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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