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).

January 2010

Response Submission Due Date: March 15, 2010
Posted by Emily J. Gallagher, MB, BCh, MRCPI

Chief Complaint: A 52-year-old black woman with type 2 diabetes mellitus (DM) comes to your office for disease management follow-up. The patient is currently taking insulin. She reports poor glycemic control and has recently seen a nutritionist and diabetes nurse educator to improve self-management of her disease.

History of Present Illness: The patient was diagnosed with type 2 DM in 1999. Her most recent glycosylated hemoglobin (A1C) level was 10.6%. She was initially treated with oral agents and has been taking insulin since 2006. Her current insulin regimen is insulin glargine 46 units once daily and insulin lispro 16 units with meals. She frequently misses insulin doses when she eats outside her home; she drinks regular (sweetened) soda and occasionally gives herself an extra 16 units of insulin lispro when her glucose readings are high. Her glucometer readings ranged from 52 to 504 mg/dL over the past 3 weeks. She was diagnosed with HIV in 1996, acquired from a blood transfusion in 1983. She is currently on a protease inhibitor–based antiretroviral treatment regimen and had an undetectable viral load and CD4 count of 1186 cells/mm³ within the past month. Review of systems was positive for weight gain over the past 12 months and lower-extremity edema.

Medical History: The patient has a history of stage 3 chronic kidney disease, dyslipidemia, and mild intermittent asthma. She had a gunshot wound in 1983 and a hysterectomy in 2007. In addition to her insulin regimen, her medications include abacavir/lamivudine 600/300 mg daily, atazanavir 300 mg daily, ritonavir 100 mg daily, furosemide 40 mg daily, and an albuterol inhaler as needed. She is allergic to aspirin, which causes a rash, and she experienced angioedema after use of an angiotensin-converting enzyme inhibitor.

Social History: The patient is widowed and a current smoker (1 pack of cigarettes per week). She does not drink alcohol and has no history of illicit drug use. She has 2 sisters who also have type 2 DM.

Physical Exam: The patient is an obese black female. Her height is 64.5 inches, weight is 177 lb (80.5 kg), body mass index is 30.9 kg/m², blood pressure is 142/84 mm Hg, heart rate is 84 beats/min, and temperature is 36.3°C. She is comfortable at rest. She has abdominal obesity but no facial fat wasting or other evidence of lipodystrophy. Examination of her head and neck is normal. Cardiovascular exam reveals normal heart sounds, with no added heart sounds or murmurs. Her lower extremities have 3+ pitting edema bilaterally to the upper calf. She has a well-healed abdominal scar from previous surgery. Otherwise, her abdominal, pulmonary, and neurological examination is unremarkable. Her injection sites are normal.

Lab Results: The patient’s A1C is 10.6%, creatinine is 1.5 mg/dL, and electrolytes are normal. Her total cholesterol is 265 mg/dL, low-density lipoprotein cholesterol is 119 mg/dL, high-density lipoprotein cholesterol is 95 mg/dL, and triglycerides are 255 mg/dL. Her CD4 count is 1186 cells/mm³. Liver function tests are normal.

Responses to this Case Study are due no later than March 15, 2010. A diabetes expert will summarize the responses we receive, and this summary will appear in the next issue of Insulin.