Case Study #2: Hector (Diagnosed with diabetes but has worsening glycemic control)
Hector is a 69-year-old Hispanic male with an eleven-year history of T2DM who presents for a routine follow up visit. At his most recent visit (one year ago), you prescribed liraglutide, but Hector never filled the prescription due to cost. He has no glucose readings, but he notes thrice-nightly nocturia. He currently takes metformin at 1000 mg twice daily. His diabetes is complicated by neuropathy, nephropathy (his eGFR is 48 mL/min/1.73 m2), and CAD (he has received an angioplasty and stent to his right carotid artery). He also has a history of hypertension, dyslipidemia, and depression. He is bothered by numbness in his toes, primarily at night.
His exam is notable for a BP of 136/82 mmHg and abdominal obesity. He takes lisinopril and rouvastatin in addition to his medications for diabetes. Hector works as a custodian and has lived alone since his wife’s death four years ago. He smokes half a pack of cigarettes per day and denies using alcohol or illicit drugs. A recent laboratory workup includes the following values:
Fasting glucose: 198 mg/dL
LDL-C: 109 mg/dL
Triglycerides: 254 mg/dL
HDL-C: 27 mg/dL.
Hector has a history of elevated A1c levels. He visits the office every 6-12 months on average, and he has ventured little information regarding his diet and activity levels outside of work.