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A 47-year-old woman was found to have hyperglycemia at a health fair when a random blood glucose level was 227 mg/dL (12.6 mmol/L). Several days later, a fasting blood glucose value was 147 mg/dL (8.2 mmol/L). She has no previous history of diabetes, is alarmed by the possibility of having this disorder, and seeks your advice.
The patient has been treated for hypertension for 10 years, currently with amlodipine 10 mg by mouth daily. She was once told that her cholesterol value was "borderline high" but does not know the value.
She denies symptoms of diabetes, chest pain, shortness of breath, heart disease, stroke, or circulatory problems of the lower extremities.
She estimates her current weight at 165 lbs (75 kg). She thinks she weighed 120 lbs (54 kg) at age 21 years but gained weight with each of her three pregnancies and did not return to her nonpregnant weight after each delivery. She weighed 155 lbs one year ago but gained weight following retirement from her job as an elementary school teacher. No family medical history is available because she was adopted. She does not eat breakfast, has a modest lunch, and consumes most of her calories at supper and in the evening.
On examination, blood pressure is 140/85 mmHg supine and 140/90 mmHg upright with a regular heart rate of 76 beats/minute. She weighs 169 lbs, with a body mass index (BMI) of 30.9 kg/m 2 . Fundoscopic examination reveals no evidence of retinopathy. Vibratory sensation is absent at the great toes, reduced at the medial malleoli, and normal at the tibial tubercles. Light touch sensation is reduced in the feet but intact more proximally. Knee jerks are 2+ bilaterally, but the ankle jerks are absent. The examination is otherwise within normal limits.
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