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).
Apr 2007
Chief Complaint: A 26-year-old black woman with type 2 diabetes mellitus (DM) presents to your office after being told by her primary care physician that her DM was poorly controlled.
History of Present Illness: The patient received a diagnosis of DM 6 years ago when she sought medical attention for polydipsia and polyuria. After several months of diet and exercise, the patient was started on metformin 1000 mg twice daily. Although the patient’s glycosylated hemoglobin (A1C) level improved markedly with this therapy, she experienced severe nausea. She was then started on acarbose 25 mg 3 times daily with meals but discontinued it due to severe gastrointestinal distress. The patient was then switched to glimepiride 4 mg daily but experienced postprandial hypoglycaemia with blood glucose (BG) levels between 50 and 69 mg/dL. The patient is currently not taking any medication for DM due to these adverse effects. She states that she has been checking her BG levels conscientiously and has preprandial BG levels of 90 to 100 mg/dL. She does not check her postprandial BG levels.
Medical History: In addition to type 2 DM, the patient has a history of peptic ulcer disease for which she takes omeprazole 40 mg daily. There is a remote history of nonspecific gastric surgery. She also has dyslipidemia, which is treated with atorvastatin 10 mg/d, and asthma, which is controlled with an albuterol metered dose inhaler.
Social History: The patient has smoked 1 pack of cigarettes daily for 8 years and drinks ~6 beers a day on weekends. Occasionally she also drinks 2 or 3 shots of whiskey on weekends. She states that she has little time to eat a healthy diet and that she tries to supplement her meals with fruit juice as snacks. Another physician started her on dietary fiber 2 years ago, but she has since discontinued it. She is married, has 4 children, and works as a secretary.
Physical Exam: The patient weighed 180 pounds and was 5 feet 4 inches tall. She was not in acute distress. Her vital signs were as follows: temperature, 99.0°F; heart rate, 76 beats/min; and blood pressure, 140/82 mm Hg. Examination of the head, eyes, ears, nose, and throat was significant only for pseudo–Argyll Robertson pupils. The patient’s chest and heart examinations were both within normal limits. Her abdomen was soft, protuberant, and nontender, with normal bowel sounds in all 4 quadrants. There was no hepatosplenomegaly. Well-healed postsurgical scarring was observed. Extremity examination revealed 1+ bilateral pitting edema with strong pedal pulses. No neurologic deficit was present.
Lab Results: The following are her lab results: A1C, 7.3%; fasting BG level, 102 mg/dL; and postprandial BG levels, 189 mg/dL, 145 mg/dL, and 115 mg/dL (1, 2, and 3 hours after eating, respectively). Her lipid profile was: total cholesterol, 222 mg/dL; triglycerides, 165 mg/dL; high-density lipoprotein, 47 mg/dL; and low-density lipoprotein (LDL), 151 mg/dL. Fibrinogen level was 297 mg/dL (normal range, 200–400 mg/dL). C-reactive protein was 0.8 mg/dL (normal range, 0.0–0.5 mg/dL).
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