Diabetes Mellitus, Type 2

DIABETES MELLITUS, TYPE 2 68A

A 53-year-old man presents to his primary care provider for a routine checkup. He complains of increased thirst and frequent urination for the past few months. On physical examination, he is an obese man; his blood pressure is 152/87 mm Hg. His urinalysis is positive for glucose. A random fingerstick blood glucose reading in the office is 352 mg/dL. Serum hemoglobin A_1c level is 10.2%.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Middle aged; obese; polyuria and polydipsia; associated hypertension; glycosuria; random blood sugar >200 mg/dL with symptoms; hemoglobin A_1c level >6.5%

How to think through: Factors that increase the risk of developing type 2 diabetes include obesity, as in this case. What other risk factors should be considered? (Family history, ethnicity; physical activity; fat distribution; smoking; and others, even sleep duration.) Besides polyuria and polydipsia, what other symptoms are often present when diabetes is first recognized? (Fatigue, weight loss, candidal vaginitis, blurred vision, peripheral neuropathy.) Do blurred vision and peripheral neuropathy necessarily indicate prolonged undetected diabetes? (Blurred vision may be caused by acute hyperglycemia rather than long-standing diabetic retinopathy, but neuropathy implies long-term hyperglycemia.) Glucosuria occurs above what serum glucose concentration? (Approximately 300 mg/dL.) How should this patient be evaluated? (Full physical examination, including ophthalmologic, neurologic, and foot examinations; complete blood count; serum electrolytes, creatinine, lipid panel; urine microalbumin test; and baseline electrocardiography.) What are the four treatment priorities to reduce his risk of macrovascular and microvascular complications? (Weight loss, blood pressure control, glucose control, and statin therapy aiming for a low-density lipoprotein cholesterol level of at least <100 mg/dL but ideally <70 mg/dL.) How should he be treated today? (If serum electrolytes and creatinine are normal and given the degree of glucose elevation, begin metformin and a long-acting insulin or sulfonylurea. Patient education. An antihypertensive should be initiated if hypertension is confirmed at the next visit, and statin therapy should follow.)