• Gangrene is far more frequent in diabetic than in non-diabetic patients, as artheriosclerosis leading to absence of peripheral pulses and ischemia are increased by a factor of 3 to 10 times by the presence of diabetes. 
• In addition, failure of wounds to heal is a classical symptom of decompensated diabetes. 
• Congestive heart failure is a common complication of diabetes in the elderly, both through coronary ischemia and non-specific cardiomyopathy, which leads to ventricular failure and dilatation independently of the presence of coronary ischemia. 
• Hypertension is a frequent companion to type II diabetes, which is associated with near-doubling of the prevalence of hypertension.
  
  

2. Why was a serious complication such as gangrene preceded by minimal symptoms of diabetes?

• Type II diabetes is preceded by several years of asymptomatic abnormality of glucose tolerance. 
• All epidemiological studies confirm that this silent period is associated with increased prevalence and acceleration of macrovascular disease.
  
  

3. Calculate the LDL cholesterol by Friedenwald's formula (total cholesterol - triglycerides divided by 5 - HDL cholesterol = LDL cholesterol).

• The LDL cholesterol is 180 mg/dl. The formula is not valid if triglycerides > 500 mg/dl.
  
  

4. Identify the cardiovascular and microvascular risk factors in the history, physical examination, and laboratory data in this patient.

Macrovascular risk factors are: hyperglycemia itself, elevated serum cholesterol (desirable levels below 200 mg/dl), or high LOW density lipoprotein cholesterol (LDL > 160 mg/dl; desirable < 130 mg/dl, or in the presence of 2 risk factors--in this case: male, diabetic, hypertensive, preexisting cardiovascular disease, HDL<35 mg/dl--LDL goal < 100 mg/dl); low HIGH density lipoprotein-Cholesterol (desirable over 35 mg/dl); elevated triglycerides (high over 400 mg/dl, desirable level below 200 mg/dl). Hyperglycemia, hypercholesterolemia, and hypertension are also associated with increased prevalence of microvascular disease, specifically diabetic retinopathy and nephropathy.

5. What are the management objectives from what you know about the clinical conditions of this patient?

• Main glycemic objectives with appropriate pharmacological management (oral agents, insulin, or combination of both) in type II diabetes include HbA1c < 7% for lean and younger patients (less than 65 years of age), with action suggested (pharmacological dose increments or additional therapy) if HbA1c > 8%. 
• In obese patients, or patients with advanced cardiovascular disease or renal disease, or disease that shortens life expectancy, glycemic goals are lessened. 
• The risk-benefit ratio of more intensive treatment, especially with insulin, is not yet known. 
• In a patient such as this, a suggested goal of HbA1c may be 8 to 8.5%. 
• This patient has combined dyslipidemia, which makes him a potential candidate for a fibrate type of drug (Gemfibrozil), to reduce triglycerides and increase HDL. 
• Should his total cholesterol remain over 200 mg/dl or LDL over 100 mg/dl, another hypolipidemic agent designed to lower LDL cholesterol, such as HMG co-reductase inhibitors, (Simvastatin, Pravastatin, Levastatin, etc.) or a bile sequestrant (Cholestyramine) is also indicated.