Case Study Diabetes
Patient A.B. a 69-year-old White male visited his local clinic for a check-up as lately he was feeling lethargic and has gained 22 lbs in the past year. He also has episodes of nocturia. He has being diagnosed with Type 2 diabetes for 5 years. However, he was diagnosed with Borderline diabetes since 1997, but never took it seriously and made no lifestyle changes. He has symptoms of hyperglycemia for the past 2 years. He does not check his glucose daily. He has never had a foot examination.
AB carbohydrate intake daily most times consists of eating at least three slices of bread with each meal and eating pasta meals at least 3 times a week. He likes his wife to cook Italian meals no less than 3-4 times a week. He drinks a glass of red wine with dinner every day. He stopped smoking 10 years ago. He exercises on occasion, maybe once or twice a month.
A.B. takes Atorvastatin 10mg daily. Gluburide 2.5mg daily. However, he reports he stopped taking the Glyburide about 6 months ago as it was making him feel dizzy whenever he took it. He has not notified his PCP about not taking the Glyburide.
Constitutional: Alert and oriented to person, place, time, and situation. He is well groomed. He is 5 feet 2 inches and weighs 178 pounds.
Eyes: Pupils round, reactive to light. EOM is intact. Fundi clear.
Hearing: No deficit noted
Mouth: Mucosa moist. Upper and lower dentures.
Heart: Rate and rhythm regular. No murmur.
Lungs: Clear to auscultation
Neurological assessment: Diminished vibrating sense to the forefoot, absent ankle reflexes. Monofilament felt only above the ankle.
Vascular: No carotid bruits. Femoral, popliteal, and dorsalis pedalis pulses 2+ bilaterally.
His Immunization is updated. He has erectile dysfunction and takes Sildenafil.
Vital signs: BP= 150/87, P= 88, RR= 20, T= 97.8, Oxygen Sat= 98%
Glucose (fasting) = 178mg/dl
Creatinine = 1.0mg/dl
Blood Urea Nitrogen = 18mg/dl
Sodium = 141 mg/dl
Potassium = 4.3 mg/dl
Total Cholesterol = 162 mg/dl
HDL Chol = 43mg/dl
LDL Chol = 84 mg/dl
Triglycerides = 177 mg/dl
AST = 14 IU/L
ALT = 19 IU/L
Alkaline Phosphatase = 56 IU/L
A1C = 8.1%
Please these are the characteristics that the Professor wants the Care Plan to have