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A 52-Year-Old Woman With Diabetes and Claudication

Martha D. McDaniel, MD, Discussant
JAMA. 1998;279(8):615-621. doi:10.1001/jama.279.8.615.
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DR DALEY: Mrs D is a 52-year-old mother of 2 children who has progressive pain in her right leg while walking. She lives in Boston and has her health care insurance through Massachusetts Medicaid and Medicare.

Mrs D has had insulin-dependent diabetes mellitus for 29 years, complicated by peripheral neuropathy, retinopathy, and nephropathy with nephrotic range proteinuria. She has had 1 atrophic kidney since childhood and has required chronic hemodialysis since June 1997. She has had hypertension since age 16 years. The patient has long-standing coronary artery disease with a history of 2 myocardial infarctions. She had percutaneous transluminal angioplasty for chronic angina without relief, followed by coronary artery bypass graft for triple vessel disease, including significant stenosis of the left anterior descending artery, in June 1997. She had an episode of congestive heart failure in 1995 with an ejection fraction of 0.25. She has hyperlipidemia and has tried several lipid-lowering agents, but has been unable to tolerate them because of adverse effects. Most recently she discontinued treatment with gemfibrozil because of gastrointestinal side effects. She has an 80 pack-year history of smoking and stopped smoking in the summer of 1997. Family history is significant for her father who died of coronary artery disease at age 53 years and for her mother who had diabetes mellitus, coronary artery disease, and renal failure requiring dialysis.

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