55-year-old Male With Chronic Disease Management

 Internal Medicine 08: 55-year-old male with chronic disease management 

 

You are working with Dr. Clay in her outpatient diabetes clinic this morning.

Your first patient, Mr. Morales, was seen by Dr. Clay once before, five years ago, but was lost to follow-up after that time.

Based on review of the electronic medical record you are able to collect the following information prior to heading into the room to meet Mr. Morales:

Mr. Morales is a 55-year-old male, diagnosed with type 2 diabetes mellitus eight years ago after experiencing a 20-pound unintentional weight loss, blurry vision, and nocturia.

He was hospitalized six weeks ago with a non-ST elevation myocardial infarction and required three vessel coronary artery bypass grafting. During his admission, he was found to have a reduced ejection fraction of 20%.

He was referred for today’s visit by the cardiologist to focus on optimizing his glycemic control and reducing his risk of the comorbidities associated with poorly controlled type 2 diabetes mellitus.

His last hemoglobin A1c (HbA1c) was 9.5% five years ago, and he had microalbuminuria at that time.

Before you see Mr. Morales, Dr. Clay reviews the chronic management of diabetes mellitus with you.

You enter the exam room and introduce yourself to Mr. Morales.

“What brought you to the office today?”

“I had a heart attack about a month ago and had to have open-heart surgery. The doctors told me that my heart is weak now. My cardiologist told me that I have to get my blood sugar under control so I don’t have another heart attack. I am here to get down to work.”

“Tell me more about that.”

“I didn’t come back to see Dr. Clay because my job at the furniture factory wouldn’t give me time off for clinic appointments, and I couldn’t risk losing my job. I wasn’t checking my blood sugar before my heart attack because the testing strips are so expensive and my supervisor wouldn’t let me off the line to check anyway. Since my surgery, I haven’t gone back to work, and I’ve been checking my sugar before each meal and before bed. The hospital social worker got me two months’ worth of testing strips and lancets before I went home, but I’m going to run out in a couple of weeks. I’m worried that I won’t be able to check anymore.”

He also tells you that while he was in the hospital, they had to use insulin through his vein to keep his blood sugar controlled, and that was very upsetting to him.

You review Mr. Morales’ medications with him:

Medications

• metformin 1000 mg twice daily
• empaglifozin 25 mg daily
• glipizide 5 mg daily
• aspirin 81 mg daily
• clopidogrel 75 mg daily
• long-acting metoprolol 100 mg daily
• furosemide 80 mg twice daily
• lisinopril 20 mg daily
• amlodipine 10 mg daily
• famotidine 20 mg daily
• gabapentin 300 mg twice daily
• potassium chloride 10 mEq twice daily
• atorvastatin 80 mg daily

Mr. Morales says, “The hospital doctors sent me home on an insulin shot – 40 units in my belly every night before I go to bed. I don’t like giving myself the shot, so sometimes I just don’t, but I take all the rest of my medicines like they told me to.”

He takes out the vial of insulin, and you see that it is insulin glargine.

You continue your interview with Mr. Morales and ask him:

“Have you brought your blood sugar log with you today?”

He hands you his blood sugar log proudly. Over the last four weeks, his morning fasting readings have ranged from 130-169 mg/dL, with before-lunch readings of 151-247 mg/dL, before-supper readings of 184-211 mg/dL, and before-bed readings of 158-305 mg/dL. There are no recorded readings under 70 mg/dL (3.9 mmol/L).

“Some days you have many readings over 200 mg/dL. Can you think of anything different going on those days, such as eating larger meals?”

“Oh, those are the days after I didn’t take my insulin shot. The readings are always higher on those days.”

“Have you had any low blood sugars?”

“I feel like I have low blood sugar several times a week, and I eat a Snickers bar because I’m afraid of passing out and going into a coma. I feel like I’m going to die — shaky, sweaty, jittery! I don’t check when I feel this way, I just eat as fast as I can – I can tell when my sugar is low.”

You ask Mr. Morales about diet and physical activity.

“Can you tell me what you typically eat in a day?”

“I usually eat breakfast and lunch at McDonald’s or Denny’s. For breakfast, I usually have a bacon, egg, and cheese biscuit with hash browns and black coffee. For lunch, I have a sandwich, fries, and soda. If I’m really hungry, I get the ‘value’ size of the fries and soda.”

“What drinks and snacks do you typically eat during the day?”

