NYU Medical Grand Rounds Clinical Vignette

Jason Feliberti, MD PGY 2 Tuesday, May 22, 2012

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Chief Complaint

• 62 year-old man presents to primary medicine clinic for establishment of care.

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History of Present Illness

• Diagnosed with diabetes mellitus 20 year prior well controlled with metformin and glyburide • Discontinued medications 1-1/2 years prior because he “felt well” and desired to control his diabetes with diet and exercise resulting in reported 40lb weight loss • He was in his usual state of good health when several months ago he noticed increasingly frequent urination (>10 times per day) thought secondary to increased water intake (~2-3L/day)

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Additional History

• Past Medical History: • type 2 diabetes mellitus • hypertension • Non-obstructive coronary artery disease • Depression, NOS • Past Surgical History: • None • Social History: • No tobacco, alcohol, or illicit drug use • Recent unemployment, former security guard • Family History: • Mother – Type 2 DM • Allergies: • None • Medications: • Glyburide 10 mg po daily [nonadherent] • Metformin 1000 mg po bid [nonadherent]

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Physical Examination

• Well developed, well nourished male, no apparent distress • Vital Signs: list afebrile, BP:178/90 HR:76 RR:12 and O2 sat:100%RA, BMI 23 kg/m2 • Normal Exam

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Laboratory Findings

Basic Metabolic panel: • Glucose 368 •

Remainder of basic was within normal limits

Hemoglobin A1c 12.6% [< 5.7%] Urine Microalbumin:Creatinine Ratio 21.9 [<20]

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Other Studies

• ECG: NSR 77 bpm, late precordial R/S transition

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Working or Differential Diagnosis

• Uncontrolled type-2 diabetes mellitus

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Outpatient Course

• Plan: – Patient was restarted on Metformin 1000 mg po bid and glyburide 10 mg po daily, glucometer and supplies provided to patient.

– Referral to diabetes nurse educator and opthomology.

• 5 months later: – Patient with evidence of diabetic retinopathy bilaterally, scheduled for photocoagulation.

– Patient self discontinued glyburide, home FSG > 200 per patient.

– FSG in clinic 222, repeat Hemoglobin A1c: 10.6%

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Final Diagnosis

• Uncontrolled Type-2 Diabetes Mellitus complicated by diabetic retinopathy.

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