Diabetic Educator Note 7/26/24

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Patient Name: Fred Jones  

Age: 48 years  

Date of Visit: July 26, 2024

 

Diagnosis: Type II Diabetes Mellitus, Hypertension, Obesity, Hyperlipidemia

 

Current Medications:

- Atorvastatin 20 mg daily

- Aspirin 81 mg daily   

- Ponatinib 45 mg daily

- Metformin 1000 mg BID

- Glipizide 5 mg daily

- Lisinopril 20 mg daily

 

History of Present Illness:

Fred Jones is a 48-year-old male diagnosed with type II diabetes 6 years ago. He also has a history of hypertension, obesity, and high cholesterol. His diabetes is currently managed with a combination of Metformin and Glipizide. He monitors his blood glucose levels regularly but reports occasional deviations due to dietary and exercise inconsistencies.

 

Recent Laboratory Results:

- HbA1c: 7.7% (measured last month)

- Fasting Blood Glucose: 155 mg/dL

- LDL Cholesterol: 63 mg/dL

-HDL Cholesterol: 38

- Blood Pressure: 130/80 mmHg

 

Diet and Exercise:

Fred attempts to follow a balanced diet but admits to occasional high-carbohydrate meals and snacks. He struggles with portion control and finds it challenging to avoid processed foods. His physical activity includes brisk walking for 20 minutes, three times a week, which is below the recommended level.

 

Education Provided:

- Reviewed the importance of consistent blood glucose monitoring and keeping a log of readings.

- Discussed the need to reduce simple sugars and high-carbohydrate foods, emphasizing portion control and the inclusion of more vegetables, lean proteins, and whole grains.

- Highlighted the benefits of increasing physical activity to at least 150 minutes of moderate exercise per week. Recommended more frequent use of his stationary bike to help achieve this goal.

- Explained the potential side effects of current medications and the importance of adherence to the prescribed regimen.

- Provided information on recognizing and managing hypoglycemia.

- Discussed the long-term benefits of maintaining a healthy weight, blood pressure, and cholesterol levels.

 

Patient Goals:

- Aim to reduce HbA1c level to below 7.0% within the next three months.

- Improve diet by incorporating more vegetables, lean proteins, and whole grains while reducing intake of high-carbohydrate and sugary foods.

- Increase physical activity to at least 30 minutes of moderate exercise, five times a week.

- Work towards gradual weight loss to help manage diabetes, hypertension, and cholesterol levels.

- Attend a follow-up appointment in 3 months to reassess blood glucose control and medication effectiveness.

 

Plan:

- Continue current medications as prescribed.

- Follow up with primary care physician in 3 months for routine check-up and laboratory tests.

- Schedule a nutrition counseling session for further dietary guidance.

- Encourage participation in a diabetes support group for additional support and motivation.

- Consider referral to a physical therapist or personal trainer to help develop a more structured and sustainable exercise routine.

 

Patient Understanding and Compliance:

Fred understands the importance of diet and exercise in managing his diabetes, hypertension, and cholesterol but acknowledges the need for improvement. He is committed to making necessary lifestyle changes to achieve his health goals.

 

Next Appointment: November 8, 2024

 

Diabetic Educator: Olive Greens, RN