# Clinical Cases: Diabetes Management in Primary Care ## 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 ![Blood glucose monitoring](case_01_image.jpg) *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. 2. **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. 3. **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. 4. **Lifestyle barriers:** Understanding occupational barriers (truck driving) helps tailor realistic lifestyle recommendations. --- ## Case 2: Diabetes with Hypoglycemia Concerns ### Patient Demographics - **Age:** 68 years old - **Sex:** Female - **Occupation:** Retired librarian ### Chief Complaint "I've been having shaky spells and I'm worried about my diabetes medicine." ### History of Present Illness Mrs. Eleanor Martinez is a 68-year-old woman with type 2 diabetes for 15 years who presents with recurrent episodes of shakiness, sweating, and confusion over the past month. These episodes occur 2-3 times weekly, typically mid-morning or before dinner. She has been checking her glucose during symptoms, which ranges from 52-68 mg/dL. Her daughter noticed her "acting confused" last week, and her glucose was 48 mg/dL. She has been taking her medications as prescribed. Her HbA1c 3 months ago was 6.1%. She recently had decreased appetite due to a stomach bug 2 weeks ago and has been eating less since then. She also started a new blood pressure medication (metoprolol) 6 weeks ago. ### Past Medical History - Type 2 diabetes mellitus (15 years) - Hypertension - Chronic kidney disease stage 3b (eGFR 38) - Atrial fibrillation - Hypothyroidism - Osteoporosis ### Current Medications - Glipizide 10mg twice daily - Metformin 1000mg twice daily - Lisinopril 20mg daily - Metoprolol succinate 50mg daily - Warfarin 5mg daily - Levothyroxine 75mcg daily - Alendronate 70mg weekly - Calcium/Vitamin D ### Family History - Mother: Type 2 diabetes - Father: Heart disease ### Social History - Never smoker - No alcohol - Widowed, lives alone - Daughter lives nearby and checks on her daily ### Physical Examination - **Vital Signs:** BP 118/68 mmHg (sitting), 108/62 (standing), HR 62, BMI 26 - **General:** Thin elderly woman, appears anxious - **Cardiovascular:** Irregularly irregular rhythm - **Neurologic:** Alert, oriented, no focal deficits - **Extremities:** No edema, mild peripheral neuropathy bilateral feet ### Assessment and Diagnosis 1. **Recurrent hypoglycemia** - Due to sulfonylurea in setting of reduced oral intake and declining renal function 2. **Type 2 diabetes with overtreatment** - HbA1c 6.1% below target for this patient 3. **Chronic kidney disease stage 3b** - Contributes to sulfonylurea accumulation 4. **Orthostatic hypotension** - Possibly medication-related ### Management Plan **For Hypoglycemia:** - **STOP glipizide** - Sulfonylureas are high-risk in elderly patients with CKD and unpredictable eating - Continue metformin at reduced dose: 500mg twice daily (appropriate for eGFR 30-45) - Relaxed glycemic target: HbA1c 7.5-8.0% for this elderly patient with comorbidities - Hypoglycemia education for patient and daughter - Glucagon emergency kit prescribed with teaching **For Blood Pressure:** - Given orthostatic hypotension, may need to reduce metoprolol - Recheck BP with lying/standing measurements in 2 weeks - Beta-blocker can mask hypoglycemia symptoms (tachycardia) - important counseling point **Safety Assessment:** - Discuss driving safety until hypoglycemia resolved - Ensure patient has rapid-acting glucose available (glucose tablets) - Daughter to call if patient seems confused - Consider continuous glucose monitoring (CGM) if recurrent hypoglycemia ### Follow-Up - Phone check in 1 week to assess for hypoglycemia - Return visit in 2-3 weeks - Repeat HbA1c in 3 months (expect rise to 7-8%) ### Teaching Points 1. **Glycemic targets in elderly:** ADA recommends less stringent targets (HbA1c <8.0-8.5%) for older adults with limited life expectancy, multiple comorbidities, or high hypoglycemia risk. Overtreatment is harmful. 2. **Sulfonylureas and hypoglycemia risk:** Sulfonylureas cause insulin secretion independent of glucose levels, leading to hypoglycemia risk, especially in elderly patients with CKD (reduced drug clearance) and irregular eating patterns. 3. **Beta-blockers and hypoglycemia:** Beta-blockers can mask adrenergic symptoms of hypoglycemia (tachycardia, tremor) while preserving neuroglycopenic symptoms (confusion). Patients and families should recognize all hypoglycemia warning signs. 4. **Precipitants of hypoglycemia:** Decreased oral intake, renal dysfunction (reduced drug clearance), and drug interactions can all precipitate hypoglycemia in previously stable patients.