PMH: Patient was diagnosed with Type II Diabetes 4 years ago. Emphasize the importance of monitoring BG per diabetes plan. …
Problem 1
Hyperglycemia
|Possible Treatments
pharmacologic vs nonpharmacologic/Dose |Assessment Justification and
Goals
|Treatment Regimen Plan and Patient Education
|Monitoring parameters
drugs and disease states | |
|Subjective Information|Current Regimen |Brief HPI/Assessment |Treatment Regimen|Therapeutic |
| |Metformin 500mg PO BID |Patient has uncontrolled |Plan |Efficacy |
|CC: Ms Julia Wilson, | |Type 2 DM, as demonstrated|Increase to |Monitoring |
|a 54 yo obese woman |Pharmacologic |by acute hyperglycemia and|Metformin 1000mg |Parameters |
|with Type II Diabetes |Increase Metformin to |recently elevated A1C of |BID |FBG daily |
|complains that her BG |1000mg PO BID |82 |Initiate |with a goal |
|is out of control |Metformin is the | |Glyburide 25mg |of 100mg/dL |
|with 200-280mg/dL post|consensus first line |In accordance with AACE |po QD
|PPBG TID |
|prandial for the past |treatment for |Guidelines for patients |Patient to begin|with a goal |
|two weeks Patient |Hyperglycemia to lower |currently treated, the |walking 30 |of |
|demonstrates noticable|FBG Her current dose |patient should begin |minutes 3x/week |90-140mg/dL |
|fatigue and reports |is still below the |combination oral therapy |Patient to begin|Pharmacist |
|polydipsia, polyurea |maximum effective dose |Metformin should be |DASH Diet |review of |
|and noctureia 3 times |of 2000mg/day The |increased to the maximum |Patient to |SBGM in two |
|per night PE |drawback to a Metformin |effective dose of 1000mg |monitor FBG Post |weeks |
|negative for signs of |increase in the |PO BID Glyburide should |Prandial BG QID |A1C in three|
|stroke, visual |increased risk of Lactic|be started at 25mg po QD,|testing |months with a|
|changes Patient |Acidosis This risk is |with the goal of titrating|Followup visit |goal of 70|
|denies hypoglycemic |low with Metformin vs |to the maximum effective |in two weeks to |
|
|episodes Patient has|Fenformin Patient |dose of 20mg po daily |check SBGM | |
|DOE after walking 2 |would require continued |Hemodynamically unstable | |Safety |
|blocks |monitoring for renal |heart failure increases |Education and |Monitoring |
|PMH: Patient was |dysfunction |the risk of Lactic |counseling issues|Parameters |
|diagnosed with Type II| |Acidosis with metformin |with the patient |Chem 7 to |
|Diabetes 4 years ago |Adding a sulfonylurea |Patient is currently | |monitor for |
|Patient also has |such as Glyburide would |hemodynamically stable |Inform patient |Lactic |
|ACC/AHA Stage C, NYHA |also provide a reduction|with no signs of edema or |of potential for |Acidosis and |
|Stage II HF, Stage I |in FBG and A1C Add on |kideny dysfunction |GI upset with |Hypoglycemia |
|HTN, and |sulfonylurea therapy |Nonetheless, the patient |Metformin |monthly or if|
|Hyperlipidemia |significantly increases |should be monitored for |Patient should |patient |
|FMH:
Patients mother|the risk of |signs of Lactic Acidosis |self monitor |reports |
|and 2 brothers have |hypoglycemia The |The addition of Glyburide |weight and report|symptoms of |
|diabetes Mother died|weight gain associated |also increases the risk of|any changes in |either |
|of breast cancer one |with sulfonylureas may |hypoglycemia, so the |weight to the |Sodium, |
|year ago Her father |also be a concern |patient should monitor her|clinic |potassium |
|died of a MI at 53yo | |blood glucose regularly |Inform patient |SCr, BUN, |
|SH: Patients use of |The increased risk of |and counseled on sign of |of risk of Lactic|Glucose |
|nicotine and alcohol |edema with |hypoglycemia Combination|Acidosis due to |should all be|
|were unavailable |thiazolindinediones |products of Metformin and |increased |WNL |
|Patient has a poor |makes them a poor choice|Glyburide are available if|Metformin |Patient |
|diet and rarely |for add-on therapy |the pill burden is |doseDyspnea, |weight should|
|exercises, which she
| |troubling to the patient |Myalgia, Malaise,|be monitored |
|blames on her shift |Beginning basal insulin |The patients BG should be|Altered Metal |as a |
