New Doctor for a Man with Diabetes and Hypertension

Michael E. Hull

A recently retired 65-year-old African-American man with a 10-year history of type 2 diabetes mellitus (DM) moved to a new city to be near his grandchildren. He presented to his new primary care physician's office for routine evaluation. Over the preceding 12 months he had been making efforts to increase his physical activity with a daily 30-minute brisk walk. He had received extensive instruction regarding an optimal diet for diabetes, but he admitted to frequent indiscretions. He produced a diary of his self-monitored whole-blood glucose values that was incomplete, and indicated sporadically inadequate control, with most fasting values in the 100-125 mg/dL range, but some above 160mg/dL. His prior medical records indicated a history of microalbuminuria of 100mg/day on several occasions.

In addition to diabetes, other medical issues included chronic hypertension and gastroesophageal reflux disease. His daily medications were insulin, hydrochlorothiazide, enalapril, aspirin, and omeprazole. He was a nonsmoker. His mother had a history of chronic hypertension and died at age 71 of complications of end-stage renal disease and congestive heart failure.

The patient's vital signs showed a temperature of 36.8°C, blood pressure of 148/86 mm Hg, heart rate of 72/min, and respiratory rate of 12/min. He weighed 97 kg and was 185 cm tall, with a body mass index of 28.3 kg/m2.

The patient had a generally healthy appearance. Of note on physical examination were fundoscopic findings of macular edema and focal dot-blot hemorrhages. Laboratory values obtained at the office visit were as follows:

Analyte

HA1c Sodium Potassium Chloride

Value, Conventional Units

141 mmol/L 4.5 mmol/L 108 mmol/L

Reference Interval, Conventional Units

Value, SI Units

Same Same Same Same

Reference Interval, SI Units

Same Same Same Same

Reference

Value,

Interval,

Reference

Conventional

Conventional

Value,

Interval,

Analyte

Units

Units

SI Units

SI Units

Carbon dioxide

24 mmol/L

23-31

Same

Same

Urea nitrogen

25 mg/dL

8-25

8.9 mmol/L

2.9-8.9

Creatinine

1.4 mg/dL

0.8-1.4

124 mmol/L

71-124

Glucose

187 mg/dL

70-110

10.3 mmol/L

3.9-6.1

Calcium

8.4 mg/dL

8.6-10.3

2.10 mmol/L

2.15-2.58

Alanine transaminase

33 IU/L

13-40

0.55 mkat/L

0.22-0.67

Aspartate transaminase

28 IU/L

19-48

0.47 mkat/L

0.32-0.80

Alkaline phophatase

75 IU/L

38-126

1.78 mkat/L

0.9-1.98

Bilirubin

1.0 mg/dL

0.2-1.1

15 mmol/L

3-19

Albumin

4.7 g/dL

3.6-5.0

47 g/L

36-50

Hb

14 g/dL

14-18

140 g/L

140-180

Hct

41%

40-50

0.41

0.40-0.50

Platelets

352 x 102/ml

150-450

352 x 109/L

150 - 450

Urinalysis

Specific gravity

1.020

pH

6

Protein

2+

Negative

Nitrite

Negative

Negative

Leukocyte esterase

Negative

Negative

Glucose

Negative

Negative

Ketones

Negative

Negative

Urine microscopy

RBC

5/hpf

Negative

WBC

0/hpf

Few

No bacteria or yeast;

No casts

The physician diagnosed mild, nonproliferative diabetic retinopathy and mild chronic renal disease secondary to diabetes mellitus and hypertension. She was interested in quantifying the current renal dysfunction and stratifying the patient's risk for future endstage renal disease. Incorporating knowledge of the patient's plasma creatinine, age, and African-American race, she estimated a glomerular filtration rate (GFR) of 65 mL/min per 1.73 m2 using the Modification of Diet in Renal Disease study (MDRD) equation [see Eq. (9.3)] that she had recently read about. She used the "GFR calculator" on the National Kidney Foundation Website to perform the calculation. She also ordered a 24-hour urine protein determination and started the patient on a low-salt, low-protein diet. The urine protein determination was 1.0 g/24 hours; normal was 0-150 mg/24 hours.

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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