A 49-year-old white man with type 1 DM presented with nausea, which was worse in the morning and which he described as lasting 5 to 7 days per week for the past several years. He had been hospitalized approximately every 6 to 8 weeks for dehydration, nausea, and vomiting. The patient also reported an intermittent decrease in appetite and headaches once per week, which were relieved with ibuprofen. He also complained of right shoulder pain. He denied fevers, chills, night sweats, syncope, chest pain, palpitations, exertional dyspnea, cough, shortness of breath, hematemesis, or changes in bowel or bladder habits, sleeping habits, vision, and weight.
He was currently taking metoclopramide for his diabetic gastroparesis, but it did not relieve his symptoms. He had "tried everything that you can imagine in the past" for the condition without relief. Other medications included amlodipine, aspirin, atorvastatin, insulin aspart (subcutaneous), levothyroxine, losartan, metoprolol succinate (extended release), and sertraline.
The patient had multiple complications of type 1 DM, including coronary artery disease, diabetic gastroparesis diagnosed 3 years previously, diabetic retinopathy, and hypertension. His hemoglobin A1c measurement 3 months previously was 8.6%. His medical history was also notable for depression, anxiety, migraines, hypo-thyroidism, and hypercholesterolemia.
His surgical history included a cardiac stent placed 1 year previously. He underwent colonoscopy and upper endoscopy that year because of gastrointestinal bleeding, but the results were inconclusive. He had 4 surgical procedures for diabetic retinopathy. Ten years previously he sustained a head injury from a motor vehicle accident during which he also fractured his lower right ribs. He had not sought medical attention for his injuries. He reported multiple undiagnosed ankle sprains from dirt biking. His family history was unremarkable.
His social history included a 90-pack-per-year smoking habit, which he quit 5 years previously, and occasional marijuana use, but he denied any other illicit drug or alcohol use. He occasionally drank caffeinated beverages. He received disability payments and was in a long-term relationship.