A 58-year-old male had type 2 diabetes mellitus diagnosed about three and a half years ago. In the first year after diagnosis he was maintained on diet alone with good blood sugar control but then increasing levels of blood sugar led to the use of metformin, which was gradually increased to 1000 mg with breakfast and dinner. With this regime, he obtained better blood sugar control with a hemoglobin A1C of 6.8% (normal to 6%). Subsequent to that he was lost to follow up and had not been checking his blood sugars at home. He now reappeared because he felt he should see his physician for a check up and, more especially, has been troubled with the onset of other problems. He has not seen an ophthalmologist in over two years and his vision is now blurred even with glasses. He also is experiencing pain in his legs on walking two blocks. This pain resolves once he sits down and rests. He has noted pain in his toes which is worse at night and impairs his ability to sleep. When he finally got to sleep, he frequently awakes with drenching night sweats. His family history is strongly positive for diabetes.
His past medical history is positive for hypertension diagnosed about five years ago; his surgical history is negative. Aside from metformin, his only other medication is hydrochlorothiazide 50 mg each morning. There are no known allergies. In addition to diabetes, his family history is remarkable for hypertension and coronary artery disease. He is married, works as a construction worker, and has two adult children, both in good health. He does not smoke or drink. Review of systems is positive for episodic constipation and impotence.
The physical examination is as follows:
Height: 5'10", weight 210 pounds (12 pounds more than at his last visit), pulse 84 and regular, blood pressure 155/94.
Eyes: Visual fields grossly intact. Extraocular muscle movements full. Funduscopic revealed bilateral microaneurysms.
Ears, nose, mouth, throat, and neck were normal.
Carotids: Left carotid bruit.
Heart: Regular rate and rhythm, S1 and S2 normal, no S3 or S4. Grade I/VI systolic ejection murmur heard at the base.
Abdominal exam: Normal.
Rectal: Normal. Stool negative for occult blood.
Prostate: Smooth enlargement. Genitalia: Normal male.
Extremities: No clubbing, cyanosis or edema.
Skin: Normal. Lymph nodes: Negative.
Peripheral vascular exam: Remarkable for bilateral femoral bruits and lack of pulses in the feet, as well as the left carotid bruit indicated above.
Neurologic: Cranials - normal. Motor - normal. Sensory - decreased vibration and pinprick sensation in the feet. Deep tendon reflexes - areflexic. Romberg: Negative. Cerebellar: Normal. Gait: Normal.
Laboratory data: Hemoglobin A1C 10.1%. BUN 17, creatinine 1.3, sodium 140, potassium 4.9, chloride 90, CO2 24. Urinalysis: Normal except for 1+ glucose. Total cholesterol 210 mg%. HDL 32 mg%. LDL 150 mg%. Triglycerides 290 mg%. TSH 1.2 mU/ml.