Question

A 82-year-old diabetic male reports losing 12 lbs. over the last month.

• Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
• In SOAP format, list:
  • Pertinent positive and negative information
  • Differential and working diagnosis
  • Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.

Answer 1

The questions we should ask a diabetic person could be :

1. How long have you had diabetes?

2. When do you check your glucose? What is your glucose level at those times?

3. Have you ever had hypoglycemia? If yes, then how often, what symptoms do you recognise?

4. What oral medications are you taking for diabetes and in what dose?

5. Questions about insulin,

When/What times ,How much,What kind of insulin ,Insulinin pen or bottle/syringe?

6. Diet: what do you eat for breakfast, lunch, dinner. Do take other food in between? Do you skip meals?

7. Do you have polyuria, or nocturia?

Do you have blurred vision?

Physical examination elements:

1)Striae

2)Thyromegaly

3)fungus between toes

4)Acanthosis nigricans

5)Edema in lower extremities

Further tests, could be to check for Trends/changes in glucose

BUN/ CREATININE levels

Albumin in urine.

SOAP format:

Subjective and Objective Findings :

1) name and age : 84 years

2)Previous medical history: diabetes

3) family history, social history, nutrition history

4)Pertinent vital signs and lab values:

Blood pressure, pulse rate, serum creatinie, blood glucose, albumin excretion, BMI, ldl.

5) cheif complaint : Loss of weight

Symptoms analysis: loss of weight of 12lbs occured in the last month.

6) HEENT ( Head, eyes, ear, nose, throat) examination

Assessment :

Main diagnosis: DIABETES  

Differential diagnosis : hyperthyroidism

treatment plan:

Pharmacological treatment:

Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

Lisinopril 10mg PO Daily

Metformin tab 500 mg one tablet daily

Diagnostics: Complete blood count (CBC)

Lipid profile

Liver function test (because the metformin requires routine monitoring)

Serum creatinine

Potassium because the ACE inhibitors requires monitoring of electrolytes

Urinalysis

Electrocardiogram

Urine to monitor ketone and glucose

Health education

Take the Metformin with foods.

Avoid drinking alcohol: Alcohol has a negative interaction with Metformin and contribute to hyperglycemia

choose diabetes footwear.

Nutrition and diet information

Lifestyle changes

Weight changes must be done to manage better the Diabetes.

Healthy diet :Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated fat.

Reduced intake of dietary sodium: <1,500 mg/d is optimal

Enhanced intake of dietary potassium

Exercises must be done at least 3 times per week like: walking, swimming or running

Measures to release stress and effective coping mechanisms.

Follow up :

Follow up appointment 1 weeks for managing blood sugars