“I drink Coke with lunch, whole milk with supper, and usually have a big bowl of fudge ripple ice cream before I go to bed. If I’m hungry in the afternoon, I’ll grab a pack of cookies from a vending machine.”

“And what do you have for dinner?”

“My wife and I eat supper at home. We share the cooking. Usually, we have fried or stewed meat with gravy, rice, or pasta along with rolls. Sometimes we have vegetables cooked with side meat.”

“Are you able to do any exercise during the week?”

“Except for moving around at work, I didn’t get much exercise before. Since my heart surgery, I feel short of breath just walking to the mailbox at the end of the driveway!”

“Do you have any chest pain or sweating?”

“Not really.”

You now decide to focus your history on screening for complications of diabetes:

“Are you having any trouble with your vision?”

“I haven’t been to the eye doctor in years, but everything is blurry most of the time. Last time I went, the doctor said that my eyes looked good, so I figured that I didn’t need to go back.”

“How about numbness or tingling in your hands or feet?”

“Both my feet are numb most of the time, and they feel like they are on fire when I stand for a long time. Before my heart attack, it was getting really hard to stand on the line for my whole shift. In the hospital, they gave me a nerve medicine, gaba-something, and it helps a lot! They told me to look at the bottom of my feet every day to check for sores or blisters, and I remember to do it once or twice a week. So far, so good.”

 

You leave the room so that Mr. Morales can disrobe for your exam. Dr. Clay asks what you have learned so far.

You present the history to Dr. Clay and tell her that you are particularly concerned about Mr. Morales’ diet. You and Dr. Clay look at the triage sheet and see that Mr. Morales’ height is 176.5 cm (69.5 inches) and his weight is 123 kg (272 lbs). You calculate his BMI: it is 39.6 kg/m2.

*Note that it is no longer recommended to use the term “morbid obesity”

Maintenance of a healthy body weight is essential in the management of patients with diabetes. However, for some patients, attainment of an ideal body weight is too large a goal, especially if they have class III obesity. Studies have shown that a modest weight loss of approximately 5-10% of the current weight can lead to significant improvement in glycemic control, blood pressure control, and lipid parameters.

You review the rest of Mr. Morales’ vital signs:

Vital signs:

• Temperature is 36.3 C (97.9 F)
• Pulse is 74 beats/minute
• Respiratory rate is 12 breaths/minute
• Blood pressure is 152/86 mmHg today (148/92 mmHg at the cardiologist’s office two weeks ago)
• Fingerstick blood glucose is 158 mg/dL (8.8 mmol/L)

You retake his blood pressure manually and read 150/90 mmHg.

You proceed with Mr. Morales’ exam, paying special attention to the fundoscopic exam.

Physical Exam

General: Obese, older male in no apparent distress.

HEENT: Normocephalic, atraumatic. Oropharynx clear and moist. Dentition and dental hygiene good. Pupils equal and reactive to light and accommodation. Extraocular movements intact. No icterus.

Fundoscopic exam: Several microaneurysms bilaterally and hard exudates on the left.

Neck: Supple and thick. No increased JVD. No carotid bruits. Carotid pulses 2+ bilaterally with normal upstroke. No thyromegaly or masses.

Lungs: Clear to auscultation bilaterally. No wheeze, rales, or rhonchi.

Cardiac: PMI diffuse and laterally displaced. Regular rate and rhythm. Normal S1, S2, no S3, no S4, no murmurs.

Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly.

You are glad you will have the opportunity to practice the diabetic foot exam you reviewed last night.

You proceed with Mr. Morales’ exam:

Physical Exam

• Extremities: Full range of motion without clubbing or cyanosis. No peripheral edema.
• Diabetic foot exam: 1+ dorsalis pedis and posterior tibialis pulses bilaterally with decreased sensation to monofilament and vibration to the mid-shin. No ulcers. + diffuse onychomycosis.
• Neurologic: Awake, alert and oriented times four. Cranial nerves II-XII are grossly intact. Muscle strength is 5/5 throughout with normal tone and bulk. Deep tendon reflexes are trace throughout. Gait normal. No tremor.

 

After completing your exam, you tell Mr. Morales that you’ll be back shortly with Dr. Clay, then step out to discuss your exam findings and the next steps for Mr. Morales with Dr. Clay.

You return to speak to Mr. Morales with Dr. Clay who clarifies some parts of the history and performs a physical exam.

