Phlebotomy Essentials
6th Edition
ISBN: 9781451194524
Author: Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher: JONES+BARTLETT PUBLISHERS, INC.
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What differential diagnoses are you considering?
What abnormals are observed from the diagnostic tests, and what are your interpretations?
What evidence-based treatment plan are you considering?
It is important to note that the only problems the patients in the case studies have been identified. This means if it is not stated you can assume it is normal and you should describe what you would expect normal to be as applicable in your post. Each portion of the case study should be written as you focus soap note
Jim is a 52-year-old insured construction shift worker diagnosed 3 years ago with T2DM. He is married with 3 teenage boys, stopped smoking 5 years ago, and is a social drinker. His father, now deceased, also had T2DM. After starting diabetes treatment with immediate-release metformin and experiencing intolerance, his current medication is as follows:
Metformin XR (2 750-mg tablets once daily)
Lisinopril (10 mg) for hypertension
Simvastatin (10 mg) for lipids
His physical exam revealed the following:
Height: 5 ft 10 in; BMI: 29.2 kg/m2; BP: 135/83 mm Hg
Laboratory Values
FPG: 135 mg/dL; A1C: 7.4%; Serum creatinine: 0.9 mg/dL; Total cholesterol: 225 mg/dL; LDL 115 mg/dL; HDL 40 mg/dL
When told his antidiabetic therapy must be intensified, Jim emphasized that he does not think he is ready for injectable therapy.
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