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VOLUME 1 ISSUE 4 CASE JJ	JJ is a 53-year-old man with type 2 diabetes diagnosed 15 years ago, who returns to the office for a scheduled follow-up visit.
CHIEF COMPLAINT Intermittent blurry vision CURRENT MEDICATIONS »  Glyburide 10 mg BID »  Metformin 1000 mg BID »  Fosinopril 20 mg QD FAMILY AND SOCIAL HISTORY Father had diabetes and died from heart failure. Patient is married with two grown children. REVIEW OF SYSTEMS Remarkable for polyuria 2–3 times at night and 5–6 times during the day, tingling sensation in the fingers and toes. No chest discomfort or intermittent claudication. EXAMINATION »  General:   --  temp 98.3°   --  weight 212 lb; height 5' 9"   --  pulse 70/min, regular   --  blood pressure 135/74 mm hg »  HEENT: Anicteric »  Funduscopy: Normal »  Neck: Supple, no goiter »  Chest: Clear to auscultation »  Heart: Normal findings »  Abdomen: Benign »  Neurologic: Impaired sensation to nylon filament in both feet; hypoactive tendon reflexes »  Extremities: No foot ulcer; normal foot pulses PROBLEMS »  Type 2 diabetes »  Blurry vision—probably from uncontrolled diabetes »  Diabetic neuropathy »  Hypertension—fairly well controlled NAVIGATION »  Q1: What would you do at this visit? »  Q2: How would you interpret JJ’s laboratory results? »  Q3: What factors are associated with microalbuminuria in the general population? »  Q4: What is the significance of microalbuminuria in the natural history of diabetic nephropathy? »  Q5: What are the risk factors for nephropathy in persons with diabetes? »  Q6: Is there a link between microalbuminuria and cardiovascular disease? »  Q7: What are the current methods of screening for diabetic nephropathy? »  Q8: What interventions have been proven to delay the progression of diabetic nephropathy? »  Q9: What is your overall approach to the management of JJ’s problems?	Q: How would you interpret JJ’s laboratory results? A: The A1c result indicates uncontrolled diabetes. Other laboratory results indicate that JJ has dyslipidemia. The Third Report of the National Cholesterol Education Program (NCEP) on detection, evaluation, and treatment of high blood cholesterol in adults (ATP III)1 guidelines stipulate an HDL-cholesterol goal of >40 mg/dL in men. Because of the increased macrovascular disease burden in diabetes, there is good consensus that LDL-cholesterol level should be maintained at <100 mg/dL, even in the absence of cardiovascular events. In addition, JJ has significant microalbuminuria. Expressed as a ratio of creatinine concentration in spot urine specimens, the upper limit of normal is < 30 µg microalbumin/mg creatinine. Values of 30 to 300 µg/mg indicate significant microalbuminuria.2
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