|work |therapy is a good choice|closely monitored while |Status, |precaution |
| |if intensive therapy is |titrating Metformin and |Palpitations |against |
|Objective Information |required or three agent |Glyburide |Inform patient |hemodynamic |
| |oral therapy has failed | |on increased risk|instability |
|- Allergy information |AACE Guidelines |The patient could also |of Hypoglycemia |Changes in |
|unavailable |Patient acceptance and |increase her insulin |due to Glyburide |weight of |
|BP 142/92,144/88, |compliance are issues |sensitivity by adding |Altered Mental |over 3 lbs |
|146/90 HR 70 |with initiating insulin |regular exercise The |Status, sweating,|are a warning|
|PE negative for |therapy Initial |patient should also begin |palpitations, |sign of |
|symptoms of stroke, |therapy would
involve |following a |sudden hunger, |hypervolemia|
|CAD, arrhythmia, |QHS dosing of NPH or |diabetes-friendly diet, |headache | |
|edema, and respiratory|glargine insulin, |such as the DASH diet |Inform the |FBG and PPBG|
|problems |titrating to FBG | |patient to |monitoring |
|Labs from 10/5/07 |100mg/dL |Her current therapy of |contact the |for |
|unremarkable except | |metoprolol succinate 100mg|clinic at the |Hypoglycemia |
|for Lipids, A1C 82, |Nonpharmacologic |QD may have some effects |first signs of |76mg/dL |
|and Blood Glucose |Begin DASH diet to lower|on her blood glucose, but |Lactic Acidosis | |
|234mg/dL |post-prandial blood |should be continued due to|or Hypoglycemia |Drug-Drug |
|TG 167mg/dL, |glucose by controlling |the benefits in patients |Provide the |Interactions |
|Cholesterol 178mg/dL, |carbohydrate |with HF |patient with an | |
|HDL 40gm/dL, LDL |consumption |
|exercise logbook |Metformin-Gly|
|94mg/dL | |Goals |Provide the |buride |
| |Initiate exercise |Per ADA Standards of |patient with the |combination |
|Current Medications: |program, progressing to |Medical Care |DASH diet |has an |
|Lisinopril 5mg PO QD |moderate exercise for |Eliminate hyperglycemia |handbook and |increased |
|Metoprolol Succinate |30-60 minutes 3-5 days |symptoms |recipe websites |risk of |
|100mg po QD |per week Exercise has |Maintain FBG of | |Hypoglycemia|
|Furosemide 40mg po QD |been demonstrated to |90-130mg/dL | | |
|Simvastatin 40mg po QD|increased insulin |Reduce Post-Prandial BG | | |
| |sensitivity, |to 180mg/dL | | |
|Metformin 500mg BID | |Reduce A1C 70 | | |
| | |Reduce DM morbidity
and | | |
| | |mortality | | |
|Problem 2 |Possible Treatments |Assessment Justification|Treatment Regimen|Monitoring |
|State Problem Here |pharmacologic vs |and Goals |Plan and |parameters |
| |nonpharmacologic/Dose | |Patient Education|drugs and |
| | | | |disease |
| | | | |states |
|Subjective Information|Current Regimen |Brief HPI/Assessment |Treatment Regimen|Therapeutic |
| |Lisinopril 5mg PO QD |Patient has uncontrolled |Plan |Monitoring |
|CC: Ms Julia Wilson, |Metoprolol Succinate |Stage I hypertension JNC |Increase to |Parameters |
|a 54 yo obese woman |100mg po QD |recommends patient with |Lisinopril 10mg |Patient |
|with blood pressure |Furosemide 40mg po QD |diabetes maintain a BP of |PO daily
|monitoring of|
|exceeding 140/90 on | |130/85mmHg |Increase to |BP |
|three consecutive |Pharmacologic | |Metoprolol |130/85mmHg |
|visits Patient has |Increase Lisinopril to |The patients existing |Succinate 200mg |Clinic BP |
|DOE after walking 2 |target dose of 10mg |therapy of Lisinopril and |PO daily |monitoring |
|blocks |daily ACEI have been |Metoprolol Succinate can |Initiate DASH |130/85mmHg |
|PMH: Patient was |demonstrated to reduce |be increased to |Diet |in two weeks |
|diagnosed with Type II|morbidity and mortality |synergistically reduce |Patient to begin|and at all |
|Diabetes 4 years ago |in HF patients, reduce |long term risk of HF |walking 30 |subsequent |
|Patient also has |blood pressure, and |morbidity and mortality |minutes 3x/week |visits |
|ACC/AHA Stage C, NYHA |increase exercise |and reduce her blood |Daily patient BP| |
|Stage II HF, Stage I |tolerance Side effects|pressure Long term, both|and HR monitoring|Safety
|
|HTN, and |of hyperkalemia and |Lisinopril and Metoprolol | logging |Monitoring |
|Hyperlipidemia |hypotension increase |Succinate should be |Follow up with |Parameters |
