You are seeing a 64-year-old Hispanic male for his diabetes management. He reports that his morning capillary blood sugar readings are ranging in the 150 to 190 range.
Last month his Hgb A1C was 7.4
He is on Metformin 1000mg twice a day and Glipizide 5mg daily.
He walks a couple miles three to five times a week.
A dietary review reveals that his daily total carbohydrate intake is in the range of 75 to 100 grams.
Last eye exam did not reveal any problems. He wears reading glasses when needed.
He does report some intermittent burning sensation in his feet.
Ht 6’2”, Wt 200 lbs, BP 118/72, P 72, R 17
Heart regular rhythm, without murmur or gallop
Lungs clear
Monifilament testing does not reveal any decreased sensation in the feet
Utilize the information provided in the scenario to create your discussion post.
Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).
Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]
Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]
Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making
Support the interventions outlined in your ‘P’ with scholarly resources.
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