52-year old black female.
• Diagnosed with type 2 diabetes 6 years ago but did to follow up with recommendations for care.
• Now complaining of weakness in her right foot and itching rash in her groin area.
Question 1 What questions would you like to ask her about her symptoms?
• Patient says her foot has been weak for about a month and is difficult to dorsiflex; feels numb.
• Denies any other weakness, numbness, difficulty speaking or walking, syncope, or seizures. She finds that watching television particularly in the evening, is becoming a problem because her eyes “are tired” more.
• Has had some increased thirst and gets up more often at night to urinate, sometimes excessively.
• Says she has a rash on and off for many years. It is worse when the weather is warm. It also occurs in her armpits. She gets some relief from salt baths. She occasionally gets a boil in these areas.
• Denies any chest pain, shortness of breath, edema, change in bowel habits, or skin ulcers.
Question 2 What other personal and family-related questions would you like to ask her about her diabetes?
• Patient remembers being told her blood sugar was “around 200” when she was first diagnosed. She had gone for a work physical and felt fine at the time and saw no need for expensive drugs.
• Her mother and sister have diabetes. Both of them were diagnosed in their 40’s and are on pills and injections.
• Has been completely asymptomatic, except for rash, until the foot weakness.
• Has gained 18 pounds over the past year and eats a diet high in fats and refined sugars.
• Employed as banking executive and gets little exercise.
Question 3 What would you like to ask about her about her medical history?
• Obese female in no acute distress.
• T= 37 C orally; P=80 and regular; RR=15 and unlabored; BP= 162/98 right arm (sitting); weight 84 kg.
• Erythematous moist rash in both inguinal areas, beneath both breasts, and in the axillae.
• No petechiae or eccymoses.
• Many dime-sized hyper pigmented spots located on the anterior shins
• Pupils equal and round, fundi with mild arteriolar narrowing.
• Nares and tympanic membranes clear.
• Pharynx clear.
• Neck without bruits or thyromegaly.
• Lungs clear to auscultation and percussion.
• Cardiac examination with distant heart tones, a regular rate and rhythm without murmurs or gallops.
• Abdomen moderately obese with bowel sounds heard in all four quadrants; no abdominal bruits, tenderness, masses or organomegaly.
• Extremities without edema; arterial pulses are diminished in volume but palpable in both feet.
• Alert and oriented.
• Cranial nerves II through XII intact (including normal vision acuity with glasses).
• Limb strength 5/5 throughout except 2/5 on dorsiflexion of the right foot.
• Sensory perception to light touch diminished on the soles of both feet along the metatarsal bar
• Deep tendon reflexes 1+ and symmetric throughout.
• Gait normal except for accommodation to a right foot drop; negative Romberg test.
Question 4. What are the pertinent positives and negatives on the physical examination?
Question 5. What laboratory tests would you order now?
INITIAL LABORATORY RESULTS
• Serum electrolytes, including BUN and creatinine, calcium, and magnesium all within normal limits.
• Random glucose=253mg/dL (taken at 11 am).
• Urine dipstick positive for glucose, negative for protein; microscopic without significant cellular or infectious findings.
• Wet prep of smear from skin rash consistent with fungal spores and mycelia.
• Electrocardiogram with evidence of early left ventricular hypertrophy (LVH) by voltage.
Please answer the case study questions.