The NP sees a 74-year-old woman with a BMI=30 kg/m2 who has a 30-year history of type 2 diabetes, HTN, and dyslipidemia. Pertinent social history includes the following: a retired elementary school teacher who lives in a 1-story home with her spouse and adult child, nonsmoker, drinks approximately 2, 5 oz glasses of wine per month, and walks approximately 2 miles per day. Her current medications include telmisartan, HCTZ, rosuvastatin, metformin, semaglutide and canagliflozin at optimized doses, and current A1c=9.2%. Her current A1c= 9.2% and is at HTN and lipid goal. Prior mediations have included sitagliptin, with patient stating, “That medication did not help my sugar at all.” She states she is adherent to her medications and dietary advice. Her eGFR is within acceptable parameters and she is feeling well. Physical exams are unremarkable.

Which of the following is the most appropriate next step?

A. Advise that her A1c is at an age-acceptable level.

B. Add post-meal sliding scale rapid acting insulin

C. Prescribe basal and pre meal insulin.

D. Add oral glipizide.

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Mrs. Mahem is a 68-year-old patient with a 25-year history of type 2 diabetes mellitus. In the past year, her A1c remains at around 8.5% with the use of the following medications: metformin, sitagliptin, and canagliflozin, at optimized doses and with adherence. She states, “ I haven’t changed the way I eat and I walk about ½ h a day, just like I have for years”. Additional health issues include HTN and dyslipidemia, treated with medications and at therapeutic goal, and obesity with a BMI= 33. Her eGFR is 65.

Which of the following is the most appropriate next step in the pharmacologic management of her diabetes?

A. Add glyburide to enhance glycemic control.

B. Consider discontinuing metformin due to age and renal function.

C. Advise that her glycemic control is adequate for an older adult.

D. Prescribe semaglutide to help her achieve A1c goal.

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A patient presents with a chief complaint of a gradual onset vision change, present for the past 6 months, while denying eye pain, redness or trauma. The funduscopic exam, extraocular movements and pupillary reactions are within normal limits. When considering a diagnosis of presbyopia, which of the following best describes patient presentation?

A. A 50-year-old who states, "I need to hold what I'm reading really far away in order to see it clearly".

B. A 75-year-old who states,"When I look at a bright light, I see a colored halo around it".

C. An 80-year-old who states, "I have a blurry spot in the middle of my eyesight".

D. A 17-year-old who states, "I went to get my driver’s license, but failed the distance vision exam".

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