While seeing patients with your preceptor, you have the opportunity to meet a 46-year-old woman who presents for her yearly physical examination.

Case #1

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While seeing patients with your preceptor, you have the opportunity to meet a 46-year-old woman who presents for her yearly physical examination. Her medical history is notable for borderline hypertension and moderate obesity. Last year her fasting lipid profile was acceptable. Her mother and brother have diabetes and hypertension. At prior visits, your preceptor has counseled her on a low calorie, low fat diet and recommended her to start an exercise program. With her full time job and four children, she finds it difficult to exercise, and she eats out most of the time. She is 67” tall and weighs 213lbs today, no current medication, takes fish oil supplements when she remembers. She doesn’t smoke, only drinks juice or soda with each meal, 3-4 cups of coffee per day. Today: BP 145/95mm Hg, TC 230 mg/dL, LDL 132 mg/dL, HDL 38 mg/dL, triglycerides 240mg/dL, fasting plasma glucose is 177 mg/dL; HgbA1C is 8.4mg/dL. Her examination is notable for acanthosis nigricans at the neck but otherwise is normal.

1. What are your treatment goals for her?
2. What is your plan for drug therapy? 3. Please give five teaching points for each drug prescribed, use patient centered language.
3. Would you change your plan if her initial HbgA1C was 10.2mg/dL and her fasting blood glucose was 305mg/dL? If so what would be the alternative plan and what is your rationale? Case #2

MT is a 48 year old diabetic woman who presents with thickened, yellow toenails that are painful when she wears dress shoes. She also has some peeling of the skin on the soles of her feet. MT’s blood sugar levels are well controlled and last HbgA1C was 6.6mg/dL and fasting today 114mg/dL.  BP in office 120/84, P78, R 16, T 98.2, htg 66 inches, weight 165 lbs.  Medications are metformin 1000mg bid, Cimetidine 300mg tid, accupril 10mg po qd. Toenail culture comes back positive for fungus

1. List specific goals of treatment for her dermatological conditions?
2. What drug therapy would you prescribe and please explain your rationale.

1. Do you need to consider any monitoring before, during or after your therapy?

1. What are 5 patient centered teaching points for MT.