In: Nursing
LM is a 52 year old white female who was diagnosed in 2012 with
Type 2 diabetes. She was treated with a diet and exercise program
for a year before needing to start metformin. Her last hemoglobin
A1C was 7.7% in 2013. She relocated to Fargo in 2016 and has not
established with a primary care provider since she moved. She has
used Quick Minute clinics to get refill prescriptions for metformin
while traveling in bigger cities.
She presents to the clinic where you are a clinical pharmacist and
says she knows she needs to see someone to help manage her diabetes
but she is an executive and is often booked with meetings and busy
travel schedules. She has been feeling fatigued but not sure if it
is because of her diabetes or her busy travel schedule. She is
adherent to metformin, has good insurance coverage, and is not
opposed to another oral or injectable medication.
Per provider and nurse visits today:
Medications:
Metformin 2000mg XR po qd
Multivitamin po daily
Ibuprofen 200-400mg by mouth every 6 hours as needed for pain
Weight 170 pounds Ht. 5 ft 8 inches
Blood Pressure Blood glucose
124/80mmHg 304 mg/dl
Heart Rate 68 Hemoglobin A1c 9.9%
Serum Creatinine
Urine : Microalbumin (<30mg/g), Ketones (-), Glucose +4 AST/ALT
Normal
TC 154, LDL 78, HDL 38, Triglyceride 160
Dilated Eye Exam Normal Foot Exam Normal Neuro Exam Normal
Lifestyle:
Exercises Occasionally (Golfs once weekly during summer, plays
tennis once weekly throughout year) Diet: No special diet, watches
carbohydrate intake
She does not smoke and drinks 3-4 glasses of wine or beers per
week.
The provider has requested you, as the clinical pharmacist, to
manage this patient’s diabetes. Please write a SOAP note reflecting
what you feel is the important subjective and objective information
and laying out your assessment and plan. (Don’t forget to include
monitoring and follow up!)
In addition to the SOAP note, please provide three relevant
counseling points to educate the patient on regarding any new
medication(s) you choose to start them on.