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Case Description: Doris
The case is of a 65-year-old woman with diabetes, hypertension and depression. She comes in today because she is worried about her diabetes because a friend started dialysis. The past three years she has noticed a burning, tingling pain in her feet that keeps her up at night, as well as swelling in her ankles, especially during the summer. The past year she has experienced a vague chest tightness and shortness of breath when she walks the 60 feet to her mailbox from her trailer home. She doesn’t check her blood sugar at home because the strips are too expensive, but at the clinic she is usually between 10 and 20. Her exercise includes walking to her mailbox, but that is the most she can manage because of the shortness of breath and chest tightness. She sleeps nine hours a night, but wakes 2-3 times a night to void.
Medications:
Metformin 1000mg PO BID
NPH insulin 30 units SQ BID
Sertraline 50mg PO daily
Valsartan 80 mg PO daily

She admits that doesn’t take her Metformin because it gives her diarrhea and she sometimes forgets one of her insulin doses. She takes Evening Primrose oil supplements.
Social:
She was divorced 20 years ago and lives alone with her cat. She talks to her neighbors “once in a great while,” but says she is “not a busy body,” so she mostly keeps to herself. Her three adult children live out of province and are struggling themselves, so she tries not to bother them. She is retired from retail work, uninsured, and living now on a low fixed income with only $100/month disposable income. She used to enjoy singing in the choir, but has had a hard time with bus fare to church for the past few years so stopped going. She does enjoy watching daytime TV and creating still life pencil drawings.

PMHx: DM type 2, HTN, MDD (Major Depressive Disorder)
Surg Hx: none
Gyn Hx: 3 NSVD (normal spontaneous vaginal delivery), no complications
Allergies: none
Immunizations – Td at age 15, annual flu shot
Review of Systems: neg save the above.

Labs:
Hgb 12.8
TSH 3.0
Microalbuminuria 90mg/24hr
Cr 106 mmol/L
Total Cholesterol – 6.1 (elevated from last check 12 months ago)
LDL – 3.6 (elevated from last check 12 months ago)
HDL – 0.92 (decreased from last check 12 months ago)
Trig – 2.3 (elevated from last check 12 months ago)
Fasting Blood Glucose – 7.2 mmol/L
HbA1c – 12.2%

Vitals: Temperature 37.0°C, Respiration Rate 18bpm, Heart Rate 80bpm, Blood Pressure 150/90 mmHg, BMI 32
Physical Exam:
Gen: obese, quiet female, in no acute distress
HEENT: normal
Lungs: Chest clear throughout, normal breath sounds
Heart: HR regular, PMI 5ICS MCL, no murmurs, S1S2 normal, no S3,S4.
Abdomen: soft, obese, nontender, no masses, no rebound/guarding/rigidity, no CVA Tenderness
Extremities: trace pitting edema B to ankles, 2+ pulses bilaterally, no lesions on feet or legs, nails thickened. Joints mobile and comfortable.
Psych: reticent, soft-spoken, depressed affect, fluent speech, no suicidal ideation

Diagnoses today

Diabetes Type 2 – uncontrolled
Exercise intolerance – r/o angina
Hypertension – uncontrolled prevent cardiovascular disease
Hyperlipidemia- uncontrolled prevent CVD
Microalbuminuria prevent ckd and repair renal damage
Depression – stable, controlled maintain mood and level of functioning
Immunizations – not up to date prevent serious disease
Poor medication adherence, financial issues, social isolation
General Information (10%)
1. State the indication for use and mechanism of action of the client’s current medications. Include the trade and generic name for each drug.

Initial Management Plan (60%)
1. Identify the overall treatment objective, and the targets for all conditions
2. What drug therapy is available for Type II Diabetes?
3. List the classes of drug therapy available for the client’s chronic conditions / goals
4. What drugs will you prescribe / change? Explain why or why not.
5. Are there any specific drug contraindications for Doris?
6. Would you consult a physician or specialist to modify current therapy? Any drugs that you would suggest discontinuing? Dosage change? Why or why not?

Client Education (10%)
1. Briefly summarize the key points for drug therapy
2. Indicate what non-pharmacology strategies (lifestyle modifications etc) you would recommend to your client today.
3. What other health professionals might you recommend she see for a consultation (assuming there is no cost for the consultation)?
4. What vaccinations would you recommend?

Follow Up Management (10%)
1. Identify time frame and parameters for monitoring progress toward goals.
2. What specifically would you assess to evaluate drug therapy?
3. List 2 adverse effects that are indications to modify or change current drug therapy.

Scholarly Writing (10%)
• APA 6th edition format, references and citations
• Organized, coherent, logical, correct grammar and spelling
• Academic, reputable sources used
• To be a maximum of 3000 words, excluding title page, references, and appendices. Include a word count at the end of the paper following the conclusion. You must stay within the maximum allotted word count

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