Diabetic Case study: Jack a 47-year-old white male presents to your office for a follow-up visit.

He was seen 2 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98. He vaguely remembered told in the past that his B/P was “borderline”. Labs were also done last visit and you are going over the results with him today. He brings his B/P diary in and it is showing elevated pressures from 144/94 to 176/96

Today: V/S: Right arm: 172/98; Left arm: 170/96; P 76; resp 16; 70 inches tall weighs 210

DOB: 3-12-7

Labs from last week: CBC normal; CMP normal; A1C 7.4; TSH normal; Lipids: Total cholesterol is 250; LDL is 190; HDL 35; Trigs 170

He feels fine, has no complaints.

Case study:

Should be no more than 1 pages. This does not count title page, reference page or prescriptions.

Title, reference page and citations must be APA format. The rest of the case study does not.

You are expected to order necessary medications and write prescriptions. See the rubric.

You do not need to write rx for OTC medications but need Drug Class and MOA on all medications.

All of the treatment plan needs rationale and reference.

The title page, citations and references need to be APA.

The plan needs to be added at the bottom of the case study after the subjective and objective data

The plan should be written like a SOAP note with a list or bullets Only difference is you will add rationale, drug class and MOA.

Measures to Prevent Falls in Elderly Demented Patients

Example

You do not need to rewrite diagnosis here. They are numbered in the assessment. Just put the treatment.

Pharmacologic all diagnoses

medication 1 and dosage and instructions

Drug class and MOA

Rationale 1-2 sentences with citation

medication 2 same as above

There are no specific number of references but you do need evidence based guidelines for treatment plan. You must use the AACE/ACE guidelines and the ASCVD risk calculator for rationale. You can download the app on the phone or go to the website. You can use Epocrates, UptoDate, Lexicomp. You may use text or epocrates or another source for MOA and Drug class.

PMH

Broken arm at age 12.

Hernia repair 10 years ago

No eye examination for about 1.5 years

Meds: zero

Allergies: NKDA

Fam hx:

Father died of stroke at age 69; diabetic

Mother alive at age 69 with HTN, DM

2 sisters ages 45 and 43; the older sister has DM

Social hx: Married. Son age 22 and daughter 20 both healthy. Sedentary job (Accountant) does not exercise. Smokes 1ppd for 10 years. Has “a couple of beers every weekend”

ROS:

Unremarkable except for above

Xavier Daniels Shadow Health Assessment

Physical examination

No thyromegaly or lymphadenopathy

Fundoscopic exam is within normal limits

Cardiac exam: S1 and S2 are normal and no murmurs are auscultated

Lung and abdominal examinations are normal.​

EKG shows nonspecific T wave changes; no acute ischemic changes

Assessment

Stage 2 HTN

Obesity

DM type 2

Hyperlipidemia

Tobacco abuse

Plan 1 page max

Should plug data in cardiac risk into ASCVD risk calculator: https://tools.acc.org/ASCVD-Risk-Estimator-Plus/ use today’s b/p; he now has past hx ofdiabetes; go to view advice

See AACE/ACE Guidelines and ADA guidelines posted in the readings in Module 6. Also read the attached article

What is the treatment plan for Jack today? Must provide rationale. This is your medical decision making. Think of how you would answer the patient if they asked why you were recommending this. Must use evidence-based reference with citations on all questions

• Pharmacologic? This should include any OTC medications

o List drug, dosage, frequency and reason for rx

o List rationale and cite

o List drug class and MOA and cite

o Then send rx for prescription meds only

Please provide rationale and reference.

Use a title page and Reference Page 

See attached Rubric for grading

This can be no more than 1 pages excluding case study, title page, reference page and rx

Can single or double space