Step 1: View clinicals

A 55 year old woman with type 2 diabetes mellitus presents for routine followup. She is accompanied by an HbA1c report, which has a value of 9.5%. Her condition was first diagnosed 5 years ago, and was initially managed with oral hypoglycemics. However, her glycemic control worsened over time, and she was changed to insulin 6 months ago. She is also on Atorvastatin and low-dose Captopril. During the evaluation, she casually mentions that she can no longer wear her wedding ring, as it is 'too tight now'. Subsequent questioning reveals that she has gone up one shoe size over the last 1 year. There is no history of headache, or changes in vision. Her surgical history is significant for right-sided carpal tunnel decompression, 4 months back. She does not smoke, and has essentially stopped drinking since being started on insulin. She insists that she is strictly compliant with a diabetic diet, although she does not exercise much.

Step 2: Order all relevant investigations

Serum IGF-1

Serum Insulin-like growth factor 1 (IGF-1): 38 ng/mL (45 - 173)

GH Suppression Test

Two hours after a 75 g load of glucose: Growth Hormone (GH): 0.6 ng/mL (normal: <1)

MRI Brain

The MRI scan of the brain appears completely normal.

Fasting Plasma Glucose

Her fasting plasma glucose is 130 mg/dL (normal: <100)

Step 3: Select appropriate management

Recommend Exercise
Transsphenoidal Surgery

Score: ★★☆