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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Jason Feliberti, MD PGY 2 Tuesday, May 22, 2012. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. 62 year-old man presents to primary medicine clinic for establishment of care. U NITED S TATES

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Jason Feliberti, MD PGY 2 Tuesday, May 22, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint • 62 year-old man presents to primary medicine clinic for establishment of care. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  3. History of Present Illness • Diagnosed with diabetes mellitus 20 year prior well-controlled with metformin and glyburide • Discontinued medications 1-1/2 years prior because he “felt well” and desired to control his diabetes with diet and exercise resulting in reported 40lb weight loss • He was in his usual state of good health when several months ago he noticed increasingly frequent urination (>10 times per day) thought secondary to increased water intake (~2-3L/day) UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  4. Additional History • Past Medical History: • type 2 diabetes mellitus • hypertension • Non-obstructive coronary artery disease • Depression, NOS • Past Surgical History: • None • Social History: • No tobacco, alcohol, or illicit drug use • Recent unemployment, former security guard • Family History: • Mother – Type 2 DM • Allergies: • None • Medications: • Glyburide 10 mg po daily [nonadherent] • Metformin 1000 mg po bid [nonadherent] UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  5. Physical Examination • Well developed, well nourished male, no apparent distress • Vital Signs: list afebrile, BP:178/90 HR:76 RR:12 and O2 sat:100%RA, BMI 23 kg/m2 • Normal Exam UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  6. Laboratory Findings • Basic Metabolic panel: • Glucose 368 • Remainder of basic was within normal limits • Hemoglobin A1c 12.6% [< 5.7%] • Urine Microalbumin:Creatinine Ratio 21.9 [<20] UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  7. Other Studies • ECG: NSR 77 bpm, late precordial R/S transition UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  8. Working or Differential Diagnosis • Uncontrolled type-2 diabetes mellitus UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  9. Outpatient Course • Plan: • Patient was restarted on Metformin 1000 mg po bid and glyburide 10 mg po daily, glucometer and supplies provided to patient. • Referral to diabetes nurse educator and opthomology. • 5 months later: • Patient with evidence of diabetic retinopathy bilaterally, scheduled for photocoagulation. • Patient self discontinued glyburide, home FSG > 200 per patient. • FSG in clinic 222, repeat Hemoglobin A1c: 10.6% UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  10. Final Diagnosis • Uncontrolled Type-2 Diabetes Mellitus complicated by diabetic retinopathy. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

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