Case study on diabetes and congestive heart failure

Case Study Three

Present Illness

Mr. Tompkins is a 62-year-old Native American male. He comes in because of increasing dyspnea on minimal exertion (DOE) and swelling in his legs for the past week. He has also noticed that his lower legs are red, warm to the touch, and mildly painful—4 out of 10 on a pain scale. His blood sugars have been high: 190 fasting in the morning and 290 before evening meal. His diet has not changed, although he has been less active the past week due to the swelling in his legs. He denies chest pain, cough, fever, hemoptysis, taking any over-the-counter medications, polyuria, polydipsia, and polyphagia.

Medical History

Diabetes mellitus (DM) type II for 5 years
Family History

His wife, children, and four living siblings have DM type II. His father and two brothers, now deceased, had hypertension and DM type II; causes of deaths are not known.

Medications

Metformin increased to 1 Gm bid 30 days month ago to bring his sugars down about 20 to 30 points in the morning and evening.

Allergies

None reported

Social History

Patient does not smoke or drink.

Physical Examination

Weight 225 lbs +10 pounds since his last visit 1 month ago, BMI 30

BP - 158/100, P - 100, T - 98, O2 sats - 94% room air at rest

S3 & S4 gallop, + JVD, bibasilar crackles, 3+ pitting edema.

The skin on his ankles to mid-calf is red, warm, slightly scaly, and tender to the touch.

Labs

TSH -5.2 (0.5- 4.5)
Free T4 - 0.8 (0.8-1.7)
Free T3 - 1.8 (2.0-4.8)

A1C - 9 (<5.7)
CBC
Hemoglobin - 12 (13.8 - 17.2)
Hematocrit - 38 (41 - 50)
RBC indices are normal
WBC - 12 (4.5 - 10.5)
BUN - 22 (7 - 20)
Creatinine - 0.6 (0.8 - 1.4)
Total cholesterol - 240
HDL - 35
LDL - 180
Triglycerides - 400

Radiology

Results of a recent chest X-ray are pending.