What initial lab orders are recommended for a patient with type 2 diabetes mellitus, mixed hyperlipidemia, elevated blood pressure, vitamin D deficiency, major depressive disorder, low back pain, and a high body mass index?

Laboratory Tests for a 47-Year-Old Patient with Type 2 Diabetes and Multiple Comorbidities

For a patient with type 2 diabetes mellitus, mixed hyperlipidemia, elevated blood pressure, vitamin D deficiency, and other comorbidities, comprehensive laboratory testing should include hemoglobin A1C, fasting lipid panel, comprehensive metabolic panel, urinary albumin-to-creatinine ratio, and vitamin D levels.

Core Diabetes Monitoring Tests

• Hemoglobin A1C should be ordered if not performed in the past 3 months to assess glycemic control 1
• Fasting plasma glucose to evaluate current glycemic status and adjust therapy as needed 1
• Urinary albumin-to-creatinine ratio (UACR) to screen for diabetic kidney disease, which should be performed at least annually 1
• Serum creatinine with estimated glomerular filtration rate (eGFR) to assess kidney function and guide medication management 1

Cardiovascular Risk Assessment

• Complete lipid panel including total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides 1
  • For patients with type 2 diabetes, LDL-C target should be <100 mg/dL 2
  • For those with established cardiovascular disease, a more aggressive target of <55 mg/dL is recommended 1, 2
• Liver function tests to assess for nonalcoholic fatty liver disease, which is common in patients with diabetes and obesity 1
• Serum potassium levels, especially important for patients with elevated blood pressure who may be candidates for ACE inhibitors or ARBs 1

Additional Essential Tests

• 25-hydroxyvitamin D level to monitor the patient's vitamin D deficiency status 3, 4
  • Vitamin D deficiency has been associated with dyslipidemia and may worsen metabolic parameters 4, 5
• Complete blood count (CBC) to screen for anemia, which can be associated with chronic kidney disease in diabetic patients 1

Tests for Comorbidity Management

• Thyroid-stimulating hormone (TSH) to rule out thyroid dysfunction, which can affect metabolic control and may be associated with depression 1
• Serum electrolytes to monitor for imbalances, particularly important with elevated blood pressure 1
• Calcium and phosphorus levels if vitamin D deficiency is severe or if the patient has evidence of chronic kidney disease 1

Frequency of Monitoring

• A1C should be tested at least twice yearly in patients meeting treatment goals and quarterly in patients whose therapy has changed or who are not meeting glycemic goals 1
• Lipid panel should be performed annually if values are in target range, or more frequently if treatment is initiated or changed 1
• Kidney function tests (UACR and eGFR) should be performed annually, with more frequent monitoring if abnormal 1

Common Pitfalls to Avoid

• Failing to recognize diabetes as placing the patient in a high cardiovascular risk category requiring aggressive lipid management 2
• Not checking vitamin D levels despite its association with metabolic syndrome components and potential impact on lipid profiles 3, 4
• Overlooking the need for direct LDL-C measurement rather than calculated values when triglycerides are elevated 2
• Inadequate screening for diabetic kidney disease, which should include both UACR and eGFR 1

By ordering these laboratory tests, you will have a comprehensive assessment of the patient's diabetes control, cardiovascular risk factors, and comorbidities, allowing for appropriate management of this complex patient.