Dr. Clay asks Mr. Morales to get redressed and go to the lab to have some blood drawn. She directs him to return to the exam room when he is finished so you can discuss the next steps for his care together.

Dr. Clay teaches you a little bit about oral and injectable medications that are used in the management of patients with type 2 diabetes.

You and Dr. Clay return to the exam room to talk to Mr. Morales about your recommendations for his diabetic care.

Dr. Clay starts, “We’d like you to stop taking the metformin because that medication is not the best or safest in patients who have heart failure like you do.”

“But won’t that make my blood sugars go up with taking fewer medicines everyday? I thought we were going to get my blood sugars lower.”

“You’re right, Mr. Morales. Without that medicine, your readings will likely increase, so we’d like to increase your glipizide to 10 mg daily to help. Taking glipizide with empagliflozin and glargine insulin every day will also help. We’d like to have you call the office in a few days with your readings so we can see how it’s going. We will be working closely in the coming weeks and months to keep your glucose well controlled, and we’d like you to see a diabetes educator and a nutritionist for help with your food choices and portions.”

You explain that you’d also like to improve his blood pressure control, and he agrees to take the increased lisinopril dose.

“The good thing, Mr. Morales, is that getting your glucose and blood pressure under control will help your kidneys function better.”

You remind him to check his blood sugar with his glucose meter when he feels “low” so that he doesn’t eat when he doesn’t need to. You reiterate the proper treatment of blood glucose to achieve a reading of > 70 mg/dL (> 3.9 mmol/L).

You make him an appointment for a dilated eye exam and advise him to check his feet daily.

You are able to give him two more weeks of testing strips and the toll-free number to the patient assistance line for glargine insulin so that he can request samples. You ask him to see the clinic’s social worker for further help with medication and supply assistance and hand him a note for work explaining his need to be allowed off the line to check his blood sugar regularly, as well as his need to be seen in close follow up with Dr. Clay.

As he leaves, Mr. Morales says, “I’ll see you in two weeks, and thank you for taking the time to really talk to me and find out how to help. I feel like I am really going to be able to take care of myself this time.”

It is two weeks later and Mr. Morales has returned to Dr. Clay’s diabetes clinic.

You review the electronic medical record, and the lab results from Mr. Morales’ initial clinic visit reveal:

Lab Values:	Conventional:	SI:
Potassium	4.8 mEq/L	4.8 mmol/L
BUN	29 mg/dL	10.4 mmol/L
Creatinine	1.8 mg/dL	159 μmol/L
Hemoglobin A1c	8.3%
Total cholesterol	213 mg/dL	5.52 mmol/L
Triglycerides	385 mg/dL	4.35 mmol/L
HDL	38 mg/dL	0.98 mmol/L
LDL	117 mg/dL	3.03 mmol/L

 

Spot urine albumin to creatinine ratio: 120 mcg/mg creatinine

You realize that the spot urine albumin to creatinine ratio confirms Mr. Morales’ prior history of increased urinary albumin excretion. Prior to seeing Mr. Morales, you decide to look up some information about diabetic nephropathy.

You are glad that you increased Mr. Morales’ lisinopril dose during the last visit since it will hopefully slow progression of his diabetic nephropathy.

You highlight that his A1c is above goal, but you tell Dr. Clay that it may not be necessary to make adjustments to his diabetic regimen since that was done at the last visit.

 

You and Dr. Clay review Mr. Morales’ vitals. His weight is down two pounds and his blood pressure is 129/72 mmHg.

Mr. Morales greets you, “You are going to love these blood sugars! That ADA website has great information and the social worker has gotten it worked out so that I receive patient assistance for most of my medications and supplies. I’ve learned so much from the nutritionist and diabetes educator. I’ve completely changed the way I eat and I’m taking a walk around the block every evening before supper.

You both review Mr. Morales’ blood sugar log and find that by taking his glargine insulin daily, his fasting readings have come into goal nicely and his prandial readings are within goal >75% of the time.

“Congratulations on all your hard work, Mr. Morales! These readings look wonderful, and your weight and blood pressure are coming down nicely. I don’t think I’ll make any changes to your diabetes regimen today but keep calling every week with your readings so that we can stay on top of your sugar control. You know, if you keep losing weight, you may be able to come off the insulin.”

“Thanks, Dr. Clay. I’ve been working hard, and I sure would like to stop giving myself that shot, so I’m going to keep on losing the weight.”

