Longstanding DM, insulin and new finding of HF
Lucy is a 48-year-old woman with 18 years of type 2 diabetes (T2DM). She had gestational diabetes with each of her pregnancies, but following her third pregnancy, the diabetes never went away. She took metformin for a long time, but then later medications were added, including glimepiride, and more recently in the last two years, insulin glargine (U100) 48 units daily. Lucy reports that her blood glucose was usually within the target ranges early on, but over the last 10 years, she has had a harder time maintaining control. She doesn’t think she is making progress, only treading water as her A1c continues to climb and she seems to require more medications to be added.
Lucy has gained 11 lbs. in the past month. She also has swelling of both legs and feet and experiences shortness of breath when climbing stairs. She attributed this to her thyroid as she was also feeling far more tired than normal. However, her CBC and thyroid tests were normal. She was also screened for depression, and this did not appear to be the issue.
Past Medical History: Gestational diabetes, T2DM 2001, mixed hyperlipidemia 2001, hypertension 1998, NAFLD 2008.
Family History: T2DM and HTN in several first-degree relatives
Medications: Enalapril/HCT 10/25 mg once daily, simvastatin 40 mg daily, ASA 81 mg daily, metformin 1000 mg bid, glimepiride 4 mg bid, glargine 48 units once daily. No supplements.
Social History: Works in an accountant’s office, commercial insurance. She is married and has three children, and a grandchild on the way. No tobacco or alcohol. No time for exercise.
She has tried to lose weight by dieting in the past and failed. Her diet is restricted only in simple carbohydrates. Her husband complains she wasn’t eating enough.
Exam: BMI 32.6 kg/m2, 5 ft. 4 inches,
190 lbs., BP 138/88, P 86, R 18
CV: HRRR, +S3, PMI widened and laterally displaced, plus two pitting edema both lower legs to mid-calf with stasis dermatitis
Resp: Bibasilar crackles noted
Ext: Normal monofilament exam, no lesions or ulcers on her feet
eGFR = 66 ml/min
HbA1c = 8.6%
Lipids: Total cholesterol 206, HDL -C 28, TG 220, LDL-C 134 mg/dL
Urine albumin/creatinine ratio: 22mg/g