Question: Clyde, age 72 returns after 5 months for refills. He missed his 3 month follow up. He did return to have his labs drawn and

Clyde, age 72 returns after 5 months for refills. He missed his 3 month follow up. He did return to have his labs drawn and comes to talk with you about them.He continues to take his medications as directed. His feet continue to feel numb at times and "it may be worse than before." No chest pain, vision changes, SOB, swelling or headaches.He states he has not "been as good with my diet as I had been". He continues to check his blood sugars at home sporadically but did not bring in any readings. He is concerned because his lowest number has been in the 160's. His blood pressures have been better since you added that new medication for his blood pressure and he cannot remember the name of it. He has also forgotten the name of the medication you prescribed for the cholesterol but he can afford it and has been taking it regularly.

PMH: Hypertension Type 2 diabetes CAD, "slight heart attack "10 years ago Hyperlipidemia (stopped meds due to cost)

Medications: lisinopril/HCTZ 20/25 1 tablet daily metformin 850 ER 1 tablet daily ASA 81 mgm daily Garlic 1 tablet daily Fish oil capsules, 2 a day

Social History: unchanged from previous visit.

Family History: Father heart disease, died at age 66, Mother Diabetes, heart disease, died age 80, Younger sister, HTN and maybe diabetes. Brother died age 70 of a stroke.

Vital signs: BP 126/72, T 98.6, P 76, R 20, Weight 216# weight 6'0' O2 sat 98% , BMI 29.3

Labs: CBC and Electrolytes, BUN, creatinine, GFR are all within normal limits.

Abnormal labs:

Glucose 186

HgB A1c 7.7

Lipids Total Cholesterol 189

LDL 98

HDL 28

Triglycerides 108

Physical Exam EENT:: PERRLA, EOMI, funduscopic exam narrowing of the ocular vessels, nicking, and no papilledema, no exudates. Cardiac: RRR, S1S2 no carotid bruits, distal pulses palpable, pedal pulses 2+. Resp: Chest clear, resp. easy even and quiet Abdomen: soft non tender, no masses, BS active x4 quads, no organomegalyMS: Gait steady. Full ROM, Toes cool, minimally decreased sensation from mid calf to his toes with monofilament testing.

What is likely the cause of his increased HgbA1c?

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