March 6, 2013

You Have Diabetes – What to Do - Part 3

Part 3 of 4 Parts

When we arrived, he started filling out paperwork and was called for the blood draw. Then he completed the papers and we talked until he was called for his appointment. I went with him and when the doctor saw me, he commented that I needed to stop bringing him patients. He said he was only joking and that I had brought him two great patients and he would continue taking them as long has he had room. When he started looking at the paperwork and saw the sheet from the week prior, he said that was good to have and that I was right in getting him in. He then said that in looking at the test results from today, that the oral glucose tolerance test would not be necessary as he clearly had type 2 diabetes and needed to start medications immediately. They started covering the results of A.J.'s tests and then I was handed a sheet at the request of the A.J.

The A1c had stayed the same and the plasma glucose was 201 even with fasting. The doctor asked if we had talked medications and A.J. admitted that we had. The doctor asked if he had objections to insulin and he answered that he was favorable to that. The doctor asked which oral medications he would accept and he opened up his laptop and showed him the ones he did not think would be good for him. The doctor said good, but the others were not good as well at this time because of his kidney functions and then he covered what the tests were telling him and why he would not suggest metformin and the others. The doctor said he would suggest starting on insulin and then when the diabetes was well managed, his kidney functions had improved, maybe he could consider one of the sulfonylureas or if the new medication was approved by the FDA, maybe that one.

A.J. asked if that could be done and was told yes. They talked about hypoglycemia and the symptoms and A.J. said he was aware of the symptoms and that he would be careful. Next, the doctor made sure A.J. had the office phone number in his records and told him to call when he had questions regarding insulin adjustments. They talked about goals and settled on one. Then he moved on to setting the original dosage and then how to adjust it after two weeks to bring him closer to the goals of nearer normal and which insulin to start adjusting and by how many units for how many days. If it became necessary to adjust the Novolog by 10 units total, then he needed next to adjust the Lantus by 2 units up to 6 units total, and then talk to him before making more adjustments. A.J. asked if patients were allowed to do this and the doctor repeated that for the first two weeks, no changes and then two units change every three days, if needed to a max of 10 units for the Novolog. If he reached that limit and he was still not at the goals, then adjust the Lantus by two units every three days until he reached his goals in blood glucose levels, but only up to six units. For more changes, A.J. was to call him. The doctor then emphasized that if the original doses were too high, he was to call immediately. He also told A.J. to pick up some glucose tablets when he picked up his prescriptions.

The doctor next brought out three different meters and asked which he might prefer. A.J. looked at me and I pulled mine out and pointed to the one like it. I asked if his insurance would cover this and the doctor said that it would cover any of the three he had shown us. He chose the Nano and I said good choice. Next, we talked about requesting extra testing supplies. The doctor said they had a standard request to cover the first four to six months and this would be sent via email as soon as the appointment was over and the pharmacy should hear within approximately 48 hours, or more over the weekend. He stated two business days was normal and he had not been turned down yet. The doctor then recorded the pharmacy he would be using.

Since I had my meter out, the doctor asked if I would show him where to test. I said I would, but first I wanted him to know it was wise to ignore the TV ads about not testing on his fingers. The doctor said thanks and went on to explain why we needed to test on our fingers or palms and not the alternate sites. I said that on insulin, we needed the “now” reading and not the delayed results from alternate sites. I told A.J. to open his kit and we would check the lancing device. First I showed him how to uncover where the lancet would go and to take a lancet out of the case and insert it and arm it. When that was complete, I asked to see his hands and looked at his fingers. I suggested that he start on the third setting and had him dial this in the dial. Then I showed him on my fingers where the area was best to start testing. I did it, showed him the blood, and carefully inserted the test strip into the blood. I told him to take out a test strip and insert it in the meter with the correct side up as he started to put it in wrong side up. Then I had him set the meter on the table and prick his finger. He had more blood than I expected and commented that it did not hurt at all. I had him pick up the meter with his other hand and carefully move it into the blood and watch the blood wick into the strip. He commented that was not difficult. I suggested that for now, he record the reading and time and then dial the depth back to two for the next time he tested. Concluded in tomorrow's blog.

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