Subjective
Medical History
- Medication: Glucophage taken two times per day, captopril (forblood pressure control and protection of kidneys), and Lipitor forcontrol of hyperlipidemia.
- Laboratory values: Last HbA1c = 8.8% (normal 4-6%); cholesterol200 mg · dL–1; low-density lipoprotein cholesterol 130 mg · dL–1;high-density lipoprotein cholesterol 35 mg · dL–1; triglycerides160 mg · dL–1; microproteinuria.
- Physical exam: Blood pressure 130/80 mmHg; resting heart rate70 beats · min–1; height 5 ft 11 in. (190 cm); weight 230 lb (104kg) with 27% body fat (skinfold).
- Complications history: Acute periodic episodes of diabetes outof control but has never experienced hyperosmolar nonketoticsyndrome or diabetic ketoacidosis. Two-vesselbypass surgery 5 yr ago, moderate peripheral neuropathy, and earlydiabetic nephropathy.
Objective and Laboratory Data
Exercise Test Results
No abnormal electrocardiogram changes;maximum blood pressure 180/83 mmHg; maximum heart rate 150 beats ·min–1; V̇O2max 25.5 mL · kg−1 · min−1; random blood glucose beforetest 180 mg · dL–1.
Assessment and Plan
Diagnosis
Mr. SD is 63 yr old and was diagnosed with type 2 diabetes 5 yrago.
Exercise Prescription
- The goals of the exercise program, mutually agreed on by thepatient and the clinical exercise professional, are to lose weightand improve body composition, improve blood glucose levels, andreduce risk for another cardiac event. When asked about interestsand hobbies, the patient indicates that he enjoys traveling, winetasting, playing with his dog, and classic movies. Participation ina supervised exercise program and frequent contact with an exerciseprofessional are advised. A warm-up and cool-down of staticstretches and low-intensity aerobic activity are prescribed.
- Mode: Stationary cycling, water exercise, or moderate walking,if tolerated without trauma to feet. Attention should be given tothe patient’s ability to safely perform weight-bearing activitiesbecause of the peripheral neuropathy. Walking his dog and walkingduring traveling are discussed. The patient must take care of hisfeet and do these activities as safely as possible.
- Frequency: 3 to 5 d per week with a goal of increasing todaily.
- Intensity: This patient is taught to monitor heart rate and touse the rating of perceived exertion (RPE) scale. The intensity isprescribed at 40% to 59% of heart rate reserve or 112 to 127 beats· min–1. An RPE rating of 11 to 13 on a 6- to 20-point Borg scaleis advised.
- Duration: An initial duration of 15 to 30 min is suggested andshould eventually be increased to 60 min per session to facilitateweight loss.
- Rate of progression: Attention is first given to frequency ofexercise. After he has reached 5 d per week or more, duration willbe increased.
- Other information: Mr. SD is instructed to increase thefrequency of blood glucose monitoring to assess the effect ofexercise on his blood glucose control. He is also advised to checkhis feet daily for redness, sores, or areas of trauma that must betreated early to prevent further issues.
Questions:
- What other health care team members should this patient workwith as he begins his exercise program? Why?
- What else should be added to his program to help him attain hisgoals?
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