The patient is a 56-year-old male who has type 2 diabetes; he was first diagnosed with the disease 12 years ago. He has come to see his primary care provider (PCP) because, for the past six weeks, he has had numbness and tingling in both feet, extending from the tips of the toes to just below the ankles. For the first four weeks, these sensations were intermittent, but now they are constant. He states that he also has occasional episodes of substernal chest pain; these are brief and occur both at rest and when he is active.
The patient is 5 feet 6 inches, weighs 267 pounds, and BMI of 43.1, placing him in the obese category. He is currently prescribed metformin, 800 mg twice a day, HCTZ, 25 mg twice a day, and lisinopril, 5 mg once a day. He had been prescribed post-prandial insulin but stopped taking it eight months ago because he "felt fine without it." His blood pressure today is 168/92 mm Hg. Aside from the subjective complaints of numbness and tingling in both feet and chest pain, the physical examination and health history are unremarkable. The patient smokes 10-15 cigarettes a day. He does not drink alcohol, and he has a desk job and a sedentary lifestyle.
When asked, the patient cannot identify any long-term complications of diabetes, and although he knows that high serum glucose is not good, he does not know why. He has not spoken in-depth about his disease with a healthcare professional for several years, and he last saw the PCP 14 months ago. The patient cannot remember when he last had an eye examination in the past several years. He confesses that he never examines his feet and does not take any special precautions to protect them. He occasionally skips his metformin doses and antihypertensives, he never exercises, and he measures his blood sugar two to three times a month. Although his primary care provider has offered the patient consultations with a dietician, a physical therapist for an exercise program, appointments with a smoking cessation program, and the name and address of a diabetes support group, the patient has not followed up with any of these as he considers them unnecessary and inconvenient.
The patient is married, and according to the patient his wife "thinks he looks fine," and she does not understand why he needs to “take all those medications” if the patient is relatively happy with his current state of health.
The primary care provider does a 12-lead ECG and obtains a blood sample for measurement of A1C, blood glucose, serum cholesterol, BUN, creatinine, and estimated GFR. The office has laboratory capabilities, and the results are:
- A1C - 9.4%
- Blood glucose - 219 mg/dL
- Serum cholesterol - 199 mg/dL
- BUN - 24 mg/dL
- Creatinine - 1.9 mg/dL
- Estimated GFR – 50-54 mL/min/1.73 m2
- The 12-lead ECG shows evidence of a mild degree of left ventricular hypertrophy.
Based on the patient's medical history, his somatic complaints, and the results of the laboratory tests and the ECG, the PCP informs the patient that he has atherosclerotic heart disease, kidney damage, and peripheral neuropathy. The PCP also informs the patient that he is at risk for diabetic retinopathy, an extension and worsening of heart disease and kidney disease, and foot ulcers, and only immediate changes in his lifestyle and health habits can prevent these complications.