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 2008
Chief Complaint: A 28-year-old woman with a 25-year history of type 1 diabetes mellitus (DM) comes to your office with her husband for preconception counseling.
History of Present Illness: The patient developed type 1 DM at age 3, when she presented in diabetic ketoacidosis. A first cousin also has a history of type 1 DM. The patient has no known microvascular or macrovascular complications; her last eye exam was 2 years ago. She has no known coronary artery disease risk factors; specifically, she denies hypertension, hyperlipidemia, and smoking. She has a family history of premature coronary artery disease; her father had a myocardial infarction at age 38. The patient relates that her diabetes control was fair during adolescence. She considers her recent control to be excellent (glycosylated hemoglobin [A1C], 6.5%–7.0%) with use of an insulin pump. She monitors her fasting serum blood glucose 4 to 6 times per day and is comfortable with carbohydrate counting, using a ratio of 1 unit:12 g and a sensitivity of 1 unit:50 mg/dL for blood glucose levels >100 mg/dL.
The patient exercises vigorously; she has run many marathons and is currently training for a triathlon. She acknowledges frequent episodes of hypoglycemia, usually associated with exercise. Her weight is normal.
Medical History: The patient has a history of Hashimoto’s thyroiditis and has been receiving a stable dose of levothyroxine for many years. A screen for celiac sprue was negative. The patient is G2P0. Her menses were regular on oral contraceptives until she discontinued them several months ago; she is not sure of the date of her last menstrual cycle.
Social History: The patient is a third-grade teacher. She has no psychosocial difficulties related to diabetes; her husband and family are very supportive.
Physical Exam: In general, the patient is pleasant, alert, lean, and in no acute distress. Her blood pressure is 118/70 mm Hg, pulse is 64 beats/min, and body mass index is 22 kg/m2. Her pupils are equal, round, and reactive to light. Her extraocular muscles are intact; the fundi are not well visualized. HEENT exam revealed clear orpharynx, midline uvula, good dentition, supple neck with no nodes, and thyroid enlarged 1.5× with no nodules. She has normal S1, S2 rate and rhythm with no murmurs, rubs, or gallops. Her lungs are clear to auscultation bilaterally with no wheezes or rales. Her abdomen is soft, nontender, and nondistended with no masses; bowel sounds are present. Her extremities reveal no clubbing, cyanosis, or edema; she has positive dorsalis pedis pulses and no skin breakdown. Her sensation to monofilament and vibration in the lower extremities is intact bilaterally with 2 positive reflexes. She has no acanthosis and no erythema or lipohypertrophy at the abdominal pump site.
Lab Results: The patient’s A1C is 6.9% and random glucose level is 137 mg/dL. Urine microalbumin is 40 mg/g creatinine. Low-density and high-density lipoprotein cholesterol are 86 mg/dL and 72 mg/dL, respectively; triglycerides are 90 mg/dL. Thyroid-stimulating hormone (TSH) is 2.73 mIU/L. Pregnancy (β−hCG) test result is pending.
Next Case Study:
All articles have been reviewed by members of our Editorial Board or independent referees.
You need Adobe Acrobat Reader installed on your computer to read the PDF version of these articles. If you don't have Acrobat Reader, click here to download it free.
