Subjective: 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 of 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.
Objective: Ht 6â€™2â€, Wt 200 lbs, BP 118/72, P 72, R 17. Heart regular rhythm, without murmur or gallop. Lungs clear. Monofilament testing does not reveal any decreased sensation in the feet.
Assessment: Based on the patient’s morning blood sugar readings, A1C level, and carbohydrate intake his diabetes is uncontrolled.
Plan: As a type 2 diabetic we would want his A1C to be under 7. His genetic makeup and age can also put him at more risk of having this condition and having trouble controlling it. He is also reporting symptoms related to microvascular complications from his type 2 diabetes.
Therapeutics: Managing type 2 diabetes requires a combination of things such as medication management, diet, and exercise regimen, daily monitoring of blood sugar levels, continued patient education, and routine follow-up appointments to reassess treatment goals and medications (Arcangelo & Peterson, 2021). His metformin can be titrated up but not higher than 2,550 mg/ day and his Glipizide titrated up to no more than 40mg/day to achieve desired results and glycemic control (Arcangelo & Peterson, 2021).
Educational: The patient needs to be educated about checking his glucose levels at mealtimes and lowering his carbohydrate intake. Increasing his exercise can help maintain healthy blood sugar levels which in turn can help prevent complications (Bodman & Varacallo, 2023). He needs to be educated about the complications that can happen when his blood sugar is not controlled. One of these complications is peripheral neuropathy which he is showing signs of with the intermittent burning sensation in his feet. He also needs to be checking his feet regularly to prevent any wounds, especially after any trauma to the foot which is why needs to see a podiatrist (Bodman & Varacallo, 2023). These are vital educational pieces to manage this chronic condition and ensure the patient understands how to care for himself and what to do when he is not feeling well.
Consultation/Collaboration: The patient is going to need to see a registered dietician, diabetic educator, endocrinologist, and podiatrist. He will need a follow-up in 3 months for repeat lab work and medication review.