YEAR 2 PBL CASE 5 January 2016

STUDENT VERSION
Case Content: Year 2 PBL Case 5
Learning objectives for each PBL:
1) Orient self and others to the current PBL case and session and review goals of session.
2) Using a patients case as a framework for discussion, work as a group to identify gaps in knowledge
and transform these learning issues into questions that can be researched. All students must
research all issues chosen by the group for further study.
3) Identify and explore resources for self-directed learning.
4) Gather information independently from these sources and synthesize it in order to effectively discuss
new knowledge with your group.
5) Share your findings in a collaborative way that improves the collective knowledge of the group.
6) Give and receive feedback on the effectiveness of your contributions to the groups learning.
Learning objectives specific to this case:
1. Assess and treat a patient with diabetes
2. Use evidence-based medicine skills to identify the quantitative benefit to the patient for
recommendations your group makes to improve her health vs the cost; how large is the benefit of
each treatment proposed? What number of patients treated with this intervention will benefit,
compared to the total number treated? What is each intervention estimated to cost, compared with
the cost of not intervening?
For expert help finding additional resources, call 852-8532 from 10 am to 2 pm on weekdays or email
kornref@louisville.edu
HPI: Raymona Stevens is a 65-year-old new patient to your family medicine residency clinic practice who is
changing doctors due to the retirement of her former physician. She reports on her clinic intake form that
she has been treated for diabetes since 2010, and that her medication is metformin 1500 mg three times a
day. Her last doctor retired over 6 months ago; it took her awhile to get into a new primary care doc. She
thinks the last labs she had drawn were over a year ago.
When you ask more about how she manages her diabetes and what lifestyle changes she has made, she
reports that she only eats white stuff (bread, potatoes, rice) 2 times a day and fried foods once or twice
a week at the advice of her former doctor, and that she knows she needs to exercise more but has been
having pains in her lower right leg with walking, which had been her main form of exercise. She doesnt
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YEAR 2 PBL CASE 5 January 2016

STUDENT VERSION
check her blood sugar or use a glucometer because no one told me I needed to.
When you ask about her leg pain, she says that when she walks more than a block or so, it feels like she
has a charley horse in her right calf and she has to stop walking until the pain goes away.
Additional history on the intake form shows:
Past medical History:
Pregnancy at age 23 and 25, both resulting in live births
Hysterectomy at age 45 due to endometriosis
Family History:
Mother died from a heart attack at age 61
Mother had diabetes
Father died from colon cancer at age 70
Medications and Allergies:
No drug allergies
Metformin 1500mg TID
Ibuprofen 100mg BID as needed for pain
Smokes about 1 pack of cigarettes a week, has cut down from pack a day formerly
Lives with her husband of 41 years, who is her emergency contact.
Physical Exam:
Blood Pressure 150/95 Pulse 87 RR 16 Wt 226 lbs Ht 5 7
General Appearance: Overweight female, well groomed
HEENT: EOMI, moist mucous membranes, no thyromegaly
CV: RRR, no murmurs
Resp: clear bilaterally
Abd : Soft, non-tender, unable to appreciate liver or spleen due to habitus
Skin: Well healed incision on lower abdomen, Skin otherwise with normal texture, color
Neuro: Foot monofilament exam demonstrates some decreased ability to feel pressure in both feet, but
otherwise normal
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YEAR 2 PBL CASE 5 January 2016

