Case Studies

1. Case Study

  • A 64 year old woman with hypertension, sleep apnea, and impaired fasting glucose is sent for annual blood tests. She is not on any medications. You receive the results on your EMR the following week.
  • She had a fasting glucose of 18.8, HgA1c of 11.2 and eGFR of 50. You call her and she denies recent infection but does have increased thirst.
  • As the numbers are so drastically changed from her last blood work, you wonder if an insulin start is advisable, given how high the sugars are and taking in to consideration her eGFR. You contact RACE and speak to an endocrinologist. You review the case and she asks if the patient was sick, symptomatic, or well. She suggests you start the patient immediately on Metformin 500mg BID. She advises that a dose higher than this would likely cause significant GI side effects. In addition, she suggests to also start glyburide 2.5mg BID.
  • You see the patient two days later to review these recommendations. The patient is still well, and happy to start medication. A potential visit to the ED was avoided.

2. Case Study

  • A 67 year old patient with a history of mild chronic kidney disease, GFR of 54, impaired fasting glucose and family history of heart disease presents to your clinic with mild chest pain that mostly occurs at night.
  • He reports recent weight gain the past few months with decrease physical activity. His physical exam is normal and you send him for an ECG and stress test which show a new Left Bundle Branch Block. The report came back “Non-diagnostic due to LBBB.”
  • You contact RACE and a cardiologist reviews the case with you over the phone.  He recommends an echocardiogram to rule out structural heart disease. He also provides some learning points about the treadmill test. He reassures you that there is no need for specialist referral
  • You and the patient are both reassured, and a long wait to see a specialist is avoided.