Diabetes Case Study Essay
Student- Vu Le
SOAPE NOTE (Diabetes Case 2)
Subjective:
1. Chief Complaint: CT is a 77 year old African American woman who comes into the clinic for her diabetes.
2. History of Present Illness: CT is coming to clinic today to seek help in controlling her diabetes.
Objective:
1. Past Medical History:
• Diabetes Mellitus Type 2 for the past 40 years
• Hypertension for the past 45 years
• Chronic Kidney Disease for the past ten years with neuropathy
• Myocardial Infarction in the year 2010
2. Family History: N/A (Not Available)
3. Social History: Patient said she had never smoked and does not drink alcoholic beverages.
4. Allergies/Reactions: N/A (Not Available)
5. Current Medications and Indications:
• Lisinopril 20mg daily
• hydrochlorothiazide …show more content…
What adjustments would you make to the patient’s insulin regimen? The patient’s fasting plasma glucose is very high in all seven reading; therefore, I would increase her basal insulin dose, so increase the insulin glargine from 60 units to maybe around 70 units every time before bedtime. Also, the patient needs to continue taking the bolus insulin with her food.
2. What is the best patient’s A1C goal for this patient? Why? 8% is a good A1C goal for this patient because of the neuropathy and the heart attack in 2010 and life expectancy because of her advanced age.
3. What intervention to the patient’s diabetes management do you recommend? Increasing the long acting insulin to help the patient with her fasting plasma glucose level while still continue using the rapid acting for when she is eating.
4. What lifestyle recommendations would you provide? I would recommend a brisk walking around the neighborhood everyday if possible, if not then at least 3 times a week. Do the nine inch plate meal choice by filling half the plate with non-starch vegetable, add a quarter of high protein meat, and a quarter of whole wheat or grain carbohydrate like brown rice or wheat paste. Also, reduced salt intake as this can lower her blood
SOAPE NOTE (Diabetes Case 2)
Subjective:
1. Chief Complaint: CT is a 77 year old African American woman who comes into the clinic for her diabetes.
2. History of Present Illness: CT is coming to clinic today to seek help in controlling her diabetes.
Objective:
1. Past Medical History:
• Diabetes Mellitus Type 2 for the past 40 years
• Hypertension for the past 45 years
• Chronic Kidney Disease for the past ten years with neuropathy
• Myocardial Infarction in the year 2010
2. Family History: N/A (Not Available)
3. Social History: Patient said she had never smoked and does not drink alcoholic beverages.
4. Allergies/Reactions: N/A (Not Available)
5. Current Medications and Indications:
• Lisinopril 20mg daily
• hydrochlorothiazide …show more content…
What adjustments would you make to the patient’s insulin regimen? The patient’s fasting plasma glucose is very high in all seven reading; therefore, I would increase her basal insulin dose, so increase the insulin glargine from 60 units to maybe around 70 units every time before bedtime. Also, the patient needs to continue taking the bolus insulin with her food.
2. What is the best patient’s A1C goal for this patient? Why? 8% is a good A1C goal for this patient because of the neuropathy and the heart attack in 2010 and life expectancy because of her advanced age.
3. What intervention to the patient’s diabetes management do you recommend? Increasing the long acting insulin to help the patient with her fasting plasma glucose level while still continue using the rapid acting for when she is eating.
4. What lifestyle recommendations would you provide? I would recommend a brisk walking around the neighborhood everyday if possible, if not then at least 3 times a week. Do the nine inch plate meal choice by filling half the plate with non-starch vegetable, add a quarter of high protein meat, and a quarter of whole wheat or grain carbohydrate like brown rice or wheat paste. Also, reduced salt intake as this can lower her blood