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Mrs. Jones is
a 74 year old African American female who has been your
patient for the past two years. She was diagnosed with
type 2 diabetes mellitus five years ago and also has hypertension
and gout. She presents to your office today for a routine
visit, and is punctual as always. She now complains of “burning
in my feet” for the past 5-6 weeks. She also reports
that her fasting blood glucose levels at home have been “a
little high lately” but she says she cannot tell
you any specific values, demurring that “my mind
is not so good anymore.” When you ask Mrs. Jones
about her diet, she staunchly proclaims “All I have
for breakfast is four strips of bacon. The rest of the
time I do pretty good.”
Mrs.
Jones currently takes the following medications:
1. Glyburide,
5 mg once daily
2. Metformin, 500 mg three times daily
3. Metoprolol 50 mg twice daily
4. Allopurinol 300 mg daily
5. HCTZ, 25 mg daily
Your
examination of Mrs. Jones reveals the following:
Weight:
187 pounds (BMI = 33)
BP: 151/88
HR: 89
RR: 16
Lungs:
Clear to auscultation
Heart: Regular rate and rhythm, II/VI systolic ejection murmur
at right sternal border
Abdomen: Normoactive bowel sounds
Extremities: 2+ pitting edema bilaterally
Neurologic: Decreased sensation to pinprick in a stocking
distribution
Laboratory data:
Sodium
142
Potassium 4.8
Chloride 99
Bicarbonate 18
BUN 22
Creatinine 1.5
Glucose 254
HbA1C 9.7
You explain
to Mrs. Jones that all of her usual indices of glycemic
control have worsened steadily over the past year. Additionally,
you note that her renal function has declined as well.
She replies, “I’m doing the best I can, but
I do miss medications sometimes.”
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