CASE #1 (Diabetes)

Hi, my name is student Dr. ____ How would you like to be referred to today?

1. History (18 points) – Glucose reading, medication compliance, ROS, Exercise

Intolerance
 HPI
 Labs (Review)
 A1C
 Microalbumin/Cr
 Lipid
 BP
 Sugars POCT >200 / Hgba1c > 6.5 / FPG > 126 / 2 Hr GTT > 200
 PMHx
 Social Hx
 Smoking
 Alcohol
 Rx
 Drugs
 Surgical Hx
 FHx
 PHQ2!!!!!!!
 Little interest or pleasure
 Feeling down, depressed, hopeless

 ROS
 Weight Loss/Gain
 Fatigue
 Chills
 Fever
 Night sweats
 Appetite
 Other ROS (SUNS – Child Porn (show SKIN & LEGS))
 SOB
 Urination
 Neuropathy
 Sexual function
 CP
 Skin changes (Wounds, ulcers)
 LE Edema
 Calf/Leg pain
 Preventative Care (HOWL if your Dentist Vaccinates your FEET)
 HTN
 Can start on ACEI or ARB if not <140
 Ophtho
 Yearly
 Weight Loss
 Labs
 A1c
 Lipid
 Microalbumin
 CMP
 Dentist
 Vaccine
 Pneumococcal
 Daily foot checks
 If neuropathic
 Pregnancy
 Referral to Podiatry + Foot Care
 Referral to Ophthalmology – yearly screening
 If DM 1 or 2 between ages of 40-75 – need to do Statins as well
 Atorvastatin –20 mg
 Offer support
 Dietician, fitness trainer, counselor, friend / case manager
 Get a home glucose monitor
 Physical Exam (6 points)
 Heart
 Lungs
 Foot
 Inspection
 Vibration
 Tuning fork @ big toe
 Continue proximal if cant feel
 Vascular
 Monofilament

 Info Sharing (3 points)

 Education
 What is diabetes - Insulin is a hormone that your body makes to control your
blood sugar, and you’re body isn’t making as much as it needs to.
 Compliance of medications
 Health maintenance
 Exercise
 150min/ wk
 Diet
 Low sugar, low fat, low carb

 Pap smear / Vaccines

 Post-encounter note (20 points) – separate medical conditions in each line,
decide if each is controlled or note, add what the plan is to each, recommend
follow up visit + labs
 Follow up in 3 months see how you’re doing
Example A+P from class
- DM II: uncontrolled , A1C target < 6.5
- Dc Avandia
- Increase Amaryl to 8 mg daily
- Continue metformin
- DM education
- Ophthalmology referral
- Podiatry referral
- Educated about DM , risks and benefits and control and exercise discussed with
target of 30 minutes - 5 X week.
- Depression screen using PHQ2 done and neg.
- HTN: uncontrolled , Target < 130/80
- Increase Lisinopril to 10 mg daily
- Wt loss and low salt and exercise.
 CASE 2 (MSK)
 HPI
 PMHx
 Prior injury
 Workup
 Previous treatments
 FHx
 Social Hx
 Alcohol

Physical exam
 Active ROM (supine) - 1 knee at a time to chest (full flexion and back to full
extension)
 Passive ROM - 1 knee at a time flex and extend knee for patient
 ACL
 Anterior Drawer (foot flat on bed, pull)
 Lachman’s (Hold at 20-30 degrees, pull)
 PCL
 Posterior drawer
 Push downwards on tibial tuberosities
 MCL
 Stress MCL @ 0 degrees & 30 degrees of knee flexion
 Outward force with hand
 LCL
 Stress LCL @ 0 degrees & 30 degrees of knee flexion
 Meniscal Injury
 THESSALY test most sensitive
 Pateint stands
 STRAIGHT LEG
 Rotate side to side
 Then bend leg to 30 degrees
 Rotate side to side
 Mcmurrays
 One hand on foot
 One hand on knee
 Twist in “C” shape to both sides
 Patellofemoral Syndrome
 Push down onto patella
 Move patella side to side
A/P (TRT PLease)
 Testing:
 MRI
 X ray
 ONLY if meets ottawa knee or ottawa ankle rules
 Referral
 Therapy
 Pain
 Limitations:
