Type 2 DM and worsening nephropathy
Manuel is a 65-year-old Filipino man who has had diabetes for 10 years. He reports that since he came to the United States to be with his family four years ago it has been harder to manage his diabetes. He is taking both oral diabetes meds and insulin, and he is not sure if they are working.
He used to check his blood glucose regularly but stopped as the constant high readings frustrated him. He thinks he is now dropping low as he gets sweaty, shaky and hungry if he misses a meal or if he is physically active in the evening.
Manuel is trying to follow a recommended meal plan, but he finds that he is always hungry if he cuts down on his portions of white rice. He walks 30 minutes every morning after dropping his grandchildren off at school. He is active around the house and is a primary caregiver of his grandchildren.
Past Medical History: T2 diabetes 2001, mixed hyperlipidemia 2001, hypertension 1998
Medications: Enalapril/HCT 10/25 mg once daily, atorvastatin 40 mg daily, ASA 81 mg daily, metformin 1000 mg bid, glyburide
5 mg bid, U100 glargine 38 units once daily when he feels like he needs it. No supplements.
Social History: Retired salesclerk. On Medicare. He is married and has two children and four grandchildren. He lives with his wife, daughter and two grandsons. No tobacco or alcohol. Conventional Filipino diet includes lots of chicken, vegetables and fruit, but also lots of oil and soy in food preparation. White rice is the centerpiece of every meal.
Exam: BMI 24 kg/m2, 5 ft 8 inches,160lbs, BP 138/88, P 86, R 18
General: Appears normal but has truncal obesity
Resp: CTA A and P
Ext: Normal monofilament exam, no lesions or ulcers on feet, edema noted to both lower extremities
eGFR = 30 ml/min
HbA1c = 7.8%
Lipids: Total cholesterol 170, TG – 240, HDL-C 42, LDL-C – 80 mg/dL
Urine albumin/creatinine ratio: 482 mg/g