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

1
Clinical Correlations The NYU Internal Medicine
BlogA Daily Dose of Medicine
http//clinicalcorrelations.org
2
Medical Grand RoundsClinical Vignette

• October 22nd, 2008
• Rosemary Adamson, MB BS

3
Chief Complaint

• 38 year old man with type 2 diabetes attending
  routine primary care appointment.

4
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.

5
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.

6
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

7
Other History

• Allergies
• No known allergies
• Medications Prescribed
• Metformin 1000mg twice daily
• Pioglitazone 15mg daily
• Medications Taking
• Pioglitazone 15mg daily

8
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.

9
Laboratory Values

• Fasting glucose 268 (70-99)
• Hemoglobin A1c 11 (4.5-6.3)
• LDL 91
• Creatinine 0.9 (0.1-1.4)
• Urine AlbuminCreatinine ratio 13 (lt20)

10
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.

11
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.

12
Follow-up data

• BP 135/75
• Fasting glucose 143 (70-99)
• Hemoglobin A1c 9.1 (4.5-6.3)

13
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.

14
Diagnosis

• Diabetes mellitus type 2 with diabetic
  retinopathy in a patient who has difficulty
  following instructions for his prescription
  medications.