A nurse practitioner who works at the student health center is scheduled to see Ms. A. M., a 23-year-old female graduate student, for a routine physical. The patient was diagnosed with type 2 diabetes mellitus approximately 2 years ago by her hometown primary care provider. She has a history of childhood obesity that continued through young adulthood, and she was initially diagnosed with glucose intolerance, hypertension, and dyslipidemia 1 year prior to progressing to diabetes. “It happened all at once.… With work, school, and everything else, I haven’t been following my doctor’s advice as much as I should,” said Ms. A. M. She had failed to make lifestyle modifications prior to starting oral antihyperglycemic therapy. She recalls that her parents had type 2 diabetes.

The patient had seen a dietitian once (after diagnosis of glucose intolerance) but has been too busy to follow up since. She acknowledges that she has not been compliant with a diabetic diet. The patient’s diet includes three meals a day with multiple snacks in between. Breakfast and lunch are usually on the go:  for breakfast, a bagel with cream cheese or a donut with a large cup of coffee; for lunch, two slices of pizza, a large burger, or cold cut sandwich with soda. She has a large dinner at home, with rice, pasta, or potatoes often accounting for more than 50% of the meal. In between meals, she consumes a variety of snack bars. She does not perform self-glucose monitoring at home.

Ms. A. M. reports leading a busy life. Her exercise is limited to walking to classes on campus and working part-time as a waitress at a chain restaurant. She routinely feels a lack of energy and gets 5 to 6 hours of sleep per night.

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Her medication profile includes metformin 1 g twice daily, atorvastatin 40 mg at bedtime, and lisinopril 10 mg once daily, all of which are taken orally.

No recent labs were available for review at time of the office visit. The patient is unaware of her last hemoglobin A1c, but recalls that her primary care provider had increased her dose of metformin from 500 mg twice daily to the current dose approximately 5 months ago. 

Her social history includes casual dating. She has been sexually active with several male partners and uses condoms during most sexual encounters. Her last menstrual period was 25 days ago, cycles every 28 days, and lasts 5 to 6 days. The patient has no previous pregnancies. She drinks socially and admits to binge drinking at parties on occasion. She does not use cigarettes or recreational drugs. 

The patient’s vital signs were as follows:

  • Blood pressure: 130/82
  • Pulse rate: 79 beats per minute
  • Respiratory rate: 19 breaths per minute
  • Body temperature: 98.8° F
  • Weight: 186 lbs
  • Height: 5’5”
  • BMI: 31
  • Point of care random glucose: 201 mg/dL
  • Point of care hemoglobin A1c: 7.8%


Physical examination reveals a well-developed, obese adult female without signs of distress. The patient is alert and oriented, conversant with fluent speech, and appears to be a good historian. She is normocephalic and atraumatic. Her scleras are white with vision grossly intact. Her oropharynx is pink, her tonsils have no exudate, and she has no thyroid nodules. Her lungs are clear to auscultation with equal expansion, unlabored respiration, and no wheezing. Her heart rate is regular with no murmur. Her abdomen is large, soft, nondistended, and nontender with no hepatosplenomegaly. Her feet have palpable pulses, and bunions are noted on the left third and right fifth toe.