Case Scenario 54-year-old male: Lab results and chronic disease management follow-up

Case Scenario

• 54-year-old male: Lab results and chronic disease management follow-up.
• Diabetes background (HPI): Checks a.m. fasting blood sugars about 3 x week. Results 140s-150s with one high reading of 200. Reports one episode of feeling “shaky.” Takes cholesterol med at bedtime nightly along with his blood pressure medicine.
• Social history: Works as high school teacher, coaches football, and lives with his wife and two dogs. Denies tobacco use or history, denies recreational drugs, but drinks beer. Involved in his church, working with community outreach ministry.

Medical:

• DM diagnosed 10 years ago
• HTN diagnosed 5 years ago
• Hyperlipidemia diagnosed 7 years ago
• OA bil knees diagnosed 12 years ago
• Tension headaches diagnosed 2 years ago

Medications:

• Metformin ER 500 mg 2 PO BID for diabetes
• Januvia 100 mg QD for diabetes
• Lisinopril 20 mg QD for HTN
• Atorvastatin 20 mg q HS for cholesterol
• Ibuprofen 200 mg 2-4 prn HA for knee pain

Vital Signs:

• VS: BP 142/88, P 97, RR 18, Temp 98.8 (temporal) F, Ht 5’11”, Wt 240, BMI 33. 5

Labs (done 2 weeks before visit):

• Total chol 225, trigs 210, non-HDL 193, HDL 32, LDL 170, VLDL 40
• BMP glucose 142, rest in range
• A1c 7.2
• CBC normal
• TSH 2.42

Questions

1. What else do you need to know about this patient’s chronic issues?
2. Are the chronic conditions managed appropriately according to current guidelines based on the information you have?
3. What is your plan for managing this patient, including education, health maintenance, medication, labs, referrals, and follow-up?