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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recognize the signs, symptoms, and risk factors associated with type 2 diabetes mellitus (DM).

  • Identify the comorbidities in type 2 DM associated with insulin resistance (metabolic syndrome).

  • Compare the pharmacotherapeutic options in the management of type 2 DM including mechanism of action, contraindications, and side effects.

  • Describe the role of self-monitoring of blood glucose (SMBG), and identify factors to enhance patient adherence.

  • Develop a patient-specific pharmacotherapeutic plan for the treatment and monitoring of type 2 DM.

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PATIENT PRESENTATION

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Chief Complaint

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“My vision has been blurred lately and it seems to be getting worse.”

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HPI

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Alfonso Giuliani is a 68-year-old man who presents to his family physician’s office complaining of periodic blurred vision for the past month. He further complains of fatigue and lack of energy that prohibits him from working in his garden.

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PMH

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  • HTN × 18 years

  • Dyslipidemia × 8 years

  • Gouty arthritis × 16 years with complicated course of uric acid urolithiasis

  • Hypothyroidism × 15 years

  • Overweight × 25 years

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FH

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Diabetes present in mother. Immigrated to the United States with his mother and sister after their father died suddenly from unknown causes at age 45. One younger sibling died of breast cancer at age 48.

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SH

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Retired candy salesman, married × 46 years with three children. No tobacco use. Drinks one to two glasses of homemade wine with meals. He reports adherence with his medications.

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Meds

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  • Lisinopril 20 mg PO once daily

  • Allopurinol 300 mg PO once daily

  • Levothyroxine 0.088 mg PO once daily

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All

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NKDA

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ROS

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Occasional polydipsia, polyphagia, fatigue, weakness, and blurred vision. Denies chest pain, dyspnea, tachycardia, dizziness or lightheadedness on standing, tingling or numbness in extremities, leg cramps, peripheral edema, changes in bowel movements, GI bloating or pain, nausea or vomiting, urinary incontinence, or presence of skin lesions.

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Physical Examination

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Gen
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The patient is a centrally obese, Caucasian man who appears to be restless and in mild distress

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VS
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BP 124/76 mm Hg without orthostasis, P 80 bpm, RR 18, T 37.2°C; Wt 77 kg, Ht 66″; BMI 27.4 kg/m2

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Skin
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Dry with poor skin turgor; no ulcers or rash

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HEENT
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PERRLA; EOMI; TMs intact; no hemorrhages or exudates on funduscopic examination; mucous membranes normal; nose and throat clear w/o exudates or lesions

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Neck/LN
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Supple; without lymphadenopathy, thyromegaly, or JVD

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