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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?	Medical History JJ was last seen in the office 6 months ago (he missed his last appointment because of work-related travel). The A1c level measured 1 week prior to that visit had been 8.9%. That result prompted adjustment of his drug regimen. Specifically, the dose of metformin was titrated from 500 mg BID to the current dose of 1000 mg BID. No other tests were obtained on that occasion. JJ’s serum creatinine was 0.8 mg/dL and total cholesterol was 225 mg/dL when last checked one year ago. The patient states that he is following an 1800 kcal diet and has been walking 1 to 2 miles approximately three times weekly. Home blood glucose tests have ranged from 140 to 265 mg/Dl in the past several weeks. Q: What would you do at this visit? A: This patient needs to be referred for an ophthalmologic exam, including dilated funduscopy and tonometry. In addition, important laboratory values must be documented, as listed below.
	Questions? Contact 1-888-JEFF-CME (533-3263) or http://jeffline.jefferson.edu/jeffcme
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