History of present illness

The patient is a 72-year-old nonsmoking man with a 30-year history of type 2 diabetes. His current therapy consists of Lantus insulin 40 units once daily in the morning and Humalog insulin 12 units 3 times a day with meals. He also takes extended-release metformin 2000 mg/d and reports 100% adherence to this regimen.

His glycated hemoglobin (HbA1c) has improved from 8.1% 3 months ago to 7.7% at this visit. At the previous visit, his mealtime doses of Humalog insulin were adjusted due to hyperglycemia noted prior to noon and evening meals. He has been on his multiple daily injection program for nearly 3 years. Prior to this, his HbA1c was elevated at 9.2% on NPH insulin twice daily and metformin.

Blood glucose monitoring

The patient brings his glucose meter to the visit. Review of the information downloaded from his meter indicates that he is using the meter 2 to 3 times per day with no hypoglycemia in the previous 3 months. Morning glucose levels average 93 to 264 mg/dL, with elevated levels occurring if the patient snacked at bedtime. There are 2 noon levels of 95 to 104 mg/dL. Pre-evening meal glucose levels average 135 to 258 mg/dL, and bedtime levels average 159 to 195 mg/dL. The elevated levels in the mornings following snacking at bedtime and elevated levels occurring primarily prior to evening meal time are the most concerning data from the meter.

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Diet and exercise

The patient reports that he has been making an effort to stay consistent with carbohydrate intake with meals but has been snacking more at bedtime, contributing to the approximate 2-kg weight gain from his previous visit. His snacks at bedtime consist primarily of carbohydrate-containing foods. He has not been exercising regularly in the last 3 months.

Review of systems

  • Eyes: Patient has annual eye exams with no reported retinopathy.
  • Cardiac: He underwent coronary artery bypass graft surgery 20 years ago. He reports no issues with chest pain or shortness of breath with activity. He also has a history of atrial fibrillation and angina. He sees a cardiologist regularly.
  • Hyperlipidemia: Cholesterol panel is checked at the current visit; low-density lipoprotein cholesterol (LDL-C) level is 63 mg/dL.
  • Hypertension: The patient’s  blood pressure is well controlled at 124/72 mm Hg.
  • Weight: The patient’s weight has increased 2 kg from his previous visit.
  • Sleep: The patient reports using a continuous positive airway pressure (CPAP) device daily.
  • Renal: Microalbumin is elevated at this time but has improved from 418.3 mg/L 6 months ago to the current level of 324.3 mg/L. Potassium is checked and is within normal limits. Creatinine is 1.2 mg/dL with an estimated glomerular filtration rate of 53 mL/min/1.73m2.
  • Medications:  The patient’s medications include low-dose aspirin, dabigatran, atenolol, atorvastatin 80 mg/d, hydrochlorothiazide, and lisinopril.

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