Kevin U. is a 54-year-old divorced male who presents for his three-month diabetes evaluation.  Kevin is a high school graduate who previously worked as a self-employed logger but now raises beef cows and does some crop farming on the family farm.  Patient is referred for continued diabetes education from his Endocrinologist, Dr. Pehling.  Kevin is accompanied today by his mother and reports it is acceptable to discuss his medical care in her presence.  Kevin presents with his blood glucose meter and denies any learning limitations or physical limitations such as hearing, visual or behavioral which would affect his ability to comprehend the information provided.

Social History

Kevin is one of two children. His sister is alive, reports her as healthy and is a mother to three healthy children.  Father is deceased, cause of death pulmonary fibrosis.  Mother is alive with diagnosis of osteoporosis, HTN, and hypocholesteremia.  Kevin has one son who is 30 years old and healthy.

Kevin was diagnosed with type 1 DM at the age of 18 months.  He denies any hospitalizations for hypoglycemia or hyperglycemia/DKA other than his first diagnosis.  Currently, he is experiencing hypoglycemia unawareness so he limits his driving to only local areas and will check his BG before starting the vehicle; glucose tablets and glucagon are readily available.  Two surgeries are documented with one being a same day surgery 14 years ago to repair an inguinal hernia and most recently had a cataract removed from his LT eye.  Right eye is free from cataracts at this time.  Immunizations are up to date, last pneumococcal vaccine documented as 2015, Tdap 03/14/2014, and influenza vaccine received every year.  Kevin reports as a child he did experience chicken pox, strep throat, and viral illnesses.  Review of medical record shows a positive titer for mumps and rubella.  No known tick exposure, but due to his history of working as a logger, a Lyme titer should be considered.  Colonoscopy completed in 2014.  Diverticulitis was present with one polyp removed.  Last PSA was in 2016 with result of 3.0.

Kevin denies any immediate family members who have mental illness or substance abuse.

Denies tobacco use presently; however, he did chew tobacco when he was in his early 20’s.

Occasional alcohol intake in the form of beer once every two weeks and reports smoking marijuana for the past ten years every evening to help with the neuropathy pain in hands and feet.  CAGE is negative.  Blood glucose meter was down loaded, and readings are reviewed.  Patient on average has been monitoring his blood glucose one to three times a day with average reading being 197.

Allergies

There is a documented reported allergy to Penicillin.  Mother reports that when he was in elementary school and was being treated for strep throat, he developed rash two days into the prescription.  Mom is unsure of any further details, just that the physician told her never to take penicillin again.

Current Medications

Lantus 65 units SQ twice daily

Humalog- insulin to carb ratio of 1:6 with a correction scale of 2 units for every 50 above BG of 150.  Administer SQ thirty minutes before each meal

Atorvastatin 80 mg daily

Lisinopril 20 mg one daily

Multivitamin daily

Mega Red 500 mg daily

Aspirin 81 mg daily

Gabapentin 300 mg one tablet three times a day

Melatonin 6 mg by mouth every evening

Glucagon kit to be used as needed for hypoglycemia

Viagra 100 mg ½ – 1 tablet as needed

Lab results

Total cholesterol of 198                                  A1c 8.8                                                ALT 51

LDL 140                                                           Cr 1.9                                                   PSA 3.0

HDL 40                                                            GFR 42                                                 HGB 14.6

Triglyceride 155                                              AST 45                                                 PLT 286,000

RUMAL 268                                                     Glucose 260                                        TSH 2.6

Vitamin D 45

Chief Complaint

Kevin’s main complaint today is the burning and tingling sensation he is experiencing in his hands and feet.  Has been using gabapentin with minimal relief, applies CBD oil twice daily which he reports provides immediate short term relief.  Kevin does state the marijuana does provide the best relief for him.  He also voices his frustration with the State of Minnesota’s process for medical marijuana and lack of markets in his area.

Blood glucose readings have been in the 200-300 range, and he is happy with this.  Kevin prefers to have his numbers higher due to his hypoglycemic unawareness.  Last episode of low BG was three weeks ago; he reportedly was ill with a GI bug, limited oral intake but continued to take insulin.  His son stopped for a visit and found him unresponsive and did administer glucagon.

Kevin continues to exercise daily by walking 2 miles on his indoor treadmill; denies any shortness of breath or chest pain with this activity.

