five times a week.

A dietary review reveals that his daily total carbohydrate intake is in the range of 75 to 100 grams.

Last eye exam did not reveal any problems. He wears reading glasses when needed.

He does report some intermittent burning sensation in his feet.

Ht 6’2”, Wt 200 lbs, BP 118/72, P 72, R 17

Heart regular rhythm, without murmur or gallop

Lungs clear

Monifilament testing does not reveal any decreased sensation in the feet

Subjective (S): The patient is a 64-year-old Hispanic male. He has come in for a scheduled office visit for

his diabetes medication management. The patient takes medications daily, but blood glucose levels in

the mornings are in the range of 150-190. The patient leads an active lifestyle and walks a couple of

miles 3 to 5 days per week. The patient reports that he maintains his carbohydrate intake between 75 to

100 grams per day. The patient takes 1000 mg of Metformin twice daily and 5 mg of Glipizide once daily.

The patient states this his last eye exam was routine, and he wears reading glasses when needed.

Patient reports some intermittent burning sensations in his feet.

(O): Hgb A1C 7.4 a month ago. Ht. 6’2”. Wt. 200 pounds. BP 118/72. Pulse 72. RR 17. Lungs clear.

Heart rhythm regular, no murmur or gallop noted. Monifilament testing does not reveal any decreased

sensations in his feet.

(A): Based on the patients’ morning blood sugars, his diabetes is not well managed due to his elevated

A1C and blood sugar levels. Based on the patients’ symptoms of burning sensations that he has diabetic

neuropathy.

(P): Therapeutics: Based on the patient’s lab results, his current medication regimen is not regulating his

blood glucose levels. The lowest dose of Metformin is 500 mg once or twice daily and the maximum

dose is 2550 mg (Arcangelo et al., 2017). The evening dose of Metformin will be increased to 1500 mg.

Patient will continue to self-monitor blood glucose in the morning. Patient will maintain a food diary for

each meal until the follow-up appointment. Hgb A1C will be rechecked in 3 months. Although the Hgb

A1C goal for most patients is generally less than 7% per ADA guidelines, a more stringent goal of 6.5%

may be established for some patients if there is no significant hypoglycemia or adverse effects (Woo &

Robinson, 2016). Neuropathic pain conditions do not react to analgesic medications since peripheral and

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central triggers cause it. (Arcangelo et al., 2017). Gabapentin or pregabalin can be useful in controlling

the discomfort from neuropathy. (Arcangelo et al., 2017). Patient education will focus on understanding

the pathophysiology of diabetes and prevention of complications, and the role of lifestyle modification.

Consultation: Patient will be referred to a diabetes self-management education (DSME) program.

Follow-up with patient in 2 weeks to review blood glucose and food diaries. Hgb A1C recheck in 3

months. If the hgb A1C is still elevated, then practitioner will start patient on long-acting or

intermediate-acting insulin. Initial dose of LAI or IAI is administered in a single dose at bedtime or in the

morning; the typical starting does is 6 to 10 units or 0.1 to 0.2 units/kg of body weight/d (Woo &

Robinson, 2016).

References

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced

practice: A practical approach (4th ed.). Wolters Kluwer.

Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for advanced practice nurse prescribers

(4th ed.). F. A. Davis.

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