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NYU Medical Grand Rounds
Clinical Vignette
Jason Feliberti, MD
PGY 2
Tuesday, May 22, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 62 year-old man presents to primary
medicine clinic for establishment of care.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Diagnosed with diabetes mellitus 20 year prior wellcontrolled 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)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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]
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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]
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•ECG: NSR 77 bpm, late precordial R/S
transition
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• Uncontrolled type-2 diabetes mellitus
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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%
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Uncontrolled Type-2 Diabetes Mellitus
complicated by diabetic retinopathy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS