Case Study Diabetes 02/07/2021 Patient A.B. a 69-year-old White mail visited his local clinic for a checkup 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. Glyburide 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 not
ified his PCP about not taking the Glyburide. Physical Examination 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 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. s 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% Laboratory Results: 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%