Type 2 DM and worsening nephropathy
Marco is a 65-year-old Filipino man who has had diabetes for 10 years. He reports that since he came to the U.S. 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. He is not certain these are working. He used to check his blood glucose regularly, but stopped as the constant high readings would frustrate him.
Marco 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. He 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.
Allergies: NKDA
Social History: Retired sale clerk. On Medicare. He is married and has two children and four grandchildren. He lives with his wife, daughter and two grandchildren. No tobacco, alcohol. Conventional Filipino diet, lots of chicken, vegetables and fruit, but food preparation is heavy on oil and salt. White rice is the centerpiece of every meal.
Exam: BMI 24 kg/m2, 5 ft. 8 inches, weight 160 lbs., BP 138/88, P 86, R 18, pain 0/10
General: Appears normal, but has a large belly
CV: HRRR
Resp: CTA A and P
Extremities: Normal monofilament exam, no lesions or ulcers on feet, edema? (has gross proteinuria)
Labs:
eGFR = 30 ml/min
Cr 1.6
HbA1c = 7.8%
Lipids: Total cholesterol 170, TG – 240, HDL-C 42, LDL-C – 80 mg/dL
Urine albumin/creatinine ratio: 482 mg/g