Grand Rounds - How come this patient...

[Richard_Hom]

Dear 3rd,4th, residents in optometry:

43 year old Latina presents for an annual eye examination for the first time. Her medical history includes diabetes of 11 years, hypertension. No prior glasses.

Lab values are as follows:

1. HgbA1c 7.5
2. BUN 25
3. Creatinine 1.0
4. SGOT 13
5. SGPT 28
6. Cholesterol 116
7. Triglycerides 233
8. HDL 30
9. LDL 39
10. RBC 3.480
11. Hgb 10.60
12. Hct 30.2
13. Microalbumin 85.0
14. Alb/Creat Ratio 88.54

Medications:

1. ASA 325 mg daily
2. Metformin 500mg 2 tablets, BID
3. HCTZ, 25mg, daily
4. Glipizide, 5mg, BID
5. Atenolol, 50mg, BID
6. lisinopril, 40mg, BID
7. Micardis, 40mg, daily

Physical findings are as follows:

1. BP 205/96
2. 197.5 lbs
3. Heart Rate 76
4. Oxygen saturation at room air is 99%
5. Temperature 98.0 F
6. BVA 20/100 in each eye
7. Macular edema in OD and suspected macular edema in OS. (see photo of OD) 2 risk factors in all 4quadrants in each eye including near the macula in each eye.
   Discuss some of the factors (history, lab, physical, etc) which you believe has impacted this patients retinal status?

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[cpw]

well, for starters she's obese (assuming she's of average female height). Her BP is elevated even on meds, which she may be non-compliant with. Her HbA1c is over the recommended 6.0 which shows moderate control over the last 3-4 months. So, the retinopathy could be primarily hyptensive with some diabetic non-prolierative.. it's hard to tell from the photo's resolution where there is neo or not.

My first questions would be compliace with meds. She needs to get that BP down SOON !! I couldn't tell from the exposure whether there was optic disc palor or whether it's just exposure on the film. The definitive CWS and flame hemes with resulting ME... all say malignant hypertension to me (not as much diabetic ret) .

Okay.. i'm babbling.. time to stop.

 

[Richard_Hom]

well, for starters she's obese (assuming she's of average female height). Her BP is elevated even on meds, which she may be non-compliant with. Her HbA1c is over the recommended 6.0 which shows moderate control over the last 3-4 months. So, the retinopathy could be primarily hyptensive with some diabetic non-prolierative.. it's hard to tell from the photo's resolution where there is neo or not.

My first questions would be compliace with meds. She needs to get that BP down SOON !! I couldn't tell from the exposure whether there was optic disc palor or whether it's just exposure on the film. The definitive CWS and flame hemes with resulting ME... all say malignant hypertension to me (not as much diabetic ret) .

Okay.. i'm babbling.. time to stop.

CPW:
Thanks for your post.

1. Do you feel that there is any importance to the systolic vs. diastolic?
2. The 'pallor' is an artifact of the photo.
3. Why would you say that the 'hemorrahages' and CWS are the result of HTN?
4. For an individual of 11 yrs of DM Type 2, is 7.5% good enough?
5. Are there any other lab values which you might have some concern?
6. Why is the patient taking lisinopril?

Richard

 

[Andrew_Doan]

CPW:
Thanks for your post.

1. Do you feel that there is any importance to the systolic vs. diastolic?
2. The 'pallor' is an artifact of the photo.
3. Why would you say that the 'hemorrahages' and CWS are the result of HTN?
4. For an individual of 11 yrs of DM Type 2, is 7.5% good enough?
5. Are there any other lab values which you might have some concern?
6. Why is the patient taking lisinopril?

Richard

Both systolic and diastolic are important when considering HTN. They both cause severe damage.

CWS and Dot-blot-heme is seen in both HTN and DM, but you must worry about HTN when Flame hemorrhages are abundant.

7.5% A1C isn't bad. You aim for 7%, but 7.5% isn't bad. I'd still encourage good DM management. Her obesity doesn't help either, so emphasize weight loss & exercise.

Worried about (assuming this is a spontaneous catch urine sample for microalbumine):
Microalbumin 85.0
Alb/Creat Ratio 88.54

This indicates renal dysfunction, either from long-standing HTN and/or DM.

Lisinopril is an ACE inhibitor and useful for HTN control in the setting of DM. It's believed that the ACE inhibitors are renal protective.

She needs better HTN control. If her macular edema doesn't improve, then she needs an FFA to determine if there are treatable microaneurysms. I'd recommend referring this patient to ophthalmology.