Evidence Based Medicine PICO SOAP Extra Credit Assignment

PICO SOAP STEPS • Step 1: Write the S and O from a patient encounter • Step 2: Form an EBM question following PICO format • Step 3: Search the Literature and evidence to answer question • Step 4: Site at least two articles to support your A and P and summarize findings • Step 5: Formulate an A and P based on your research.

Subjective • 65 yo obese male with PMH diabetes present for routine labs for DM. • Reports good dietary habits and adherence to medications specifically metformin, glipizide and sitagliptin. • Upon hearing his Hb. A 1 c has not improved has asked about gastric bypass and the endrocrinologic effects pertaining to “reversal of diabetes”

Objective • Vitals: – HR 85, BP 136/78, T: 98. 0, RR 13 – Height 6’ 0”, weight 280 lbs. , BMI 37. 9 • General: NAD • HEENT: Normocephalic, atraumatic. PERRLA, no icterus, conjunctiva pink. • Heart: RRR, No M/G/R • Lungs: CTAB/L • Abdomen: Obese, soft, non-tender to palpation, no masses or organomegaly. • Extremities: Pulses 2+ B/L and symmetrical, no pedal edema.

Objective • Labs – Hb. A 1 c: 11% – Fasting glucose: 145 mg/d. L – Lipids: WNL – CBC: WNL – Electrolytes: WNL

PICO EBM Question • P: Patient Problem – 65 yo male with 10 year history of Type II DM, uncontrolled with diet, exercise and medicine.

EBM Question • I : Intervention – Gastric bypass

EBM Question • C : Comparison – Gastric bypass vs. continued medical management

EBM Question • O : Outcome – Reversal of diabetes

PICO EBM Question • In an obese diabetic patient, is bariatric surgery more effective than standard medical therapy at increasing the probability of “reversal of diabetes”?

• Pub. Med Evidence

Evidence Summary • According to the latest literature (Kashyap et al. 2013), Schauer et al. (2012), gastric bypass (Roux-en. Y) along with intensive medical management are able to produce endocrinological changes and glycemic control in obese diabetics as evidenced by improvement in Hb. A 1 c and improvement in beta cell function. • Roux – en – Y with medical management was superior to medical management alone for decreasing Hb. A 1 C, increasing insulin sensitivity, and increasing beta cell function.

Assessment • 65 yo obese male with 10 yr history of type 2 DM, presents for annual labs. Fasting blood glucose 145 mg/d. L, Hb. A 1 c is 11. 0% with no improvement over the past year. Medical management, diet and exercise have not improved diabetes to target Hb. A 1 c. Diabetes remains uncontrolled. Patient is class II obese (BMI >35) with comorbid condition (diabetes), with good adherence to medical management with diet and exercise; patient may be a good candidate for gastric bypass.

Plan 1. DM: Continue metformin 1000 mg PO q 12 hrs Continue glipizide 10 mg PO q 12 hrs Continue sitagliptin 100 mg PO q 24 hrs Continue exercise 30 -60 minutes moderate intensity most days of the week – Continue to follow ADA 1800 cal diet – Educate patient re: evidenced supported effect of bariatric surgery on glycemic control and diabetes. – Referral to bariatric surgeon for consult re: bariatric surgery. – – 2. Schedule follow-up in 3 months 3. Consider closer follow-up pending surgical recommendations

References • Andrews, R. A. , and R. B. Lim. (2013). Surgical management of severe obesity. Up. To. Date. Retrieved July 22, 2013, from http: //www. uptodate. com/contents/surgical-management -of-severe-obesity-inadolescents? detected. Language=en&source=search_result &search=gastric+bypass&selected. Title=5%7 E 94&provider= no. Provider#H 12 • Kashyap et al. (2013). Metabolic Effects of Bariatric Surgery in Patients with Moderate Obesity and Type 2 Diabetes: Analysis of a randomized control trial comparing surgery with intensive medical treatment. Diabetes Care 36 (2). • Schauer et al. (2012). Bariatric Surgery versus intensive medical therapy in obese patients with diabetes. New England Journal of Medicine 366 (17): 1567 -76.