Pathophysiology scenario: diabetes

History
Dolores is a 59 year old paediatric nurse who presents to her doctor because while learning how to use a new automatic sphygmomanometer, her blood pressure read 152/110 mmHg. She admits not looking after herself other than taking her Metformin, because “she is too busy looking after everyone else”. She says she was diagnosed with “pre-diabetes” four years ago, and prescribed Metformin one year later because she had not lost any weight or done exercise. She had not visited the doctor since then because she feels fine. She checks her blood glucose at work occasionally, just to keep an eye on it.
Physical and dietary assessment
Dolores has gained 8kg in the last two years, bringing her weight to 89kg, but feels that being tall (1.72m) she can carry them well. Her waist is now 91cm.
Her finger-prick fasting blood glucose is 8.3mmol/L, resting heart rate 106bpm and blood pressure 144/95 mmHg.
Upon examination of her feet the doctor noticed a small infected ulceration on the side of her left foot. She attributed it to the new shoes that she wore to a wedding two weeks ago because her feet got swollen, but said it had not bothered her, she had not even noticed it. She has mild bilateral pitting oedema to her ankles that tightens her shoes, but otherwise she can move her feet and toes without problems.

Her pathology results include the following information:
Fasting Plasma Glucose: 8.7 mmol/L (<5.5 mmol/L)
HBA1c 8.1 % (<7%)
Total cholesterol 7.0 mmol/L (<5.5 mmol/L)
HDL 0.94 mmol/L (>1.2 mmol/L)
LDL 4.1 mmol/L (<4 mmol/L)
Triglycerides 3.1 mmol/L (<2 mmol/L)

Preliminary dietary assessment (GP)
Dolores admits to eating “non-diabetic food” when eating out, because it is too hard to find it in restaurants. When queried further about her eating habits, by asking what she had eaten in the last 24h, her answer was:
“I had a coffee at home, and something (a bacon and egg roll) when I get to work. Yesterday we had a morning tea for a colleague’s birthday, so I had some cheesecake then. For lunch I had a salad that I had made at home using wholegrain pasta, tomato, lettuce, capsicum and dressing for diabetics. We took the colleague out to dinner for her birthday to a Chinese restaurant near the hospital, and we shared the standard dishes: spring rolls, chicken with cashews, sweet and sour beef, her favourite pork belly, and that sort of dishes. I tried to avoid eating too much rice because of my diabetes, and passed on the dessert, except for a mouthful of lychee ice-cream to try it. We shared a couple of bottles of wine between the five of us”.
Dolores admitted that she drinks two or three of glasses of wine every night watching television, but that night she didn’t because she had drunk enough at dinner.

Management
Dolores is diagnosed with the Metabolic Syndrome, referred to a diabetes educator for ongoing advice about looking after herself. She was prescribed a higher dose of metformin plus medication to control her blood pressure.
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