Case #5

Directions:
Click here to open your browser's e-mail system. This is where you will record your answers to questions plus any comments you want to pass along to your instructor. After entering your answers, you can check your response by clicking "Faculty Comments".  In the subject line of the e-mail form, enter your name and the name of the case being submitted, i.e., Case #5." When you finish your session with Family Medicine On-line, click the Send button in the e-mail window to forward your answers to your instructor. If you end your session before completing the case, click the Send button to submit your answers, and then exit your browser.

To complete the case during another session, go to the first page of the case and click the link above and then advance to the page where you left off. When finished with this session, click the Send button in the e-mail window. All materials copyrighted 2003 by Penn State University.

If you have completed case E, this is a review. Completion of this case will not be counted toward your assignment.

Chief Complaint

 

August 27

 

Mrs. White is a 56 year old white female with a 4 month history of increasing fatigue and frequent urination. She denies fever, chills, back pain, or hematuria. She denies any recent viral illnesses. Height 5'1" and weight is stable at 190 lbs. Appetite is normal. Fatigue is chronic over the past few months, which has made it difficult for her to carry out her duties as a cashier at a local grocery store.
  1. Given this history, what are your working diagnoses and why?
  2. What additional inquiries would be important in clarifying your diagnosis?
  3. In considering the diagnosis of diabetes, why is the family and social history so important?

Medical History

Past Medical History:
  • Hypertension - well controlled
  • Menopause age 53

Past Surgical History:

  • tonsillectomy age 6
  • cholecystectomy age 51

Family History:

  • Father deceased, age 68 of myocardial infarction. History included HTN & AODM.
  • Mother deceased, age 74 of ruptured aortic aneurysm. History included osteoarthritis and HTN.
  • Brother alive age 61 - AODM, HTN, BPH.
  • Maternal grandmother deceased, age 54 of breast cancer
  • Maternal grandfather deceased, age 31 of industrial accident
  • Paternal grandmother deceased, age 70 of a stroke. History included HTN, AODM, obesity.
  • Paternal grandfather deceased, age 45 of myocardial infarction.

Medications:

  • hydrochlorothiazide 12.5mg daily
  • conjugated estrogen 0.625mg daily
  • medroxyprogesterone acetate 2.5mg daily

Social History:

  • Married, rare alcohol intake and has never smoked.
  • Employed as a cashier in a local grocery store.
  • Three grown children. Good relationship with her husband. Completed high school education.
 
  1. With this information what are your working diagnoses and why?
  2. What are the hypotheses concerning the pathophysiology of type II diabetes.
  3. What data would be important to include in your physical exam and what specifics would you be looking for?

Physical Examination

Results of your exam are as follows:

height 5'1" weight 190# (86.36kg)

B/P 146/88 Pulse 82 Resp.16

Opthamologic exam- PERRLA, EOMI

fundoscopic exam - disc sharp, macula appears normal, vessels without nicking, no abnormalities noted

Cardiac exam - regular rate and rhythm, without murmur, rub, gallop PMI normal

Pulses- femoral, popliteal, dorsalis pedis, posterior tibial normal. No bruits noted.

Foot exam - skin and nails free from breaks in the

skin/ulcers, 6mm callous plantar surface of L foot, monofilament testing reveals normal sensation. Proprioception intact R & L. Gait reveals pronation during walking.

Thyroid- smooth, not enlarged, no nodules palpated

Skin exam - multiple nevus (normal appearing), few seborrheic keratosis on back, no skin lesions or ulcers noted.

Neurologic exam - grossly intact

Dental exam - adentuous, upper and lower dentures removed - no ulcers or lesions noted. Well fitted dentures. 
  1. What laboratory/diagnostic test would you order on the initial visit?

Test Results

Lab results for the patient are as follows:
  • plasma glucose (70-100)  205mg/dl (fasting)
  • TSH (0.3-5.0)                            3.2ulU/m
  • Serum creatinine (0.8-1.4)     1.4
  • sodium (135-145)                    141
  • potassium (3.5-4.5)                  3.6
  • chloride (80-110)                      92
  • WBC ( 5-103)*                          5.5
  • RBC (3.6-5.0)*                         4.3
  • Hgb (12-16)*                            13.7
  • HCT (37-47)*                           38.6
  • MCV (87-103)*                        96
  • MCH (26-34)*                          28
  • MCHC (31-37)*                       35
  • ALT (10-35)*                            25
  • total bili (0.1-1.2)                      1.0
  • alk.phos (40-130)                     88
  • urinalysis
    • pH                              5.0
    • Sp.gravity                   1.020
    • leukocytes neg.
    • nitrates neg.
    • protein neg.
    • glucose neg.
    • ketones neg.
    • urobilogen neg.
    • bilirubin neg.
    • blood neg.

*normal values for women  
  1. What are the diagnostic criteria for the diagnosis of diabetes mellitus?
  2. What are your diagnoses now?
  3. Now that you have diagnosed the patient with diabetes, what additional labs or tests should be ordered?
  4. What factors need to be taken into consideration when developing a treatment plan?
  5. What would be Mrs. White’s goal blood pressure? At what point should an antihypertensive drug be started?
  6. What class(es) of antihypertensive drugs would be preferred for Mrs. White?
  7. What would be Mrs. White’s lipid goals? At what point is drug therapy indicated?
  8. What interventions would be the initial therapy for Mrs. White?
  9. What would be the blood glucose targets and short term goals for this patient?
  10. Would you start Mrs. White on aspirin therapy? Why or why not?
  11. What is the metabolic syndrome? What is its importance?

You start Mrs. White on lisinopril 10 mg daily for her blood pressure, atorvastatin (Lipitor) 10 mg each evening for her hypercholesterolemia, and aspirin 81 mg daily.  You arrange for her to meet with a dietician and diabetes educator for diet and exercise guidance, and to obtain a home blood glucose monitor and be instructed in its use.  She will also monitor her blood pressure at home. 

  1. What laboratory values need to be followed during Mrs. White’s follow-up care?
  2. Are there any vaccinations that Mrs. White should receive?

Follow-up

October 9

You have now followed Mrs. White for six weeks. She has tried to follow her diet and exercise program as outlined and she has had a 3 lb. weight loss. Her home glucose monitoring for the past three days is as follows:

  24 hrs prior to visit 48 hours prior 72 hours prior
am 168 180 167
lunch 188 196 199
pm 166 201 220
hs 172 187 188

Her labs today are as follows:

glycohemoglobin           9.0       (4.0-6.0)
creatinine                      1.0       (0.8-1.4)

potassium                     4.2       (3.5-4.5)

AST                             26        (10-35)

ALT                             22        (10-35)

alkaline phosphatase     87        (40-130)
  1. What would be the next step in your treatment plan and why?

Continue to next page



Penn State Milton S. Hershey Medical Center ©2004
This page was last updated on April 24, 2006
Contact Us