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Clinical Correlations The NYU Langone Online Journal of Medicine http://clinicalcorrelations.org NYU Medicine Grand Rounds Clinical Vignette Matthew Dallos, PGY-2 April 2, 2014 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Chief Complaint •74 year old man presenting to geriatrics clinic for follow-up after a recent hospital admission for treatment of community acquired pneumonia and asthma exacerbation. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness •His asthma was being treated with fluticasone/salmeterol, montelukast, and albuterol but he was using his inhalers on an as needed basis. •His recent hospitalization was preceded by several weeks of cough and shortness of breath which was initially treated with 4 days of prednisone. •His symptoms initially improved, however 3 days prior to admission he developed worsening cough, shortness of breath and fever. •During his hospitalization, he was treated with a course of ceftriaxone and azithromycin for community acquired pneumonia and was given albuterol and ipratropium nebulizers and a course of steroids for asthma exacerbation. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness •Since discharge he completed his course of antibiotics and 4 days of 40mg prednisone daily with improvement in his cough and shortness of breath. •During the hospitalization an A1C was checked which was 8.2 •The patient was discharged on metformin 1000mg twice per day, glipizide 5mg before breakfast and 2.5mg before dinner. Prior to admission the patient had been on metformin 500mg twice per day and glipizide 2.5mg twice per day. •Since discharge he has been checking his glucose which have been in the high 200s to low 300s. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History •Past Medical History: •Asthma •Type II Diabetes Mellitus (A1c 2012 6.8%) •Hypertension •BPH •Hyperlipidemia •Past Surgical History: •None •Social History: •Never smoker, no alcohol or illicit drugs •From Albania and lives intermittently in Albania and with son in NYC. Post grad education in Albania, previously worked on a farm. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History •Family History: •None •Allergies: •NKDA •Medications: •Albuterol 90mcg 2 puffs every 6 hours as needed •Montelukast 10mg daily •Fluticasone/Salmeterol twice per day •Metformin 1000mg twice per day •Glipizide 5mg before breakfast and 2.5mg before dinner •Aspirin 81mg daily •Atorvastatin 20mg daily •Losartan 50mg daily •Tamsulosin 0.4mg daily UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination •General: No acute distress. Breathing comfortably. •Vital Signs: list T:97.8 F BP: 141/71 HR:95 RR:16 and O2 sat: 95% on room air. •Pulm: Mild expiratory wheezes bilaterally. •Neuro: Mini-cog 2/3 recall. Mini-mental status exam 24/30 •Remainder of physical exam within normal limits. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Laboratory Findings •CBC: white blood cell count 8.4 (77.6% neutrophils), hemoglobin 12.6, platelets 141 •Basic Metabolic panel: CO2 32, glucose 207, creatinine 0.8 •Remainder of basic was within normal limits •Hemoglobin A1c 8.2% •Low-Density Lipoprotein 96 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Other Studies •Chest X-Ray: Increased interstitial markings without focal consolidation •PFTs 2006: FEV1 1.39 (58% predicted), FEV1/FVC 0.48, good bronchodilator response, normal DLCO and TLC • Transthoracic Echocardiogram: mildly dilated left atrium, minimal left ventricular hypertrophy, ejection fraction 60%. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Problem List • Diabetes Mellitus Type II- with poorly controlled fingerstick glucoses with recent courses of steroids contributing. • Mild cognitive impairment • Asthma exacerbation from recent infection UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Treatment Plan • • • Type II Diabetes Mellitus: – Continue current medication regimen and recheck A1C in 3 months since completing steroid course. – Goal A1c <8.0 given multiple medical problems. Asthma: – Continue fluticasone/salmeterol, montelukast and albuterol – Patient and care-giver education regarding the appropriate use of controller inhalers. Mild Cognitive Impairment: – Plan to check TSH, vitamin B12, and RPR – Head CT without contrast – Continue to monitor with serial Mini-mental Status Exams. – Although patient with post-grad training, unclear whether education cutoffs for mini-mental status exam are easily translated from the Albanian education system UNITED STATES DEPARTMENT OF VETERANS AFFAIRS