STUDENT VERSION
Extremities: pulses palpable in bilateral dorsalis pedis and posterior tibialis distribution
You discuss the main goals of this visit and advise Mrs. Stevens that a new set of baseline labs are needed
with close follow-up in the next week to address findings. In addition, you explain that her blood pressure
is high and will need follow-up and action after the next office visit as well. You refer her to a nutritionist to
discuss optimal dietary changes, and ask her to hold off on exercise until you can get more test results
back. You also explain that you need to refer her to an ophthalmologist for an exam and recommendations.
Finally, you tell her she needs special testing to look for problems with blood flow that could be causing the
pain in her right calf.
She is skeptical because she has been feeling OK and will have to take additional time off work for these
visits and work-up, but reluctantly agrees to get the tests done and see you in the following week.
She has the ordered diagnostic tests performed and they return:
Hba1c: 9.8%
Fasting blood sugar: 163
Post-Prandial Blood sugar: 298
Creatinine: 1.3
Spot urine albumin to creatinine ratio 45 ug/mg
Total cholesterol 210, LDL 120, HDL 36, Triglycerides 241
Right ankle-brachial index (ABI): 0.52
Left ankle-brachial index (ABI): 0.9
Mrs. Stevens has a 9 am appointment with you the following day. What course of management will you
propose?
References and Additional Reading for faculty only:
1. Standards of Medical Care in Diabetes2015. American Diabetes Association. January 2015, 38 (1)
2. Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient-Centered Approach: Update to a
Position Statement of the American Diabetes Association and the European Association for the Study
of Diabetes. Silvio E. Inzucchi, Richard M. Bergenstal, John B. Buse, Michaela Diamant, Ele Ferrannini,
Michael Nauck, Anne L. Peters, Apostolos Tsapas, Richard Wender and David R. Matthews. Diabetes
Care January 2015 vol. 38 no. 1 140-149
3. Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of
Recent Evidence: A Scientific Statement From the American Heart Association and the American
Diabetes Association. Caroline S. Fox, Co-Chair; Sherita Hill Golden, Co-Chair on behalf of writing
groups of the American Heart Association and the American Diabetes Association. Diabetes Care
September 2015 vol. 38 no. 9 1777-1803
4. Diabetic Kidney Disease: A Report From an ADA Consensus Conference. Katherine R. Tuttle, George
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STUDENT VERSION

5.

6.

7.

8.

L. Bakris, Rudolf W. Bilous, Jane L. Chiang, Ian H. de Boer, Jordi Goldstein-Fuchs, Irl B. Hirsch, Kamyar
Kalantar-Zadeh, Andrew S. Narva, Sankar D. Navaneethan, Joshua J. Neumiller, Uptal D. Patel, Robert
E. Ratner, Adam T. Whaley-Connell and Mark E. Molitch. Diabetes Care October 2014 vol. 37 no. 10
2864-28
Exercise and Type 2 Diabetes - The American College of Sports Medicine and the American Diabetes
Association: joint position statement. Sheri R. Colberg, PHD, FACSM, Ronald J. Sigal, MD, MPH,
FRCP(C), Bo Fernhall, PHD, FACSM, Judith G. Regensteiner, PHD, Bryan J. Blissmer, PHD, Richard R.
Rubin, PHD, Lisa Chasan-Taber, SCD, FACSM, Ann L. Albright, PHD, RD and Barry Braun, PHD, FACSM.
Diabetes Care December 2010 vol. 33 no. 12 e147-e167 83
Dyslipidemia Management in Adults With Diabetes. The initial draft of this paper was prepared by
Steven M. Haffner, MD. This paper was peer-reviewed, modified, and approved by the Professional
Practice Committee and the Executive Committee, November 1997. Most recent review/revision,
2003. Diabetes Care January 2004 vol. 27 no. suppl 1 s68-s71
Peripheral Arterial Disease in People With Diabetes. Consensus Panel: Peter Sheehan, MD, Chair;
Michael Edmonds, MD; James L. Januzzi, Jr., MD, FACC (American College of Cardiology); Judith
Regensteiner, PhD; Lee Sanders, DPM; and Mellick Sykes, MD. Diabetes Care December 2003 vol. 26
no. 12 3333-3341
Hypertension Management in Adults With Diabetes. The initial draft of this position statement was
prepared by Carlos Arauz-Pacheco, MD, Marian A. Parrott, MD, MPH, and Phillip Raskin, MD. The
paper was peer-reviewed, modified, and approved by the Professional Practice Committee and the
Executive Committee, October 2001. Diabetes Care January 2004 vol. 27 no. suppl 1 s65-s67