Washington – Internal Medicine – Incidental Finding Of Glucose Level Of 283 mg/dl Without Fasting

On 2/11/2011, a 76-year-old man saw an internist in a clinic to address the patient’s report of a wound on his head that was not healing, hand lesions, diarrhea and white stools, gassiness, and having to go to the bathroom more frequently than normal.  The internist was the patient’s primary care provider and ordered a complete blood count (CBC) and complete metabolic panel.  The lab work identified that the patient had worsening renal function and a blood glucose level of 132 mg/dl (non-fasting).  The internist asked the patient to return in one month for a follow-up basic metabolic panel.

On 3/13/2011, the patient’s follow-up lab work identified improved kidney function; however, the patient’s blood glucose level increased to 283 mg/dl, indicative of diabetes even if the patient had not fasted prior to the lab test.  Medical staff documented that the clinic’s physician assistant called and spoke with the patient’s wife regarding the improved kidney results only.  The patient’s high glucose level was not identified as an issue and the staff did not raise it with his wife.  The internist did not see or speak to the patient following the lab results for the next ten months.

The internist saw the patient on 11/20/2011 to address the patient’s wife’s concerns about changes in the patient’s mentation, including a time when he got lost coming home.  The internist administered the Mini-Mental State Exam, on which the patient scored 28/30.  The internist did not order any lab tests.  The internist failed to discuss the March lab results and failed to review the patient’s significantly increased blood glucose level from February to March 2011.  The internist’s notes indicated that he reviewed medications, allergies, and past medical history as reported during the February 2011 visit, and social history as reported during a December 2009 visit.  The internist’s notes did not indicate that he reviewed the February 2011 lab results or the March 2011 lab results.

On 12/27/2011, the patient called the clinic to request a fasting blood sugar test because he reported he had lost seven pounds in a week and was thirsty all the time.  When his glucose level tested at 655 mg/dl, the clinic staff called the patient and directed him to be seen immediately, either at the clinic or at the emergency department (ED).  The patient was seen in the clinic and was diagnosed with Diabetes Mellitus Type 2.  Due to his altered mental state, the patient was directed to go to the ED for insulin and IV fluids.

The patient was diagnosed with acute renal injury secondary to dehydration.  The patient’s A1C test result indicated that he had had elevated blood sugars at least over the past three months.  The patient was discharged the following day without evidence of diabetic ketoacidosis or a hyperosmolar state.

The Commission stipulated the internist reimburse costs to the Commission and develop and submit a protocol which will ensure that the internist reviews the results of any lab work or tests he orders, follows up on forwarded reports and pertinent test results, documents his review of all lab work, test results and reports, and follows up in a timely manner with patients about test results or missed tests which had been ordered.

State: Washington

Date: September 2015

Specialty: Internal Medicine, Family Medicine

Symptom: Urinary Problems, Confusion, Diarrhea

Diagnosis: Diabetes, Renal Disease

Medical Error: Diagnostic error, Failure to follow up

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

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