Mrs.
S is a 45-yr. old woman who presents with a 2 month history of fatigue and
excessive thirst. She is a new patient to your practice, relevant history
includes possible borderline hypertension, obesity and two children whose
birth weights exceeded 9 lbs. She is a 1-2 pack a day smoker and family
history is significant for premature CAD, hypertension and diabetes. Her exam
is normal and BP is 135/82 mmHg. Fasting Glucose 138 mg/dl. Other results
include a total cholesterol 215, HDL-C 31 mg/dl. j
A
week later Mrs. S returns and further fasting glucose is 167 mg/dl. Subsequent
HbA1c is 7.1% (normal range 3.6-6.4%). Mrs. S comes to the office to discuss
her results. You tell her she has diabetes and
refer her for diabetes education and nutritional counseling.
Mrs.
S follows up 1 year later for her annual diabetes evaluation, having lost 20
lbs in weight, adhering to her diet and exercise plan, home glucose monitoring
reveals fasting glucose readings in the 130-150mg/dl range and HbA1c of 7.2%.
Exam is normal, BP 128/75mmhg. You would now:
Refer
her for a dilated retinal exam.
Obtain
urine for assessment of proteinuria.
Strongly
encourage Mrs. S. to stop smoking.
Assess
lower extremities for evidence of foot deformity, ulcers and sensory
abnormalities.
All
of the above.
Answer
is 5: All of the above
There
is good evidence to support regular retinal examination and early intervention
and treatment in reducing the risk of blindness in diabetic individuals.
Patients with diabetes benefit from screening for proteinuria and
microalbuminuria and treatment with ACE inhibitors can reduce the incidence of
renal failure. Smoking is known to increase the risk of developing CAD and
diabetes significantly increases women's risk of CAD. The patient should
therefore be strongly encouraged and given appropriate support to stop
smoking.
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