Case Study #1: Sandra (Managing diabetes for several years)

Sandra is a married 45-year-old with two children aged 11 and 13 years. She has been your patient for approximately five years. Ten years ago, she underwent cholecystectomy to remove gallstones. She was diagnosed with T2DM six years ago and presents with dyslipidemia. Her BMI is 29.5 kg/m2, although it has fluctuated between 27 and 29 kg/m2 for the past five years. When she was diagnosed with T2DM, Sandra initially attempted lifestyle interventions. She initiated metformin approximately four years ago after her A1c rose from a range of 6.2-6.6% to 7.5%. Moreover, at that time, she was unable to maintain a consistent diet/activity regimen due to time constraints imposed by work and family. She reports social alcohol use (1-2 drinks/month) and does not smoke. In addition to metformin, she takes 20 mg of simvastatin nightly and a multivitamin each day. Monofilament and reflex tests are normal. A neurologic examination is unremarkable, and no retinopathy was noted on an ophthalmoscope examination.

Her mother was diagnosed with T2DM, and her older brother (age 49) also has T2DM and dyslipidemia. He father has a history of coronary artery disease and myocardial infarction.

Metformin at a dose of 2,000 milligrams has maintained her A1c below 7% until now. Lab results from six weeks prior show an A1c of 7.7% and a fasting glucose of 120 mg/dL. You request that she have another A1c and fasting glucose completed prior to today's appointment, which indicated an A1c of 7.8% and a fasting glucose of 124 mg/dL.

At the visit, she discusses her difficulty maintaining a healthy diet and regular activity, though she continues to make an effort to do so. However, she has gained approximately five pounds since her most recent last visit six months ago.

Other pertinent laboratory results and vital signs are as follows:

  • Pulse: 65 bpm
  • BP: 128/76 mm Hg
  • Total Cholesterol: 180 mg/dL
  • LDL-C: 95 mg/dL
  • HDL-C: 50 mg/dL
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