“That’s great, Mr. Morales!” You review the remainder of Mr. Morales’ labs with him, including his HbA1c, renal function, and the presence of microalbuminuria.

Dr. Clay tells Mr. Morales to return to the office in four weeks for a follow-up visit and reminds him to stop at the lab to check on his potassium and kidney function because of the higher ACE inhibitor dose.

“See you then, Dr. Clay. I’ll be calling with my readings in a week or two.”

 

CASE #2  Internal Medicine 15: 50-year-old male with cough and nasal congestion.

It is September and you are working with Dr. Erin Griffin in her outpatient general medicine clinic. She asks you to see Mr. Fadil Taleb, a 50-year-old male with respiratory symptoms. Dr. Griffin tells you he is relatively new to the practice and has been seen only once in the past for a general physical. In addition, she points out that when he initially called to schedule an appointment, he was directed to get SARS-CoV-2 testing—this was negative.

 

You enter the room, introduce yourself to Mr. Taleb, and begin taking a history.

“What brings you to the office today?”

“I have been sick for the past three or four days. It started with my throat being scratchy and lots of sneezing. Now my nose is all stopped up, and I’m blowing it constantly. I’m also coughing a lot. Initially I was worried I could have COVID, but I’ve been vaccinated, and I got a test a couple days ago—it was negative.”

“Have you had a fever?”

“I felt warm the first day but now I just have the chills occasionally. I am also really tired.”

“Is anyone else you know ill?”

“My kids were sick at the end of last week; we also had them tested for COVID and thankfully they were negative, too. One of them is still coughing but the others seem better. During the school year it seems like one of them picks up something at school almost every other week. I ride the bus to and from work, and there are always people coughing there.”

“Do you smoke?”

“Yeah, doc, I know it’s not good for my health, but I do smoke. Usually it’s about a half pack per day, but since I have been sick, I have been smoking only one or two cigarettes a day.”

 

“Tell me more about your cough. Do you bring anything up?”

“No, it’s a dry cough, but it wakes me up at night several times.”

“Do you feel short of breath?”

“No, not really.”

“Does your chest hurt?”

“No. Can’t say that it does.”

“Have you tried any medicine to help?”

“My face has felt full, so I took some Actifed Cold and Allergy tablets, but they didn’t seem to do much. I’ve also taken some Cold-EEZE, vitamin C, and Waltussin DM, but nothing is helping.”

“Have you had problems like this before?”

“I had this same thing last fall and it lasted a couple of weeks. I hate to bother you doctors with this, but I don’t want to get any worse.”

You review Mr. Taleb’s chart and confirm the following:

Past Medical History:

Hyperlipidemia

Medications:

• None except over-the-counter medications
• OTC Cold and Allergy medication (phenylephrine and chlorpheniramine)
• OTC cold preparation (zinc gluconate)
• Vitamin C
• OTC cough medication (guaifenesin and dextromethorphan)

Allergies:

None

Family History:

• Mother: Alive and well.
• Father: High cholesterol, HTN.
• Three sisters: Alive and well.

Social History:

Married and monogamous. Works as a computer specialist for the help desk at the hospital. Three children ages 12, 15, and 18 years old. Has smoked half a pack per day for the past 25 years. Quit with each of his wife’s pregnancies, then resumed a year or so later. He rarely drinks alcohol and has never used IV drugs.

Review of Systems:

No headache, myalgias, hemoptysis, weight loss, or night sweats.

You proceed with the physical examination and note the following:

Vital signs:

• Temperature is 37.2 C (98.9 F)
• Pulse is 76 beats/minute
• Respiratory rate is 14 breaths/minute
• Blood pressure is 125/76 mmHg
• Weight is 91 kg (200 lbs)
• Height is 178 cm (70 in)
• Body mass index is 28.7 kg/m2

General: Well-developed, well nourished male. No acute distress.

Eyes: Clear conjunctiva, no discharge, anicteric sclera.

Ears: Canals are clear. TMs are clear. No redness or bulging.

Nose: No maxillary or frontal sinus tenderness on palpation. No dullness on transillumination.

Throat: Slightly reddened posterior pharynx but no exudates or tonsillar enlargement. There is no cobblestoning.

Neck: No cervical or supraclavicular lymphadenopathy.

Chest: Good excursion. No dullness to percussion. Rhonchi throughout all lung fields. There are no wheezes or crackles.

CV: RRR normal S1 and S2. No murmurs, rubs, or gallops.

