Mrs. D, aged 58 years, has a history of uncontrolled type 2 diabetes mellitus. She visited her primary care nurse practitioner’s office, reporting that her diabetes specialist had recently moved away and there is a 1-month waiting period to be seen by a different diabetes specialist. The patient is concerned about her continued elevated blood glucose level, which ranges from 200 to 400 mg/dL. She reported worsening of vision, frequent urination, and increased thirst. She denied urinary hesitancy or discomfort during urination.

The patient’s medical history included class III obesity, hypertension, hyperlipidemia, recurrent urinary tract infections, diabetic neuropathy, and a myocardial infarction 3 years ago.

She was diagnosed with type 2 diabetes mellitus 20 years ago. The patient had been on oral hypoglycemic agents for 4 years prior to transitioning to insulin therapy. With progressive weight gain secondary to a sedentary lifestyle and poor dietary habits, she had required a steady increase in insulin dosage during the past few years. She now takes more than 240 units of insulin daily via subcutaneous injections. For the last month, her former diabetes specialist had been titrating up her insulin regimen due to persistent hyperglycemia. The patient performs self-monitoring of her blood glucose level about 4 to 5 times daily, usually prior to administering her scheduled insulin doses: fasting, pre-lunch, pre-dinner, and at bedtime.

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The patient’s medication profile includes:

  • Lantus 60 units subcutaneous twice daily
  • Insulin aspart 42 units before each meal (breakfast, lunch, and dinner)
  • Insulin aspart as a supplemental sliding scale regimen, starting with glucose 150 mg/dL; every 30-mg/dL dosage of glucose will provide 3 units of additional insulin before each meal and at bedtime
  • Rosuvastatin 40 mg by mouth daily
  • Lisinopril 30 mg by mouth twice daily
  • Hydrocholorothiazide 25 mg by mouth daily
  • Gabapentin 600 mg by mouth 3 times daily
  • Ciproflaxin 500 mg by mouth every 12 hours as needed for urinary tract infection
  • Aspirin 325 mg by mouth once daily

Recent labs (done 1 month ago):

  • Hemoglobin A1c: 9.4%
  • Blood urea nitrogen (BUN): 26
  • Creatinine: 1.1
  • Glucose: 300 mg/dL
  • Urinalysis: positive glycosuria, no pyuria or proteinuria
  • Complete blood count (CBC) with differential: within normal limits
  • Liver function tests: within normal limits

When asked about her diet, the patient said she eats 3 large meals per day with 3 snacks in between meals. She eats pizza and fried chicken once a week, snacks on occasional candy bars, and has recently stopped drinking non-diet soda. Her portion sizes are relatively large. The patient she said that she had seen a dietitian 1 month ago and is not ready to make any additional changes to her diet at this time.


Physical examination revealed an obese adult female without signs of distress. The patient was alert, oriented, conversant, normocephalic, and atraumatic. The patient’s oropharynx was pink, and her tonsils had no exudates. She had velvety hyperpigmentation on her neck. Her lungs were clear to auscultation with equal expansion. Her respiration was unlabored and well profused with no wheezing. The patient’s heart rate was regular with no murmur. Her abdomen was large, soft, nondistended, and nontender. She displayed no lipoatrophy or lipohypertrophy at insulin injection sites. She had decreased sensation in her feet.

The patient’s vital signs were as follows:

  • Blood pressure: 128/86 mm Hg
  • Pulse rate: 90 beats per minute
  • Respiratory rate: 22 breaths per minute
  • Body temperature: 98.8° F
  • Weight: 322 lbs
  • Height: 5’8”
  • BMI: 49