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Asked by LambSmith
James Taylor, a 75 year-old Caucasian man come to you for the first time. He moved from New York this month and is looking to get established. He has diabetes and hypertension and has been taking atenolol and glyburide for the last ten years. He does have a history of myocardial infarction approximately 6 months ago, but refused angioplasty at that time. He endorses some fatigue, polyuria and blurred vision. He denies chest pain or dyspnea. He has pain in his legs, especially when walking and numbness in his feet. He tells you his cholesterol “has always been a bit high,” but “I’m on enough pills as it is and it really doesn’t do much good to lower my cholesterol at my age.” He denies smoking, is not on or following any diet and leads a sedentary lifestyle. As far as family history, his sister has diabetes since her early 60’s. His mother was also diagnosed with diabetes at age 78, when she became comatose and was found to have an extremely high blood glucose level. Unlike the patient and his sister, his mother was considered “slender”.Â
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The patient is 5′ 8″ tall and weighs 235lbs. BP 168/90, HR 68 and regular. Fundoscopic examination reveals silver wiring and exudates in the retinae. He has a left carotid bruit, but no cardiac murmur. His abdomen is obese. He has trace pedal edema with diminished dorsalis pedis pulses and diminished pinprick and vibration.
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Lab values: A1C: 10%, HDL 31mg/dl, LDL 155mg/dl, triglycerides 298 mg/dl and serum creatinine 1.9mg/dl. U/A revealed 2+ protein by dipstick, but no cells or casts.Â
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Questions:
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What is your differential and primary diagnosis? (please give rationale).
What diagnostic tests would you order with a pt with his history and and problem list?
What argument should be made regarding cholesterol lowering and the use of lipid-lowering agents?
What long-term morbidity can result is Mr. Taylor’s diabetes management does not improve? (Pt teaching/education).
Based on the pathophysiology of type II diabetes, how should the patient be treated in order to improve outcomes and to avoid risks of treatment? (Treatment plan).
What age-related changes accounted for the acute syndrome in Mr. Taylor’s mother?
What practical obstacles in the elderly have an impact on diabetes management?
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HEALTH SCIENCE
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