1. Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine http://clinicalcorrelations.org

2. Medical Grand Rounds Clinical Vignette October 22 nd, 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 Albumin:Creatinine ratio 13(<20)

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 A1c9.1%(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.