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Case History
Patient is a
68-year-old African American female. It is 3am and she is admitted
with congestive heart failure. You note in your exhaustive H&P that
she has had Type 2 diabetes for at least 8 years. She has been taking
glyburide 5 mg (2 tabs bid), metformin 1000 mg (1 tab bid) and rosiglitazone
8 mg (1 tab qd).
Key Medical History
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Tobacco:
Patient smoked in the past |
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Alcohol:
Patient does not drink |
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Family History:
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6 siblings. 4 have been diagnosed with diabetes.
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1 sister (age 71) died with DM and heart myocardial
infarction. |
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1 sister alive – takes insulin |
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1 brother - no information other than has DM |
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1 brother who takes pills |
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Patient
has 2 daughters and 1 son. She thinks a daughter may have had diabetes
in pregnancy |
|
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Eye exam:
did see optometrist for new glasses last year. No mention of diabetes |
Key Social History
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Patient
lives alone. |
Key Physical Exam
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Blood
Pressure: 173/94 (not orthostatic) |
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Lungs: Rales |
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legs: edema to thighs |
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Foot exam:
Normal sensation (with 5.01 monofilament) |
Key Lab Tests
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HgA1c 9.7
(found in computer system - clearly not back on admission labs) |
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Creatinine 2.1
|
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AST, ALT: both 30% over
the upper limit of normal.
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