CASE 8

Opening Scenario.

Raymond Stern, a 56-year-old male, comes to the clinic for diabetes follow-up.

Vital Signs.

BP: 139/85 mm Hg.

Temp: 98.0°F (36.7°C).

RR: 15/minute.

HR: 75/minute, regular.

What brings you into the office today? I am here for a diabetes checkup. The last time I saw the doctor
was 6 months ago.

How long have you had diabetes? I have had diabetes for the past 25 years.

What medications are you taking?” I am on NPH insulin. I take 20 units every morning and 15 units in the
evening.

Have you been experiencing any side effects with the medication?” No, it’s been a stable regimen and I
don’t have any problems with it.

Are you able to take these medications consistently every day?” Yes, I never miss any doses.

Do you check your blood sugar regularly at home? How often? What are your levels usually like?” Yes, I
have a blood sugar monitor at home, and I check my blood sugar twice a week. It usually ranges between
120 and 145.

What was your most recent blood sugar reading? I checked 3 days ago and it was 135.

Have you had your hemoglobin A1c measured recently? Do you know what it was?” The last time it was
checked was 6 months ago, and it was 7.

Do you see an eye doctor regularly?” I saw one about 1 year ago, and he said there were no signs of
diabetic eye disease.

Any changes in your vision recently?” No.

Do you see a podiatrist, or a foot doctor, regularly?” I did years ago, but I haven’t in the past couple of
years.

Have you had any foot infections?” No.

Do you ever have symptoms of low blood sugar, such as dizziness, palpitations, confusion, or sweating?”
Yes, I start sweating and can feel my heart racing sometimes. It happens rarely if I miss a meal. I feel better
after drinking orange juice.
Do you ever feel chest pain or palpitations?. Just the palpitations I mentioned. No chest pain.

Do you ever feel short of breath? Any cough? No.

Any headaches, dizziness, weakness, numbness, or tingling?. I have tingling and numbness in my feet all
the time, especially at night, and it’s gotten worse over the past 2 months.

Do you have frequent urination? Any pain with urination or blood in your urine?” No.

Any abdominal pain? Indigestion? Nausea or vomiting? No.

Any changes in your bowel habits, such as constipation, diarrhea, or irregular stools? No.

Do you ever feel anxious or stressed? No.

Any recent weight gain or loss? No.

Any changes in your appetite? No.

Have you ever been diagnosed with high blood pressure? No.

Have you ever been diagnosed with high cholesterol? Yes, it was diagnosed 2 years ago.

Have you ever had any heart problems, such as a cardiac arrest or arrhythmia? I had a heart attack last
year.

Have you ever had a stroke? No.

What medications are you currently taking?” Insulin, lovastatin, aspirin, atenolol.

Do you have any allergies to medications?” None.

Besides diabetes, what medical problems do you have?” I mentioned the heart attack last year and the
high cholesterol, which I have had for 2 years.

Have you ever had any surgeries?” None.

What medical problems run in your family?” My father died at age 60 of a stroke. My mother is healthy.

What is your occupation?” I’m a clerk.

Tell me about your diet. I eat everything that my wife cooks—meat, vegetables, etc. I don’t follow any
special diet.

Do exercise on a regular basis?” No.

Do you drink alcohol? How much? How often?” Yes, whiskey, but only on the weekends.

Do you smoke? Did you ever smoke in the past?” No.

Do you use any recreational drugs?” No.

Where do you live? Who do you live with?” I live in my own home with my wife.
Are you currently sexually active?” Well, I am not doing my job the way I used to, but my wife understands
and is supportive. They told me it is the diabetes. Is it?

Would you describe what problems you are having with your sexual functioning? Do you have problems
attaining or maintaining erections?” I can’t get it up, doc. I don’t even wake up with erections anymore.

How long has this been happening?” One or 2 years.

Has your libido, or sex drive, decreased at all?” I think it’s about the same.

Do you ever have feelings of sadness or depression?” No, I am not depressed.

Physical exam.

Pretend that you have a loss of sharp and dull sensations, vibration sense, and position sense in both feet
(stocking distribution).

Pretend to have a normal knee-jerk reflex and absent ankle reflex.

Sample Closure.

Mr. Stern, the palpitations and sweating you have experienced are most likely due to episodes of low
blood sugar, which may have resulted from a higher-than-normal dose of insulin or from skipping or
delaying meals. The numbness you describe in your feet is probably related to the effect of diabetes on
your nervous system. Better control of your blood sugar may help improve this problem. Many factors,
including diabetes, can cause the erection difficulties you describe. I will need to perform an examination
of your genital area and run some blood tests. At a later point, we may also need to conduct some more
complex tests to identify the cause of your problems. Do you have any questions for me?

Challenging Questions to Ask.

Will I lose my feet, doctor?

Sample Examinee Response.

Amputation is a last resort in patients with diabetes who develop an infection in their feet, but fortunately
we are not at that point. The nerve damage to your feet is uncomfortable, but it will not lead to
amputation as long as you take the proper measures to protect your feet from injury. If we continue to
keep your blood sugar and cholesterol well controlled, we should be able to manage this condition
through medications. We’ll discuss more about your diabetes management later in the visit.