1. 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

2. 62 year-old man presents to primary medicine clinic for establishment of care. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. 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) History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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] U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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] U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Other Studies ECG: NSR 77 bpm, late precordial R/S transition U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Uncontrolled type-2 diabetes mellitus Working or Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. 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% Outpatient Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Uncontrolled Type-2 Diabetes Mellitus complicated by diabetic retinopathy. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS