Case study question:

A 49-year-old woman who self-reports as American Indian, had high, fasting blood sugar (141 mg/dL) and cholesterol level (225 mg/dL) three years ago but did not follow-up with a healthcare provider because she felt fine and could not afford medications is now currently at a free-standing emergency center. She reports having right foot weakness and numbness for three and a half weeks and it is not going away. She denies any other weakness or numbness at this time. She also says that her mouth is constantly, not sleeping well because she is urinating several times at night, and feels fatigue all the time. Reports feeling lightheaded in the mornings and sometimes have blurry vision when waking up but goes away. 



  • Gained 70 pounds in the last 5 years
  • Gestational diabetes with the third pregnancy
  • Diagnosed with hypertension 8 years ago
  • Arthritis to knees the last 3 years
  • Used over the counter anti-fungal vaginal creams several times in the past year
  • Menopause at 44 years and has hot flashes. Menstruation started at age 12.
  • Fibroadenomas in both breasts for 15 years
  • Last PAP smear 6 years ago
  • Married for 25 years
  • Works at a dry cleaner
  • Smokes 1.5 packs per day
  • Drinks 1-2 beers each day
  • Denies use of drugs
  • Does not exercise
  • Usually eats after 5PM
  • Intermittent constipation


Family History:

  • Mother and sister with Diabetes type 2
  • Father with COPD
  • Children are healthy


No known drug allergies



Lisinopril 20mg once a day 

Naproxen 220mg, two tablets, twice a day as needed (Over the Counter)

Omeprazole 20mg once a day (Over the Counter)

Colace 100mg as needed (Over the Counter)

Loratadine 10mg as needed (Over the Counter)


Vital Signs:

Blood Pressure 166/102

Pulse 90/min, regular

Respiratory rate 16/min

Temp 98.4F

Weights 212 lbs.

Reports a height of 5 feet 4 inches


Assessment Findings (Below are the only abnormalities found):

  • Oral mucous membranes dry
  • Skin dry and flakey
  • Red, scaley rash to axillary areas bilaterally
  • Feet with thick, dry, scaley patches with cracking on the heels
  • Unable to flex the right toes
  • Abdominal bruit auscultated but faint
  • Deceased range of motion to bilateral knees
  • Dorsal Pedal and Posterior Tibial pulses +1 bilaterally
  • All extremities 5/5 strength except for 2/5 right foot
  • Unable to flex the right toes
  • Noted decrease sensation on testing using light touch to right foot
  • Noted right foot weakness when observing gait


Fasting Blood Test Results (Normal values): 

  • Na 141 meq/L (135-145)
  • K 3.9 meq/L (3.5-5)
  • Cl 104 meq/L (101-112)
  • HCO3 23meq/L (22-32)
  • AST 21 IU/L (0-35)
  • Trig 462 mg/dL (< 165)
  • BUN 16 mg/dL (8-20)
  • ALT 12 IU/L (7-56)
  • HbA1c 8.4% (3.9-6.9)
  • Cr 1.1 mg/dL (0.6-1.2)
  • Alk phos 45 IU/L (41-133)
  • Insulin 298 μU/mL (6-35)
  • Glu 172 mg/dL (60-110)
  • T. bilirubin 1.1 mg/dL (0.1-1.2)


Urinalysis Results:

  • Appearance – yellow, pale, and clear
  • pH 5.7 (5-6.5)
  • Specific Gravity 1.006 (1.016-1.022)
  • Bilirubin negative
  • Ketones negative
  • Protein negative
  • Microalbuminuria negative
  • Glucose positive
  • Negative for microbes, red cells, and white cells


No notable abnormalities on electrocardiogram


Question: What are the red, scaley rash to axillary areas? How did this develop? Discuss at cellular level.