case study

The patient presents to the clinic today for care transition follow up after a recent hospital admission.

Jim is a 62-year-old patient who has difficulty coming in for primary care visits due to limited mobility. He also sees cardiology, pulmonary and endocrine specialists for his comorbid conditions of diabetes mellitus, postcoronary artery bypass grafting (CABG) 2 years ago and mild chronic obstructive pulmonary disease issues related to a 30 pack-year history of smoking. He is also recently discharged from the hospital following a brief stay due to a flare up of his COPD. His last visit with you was over a year ago. During the triage by the nurse, the patient indicates he needs a refill of his Crestor prescription, which was ordered by cardiology soon after his CABG. Per the electronic link to the cardiology service within your facility, the medication was due to be renewed about 2 months ago. His last lipid labs were a year ago. His most recent complete metabolic panel taken during the hospital stay was notable for a blood glucose of 187 and his last recorded HgA1C was 9.0 from a visit to endocrine 4 months ago