A 58-year-old woman comes to the office complaining of fatigue and dry mouth over the last 4 months. She has recently been waking up 2 or 3 times a night to urinate. She has no chest pain, cough, dyspnea, abdominal pain, or diarrhea. The patient has hypertension that has been treated with losartan for many years. Her medications also include 81 mg of aspirin daily. Family history is significant for type 2 diabetes mellitus and hypertension. She does not use tobacco or alcohol. Blood pressure is 143/87 mm Hg and pulse is 76/min. The patient's body mass index is 32 kg/m². Physical examination is unremarkable. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_beb4_24d1_8f63_2b9bf6295008_MD0005_00 The updated American Diabetic Association guidelines suggest the following screening tests for diagnosing diabetes: hemoglobin A1C >6.5%, fasting (>8 hours) blood sugar >126 mg/dL, glucose >200 mg/dL after oral glucose tolerance test, or random glucose >200 mg/dL in symptomatic patients. Patients with abnormal values under the diabetes threshold are referred to as prediabetic (impaired glucose tolerance). HbA1c was previously used only for monitoring glycemic control in patients with known diabetes. Due to variations in assays between different centers, HbA1c was not a reliable screening test in the past. However, the National Glycohemoglobin Standardization Program has calibrated >99% of HbA1c assays in the United States to the Diabetes Control and Complications Trial standard. As a result, HbA1c is now preferred by many clinicians in nonfasting patients. Asymptomatic patients with an abnormal screening test for diabetes require a repeat measurement with the same test to confirm the diagnosis. If 2 different tests are available and are concordant (eg, fasting glucose, HbA1c), no repeat testing is necessary. If the 2 tests are discordant, then additional diagnostic testing is required to confirm the diagnosis. However, patients with symptomatic hyperglycemia (eg, polyuria, polydipsia, weight loss, nocturia) and random glucose >200 mg/dL can be diagnosed with diabetes without confirmatory testing. Although this patient's random glucose is <200 mg/dL, her symptoms (eg, dry mouth, nocturia), combined with the elevated HbA1c and positive family history, can confirm the diagnosis of diabetes without further confirmatory testing (Choices B, C, and D). (Choice E) Glucosuria can be seen in patients with diabetes and may likely be the cause of this patient's nocturia, but glucosuria by itself cannot be used to confirm a diagnosis of diabetes. Educational objective: The updated American Diabetic Association guidelines suggest the following abnormal screening tests for diagnosing diabetes: hemoglobin A1C >6.5%, fasting (>8 hours) blood sugar >126 mg/dL, glucose >200 after oral glucose tolerance test, or random glucose >200 mg/dL in symptomatic patients. Asymptomatic patients with an abnormal screening test for diabetes require a repeat measurement with the same test to confirm the diagnosis. Patients with symptomatic hyperglycemia and abnormal screening tests can be diagnosed with diabetes without repeating confirmatory testing. References: Use of glycated hemoglobin in the diagnosis of diabetes mellitus and pre-diabetes and role of fasting plasma glucose, oral glucose tolerance test. (http://www.ncbi.nlm.nih.gov/pubmed/24130943)

A 58-Year-Old Woman Comes to the Office Complaining of Fatigue