The Case Study section of Insulin concludes with questions about the case being presented. A summary of the responses we receive for each case study will appear in the next issue along with a new case study (and its accompanying questions).
April 2006
Chief Complaint: A 56-year-old African American man with type 2 diabetes mellitus (DM) presented for follow-up.
History of Present Illness: He was diagnosed with DM when he was 46 years old after he had a random blood glucose measurement of 264 mg/dL and a fasting blood glucose (FBG) level of 180 mg/dL. His initial glycosylated hemoglobin (A1C) value was 9.6%. At diagnosis, he commenced metformin therapy at 500 mg QD. Over the next 2 years, this dosage was titrated to 500 mg BID. At 49 years of age, his A1C level was 8.8% and glipizide was added, starting at 5 mg QD. By age 51 years, this dose had been titrated to 10 mg BID. At age 54 years, his A1C level was 8.2% and rosiglitazone was added at 4 mg QD, which was titrated after 3 months to 4 mg BID. He stated that he misses <1 dose of medication per week. During his visit today he complained of intermittent burning in his feet that has gotten progressively more severe over the past year. He stated that he checks his blood sugars at random ~3 times per week and reported blood sugars ranging from 190 to 300 mg/dL. He reported no symptoms of hypoglycemia and has gained 20 pounds since the initiation of rosiglitazone. He was recently diagnosed with nonproliferative diabetic retinopathy during a routine dilated ophthalmologic examination.
Medical History: He has had hypertension for 20 years and has been treated with hydrochlorothiazide 25 mg/d and fosinopril 40 mg/d for the past 5 years. At age 47 years, his total cholesterol measurement was 240 mg/dL and his low-density lipoprotein cholesterol measurement was 163 mg/dL. He takes atorvastatin 40 mg/d for the treatment of his hyperlipidemia.
Social History: He is employed as a computer programmer and is sedentary at work. He is married with 2 children and exercises minimally. He smoked 1/2 pack of cigarettes per day for ~10 years but quit when he was 29 years old. He reported that he consumes ~2 to 3 beers per week, primarily on weekend days.
Physical Exam: He is an overweight man (weight: 220 pounds; height: 6 feet, 1 inch; body mass index: 29 kg/m2) in no acute distress. His blood pressure was 124/74 mm Hg. His heart rate was 84 beats/min and regular. He has acanthosis nigricans on skin examination and scattered skin tags. He has impaired sensation to 5.07-mm/10-g monofilament at 4 of 0 sites. He reported symptoms of mild fatigue with nocturia once nightly. The remainder of the physical examination was unremarkable.
Lab Results: The result of a fingerstick blood glucose test taken during the examination was 270 mg/dL. The A1C value today was 10.3%. A random (spot) urine microalbumin test 3 months ago revealed 56 μg/mg creatinine.
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