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  • Diabetes: Subjective and Objective

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    TopGrade Achïęvers Rêsęárch
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    R.C., a 57-year-old man with type 2 diabetes and obesity, presented for routine follow-up. His blood pressure was 168/100 mmHg. Laboratory tests showed an A1C of 9.5%, LDL of 134 mg/dl, albumin excretion of 250 mg/day, and creatinine clearance of 105.6 ml/min. The patient's complications include hypertension, dyslipidemia, and nephropathy manifesting as proteinuria. His treatment goals are to tightly control blood sugar to reduce A1C below 7% without hypoglycemia and prevent cardiovascular disease.

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    R.C., a 57-year-old man with type 2 diabetes and obesity, presented for routine follow-up. His blood pressure was 168/100 mmHg. Laboratory tests showed an A1C of 9.5%, LDL of 134 mg/dl, albumin excretion of 250 mg/day, and creatinine clearance of 105.6 ml/min. The patient's complications include hypertension, dyslipidemia, and nephropathy manifesting as proteinuria. His treatment goals are to tightly control blood sugar to reduce A1C below 7% without hypoglycemia and prevent cardiovascular disease.

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    12 views2 pages

    Diabetes: Subjective and Objective

    Uploaded by

    TopGrade Achïęvers Rêsęárch
    R.C., a 57-year-old man with type 2 diabetes and obesity, presented for routine follow-up. His blood pressure was 168/100 mmHg. Laboratory tests showed an A1C of 9.5%, LDL of 134 mg/dl, albumin excretion of 250 mg/day, and creatinine clearance of 105.6 ml/min. The patient's complications include hypertension, dyslipidemia, and nephropathy manifesting as proteinuria. His treatment goals are to tightly control blood sugar to reduce A1C below 7% without hypoglycemia and prevent cardiovascular disease.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    Joy A.

    Aw
    oniyl Ambulatory care
    Rotation Preceptor:Dr.Daryl
    Norwood

    Diabetes Case

    Presentation
    R.C is a 57-year old man w ith Type 2 diabetes first diagnosed two yea rs ago. Other medical
    problems include obesity a nd hypothyroidism.He has a history of heavy a lcohol use but quit
    drinking a lcohol 2 years ago.He presents now for routine follow-up and is noted to have a blood
    pressure of 168/100 mmHg.He is a.symptomatic.
    Physicalexam reveals a height of 5'8" (172cm),weight of 243 pounds ( Okg),blood pressure of 160/100
    mmHg, and a regular pulse of 84 beats per minute.There is no retinopathy or thyromega ly.There is no
    clinica l evidence of congestive hea rt failure or peripheralva,scular disea.se.
    Laboratory eva lua tion revea ls trace protein on urina.lysis,a low-density lipoprotein (LDL) cholesterol
    level of 134
    mg/d ,a high-density lipoprotein (HDL) cholesterollevel of 35mg/d ,a triglyceride level of 460mg/dl a nd
    a tota l cholesterol level of 240 mg/d ,blood urea nitrogen ·of 14mg/d ,serum creatinine of .2mg/d
    ,random serum glucose of 192 mg/d ,a glycosyla ted hemoglobin le>.1e lof 9.5%,normal
    electrolytes,and nor ma lthyroid· stimulating hormone levels.A 24-hour urine collection revea ls a
    urinary albumin excretion rate of 250mg daily.

    Subjective and Objective Findings


    • Patient is asymptomat ic
    • PMH of alcoholabuse (quit 2 years ago),obesity,and hypothyroidism
    • Pertinent vital signs a nd Lab
    Values oBlood
    Pressure:168/100
    o Regular pulse:84 bpm
    o Serum Creat inine: .2mg/dl
    • Crea tinine Cleara nce calculated at 105.Gml/min or 65.7m /min (Based on
    ABW and IBW,respectively)
    o BMI was ca lculated to be 36.94kg/m2
    • Possible relation to hypothyroidism
    o A lbumin excretion of 250mg/day (normal levels between SO and
    80mg/24hrs) o LDL:134 mg/dl
    • Diagnostic Tests:HgA C of 9.5o/o

    Assessment
    • Related Complications
    o High blood
    pressure o
    Oyslipidemia
    o Nephropa thy ma nifested a.s proteinuria
    • R isk Factors
    o Obesity (BMIgreatertha n 25)
    o A C >/= 5.7%
    o Blood pressure >/= 140/90;Hyperte nsion
    • Therapeutic Goals
    o Tight glycemic control:Reduce A C t o less than 7% without causing
    hypoglycemia o Prevention of cardiova.scula r disease
    Diabetes Case SOAP !1

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