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).
July 2006
Chief Complaint: A 36-year-old white man with diabetes mellitus (DM) for 4 years presents with persistent hyperglycemia while taking multiple oral agents.
History of Present Illness: The patient was diagnosed with DM at 32 years of age when he was found to have an elevated fasting glucose level of 150 mg/dL during routine blood testing. His initial glycosylated hemoglobin (A1C) level was 7.6%, and his examination and history were notable for an absence of obesity or family history of DM. At the time of diagnosis, he was started on glipizide 5 mg daily and made recommended changes in his diet and activity. One year after his initial diagnosis, the patient’s A1C value was 6.8%. The patient continued to feel well without symptoms of polyuria, aresthesia, or blurry vision. Over the next 2 years, he maintained an A1C level <7.0% but required increasing doses of the sulfonylurea. Oral metformin 500 mg BID and oral pioglitazone 15 mg QD were added 1 year ago. Despite dose increases in both metformin and pioglitazone, the patient noted elevated fasting blood glucose levels as well as frequent postprandial glucose levels >200 mg/dL. At this visit, initiation of insulin therapy is being considered. Blood samples for laboratory tests (including autoantibodies) are drawn in the office.
Medical History: He has been treated for hypertension for the past 2 years with lisinopril 5 mg daily. He was diagnosed with Hashimoto’s thyroiditis several years ago and has since been on thyroid hormone replacement therapy (levothyroxine 125 μg daily).
Social History: The patient works as an accountant and is married with 3 children. He plays tennis 1 to 2 times per week and does additional aerobic exercise 3 times weekly. He does not smoke tobacco or drink alcohol.
Physical Exam: He is a lean man (height: 5 feet, 9 inches; weight: 148 pounds; body mass index: 22 kg/m2) in no acute distress. His blood pressure was 142/70 mm Hg, and his heart rate was 82 beats/min. There was no evidence of acanthosis nigricans or skin tags on examination. He has no evidence of retinopathy or impaired peripheral sensation to monofilament.
Lab Results: Following are his laboratory test results: A1C, 9.0%; triglycerides, 180 mg/dL; high-density lipoprotein, 38 mg/dL; urine microalbumin ratio, 4 μg/mg creatinine; thyroid-stimulating hormone, 3.8; anti–glutamic acid decarboxylase (GAD) antibodies, 60 ng/mL (elevated); anti–islet cell antibodies, absent; and anti–thyroid peroxidase (TPO) antibodies, 120 IU/mL (elevated).
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