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Maria is a 46-year-old woman who presents for her yearly physical examination. Her review of systems is significant for fatigue, constipation, and hair loss. Her previous medical history is notable only for obesity. She reports her understanding that she should be on a low calorie, low-fat diet with moderate aerobic exercise 4-5 times per week but also notes that having a full-time job and four children make this difficult to achieve.

She has NKDA and takes a multi-vitamin daily. Maria reports a family history of diabetes (mother) and hypertension (brother). She is a nonsmoker. Her diet largely consists of fast food meals. She drinks sweet tea with every meal and an additional 3-4 cups of coffee per day. Previous labs and exam last year are unremarkable.

Vitals today: BP 120/70 mm Hg, pulse 76, temperature 98.7, respirations 18, height 59, weight 225 pounds. Urine dip + glucose, fasting plasma glucose 179 mg/dl, HgbA1C is 7.4%, TSH 8.5mU/L and Free T4 0.1 ng/dl. The physical exam is notable for acanthosis nigricans at the neck but otherwise is normal.

1. What are your treatment goals for Maria?
2. What is your pharmacologic plan and rationale? (cite with appropriate clinical practice guidelines or scholarly, peer-reviewed journals)
3. What is the mechanism of action for each drug?
4. Please give five teaching points for each drug prescribed.
5. How would you change the plan if her initial HbgA1C was 10.2mg/dL and her fasting blood glucose was 305mg/dL? Provide a detailed alternative plan with the rationale.

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