|FMH: Patients mother|with increasing dose and|titrated to maximum |patient in 2 |Patient |
|and 2 brothers have |should be monitored |effective dose Both |weeks to check |monitoring of|
|diabetes Mother died| |Lisinopril 5mg daily and |blood pressure |HR Monitor |
|of breast cancer one |Increase Metoprolol |Metoprolol Succinate 100mg| |for |
|year ago Her father |succinate to target dose|daily are below target |Education and |Bradycarida |
|died of a MI at 53yo |of 200mg daily The |doses Doubling the daily|counseling issues|HR60BPM |
|SH: Patients use of |MERIT trial used 200mg |dose of each will bring |with the patient |Clinic BP |
|nicotine and alcohol |QD and demonstrated a |them to the low end of |Inform patient |monitoring |
|were unavailable |34 reduction in all |target doses Increasing |of hyperglycemia |130/85mmHg |
|Patient has a
poor |mortality and 38 |the Lisinopril dose may |masking risk |in two weeks |
|diet and rarely |reduction in CV |have the added benefit of |sweating will be|and at all |
|exercises, which she |Mortality |reducing the patients |the only |subsequent |
|blames on her night |Cardioselective Beta |DOE The risk of masking |remaining sx |visits |
|shift work |Blockers have both |hypoglycemia is of |Emphasize the |FBG and PPBG|
| |cardioprotective effects|moderate concern with the |importance of |monitoring |
|Objective Information |and reduce blood |concurrent addition of |monitoring BG per|for |
| |pressure Relevant side|glyburide see |diabetes plan |Hypoglycemia |
|- Allergy information |effects are risks of |Hyperglycemia SOAP The |Inform the |76mg/dL |
|unavailable |bradycardia and masking |patient should be |patient of the | |
|BP 142/92,144/88, |of hypoglycemia |counseled on this risk |minor risks of |Drug-drug |
|146/90 HR 70 |
|Risks of bradycardia HR |hypotension and |Interactions |
|PE negative for |Discontinue Metoprolol |50 and hypotension are |bradycardia |Lisinopril-Me|
|symptoms of stroke, |and initiate Carvediol |low Additional agents or|Instruct the |tformin |
|CAD, arrhythmia, |Carvediol has the |substitutions are not |patient on proper|combination |
|edema, and respiratory|theoretical advantage of|indicated until these |BP and HR |has a |
|problems |being both an alpha and |agents are optimized |monitoring |moderate risk|
|Labs from 10/5/07 |beta antagonist The | |technique |of |
|unremarkable except |COMET trial demonstrated|Patient should begin the |Provide the |hypoglycemia|
|for Lipids, A1C 82, |a modest reduction in CV|DASH diet and start a |patient with an | |
|and Blood Glucose |for Carvediol over |program of moderate |exercise logbook | |
|234mg/dL |Metoprolol Tartrate IR|exercise 30-60 minutes per|Provide the | |
|TG 167mg/dL, |50mg BID Carvediol is |day 3-5
days per week |patient with the | |
|Cholesterol 178mg/dL, |a good choice if |Both diet improvements and|DASH diet | |
|HDL 40gm/dL, LDL |Metoprolol Succinate |moderate, regular exercise|handbook and | |
|94mg/dL |therapy is unsuccessful|reduces blood pressure |recipe websites | |
| | |Self blood pressure and | | |
|Current Medications: | |heart rate monitoring | | |
|Lisinopril 5mg PO QD |Diuretics are not |should be initiated | | |
|Metoprolol Succinate |indicated because | | | |
|100mg po QD |patient is managing |Goals | | |
|Furosemide 40mg po QD |fluid levels with |Reduce BP to 130/88mmHg | | |
|Simvastatin 40mg po QD|furosemide |in accordance with JNC 7 | | |
| | |Hypertension
Guidelines | | |
|Metformin 500mg BID |Digitalis Glycoside is |Improve CV morbidity and | | |
| |only warranted in |mortality | | |
| |patients with repeated |Reduce symptoms of HF | | |
| |hospitilizations and | | | |
| |poor symptom control | | | |
| | | | | |
| |Nonpharmacologic | | | |
| |The DASH diet may help | | | |
| |reduce blood pressure by| | | |
| |reducing dietary sodium | | | |
| |intake |
| | |
| | | | | |
| |Initiate exercise | | | |
| |program, progressing to | | | |
| |moderate exercise for | | | |
| |30-60 minutes 3-5 days | | | |
| |per week Exercise has | | | |
| |been demonstrated to | | | |
| |reduce systolic and | | | |
| |diastolic blood | | | |
| |pressure | | | |
Source:pacdaa.org
