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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: Is there a link between microalbuminuria and cardiovascular disease? A: The mortality rate (predominantly from cardiovascular disease) among patients with diabetic nephropathy is unusually high, compared with those without nephropathy. Microalbuminuria is a recognized risk factor for macrovascular complications of diabetes. There is a clustering of hyperlipidemia, abnormal coagulation/fibrinolysis, echocardiographic evidence of left ventricular hypertrophy, and evidence of endothelial dysfunction in persons with microalbuminuria. The endothelial injury that generates microalbuminuria is believed to be a diffuse systemic phenomenon that also affects coronary and cerebral vascular territories.6-8
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