Part A: C.K. is a 54 year old postmenopausal female who presents to your office today for her complete physical exam.

Her past medical history includes: hyperlipidemia, diabetes with retinopathy and nephropathy, hypothyroidism, CAD, and vitamin d deficiency.

Past surgical history includes: left inguinal hernia repair, cardiac stents x 2 as well as CABG x 3 a few years ago.

 Allergies: Metformin: diarrhea

Besides her cardiologist and ophthalmologist, you are the only other provider that she sees on a routine basis.

Medication List:

Gabapentin 300mg, 2 capsules 3 times a day

 Nitrostat 0.4mg tablet sl as directed for angina/chest pain

 Plavix 75mg, 1 tablet once a day

ASA 81mg, 1 tablet once a day

Synthroid 25mcg, 1 tablet once a day

Lantus Solostar Pen 100U/ML, 50 units sc once a day at bedtime

Onglyza 2.5mg, 1 tablet once a day

Metoprolol Succinate ER 50mg, 1 tablet once a day

Atorvastatin 80mg, 1 tablet once a day

Furosemide 20mg, 1 tablet once a day as needed

 Lisinopril 2.5mg, 1 tablet once a day

(1) What ROS questions pertinent to her diagnoses list would be most important at this visit? (Please do not address the entire ROS, just list questions pertinent to her diagnoses).

When speaking to her about diabetes, she tells you that she has been testing his blood sugars and they have been in the mid to low 100 range and that he has been feeling well. She does not have any concerns today.

 Vital Signs: 163lbs, 65”, BMI: 26.96; BP: 118/80, O2Sat: 96%, Pulse: 64, RR: 18, Temp: 97.8

(2) What aspects of his physical exam are MOST important given his diagnoses list and why? Your physical exam is unremarkable on this patient.

You look back in the chart and the patient has not had any lab work from any provider in the past 6 months.

(3) What lab/diagnostic tests would be appropriate to order for this patient at this time, given the patients reason for visit, medication and diagnoses lists?

 (4) Please explain what would be appropriate:

a. Primary Prevention for this patient?

b. Secondary Prevention for this patient?

c. Patient education

d. Referrals for this patient?

Part B.

Two weeks later the patient goes for labs and you are reviewing the lab results in your EMR. You notice the following abnormal labs (if not listed, all other labs ordered were normal):

A1C: 9.1%

Fasting Blood Sugar: 366

BUN: 27, Creat: 1.350, eGFR: 40

Microalbumin/Creat ratio: 329

K: 5.4

H and H: 12.7 & 37.6 (other aspect of CBC normal)

 TSH: 4.700

Vitamin D: 15

You have the patient make an appointment to discuss these abnormalities and discuss changes in medication/other labs/diagnostic tests that you might order:

(5) How would you explain each of the above results to the patient?

(6) What additional tests (labs or diagnostics), if any, would you order now on this patient?

(7) What medication changes, if any, would you make based on the above lab results?

(8) Are there any additional referrals you would now make based on the above lab results? If so, to whom and why?

(9) She tells you that she hates checking her blood sugars because her fingers hurt so much. What options can you offer her so that she will check her blood sugars to better manage her diabetes? How would you verify insurance reimbursement/coverage?

Part C.

If she were a 32 year old female with type II diabetes, with the following meds below who comes into see you for a primary care visit and tells you that she and her husband are planning on starting a family what changes would you make to her plan of care? Please explain.

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