Dr. Griffin joins you to review what you have covered with Mr. Taleb up to this point. She asks what you found on the nasal examination. You confess you didn’t look up his nose, but will now.

You examine Mr. Taleb’s nose and find clear discharge with slight erythema of the nasal mucosa.

You tell Dr. Griffin, “I think Mr. Taleb has a viral upper respiratory infection, and thankfully COVID tests have been negative for him and his kids so that’s unlikely. He does not have a fever, productive cough, or signs of lung consolidation—ruling out pneumonia. His throat is not very red, and there are no exudates, so I don’t think it is strep throat. Since he does not have purulent nasal discharge, sinus tenderness, or tooth pain, sinus infection is unlikely. His rhonchi support the possibility of early viral bronchitis, but it is too early in his illness to say for sure. Given the constellation of nasal congestion, scratchy throat, and cough with a benign physical, I think a viral URI is the most likely diagnosis.”

Dr. Griffin says, “I agree with you that Mr. Taleb is suffering from the common cold. How do you think we should treat him?”

At this point, Mr. Taleb interjects, “A Z-Pack (azithromycin) has worked for me in the past.”

With some help from Dr. Griffin, you explain to Mr. Taleb that you believe he has a common cold. You go on to explain that colds are caused by viruses and not bacteria and that antibiotics treat bacterial infections only. You end by telling him that viral infections are self-limited, and treatment is supportive. You discuss how to prevent spreading the cold and inform Mr. Taleb when he can expect to feel better. You then ask if he has any questions.

“Are you sure it is not the flu? Should I get a flu shot?”

“Yes, I am sure it is not the flu. With the flu you would have a high fever that started all of a sudden, a lot of muscle aches, a headache, as well as a bad cough. And yes, you’re right, as a smoker you should receive a flu shot. We start administering it as soon as it is available; ideally you should have it before October 1st.”

“My last doctor always gave me antibiotics. Are you sure I don’t need them?”

“Yes. Antibiotics will not work for your viral infection and they can cause problems, such as diarrhea. Furthermore, using antibiotics unnecessarily can cause bacteria to become resistant to them, so the antibiotic won’t work when you do need it. There is a tiny chance you could develop bacterial sinusitis, but this happens less than 2% of the time. If you develop a toothache in your upper teeth, or a fever, you should give us a call.”

You give Mr. Taleb a patient handout about colds and antibiotics that he can look over at home.

 

 

You are about to discuss treatment options with Mr. Taleb when he asks, “Should any other tests be done? My daughter had a throat swab when she got sick. Since I smoke, do I need an x-ray to make sure I don’t have cancer?”

You explain to Mr. Taleb why he does not need an x-ray or a throat swab.

Most pharyngitis is viral, with rhinoviruses being the most common etiology. Only 5-15% of cases of pharyngitis are bacterial, with group A Streptococcus causing almost all bacterial pharyngitis.

Although streptococcal pharyngitis is usually self-limited, treatment with antibiotics is indicated to prevent acute rheumatic fever, reduce person-to-person transmission, and decrease the incidence of local complications, such as peritonsillar and retropharyngeal abscesses.

Post-streptococcal glomerulonephritis is an uncommon complication of strep throat; there is no evidence that antibiotic treatment prevents it.

Mr. Taleb smiles and says, “Ok, Doc. You’ve convinced me—I have a cold. If antibiotics aren’t the answer, what can I do to get better?”

You and Dr. Griffin step out of the room so Mr. Taleb can dress. Dr. Griffin says, “I want to go over some information with you that is good to review before discussing tobacco use with patients: the five A’s and five R’s for smoking cessation.”

You and Dr. Griffin return to the exam room.

“Mr. Taleb, we recommend ibuprofen and an antihistamine/decongestant combination, such as fexodenadine/pseudoephedrine, to help with your symptoms. You can get them without a prescription. If you don’t get better within the next week, or if you develop a fever, give us a call.”

“Sure thing. I’m glad you took the time to explain why I don’t need antibiotics.”

“Before you go, I want to remind you that the most important thing you can do for your health is to stop smoking, and I strongly encourage you to quit. I know it is hard, but I also know that you can do it! … Are you willing to give it a try?”

“Thanks, Doc. I understand what you are saying about my overall health. I am not sure I am ready to quit, but I’ll think about it. My kids are giving me a hard time about smoking, too.”