Physical Exam

Patient is noted to be alert and orientated times 4.  PEARL, mild film noted over RT eye, possible beginning of cataract. Peripheral vision screen is completed and noted to be intact.  Denies any burning or itching of eyes.  Denies any nasal congestion or drainage, nasal polyp in RT nare noted on exam.  Dental caries are noted, ear exam completed with no redness of ear canal or turbinate’s, no drainage noted.  Whisper test completed, and hearing noted to be intact.  Neck negative for any lymphadenopathy, no carotid bruits noted, and thyroid is noted to be with in normal size, no lumps or abnormalities noted.  No jugular vein distention noted. Cardiac is noted to S1 & S2, negative for murmur.  Lungs auscultate clear, and Kevin denies any shortness of breath.  Abdomen is soft and non-tender with bowel sounds being present. Dullness is noted to percussion over liver and noted to be 8 cm midclavicular line, no abnormalities noted on palpitation.  Spleen is intact.

Spine is midline with no deformities noted.  Genital exam deferred due to his mother’s presence.  Distal and central pulses are present and are a +2. Skin exam reveals topic dermatitis on his bilateral posterior elbows, bilateral hand and lower leg redness.  No open areas are noted.   A foot exam completed including a monofilament exam.  There is a callous noted on the bottom of his RT foot, below his great toe.  No open areas are noted.  A monofilament exam completed 5/10 on RT foot and an 8/10 on LT foot. Onychomycosis noted on bilateral nail beds.  There is no evidence of Charcot joint; Kevin does see a Podiatrist for nail care every three months.

Evaluation and Plan

Review of lab work shows elevated cholesterol, A1c, glucose, RUMAL, creatinine/GFR and liver labs.  Total cholesterol is with the recommended range of <200. However the LDL is out of range at 140.  Recommended level for LDL is <100.  LDL is also known as the “bad cholesterol which also has a genetic component.  Better diet control and exercise can assist the atorvastatin in lowering the LDL and raising the HDL to a level of >50.  “People with high blood triglycerides usually also have lower HDL cholesterol. Genetic factors, type 2 diabetes, smoking, being overweight and being sedentary can all lower HDL cholesterol.” (heart.org, 2018) On average for past three months, Kevin’s glucose has been in the range of 180-200.  This is documented by his A1c.  The A1c is an average of glucose readings over the past 2-3 months.  It is measured by the amount of glucose that is attached to red blood cells circulating in the body.  This is an acceptable A1c reading for a brittle type 1 diabetic who is experiencing hypoglycemic unawareness.  Adjusting insulin to lower the A1c could have a detrimental effect on the individual, so no changes will be recommended regarding insulin.   Kevin has been a diabetic for over fifty years and his kidneys are being stressed.  This is based on his RUMAL (the amount of albumin/protein released in system when kidneys are stressed) Kevin’s results are >300 which is considered moderate kidney disease.  Normal RUMAL is up to 30, mild kidney disease is 30-300, and >300 shows moderate kidney disease.  Consider increasing the dose of his ACE inhibitor to 40 mg once daily.  The creatinine is elevated at 1.9, normal range being 0.5-1.5.  The creatinine shows how kidneys are functioning, but the GFR which shows how the kidneys are filtering is diminished at 45.  Any result <60 is considered a sign of kidney disease. If the dose of ACE inhibitor is increased, careful monitoring of renal functions and electrolytes is needed. The liver functions test AST is used to detect a liver injury or active or chronic liver problem.  The normal range for males is 8-46.  The ALT which is mildly elevated at 51.  This test is used to detect liver injuries or long-term liver disease.  Normal range is 5-40.  The slight elevation could be related to use of atorvastatin or could be related to “fatty liver.”  Monitoring should be completed every three months.

The benefits of diet and exercise and how simple changes can improve blood pressure, glucose readings and cholesterol results should be reviewed in detail with Kevin and his mother.  A referral to a dietician should be considered.  Encourage Kevin to continue to see the Podiatrist every three months for foot exams and nail care.  Consider Penicillin testing for the questionable allergy to penicillin when he was a child. One can question if the rash was related to the strep infection or the medication.  Completing a penicillin challenge could prove beneficial in the future if he should develop a foot ulcer which needs antibiotic coverage. A Lyme titer should be completed to determine if Lyme disease is enhancing his neuropathy pain in hands and feet.  One could consider a referral to a vascular surgeon for ABI assessment and evaluation for peripheral vascular disease.  Further referrals for massage therapist, acupuncture or physical therapy should be considered.  Medication change from gabapentin to Lyrica could also be considered.  Encourage Kevin to continue to monitor blood glucose before driving farm equipment or his vehicle.  Review automobile safety; if there is an accident which involves a person with diabetes, their license is automatically suspended until a provider deems the individual safe behind the wheel.  The potential to be with out a driver’s license could be months to lifetime.  Blood glucose should be monitored before meals and at bedtime, minimum of four times a day.  EKG should be completed, for baseline comparison.  Reinforce the need for dental exam every six months along with regular Ophthalmologist visits for dilated eye exams.  Kevin will be seen back in three months for evaluation of diabetes and discussion following referrals to the recommended providers.