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Case 4
A 45-year-old African American man with a history of obesity, hypertension and hypercholesteremia has been under your care for the past three years. He has a family history of both T2DM (type 2 diabetes mellitus) and cardiovascular disease but no history of cardiovascular events. About a year ago, the patient requested blood glucose screening because his brother had just been diagnosed with T2DM. At that time, his HbA1c level was 5.8%. You recommended weight loss and exercise of 30 minutes daily. The patient reports intermittent success with weight loss but has been unable to sustain it. He reports attempting to walk most days but notes that work and family obligations as well as inclement weather often make this impossible.

Medications: simvastatin 20 mg daily aspirin 81 mg daily lisinopril 20mg daily. He reports taking these medications consistently.
Physical examination: BP 140/90. He has also gained 4 pounds, resulting in an increase in BMI (body-mass index) from 31 to 32 kg/m2over the past year.
The patient has acanthosis nigricans behind his neck.
Normal cardiorespiratory, abdominal, and neurologic findings.
Lab results:
HbA1c 6.3%
FBS 115mg/dl
Lipids: LDL 98, HDL 35 mg/dL and Triglycerides197 mg/dL
Additional lab tests show normal renal and liver function, including a serum creatinine of 0.9 mg/dL, SGOT of 36 mg/dL, and a SGPT of 42 md/dL.
Thyroid function tests are normal.

Question two: What are your diagnoses for this patient and what are the differentials you would also consider? What would your management plan be for each of his diagnoses? Include diagnostics, therapeutics, education/counseling and f/u.

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