Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine

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Clinical Correlations The NYU Internal Medicine
BlogA Daily Dose of Medicine
http//clinicalcorrelations.org
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• Medicine-Surgery Conference
•  
• Thursday, March 26th at 5pm
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• Early-Stage Lung Cancer
• Speakers
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• Linda Rogers
• Division of Pulmonary Medicine
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• Kent Friedman
• Department of Radiology
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• Jessica Donington
• Department of Cardiothoracic Surgery
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• Farber Auditorium
• Light snacks will be served

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Medicine Grand Rounds

• Clinical Vignette
• Joe Philip, PGY-3
• March 25th, 2009

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Chief Complaint

• A 53 year-old female presents to clinic for a
  scheduled follow-up appointment.

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History of Present Illness

• The patient has a long history of poorly
  controlled type-2 diabetes mellitus.
• At the last visit approximately 3 months ago, her
  Hemoglobin A1C was 8.2. At that time, she
  complained of occasional episodes of dizziness
  and lightheadedness, especially on mornings after
  taking her insulin if she had not eaten.
• At that time, you asked her to keep a diary of
  her finger-sticks and bring it in to clinic
  today.
• Today, she reports similar episodes of
  lightheadedness and dizziness. During those
  episodes, her finger-sticks are usually in the
  low-50s.
• However, looking through her diary, you notice
  that her fasting glucose values range from 130
  280 and her post-prandial glucose values range
  from 200 320.

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Additional History

• Past Medical History
• Type-2 Diabetes
• Morbid Obesity
• Hyperlipidemia
• Hypertension
• Obstructive Sleep Apnea
• Past Surgical History
• Left Below-Knee Amputation
• Social History
• Ex-tobacco user (quit 8 years ago) denies other
  toxic habits
• Currently unemployed
• Family History
• Non-contributory
• Allergies No known drug allergies
• Medications
• Insulin Glargine 45 Units at bedtime
• Insulin Aspart 4 Units before meals
• Lisinopril 20 mg daily
• Simvastatin 40 mg at bedtime

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Physical Exam

• General Obese Female in no apparent distress
• Vital Signs T 98.7 BP 128/70 HR 91 R 12
  BMI 38
• Extremities L below-knee amputation stump clean
  no edema diminished pulses in right lower
  extremity
• Neuro decreased sensation to diabetic
  monofilament on soles of feet bilaterally
• The remainder of the physical exam was within
  normal limits

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Labs

• CBC is within normal limits
• Basic Metabolic Panel
• Na 140 K 4.5 Cl 109 CO2 27 BUN 15 Creat
  1.1 Gluc 237
• Hemoglobin A1c 8.5
• LDL 97, HDL 54, Trig 121
• UA 1 protein and 2 glucose

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Follow-Up

• Despite the patients poorly controlled diabetes,
  only small adjustments were made to her home
  insulin regimen due to concern about her
  hypoglycemic episodes.
• Her Insulin Glargine was increased from 45 to 50
  units and her Insulin Aspart from 4 units to 5
  units before meals.
• She is scheduled for repeat blood work and a
  follow-up appointment in 3 months.