Mrs. Tiffen’s Case Study

QUESTION

Mrs. Tiffen is 63 years old. She has had diabetes for about 10 years. She is here for her six-month diabetes recheck. She is currently prescribed metformin ER 500 mg (4 tabs at dinner), sitagliptin 100 mg each morning, and Glimepiride 4 mg each morning. Despite all of these medications, your spot in-office A1C demonstrates an A1C of 8.2. She also brings in her glucose log and her average fasting blood sugars are about 170 and her two-hour post meal sugars are about 250. Her in office spot urine demonstrates albumin of <30. Her current TC is 194, her LDL is 90 and her HDL is 54.

Her VS are 126/80, and P 78 and regular. Her weight is 162 lb and height is 5’5″.

Mrs. Tiffen is also taking rosuvastatin 5 mg for hyperlipidemia and losartan 100 mg for her blood pressure.

1. What components of Mrs. Tiffen’s physical examination should be performed today?
2. Are there any other questions you would ask Mrs. Tiffen?
3. How often should Mrs. Tiffen have an eye examination?
4. What is the target goal for Mrs. Tiffen’s fasting blood sugar and A1C?
5. What changes would you make to Mrs. Tiffen’s diabetes medication plan today based on the above information?
6. What is the target goal for Mrs. Tiffen’s cholesterol?
7. Would you change Mrs. Tiffen’s cholesterol medication? If so, to what and what dose?
8. Would you do anything about Mrs. Tiffen’s blood pressure medication today?
9. If you made changes to Mrs. Tiffen’s diabetes medication, when would you recheck her?
10. What immunizations do you need to ensure that Mrs. Tiffen has had?

ANSWER

Components of Mrs. Tiffen’s physical examination that should be performed today include measuring her height, weight, and blood pressure. Additionally, it is important to assess her overall general appearance, skin condition, and examine her extremities for any signs of peripheral neuropathy or vascular disease. An examination of her cardiovascular system, including auscultation of the heart and palpation of peripheral pulses, should be conducted. An examination of her eyes, specifically looking for signs of diabetic retinopathy, is crucial. Furthermore, a neurological examination to evaluate her reflexes, sensory perception, and motor function should be performed to assess for any complications related to diabetes.

In addition to the physical examination, it would be beneficial to ask Mrs. Tiffen a few questions to gather more information. Some potential questions to ask could include

Are you experiencing any symptoms such as excessive thirst, frequent urination, or unexplained weight loss?
How often and how much physical activity do you engage in?
Can you describe your current dietary habits and any challenges you face in managing your diet?
Have there been any recent changes in your stress levels or emotional well-being?
Are you taking any over-the-counter medications or supplements that have not been mentioned?

Mrs. Tiffen should have an eye examination at least once a year. Since she has had diabetes for 10 years, she may be at an increased risk of developing diabetic retinopathy. Regular eye exams are essential for early detection and management of any eye-related complications.

The target goal for Mrs. Tiffen’s fasting blood sugar should be around 80-130 mg/dL, while her A1C should ideally be less than 7%. Given her current values of 170 mg/dL for fasting blood sugar and an A1C of 8.2%, adjustments to her diabetes medication plan are warranted to achieve better glycemic control.

Based on the provided information, the following changes can be made to Mrs. Tiffen’s diabetes medication plan

Increase the dose of metformin ER to achieve a total daily dose of 2000 mg (4 tablets at dinner).
Consider adding a long-acting insulin regimen, such as basal insulin, to help improve glycemic control.

The target goal for Mrs. Tiffen’s cholesterol, specifically LDL cholesterol, should be based on her overall cardiovascular risk. Generally, a target LDL level of less than 100 mg/dL is recommended for patients at moderate risk.

Considering Mrs. Tiffen’s LDL level of 90 mg/dL, her cholesterol is currently within the target range. Therefore, no changes to her cholesterol medication, rosuvastatin 5 mg, are necessary at this time.

Regarding Mrs. Tiffen’s blood pressure medication, losartan 100 mg, no immediate changes appear to be required as her blood pressure is well-controlled with a reading of 126/80 mmHg. However, ongoing monitoring of blood pressure and potential adjustments to the medication regimen may be necessary based on subsequent assessments.

If changes are made to Mrs. Tiffen’s diabetes medication plan, it would be appropriate to recheck her in approximately three months to evaluate the effectiveness of the adjustments and assess her glycemic control.

In terms of immunizations, it is important to ensure that Mrs. Tiffen has received the following vaccinations

Influenza (yearly)
Pneumococcal vaccine (one or two doses, depending on previous vaccination history)
Hepatitis B (if not previously vaccinated)
Tetanus, diphtheria, and pertussis (booster every 10 years)

Regularly reviewing and updating her immunization status will help protect Mrs. Tiffen from vaccine-preventable illnesses and maintain her overall health and well-being.