Test Your Knowledge #495

On physical exam, his height is 68" and weight 214 lb (body mass index [BMI] 31). His blood pressure (BP) is 154/90. The remainder of his exam is notable only for abdominal obesity and a decreased right pedal pulse. He stopped smoking 10 years ago and has 1 glass of wine with dinner several nights per week. He takes an occasional over-the-counter antacid for heartburn and a non-sedating antihistamine for springtime allergies.

John’s family history is positive for Type 2 diabetes in both parents. Father had a heart attack at age 61 with subsequent coronary artery bypass graft surgery. Mother has osteoporosis; his children are both alive and well.

On further discussion, John believes that his weight gain is related to the change in his living situation. In the past, his wife cooked most of their meals and tried to "make them nutritious." His daughters frequently invite him for dinner, but he typically declines so as "not to be a burden." They are worried about his health and whether "he is taking care of himself."

Labs: After an 8-hour fast, fasting blood sugar (FBS) = 142 mg/dL on initial evaluation and 139 mg/dL on reevaluation, indicating Type 2 diabetes. High-density lipoproteins (HDL): 36; Low-density lipoproteins (LDL): 147; TG: 130 mg/dL.

After a frank discussion about his risk of cardiovascular disease and diabetes, EC expresses a desire to begin a trial of lifestyle changes prior to beginning any diabetes medication. You recommend that EC start a moderate walking program and that he begin to join his daughters for dinner at least twice a week. You also recommend that he and his daughter make an appointment to see a nutritionist/certified diabetes education (CDE). You prescribe the following medications: simvastatin 20 mg daily; losartan/HCTZ 100/12.5 mg daily; ASA 81 mg daily. You ask him to return in 2 months.

On his return visit, he has lost 8 lbs. His weight now is 201 lbs (BMI 29.7); BP 126/74. He is taking medications as prescribed and is participating in a walking group at work 2 mornings per week. He is eating dinner with his daughters 2 nights per week and they are preparing foods for him to eat at home and work.

Labs today were: HbA1c: 7.6; LDL: 95; TG: 130

EC agrees that despite his efforts, he has not achieved optimal glycemic control and agrees to begin medication to treat his diabetes.

Patient begins on metformin therapy. 

Which of the following referrals is NOT required for John at this time?

1. Ophthalmology referral
2. Endocrinology referral
3. Podiatry referral
4. Dental referral
5. Flu shot