Family Medicine · Year 3 · from Family Medicine

Case 1: New Diagnosis of Type 2 Diabetes

Patient Demographics

  • Age: 52 years old
  • Sex: Male
  • Occupation: Long-haul truck driver

Chief Complaint

"My doctor at the urgent care said my sugar was high and I need to see you about diabetes."

History of Present Illness

Mr. Robert Jackson is a 52-year-old man presenting for follow-up after an urgent care visit 5 days ago for a skin infection on his leg. At that visit, a random glucose was 287 mg/dL. He reports increased urination for the past 2-3 months, which he attributed to drinking more water in hot weather. He has also noticed increased thirst and unintentional weight loss of 12 pounds over 3 months despite "eating the same." He denies visual changes, numbness, or tingling. No prior history of diabetes.

Past Medical History

  • Hypertension, diagnosed 5 years ago, on lisinopril
  • Hyperlipidemia, not on medication
  • Obesity
  • Cellulitis, left lower leg (recent)

Family History

  • Mother: Type 2 diabetes, died of stroke at age 71
  • Father: Type 2 diabetes, coronary artery disease
  • Brother: Type 2 diabetes, age 55

Social History

  • Former smoker (quit 10 years ago, 20 pack-years)
  • No alcohol
  • Married, two adult children
  • Diet: Fast food frequently due to work schedule
  • Exercise: Sedentary, sits for extended periods while driving

Physical Examination

  • Vital Signs: BP 142/88 mmHg, HR 82, RR 14, BMI 34, Weight 238 lbs
  • General: Obese male in no acute distress
  • HEENT: Normal
  • Cardiovascular: Regular rate and rhythm, no murmurs
  • Lungs: Clear bilaterally
  • Abdomen: Obese, soft, non-tender
  • Extremities: Healing cellulitis left shin, no edema, pedal pulses palpable bilaterally
  • Neurologic: Monofilament testing intact bilateral feet
  • Skin: Acanthosis nigricans at neck

Clinical Image

Image: Blood glucose self-monitoring, an essential component of diabetes management that allows patients to track glycemic control and adjust lifestyle and medications accordingly.

Image Source: Wikimedia Commons Attribution: David-i98, CC BY-SA 3.0 URL: https://commons.wikimedia.org/wiki/File:Blood_Glucose_Testing.JPG

Outpatient Workup

  • Fasting glucose: 198 mg/dL
  • HbA1c: 9.2%
  • Basic metabolic panel: Creatinine 1.0 mg/dL, eGFR 85 mL/min/1.73m2
  • Lipid panel: Total cholesterol 242, LDL 156, HDL 38, Triglycerides 240
  • Urine albumin-to-creatinine ratio: 45 mg/g (mildly elevated)
  • AST/ALT: Normal
  • TSH: Normal

Assessment and Diagnosis

  1. Type 2 diabetes mellitus, newly diagnosed - HbA1c 9.2%, symptomatic hyperglycemia
  2. Hypertension, not at goal - Target <130/80 mmHg in diabetic patient
  3. Hyperlipidemia, untreated - High ASCVD risk
  4. Obesity - BMI 34
  5. Albuminuria - Early diabetic nephropathy vs. hypertensive nephropathy

Management Plan

For Diabetes:

  • Start metformin 500mg with dinner, increase to 500mg BID after 1 week, then to 1000mg BID as tolerated
  • Given HbA1c >9%, consider starting second agent (SGLT2 inhibitor - empagliflozin 10mg daily)
  • Provides CV and renal protection given albuminuria
  • Diabetes self-management education (DSME) referral
  • Glucometer and test strips for home monitoring
  • Target HbA1c <7% (individualized)
  • Medical nutrition therapy referral

For Hypertension:

  • Increase lisinopril to 20mg daily (also provides renal protection)
  • Target BP <130/80 mmHg
  • Home blood pressure monitoring

For Hyperlipidemia:

  • Start atorvastatin 40mg daily (high-intensity statin for diabetic patient age 40-75)
  • Target LDL <70 mg/dL given ASCVD risk

Lifestyle Counseling:

  • Dietary changes: Reduce carbohydrate intake, portion control, avoid sugary beverages
  • Discuss strategies for healthy eating while on the road
  • Physical activity: 150 minutes/week moderate activity, break up sitting time
  • Weight loss goal: 5-7% body weight (12-17 lbs)

Preventive Care:

  • Dilated eye exam referral (within 3 months of diagnosis)
  • Podiatry referral for foot care education
  • Pneumococcal and influenza vaccinations
  • Hepatitis B vaccination (recommended for diabetic adults)

Follow-Up

  • Return in 2-3 weeks to assess medication tolerance
  • Repeat HbA1c in 3 months
  • Repeat urine albumin-to-creatinine ratio in 3 months
  • Annual comprehensive diabetes care visits

Teaching Points

  1. Diagnosis of diabetes: HbA1c ≥6.5%, fasting glucose ≥126 mg/dL, or random glucose ≥200 mg/dL with symptoms confirms diagnosis. This patient meets criteria with both HbA1c and fasting glucose.
  1. Initial therapy selection: Metformin remains first-line for type 2 diabetes. Given HbA1c >1.5% above target, combination therapy is reasonable at diagnosis. SGLT2 inhibitors provide additional CV and renal benefits.
  1. Comprehensive risk factor management: Diabetes management extends beyond glucose control to include BP, lipids, and preventive care. This patient needs optimization of all cardiovascular risk factors.
  1. Lifestyle barriers: Understanding occupational barriers (truck driving) helps tailor realistic lifestyle recommendations.

All cases for this lecture as Markdown