“Okay, but keep in mind that there are a lot of benefits to quitting—you’ll feel better, save money, and live longer. Besides that, your children will have a healthier place to live.”

“Well, you might have a point there.”

You feel that he is in the contemplative stage, so you educate him about the diseases associated with cigarettes. After a pause, you continue with your questions to Mr. Taleb.

“You’ve quit three times before, and this tells me you can quit forever if you want to. Are there things holding you back?”

“Well, I’m worried that I’ll get cranky and irritable and not stick with it. I’m just not ready.”

“The truth is quitting isn’t easy, but it’s not impossible. There are medications that can help with symptoms like cravings and irritability, and we will help you as much as we can. Just so you know, I’m going to talk to you about this every time I see you!”

“Well, okay. Right now, though, I’m going to work on getting rid of this cold! I’ll call you if I run into problems.”

You say goodbye to Mr. Taleb and wish him well.

Two weeks later, Dr. Griffin asks you to go in and see Mr. Taleb again. She is not sure why he is here because the schedule just says “Follow-up.”

“Hi, Mr. Taleb. How are you doing?”

“I’m feeling just fine. You were right; I had a cold and I’m over it now.”

“What seems to be the problem today?”

“Well, I’d like to stop smoking cigarettes. My uncle, who smokes, just had a heart attack, and I don’t want the same thing to happen to me. You mentioned that there are things that can help make quitting easier. Can we talk about them?”

 

 

“I’m so pleased you want to stop smoking! Yes, there are several medications that can help with symptoms that occur with nicotine withdrawal. An exercise program and family support can help, too. You told me before that your kids are in favor of you quitting, so it sounds like you will have the family support you need to be successful.”

“Will I gain weight?”

“Maybe. The average weight gain of people who quit is around five pounds, but it doesn’t happen to everyone. If you are aware of the possibility of weight gain, you can try to avoid the pitfall of substituting food for cigarettes.”

You explain to Mr. Taleb that the symptoms of withdrawal peak on the third day after quitting, which makes this a risky time for relapse. “Weekends may be difficult too, especially if you’re drinking alcohol or doing something associated with smoking. I know you can do this if you keep at it!”

Dr. Griffin joins you and is pleasantly surprised that Mr. Taleb is motivated to quit smoking. She reiterates your previous message that quitting is the most important step Mr. Taleb can take in improving his long-term health. She refers Mr. Taleb to a smoking cessation group and then asks you which agent you would prescribe.

Mr. Taleb says, “I’d like to take a medication that you recommend, rather than quitting cold turkey, if the side effects aren’t too bad.”

But after Dr. Griffin informs him of the side effects, Mr. Taleb is hesitant to take a medication daily so he opts for nicotine replacement therapy. You make a plan to call him in one week, and he will be seen back in the office in one month.

You recommend a nicotine patch at 14 mg/day for four weeks and then 7 mg/day for an additional four weeks. You also recommend that Mr. Taleb use 2 mg nicotine lozenges or gum as needed, but especially during the first week.

You write down the instructions for him to have at home.

Later in the week, you call Mr. Taleb to see how he is doing.

Mr. Taleb tells you, “Thanks for calling. Things are not going so well. My wife lost her job, and I couldn’t afford the medications. But my friend at work said his insurance covered bupropion, and he stopped smoking using it, so I want to try that. My insurance should cover it, too.”

You confer with Dr. Griffin and plan to call the bupropion prescription into the pharmacy. You advise him that he may still want to use nicotine replacement to prevent or treat nicotine withdrawal while first starting the bupropion and weaning off of cigarettes. You arrange a follow-up visit with Mr. Taleb next week.

Several months later, after finishing your rotation with Dr. Griffin, you call her to update her after one of her patients has surgery. During your conversation, she tells you that Mr. Taleb has been successful in his smoking cessation. He finished the bupropion but he uses a nicotrol inhaler as needed when he feels the urge to smoke. He still uses it several times weekly.

“Mr. Taleb said he couldn’t have quit smoking without your help and encouragement.”

INSTRUCTIONS

Apply information from the Aquifer virtual case studies to answer the following questions:

• What is the CC in the case studies? What are important questions to ask the patients to formulate the history of present illness and what did the patients tell you?
• What components of the physical exams are important to review in the cases? What are pertinent positive and negative physical exam findings to help you formulate your diagnosis?
• Which differential diagnosis is to be considered with each case study? What was your final diagnosis?