Family Medicine · Year 3 · from Family Medicine
Case 1: The Complex Patient with Multiple Comorbidities
Patient Demographics
- Age: 63 years old
- Sex: Male
- Occupation: Retired electrician
Chief Complaint
"I'm here for my diabetes check-up. I've also been feeling more tired lately."
History of Present Illness
Mr. William Thompson is a 63-year-old man with type 2 diabetes, hypertension, hyperlipidemia, and COPD presenting for routine chronic disease follow-up. His last HbA1c was 8.4% three months ago. He reports increased fatigue over the past month and admits he has been "slipping" on his diet, particularly over the holidays. He occasionally forgets his evening medications.
He uses his COPD inhaler "when I need it" but is unsure which one is for daily use versus rescue. He denies chest pain, orthopnea, or leg swelling.
Current Medications
- Metformin 1000 mg twice daily
- Glipizide 10 mg twice daily
- Lisinopril 20 mg daily
- Amlodipine 5 mg daily
- Atorvastatin 40 mg daily
- Tiotropium inhaler daily
- Albuterol inhaler PRN
- Aspirin 81 mg daily
Past Medical History
- Type 2 diabetes (diagnosed 12 years ago)
- Hypertension (15 years)
- Hyperlipidemia
- COPD (former smoker, 30 pack-years, quit 5 years ago)
- Osteoarthritis, bilateral knees
Social History
- Former smoker (quit 5 years ago)
- Occasional alcohol (1-2 beers on weekends)
- Lives with wife
- Sedentary lifestyle due to knee pain
Physical Examination
- Vital Signs: BP 142/88, HR 78, RR 16, SpO2 95% on RA, BMI 32
- General: Overweight, appears fatigued
- HEENT: Normal
- Cardiovascular: Regular rate and rhythm, no murmurs, no JVD
- Lungs: Decreased breath sounds bilaterally, no wheezes
- Abdomen: Obese, soft, non-tender
- Extremities: No edema, distal pulses intact
- Feet: Intact sensation to monofilament, no ulcers, nails thickened
Clinical Image
Image: Self-monitoring of blood glucose using a glucometer and test strip. Regular glucose monitoring is an essential component of diabetes self-management.
Image Source: Wikimedia Commons Attribution: David-i98, CC BY-SA 3.0 URL: https://commons.wikimedia.org/wiki/File:Blood_Glucose_Testing.JPG
Laboratory Results
- HbA1c: 8.6% (up from 8.4% three months ago)
- Fasting glucose: 178 mg/dL
- Creatinine: 1.4 mg/dL (eGFR 52)
- Potassium: 4.8 mEq/L
- LDL cholesterol: 78 mg/dL
- Urine albumin/creatinine ratio: 180 mg/g (elevated)
Chronic Disease Assessment
Diabetes:
- HbA1c 8.6% - Above individualized target of <8.0% (considering age, comorbidities, hypoglycemia risk)
- Evidence of diabetic nephropathy (elevated UACR, reduced eGFR)
- No retinopathy on last eye exam (1 year ago)
- Feet exam: protective sensation intact
Hypertension:
- BP 142/88 - Above target of <130/80 for patient with diabetes and CKD
COPD:
- Stable symptoms
- Uncertain about inhaler use - needs education
CKD Stage 3b:
- eGFR 52, albuminuria
- Medication review needed for renal dosing
Assessment and Problem List
- Type 2 diabetes, uncontrolled with diabetic nephropathy
- Hypertension, uncontrolled
- CKD Stage 3b (likely diabetic nephropathy)
- COPD - stable, needs inhaler education
- Medication non-adherence - forgetting evening doses
- Hyperlipidemia - at goal on current therapy
Management Plan - Applying the Chronic Care Model
1. Self-Management Support:
- Discussed barriers to adherence - identifies evening busyness as issue
- Action plan: Set phone alarm for 7 PM as medication reminder
- Provided written medication schedule
- Reinforce diet goals: carbohydrate counting, portion control
- Confidence assessment: Patient rates 7/10 for taking meds with alarm
2. Decision Support - Evidence-Based Treatment Adjustments:
Diabetes:
- Continue metformin 1000 mg twice daily (renal-safe at eGFR 52)
- Discontinue glipizide (hypoglycemia risk, not kidney protective)
- ADD empagliflozin 10 mg daily (SGLT2 inhibitor)
- Benefits: Cardiovascular protection, renal protection, weight neutral
- Counsel on genital yeast infection risk, volume depletion
- Target HbA1c: <8.0% given comorbidities
Hypertension:
- Already on ACE inhibitor (appropriate for diabetic nephropathy)
- Increase lisinopril 20 mg to 40 mg daily
- Continue amlodipine 5 mg
- Target BP: <130/80
3. Delivery System Design:
- Scheduled diabetes educator visit for carbohydrate counting review
- Scheduled respiratory therapist visit for inhaler technique
- Care coordinator to call in 2 weeks to check on medication adherence
4. Clinical Information Systems:
- Added to diabetes registry for population health management
- Set reminder for repeat HbA1c in 3 months
- Set reminder for annual eye exam
- Set reminder for recheck of creatinine/potassium in 1-2 weeks (after ACE inhibitor increase)
SMART Goal Setting with Patient
Patient goal: "I want to have more energy and feel better"
Collaborative SMART goals:
- "I will take my medications every evening by setting a 7 PM phone alarm, 7 days per week, for the next 3 months" - Confidence: 8/10
- "I will check my blood sugar before breakfast 3 days per week and record the numbers in my log" - Confidence: 7/10
- "I will walk for 15 minutes after dinner, 3 days per week" - Confidence: 6/10 (modified from initial 30 minutes due to knee pain)
Follow-Up Plan
- Phone check-in by care coordinator: 2 weeks
- Labs (Cr, K+): 2 weeks (after lisinopril increase)
- Office visit: 6 weeks
- HbA1c: 3 months
- Annual comprehensive diabetes visit: Review all complications, referrals
Teaching Points
- Chronic Care Model: This case demonstrates all six elements - self-management support, decision support, delivery system design, clinical information systems, community resources, and health system organization.
- SMART goals: Patient-centered goals should be Specific, Measurable, Achievable, Relevant, and Time-bound. Adjusting the walking goal from 30 to 15 minutes maintained achievability.
- Evidence-based medication changes: Adding an SGLT2 inhibitor provides cardio-renal protection beyond glucose lowering. Discontinuing the sulfonylurea reduces hypoglycemia risk.
- Care coordination: Team-based care with diabetes educators, care coordinators, and respiratory therapists extends the physician's impact.