Obese Woman With Polyuria and Blurred Vision
Mrs. T, aged 40 years, presented to the clinic with complaints of polyuria, polydipsia and blurred vision, progressively worsening over a period of weeks. An obese woman with a family history of diabetes, Mrs. T underwent laboratory studies confirming fasting hyperglycemia (353 mg/dL), glucosuria and elevated hemoglobin (Hb)A1c (10.2%).
She was newly diagnosed with type 2 diabetes and started on metformin (Fortamet, Glucophage, Glumetza, Riomet) 500 mg daily and sent for a dietary consultation and diabetic education. Mrs. T was given a glucometer and told to check her blood glucose at least once a day, and to report to the office in eight days with her readings; further adjustments would be made thereafter.
Unfortunately, Mrs. T failed to report with her blood glucose levels, nor did she appear for a scheduled two-month follow-up visit. Three months after initial presentation, she came into the office with several more complaints. She reported progressive malaise and fatigue, bilateral upper and lower extremity cramps, nausea, abdominal pain and headache.
She denied fever and chills, but a review of systems was positive for an unintentional 50-lb weight loss over the past five months. She reported no cough, chest pain, or palpitations, but admitted to shortness of breath at rest. She had significant nausea but no vomiting and complained of early satiety and slight constipation. No dark or bloody stools were reported.
Mrs. T's abdominal pain was described as generalized achiness and cramp-like, worsening with food. She had urinary frequency, but no dysuria. She had a dull nonlocalized headache and felt off-balance and was having difficulty concentrating. Moreover, her blurry vision and polydipsia had not improved.
Mrs. T stated that she took the metformin as directed and was checking her blood glucose on occasion. Her numbers, including fasting numbers, ranged from 300 mg/dL to 400 mg/dL.
A physical examination revealed an ill-appearing obese woman. Mrs. T was afebrile with the following vitals: BP 152/84, pulse 72 beats per minute and regular, respiratory rate 20 breaths per minute, weight 250 lb, height 68 in (BMI 41.5). Notably, the woman's weight was down from 308 lb, measured four months ago. Her head and neck exam was unremarkable. The ears, nose and throat were also normal with moist mucous membranes.
Mrs. T's lungs were clear to auscultation and percussion, and no cough was apparent. A cardiovascular exam showed regular heart sounds with an intact S1 and S2 and no audible murmurs. Her abdomen was protuberant but revealed normoactive bowel sounds. She was tympanic and soft to percussion and palpation, respectively. Diffuse, nonlocalized tenderness was noted with no rebound or guarding and no fluid wave. No obvious organomegaly or mass was noted on presentation.
Mrs. T's skin had good turgor and was dry to the touch with no rash. A 1-cm abscess actively draining pus-like fluid was noted beneath her right breast. The abscess was mildly tender with surrounding erythema extending approximately 1 cm in every direction. There was no lower-extremity edema, and pulses were 2+ and symmetric.
Neurologic exam revealed a lethargic woman who was oriented to person, place and time. Despite a flat affect, Mrs. T's judgment appeared intact. However, she had mild difficulty expressing her thoughts and completing sentences. Her gait was sluggish and mildly off-balance. Deep tendon reflexes throughout were 2+ and symmetric, and her strength of upper and lower extremities was normal and symmetric. Motor power and sensory perception were intact.
2. Laboratory Data
A study of Mrs. T's lab results requires a retrospective view of those from three months earlier, which included a basic metabolic profile (BMP), urinalysis, lipid panel, HbA1c and urine microalbumin/creatinine ratio. Her fasting blood glucose was 353 mg/dL; blood urea nitrogen and creatinine were 7.0 mg/dL and 0.76 mg/dL, respectively. Sodium, potassium, and calcium levels were all normal.
Mrs. T's carbon dioxide reading was 19 mmol/L (reference range 20-32). Her urine showed a specific gravity of >1.030 and had 3+ glucosuria and 1+ ketonuria. A trace of protein was also found. Her fasting lipid panel expressed a total cholesterol level of 199 mg/dL, triglycerides modestly high at 154 mg/dL, HDL 37 mg/dL, and LDL above goal at 131 mg/dL. The microalbumin/creatinine ratio was normal. Her HbA1c, however, was very high at 10.2%.
When Mrs. T presented to the clinic three months later, a finger-stick glucose was 386 mg/dL, which led to a BMP and complete blood count. WBC was 16.3 × 103/µL with a left shift: neutrophils 13.2 (reference range 1.63-6.96). Hemoglobin and hematocrit were 16.1 g/dL and 50.9%, respectively, and platelets were normal at 327 × 103/µL.