INTRODUCTION
CASE IN DETAIL
DP was admitted to hospital 1 day ago by her physician to optimise her blood sugar control. The blood sugar levels have varied between 16 and 28 mmol/L for about 6 months. She has also complained of polyuria, polydipsia, nocturia and lethargy associated with a weight gain of 7 kg in 3 months.
DP’s diabetes was diagnosed 22 years ago when she presented with polyuria, polydipsia and lethargy. Initially she was treated with oral hypoglycaemic agents, namely metformin and glibenclamide. She is currently on metformin 500 mg three times daily. Fourteen years ago glibenclamide was replaced by regular insulin.
Her insulin regimen includes subcutaneous rapid-acting insulin 30 units given before meals three times daily and long-acting insulin 50 units given before dinner. She self-injects these. She monitors her blood sugar levels only occasionally. She regularly experiences mild episodes of hypoglycaemia, which manifest as lethargy and intense hunger, but has never had seizures or loss of consciousness. She has multiple complications associated with diabetes mellitus:
1. She suffers from recurrent urinary tract infections, for which she has had multiple hospital admissions in the past at irregular intervals, and the last admission was 3 months ago. She is currently managed with prophylactic antibiotic therapy with nitrofurantoin 50 mg daily. She denies any urethral symptoms currently and any side effects associated with this therapy.
3. She was diagnosed with early diabetic nephropathy 3 years ago on detection of proteinuria by her diabetician. She is unaware of her current level of renal function. She suffers from early-morning headaches and bilateral ankle oedema, symptoms suggestive of possible renal failure. The ankle oedema is treated with indapamide hemihydrate 5 mg every morning with good effect. She denies nausea, pruritus or any other symptom of uraemia.
4. She suffers from postural dizziness and chronic diarrhoea, symptoms suggestive of diabetic autonomic neuropathy, but no formal diagnosis has yet been made. She has had watery diarrhoea 7–8 times a day for many years with occasional abdominal discomfort and bloating. Despite multiple investigations including colonoscopy, no diagnosis has been made. Her bloating is treated with cisapride 10 mg daily, with some relief.
5. She has paraesthesias in the feet bilaterally but denies any loss of sensation or chronic superficial pain. She has never had nerve conduction studies performed.
6. She suffers from ischaemic heart disease and experiences frequent unstable angina, almost daily. She also suffers from dyspnoea on minimal exertion, orthopnoea and paroxysmal nocturnal dyspnoea. She has been investigated with exercise stress testing and nuclear imaging within the past 3 months, but surprisingly she is not on any anti-ischaemia therapy.
She denies ever having had a stroke or leg claudication.
She was diagnosed with hypercholesterolaemia 6 months ago, and is treated with simvastatin 40 mg daily. Her latest blood cholesterol level was 4 mmol/L. She denies any side effects associated with this treatment.
She was diagnosed with hypertension 3 years ago and is currently managed with verapamil one tablet daily. She denies any side effects associated with this therapy. Her GP monitors her blood pressure every 2 weeks, and lately the readings have been around 160/90 mmHg.
Her risk factor profile for coronary artery disease, in addition to diabetes mellitus, hypertension and hypercholesterolaemia, includes physical inactivity, obesity and a positive family history. Her mother had an acute myocardial infarction at age 55 and she has a brother aged 63 who suffers from ischaemic heart disease.
She has hypothyroidism, diagnosed many years ago when she presented with lethargy and cold intolerance. She is currently treated with thyroxine 100 µg daily. She does not know the causative pathology behind her hypothyroidism and denies any symptoms suggestive of ongoing thyroid disease.
She has had osteoarthritis involving the distal and proximal interphalangeal joints bilaterally, the lower cervical spine and the lumbar spine, for many years. She experiences frequent pain and impairment of mobility due to stiffness, particularly at night. However, she is not on any treatment.
She has had asthma for almost 20 years. She is currently managed with salbutamol via a metered dose inhaler as needed. Currently she uses it on average four times a week. She has previously been treated with inhaled steroids but the treatment was stopped due to the side effect of persistent cough. She has never been treated with systemic steroids. Five years ago she had an admission to hospital with exacerbation of asthma. She has not had any other hospital admissions for asthma. She has recurrent nocturnal cough. She does not monitor her peak flow. The only trigger factor for exacerbations she has identified is exercise, and she has not noticed any seasonal variation of her asthma symptoms.
She has glaucoma in both eyes, diagnosed 12 years ago. She has previously been treated with laser iridotomy bilaterally and is currently on topical pilocarpine therapy twice daily and topical acetazolamide twice daily.
She was diagnosed with reflux oesophagitis 10 years ago when she presented with burning epigastric pain. She was investigated with upper gastrointestinal endoscopy. She is being treated with omeprazole 10 mg twice daily but still suffers from dyspeptic symptoms.
She was diagnosed with Ménière’s disease 5 years ago. Although she experiences the symptoms of tinnitus and vertigo very often she is not on any treatment. She denies deafness.
She was diagnosed with obstructive sleep apnoea 2 years ago and is managed with nocturnal nasal continuous positive airway pressure; however, she still has daytime somnolence and early-morning headaches.
She started gaining weight after commencing insulin therapy 15 years ago. She has previously attempted to lose weight, particularly through dieting, without much success. She has never attempted regular exercise.
Her medications in summary are metformin, insulin, nitrofurantoin, indapamide, cisapride, verapamil, salbutamol and thyroxine. She claims appropriate compliance with all her medications.
She is intolerant to sulfur-containing medications, which cause ‘dizziness’, the description of which suggests presyncope rather than vertigo.
She has never smoked. She was a heavy alcohol consumer 15 years ago when she drank 50 g/day of whisky for almost 2 years. She now consumes alcohol only on social occasions.
She lives with a female friend. She has been married three times before and the last partner she divorced 10 years ago. She has one daughter, aged 27, from her first marriage. She keeps in regular contact with her daughter, who is well and lives separately.
She is independent with the activities of self-care but requires assistance with shopping and housekeeping. Her friend provides help with these.
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