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VOLUME 1 ISSUE 3 CASE SW	SW is a 49-year-old man who presents for an employment physical. He has not seen a physician in the last 10 years, but considers himself healthy. He has had no hospitalizations as an adult.
PHYSICAL EXAM »  Height: 5 ft. 8 in. »  Weight: 200 lbs. »  Body mass index (BMI): 30 »  Waist circumference: 42 in. »  Pulse: 84 »  Blood pressure: 160/100 mm Hg »  Diminished pedal pulses »  Absent Achilles reflexes »  Remainder of examination is normal LABORATORY VALUES »  Fasting blood glucose: 210 mg/dL »  Uric acid: 9 mg/100 mL »  Remainder of chemistry panel is normal »  Lipid profile   --  Total cholesterol: 194 mg/dL   --  Triglycerides; 320 mg/dL   --  HDL: 18 mg/dL   --  Calculated LDL cholesterol: 112 mg/dL   --  hs CRP: 2.0 mg/dL (normal, <0.8)   --  Microalbumin/creatinine ratio: 40 µg/mg creatinine (normal, <30) NAVIGATION »  Q1: What findings are of concern to you at this visit? »  Q2: What other findings are suggestive of the Insulin Resistance Syndrome? »  Q3: How would you categorize SW’s blood pressure? »  Q4: What are the benefits of treating hypertension? »  Q5: What is the recommended initial therapy for patients with hypertension? »  Q6: What other management strategies would you institute at this time? »  Q7: How do you explain SW’s worsening lipid profile and fasting glucose levels? »  Q8: What is your diagnosis now? »  Q9: What are your treatment goals for SW? »  Q10: How should you modify SW’s antihypertensive regimen at this time?	1 Year Later Despite frequent reminders from his PCP, SW does not keep scheduled appointments and then appears 1 year later for a flu shot with a 20-lb weight gain, a blood pressure of 160/100 mm Hg, and a random glucose of 210 mg/dL. His lipids include total cholesterol of 194 mg/dL, triglycerides of 320 mg/dL, HDL cholesterol of 18 mg/dL, and calculated LDL cholesterol of 112 mg/dL. His A1c is 8.6%. He states that he has been getting his prescriptions for ramipril and atorvastatin refilled at work and that he takes them most of the time. Q: What is your diagnosis now? A: With a random glucose of 210 mg/dL, SW has progressed from insulin resistance and impaired glucose tolerance to type 2 diabetes. Although A1c values are not included as diagnostic criteria for diabetes, his A1c clearly is abnormal. SW also has progressed to stage 2 hypertension, and still displays dyslipidemia (high triglycerides, low HDL).
	Questions? Contact 1-888-JEFF-CME (533-3263) or http://jeffline.jefferson.edu/jeffcme
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