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Type 2 Diabetes Case Studies

Mary is a 70-year-old female here today with her friend Barbara, after receiving Phytel call regarding follow up of her diabetes and hyperlipidemia.

HPI The patient tells me that she is doing reasonably well, since I have last seen her. She has been to see several specialists, including Dr. Kunz and Dr. Meattey. Dr. Kunz, rheumatology Dr. Meattey for endocrinology. She reports that there was some discussion as to a diagnoses, but she was finally diagnosed with PMR and was placed on steroids. She, however is somewhat frustrated with Dr. Kunz’s office as she feels she is unaware of how she is supposed to taper her prednisone and reportedly has a couple of calls into his office and has not had a return call back. She is not sure how she should proceed regarding that, at this time.

The patient has also been to see Dr. Catcher, a hematologist because of a monoclonal gammopathy. He wants to recheck her in six months.

The patient currently has some cold symptoms. She has had a little bit of a stuffy nose, little bit of a runny nose for the last couple of days. She is not really coughing. Her friend, Barbara, also has similar symptoms. They think they were exposed at the bakery that they own.

The patient does have type 2 diabetes. She tells me her glucose levels are excellent in the morning. They are running, fasting, around the 80s, rarely goes about 100. She is not having any hypoglycemic episodes. She does not check her glucose values outside of just the morning fasting testing. Her most recent hemoglobin A1C was done with her labs and was 6.6% down from 7% back in February. They have made some changes in that they become gluten-free.

With that, she thinks that she has lost some weight. Review of the chart shows that she is down approximately 11 pounds since her last visit in March, some of which sounds purposeful, some however not. She admits to just having a decreased appetite, some early satiety, feeling as though nothing has a good taste to her any more. She is not having true belly pain. There is no constipation or diarrhea. She reports one episode of blood in her stool. She has not had a colonoscopy since 2008. She was recommended for a five year check. She would be willing to see gastroenterology for this.

The patient also admits to a lot of anxiety. She is currently on Lexapro 20 mg daily. She uses Xanax as needed. Typical use is not weekly. She reports that she just feels she is under a lot of stress. She and her friend Barbara own a bakery. They are working on trying to sell that for that so they can retire. She feels compelled to need to go into the bakery to work, but at the same time gets very worn out when she does that. She wants to spend more time there, but feels that it really is not good for her health and it is something that they are constantly trying to work on a good schedule for her. Her friend is quite supportive of her health needs. She is not interested in seeing a counselor. She is not interested in any medication adjustments at this time.

The patient was diagnosed with Parkinson’s disease followed by Dr. Stakes at Massachusetts General Hospital. She has not seen him in several months. She is due to see him this fall. She is feeling that she is doing much better from that standpoint. She feels sturdier on her feet. She has been with a special physical therapist, who deals with Parkinson patients, which she said made a world of difference. She is quite pleased with her current progress.

Medications 81 mg aspirin, Xanax 0.25 mg as needed, metformin 850 mg twice daily, Crestor 5 mg daily, Lexapro 20 mg daily, Sinemet 25/100 mg three times daily, prednisone 8 mg daily, probiotic supplement, a vitamin E supplement.

O Vital Signs Temperature: 98.6. BP: 120/70. HR: 78. R: 14. W: 176.

General A well-developed female seated comfortably in the exam room. She is alert and oriented, sometimes getting very frustrated when thinking of dates and names of doctors, often looking to her friend to help her with that. Occasionally, feeling very frustrated with her friend for her interruption of her answers.

HEENT TMs are without erythema or bulging. Mucous membranes are moist. There is postnasal drainage. No erythema. No exudate.

Neck Supple. No bruits or JVD. No masses or tenderness.

Heart Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops.

Lungs Clear bilaterally with good breath sounds.

Abdomen Soft and nontender. No masses or discomfort.

Extremities There is no lower extremity swelling. She is able to stand from the exam table on her own without assistance from me or her friend.

Neurologic Gait from the office is somewhat slow though otherwise stable.

Labs from September 8th were reviewed. TSH normal at 1.34, A1C lower at 6.6%, urine microalbumin/creatinine ratio was normal at 6, metabolic panel normal with the exception of creatinine at 1.2, though down from June at 1.32, CBC shows a normal white blood cell count at 9.6. Hemoglobin/hematocrit slightly low at 10.6 and 34.1, compared to 11.5 and 35.1 in June, platelets are normal at 380.

A/P Mary Gorst is a 70-year-old female here today for a followup.

Type 2 diabetes. Her A1C is better. I have encouraged her to really try to eat those regular meals, monitor her glucose values and we did discuss the possibility of decreasing or stopping the metformin at this time. She does understand that with the prednisone, that her glucose values would likely increase. It is something she is not willing to do at this point, but would consider for the future, depending on how her stomach is feeling. We will check an A1C in approximately six months.

Hyperlipidemia. She seems to be tolerating the Crestor. She will continue with that for now and I will update labs again with the next blood draw.

Recent diagnoses of polymyalgia rheumatica. I discussed with her that I would be happy to speak with the office manager at Dr. Kunz’s office to see about the messages that she has left. She is considering whether to see a new rheumatologist down in Boston anyway. For now, she will continue with her current dosing of prednisone until I am able to speak with Dr. Kunz’s office staff.

Monoclonal gammopathy of undetermined significance being followed now by Dr. Catcher. I do have his most recent note. I have reviewed that with them here in the office and they will keep their follow up with him in six months.

Anxiety. We did discuss this at length. At this point, she does not want to change her medication. I offered counseling appointment. We discussed psychiatry versus a change in medicine. She declines that for now, but just wants to monitor her symptoms.

Upper respiratory tract symptoms. We did discuss URI care. She did ask for a prescription for an antibiotic “just in case” her symptoms do not improve in the next week or so. I reluctantly agreed to write her for a Z-Pak take as directed for five days #1 with no refills. I reviewed with her the limitations of the antibiotic if we are not dealing with something bacterial and she and her friend are aware of that and will monitor her symptoms closely. They are aware if her symptoms worsen acutely, that she would need to be evaluated and they do voice understanding of that.

Parkinson’s disease. She will continue her follow up with Dr. Stakes. They will continue with the carbidopa, levodopa that she is currently taking. She will continue with her home physical therapy as well.

Weight loss with decreased appetite and early satiety. I think at this point a GI referral is in order, consideration for EGD and colonoscopy will need to be done as well. Should her symptoms worsen acutely, they will let me know. Otherwise, we will schedule that appointment. We also talked about some medication adjustments as she may be having side effects. For now, she like to avoid that. She will see the specialist and then I can make recommendations from there.

I will see her back in about three to four months. She will follow up sooner if questions or concerns arise in the meantime. She does voice understanding of these recommendations. All questions answered.

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