Transcript Journal Club

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