Transcript Morbidity & Mortality Conference

Clinical Correlations
The NYU Internal Medicine Blog
A Daily Dose of Medicine
http://clinicalcorrelations.org
Medical Grand Rounds
Clinical Vignette
October 22nd, 2008
Rosemary Adamson, MB BS
Chief Complaint
38 year old man with type 2 diabetes attending
routine primary care appointment.
History of Present Illness
In February 2006 he had been diagnosed with
diabetes when he had been found to have a
fasting blood glucose of 212. Hemoglobin A1c
was 9%. He had started metformin which had
been titrated up to 1mg twice daily.
Ophthalmology had found mild non-proliferative
diabetic retinopathy on fundoscopy.
History of Present Illness (cont.)
3 months ago he had come for follow-up without
having had labs drawn in advance. Labs drawn
that day revealed a hemoglobin A1c of 8.2%.
He was then called at home and informed that
he should collect a prescription for pioglitazone
15mg daily and take this as well as metformin.
Upon re-presenting to clinic, he stated that he
was taking the pioglitazone, but not the
metformin.
Other History
Past Medical History:
Type 2 diabetes mellitus
Non-proliferative diabetic retinopathy
Past Surgical History:
None
Family History:
Non-contributory
Social History:
Immigrated from Bangladesh in 1991
Lives with wife and children
Works as salesman in a grocery store
Tobacco: has reduced from 1 pack per day to 1
pack over 3 days
No alcohol or recreational drugs
Other History
Allergies:
No known allergies
Medications Prescribed:
Metformin 1000mg twice daily
Pioglitazone 15mg daily
Medications Taking:
Pioglitazone 15mg daily
Physical Exam
General:
alert and oriented
Vital signs:
HR 60 BP 130/80
weight 65kg BMI 24.6
The remainder of the physical exam was normal.
Laboratory Values
Fasting glucose
268 (70-99)
Hemoglobin A1c
11% (4.5-6.3)
LDL
91
Creatinine
0.9 (0.1-1.4)
Urine Albumin:Creatinine ratio 13
(<20)
Management
 Pioglitazone was increased to 45mg daily and
metformin was re-introduced.
 Patient was instructed to take 500mg metformin
once daily for one week, then 500mg twice daily
for one week, then 1g twice daily.
 This was written down for him.
 He was cautioned about GI side effects.
 Smoking cessation was discussed.
 Follow-up appointment was scheduled for one
month.
Follow-up
In one month the patient explained that he was
taking pioglitazone 45mg daily and metformin
500mg twice daily.
He had misunderstood the instructions and had
started taking metformin 1g twice daily and, over
3 weeks, had decreased to 500mg twice daily.
He had quit smoking.
Follow-up: data
BP 135/75
Fasting glucose
Hemoglobin A1c
143 (70-99)
9.1% (4.5-6.3)
Management
 Again, it was explained that he should take
pioglitazone 45mg daily and metformin 1g twice
daily.
 His blood pressure goal is less than 130/90 but it
was felt that introducing a third medicine at this
point would risk more misunderstandings.
Diagnosis
Diabetes mellitus type 2 with diabetic retinopathy
in a patient who has difficulty following
instructions for his prescription medications.