INTEGRATION CASE

GENERAL DATA:

R.D., 61-year-old male, Filipino, Catholic, married, residing in Dasmariñas, Cavite, consulted
the out-patient clinic of DLSUMC.

CHIEF COMPLAINT: Non-healing wound, R foot

HISTORY OF PRESENT ILLNESS:

One month prior to consult, the patient noticed swelling of his R foot with no associated pain or
fever. The patient initially attributed it to the longer-than-usual walk he had a few days prior,
but he eventually sought consult at an out-patient clinic. A serum uric acid level was requested,
which came back at 7.4 mg/dL. A diagnosis of acute gouty arthritis was made; Indomethacin
(to be taken for 1 week) was prescribed and low purine diet was advised.

The swelling persisted, however. Two weeks after the initial consult, the patient started feeling
2/10 pain in the area, with no associated fever. There was apparent limping that was more
than his baseline which the patient had “for quite a while now.”

About a week prior to consult, the patient’s wife noted an ulcer in the plantar aspect of his R
foot while he was sleeping. Pain intensity remained the same and patient would still ambulate
but with support from a cane. Non-improvement of the ulcer despite home wound care
prompted this current consult.

PAST MEDICAL HISTORY:

The patient was diagnosed with diabetes mellitus and hypertension about 20 years ago. His
current medications are Glimepiride 2 mg twice a day, Metformin XR 1000 mg daily, Telmisartan
40 mg daily and Aspirin 75 mg at night. His medical compliance is fair, and he does not regularly
follow-up with his primary care physician.

FAMILY HISTORY:

Father died from a massive stroke. Mother died from diabetic nephropathy.

PERSONAL/SOCIAL HISTORY:
The patient is a former smoker of 20 pack-years, as well as a former alcoholic-beverage drinker
(only during weekends). He stopped both about 15 years prior. He is a semi-retired office
worker. He is married with three children, with the youngest (in college) still living at home with
her parents. The patient’s residence is a well-lighted well-ventilated two-story suburban home
with adequate water supply.

REVIEW OF SYSTEMS:

(+) weight gain of 1-2 kg over the past year

(+) weakness on occasion
(+) some blurring of vision at times, especially in the afternoon
(+) tingling and numbness of fingers
(+) lower extremity numbness from midway of shin downwards (preceded by uncomfortable
paresthesias several years prior)
(+) polyuria (would get up 2-3 times a night to urinate)

PHYSICAL EXAMINATION:

General survey: Patient alert, conscious, coherent, oriented to time, place and person. Not in
apparent cardiorespiratory distress. Appears the stated chronological age.
Weight: 97 kg; height: 180 cm; BMI = 29.9
Vital signs: BP = 142/87 mmHg, HR = 91 bpm, RR = 14 cpm, Temp = 37.0ºC
Skin: (-) pallor, (-) jaundice, (-) cyanosis, warm to touch
Head and neck: normocephalic, (-) neck bruits, (-) masses, (-) lymphadenopathy
Eyes: (-) icteresia, (+) red-orange reflex
ENT: unremarkable
Chest and lungs: symmetrical chest expansion, (-) retractions, (-) fremitus, bronchovesicular
breath sounds, resonant on all fields
Heart: regular rate and rhythm, S1>S2 at apex, S2>S1 at base, (-) murmurs, PMI at 5th
intercostal space, L midclavicular line
Abdomen: (+) abdominal obesity, normoactive bowel sounds, (-) abdominal bruits, soft,
nontender, (-) masses, liver span at 8 cm
Extremities: (+) swelling over dorsum and ankle joint areas of R foot, with erythema and
increased warmth of overlying skin, (+) grade 1 ulcer on plantar aspect of R midfoot
Neuro exam:
Cranial nerves: decreased visual acuity not corrected by refraction; otherwise
 unremarkable
Sensory: decreased pain (pin prick), light touch (brush) and pressure (filament)
sensation over both distal lower extremities
Motor: 5/5 strength; normal muscle tone
Reflexes: 2+
Cerebellar: unremarkable

LABORATORY DATA:

Complete blood count:

Hemoglobin = 15 g/dL
Hematocrit = 42%
WBC count = 10.9 x 109/L
Neutrophils = 82%
Lymphocytes = 17%
Monocytes = 1%
Chemistry:
Sodium = 141 mEq/L
Potassium = 4.5 mEq/L
Random glucose = 200 mg/dL
BUN = 19 mg/dL
 Creatinine = 1.5 mg/dL
Hemoglobin A1c = 9.1%
hsCRP = 5 mg/L
Urinalysis: Glucose 1+, negative ketones, protein 1+

RADIOLOGY (R foot x-ray):

BIOCHEMISTRY QUESTIONS:

1. Biochemically describe:
a. How insulin is released following an oral glucose load, and
b. How insulin normalizes blood sugar levels in the fed state.
2. What is a unifying biochemical basis behind the patient’s sensory dysfunction,
decreased visual acuity, elevated creatinine and proteinuria? Elaborate.
3. What are proposed mechanisms behind development of diabetes mellitus? Is high
sugar consumption directly related to development of diabetes mellitus?

ANATOMY QUESTIONS:
1. Based on your knowledge in Anatomy, what are the bones that will comprise the Hind foot,
Mid foot, and Forefoot?
2. What are the different arches of the foot and how do they contribute and affect the function
of our foot?

PHYSIOLOGY QUESTIONS:
1. Discuss how the sodium pump (Na+ K+ ATPase) play a role in excitability of neurons/ nerve
cells, and in the induction of action potentials.
2. Which nerve fibers are seen to be affected in this patient : large-diameter nerve fibers or
smaller-diameter nerve fibers, and what are the symptoms from the physical examination ?
3. Discuss the effects of chronic hyperglycemia on nerve function and the current evidence-
based mechanisms behind the resulting nerve dysfunctions, with special focus on:
a. Axons of neurons
b. Schwann/glial cells
c. Microvascular changes around nervous tissues