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).
October 2006
Chief Complaint: The patient is a 48-year-old Hispanic male with type 2 diabetes mellitus (DM) who presents with elevated levels of glycosylated hemoglobin (A1C).
History of Present Illness: The patient was diagnosed with type 2 DM 8 years ago. He had presented initially 2 years prior for treatment. He was taking glimepiride 2 mg QD and metformin 500 mg BID. Over time, however, doses of both agents were increased to the maximum due to worsening glycemic control. Insulin glargine was added 1 year ago because of rising A1C levels and polyuria. The patient is currently taking glimepiride 4 mg BID, metformin 1000 mg BID, and insulin glargine 30 units QHS. He also takes simvastatin 40 mg at night, enalapril 20 mg QD, and acetylsalicylic acid 81 mg daily. The patient was testing his glucose levels before breakfast and dinner, with records revealing fasting blood glucose (FBG) levels of 90 to 130 mg/dL and predinner readings in the 90- to 130-mg/dL range. Review of the memory of his glucose meter supports these results. He does not do blood glucose measurements at work or on weekends, and he stated he was too tired to check at bedtime. Diet history reveals meals high in carbohydrates (eg, bagels, rice and beans, pasta).
Medical History: In addition to the DM as discussed above, he was diagnosed 5 years prior with hypertension that is now controlled with enalapril. He also has hyperlipidemia, which is being treated with simvastatin. He has a history of intermittent nausea and gastroesophageal reflux disease; at the present time both are stable. He is currently taking the medications as listed above. He has no allergies but had experienced fluid retention 1 year prior when taking pioglitazone 15 mg. Both parents and an older brother have DM. His father was diagnosed with coronary artery disease at 64 years of age.
Social History: The patient is married with 2 children. He works during the day as a paralegal. He does not smoke or drink alcohol, and he does minimal exercise.
Physical Exam: The patient is 5 feet, 8 inches tall and weighs 100 kg. His blood pressure was 120/80 mm Hg. His FBG was 108 mg/dL. His heart rate was 72 beats/min; his respiration was 12 breaths/min. No retinopathy or thyromegaly was noted. Neck examination revealed 2+ carotids and no bruits. His lungs were clear. A cardiac examination showed a normal S1 and S2, a regular rate and rhythm, and no murmur, rubs, or gallops. His abdominal examination revealed a soft abdomen with normal bowel sounds and no organomegaly. His extremity examination showed 2+ peripheral pulses with no signs of clubbing, cyanosis, or edema. With the neurologic examination, the patient displayed intact sensation to a 5.07-mm monofilament and 2+ reflexes, except for 1+ ankle jerks.
Lab Results: The following are his laboratory test results: normal creatinine, 0.9 mg; microalbumin, 12 mg/g creatinine; total cholesterol, 160 mg/dL; high-density lipoprotein cholesterol, 48 mg/dL; triglycerides, 250 mg/dL; and low-density lipoprotein cholesterol, 62 mg/dL. His A1C was 8.2%. A fingerstick in the office 2 hours after breakfast showed a reading of 232 mg/dL. The patient’s FBG was 102 mg/dL that morning.
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