1.

A 59-year-old male (height: 5'8''; weight: 160 lbs)

presented to the emergency department with nausea and
emesis. On examination the patient was slightly febrile
(99.4F) and had left upper abdominal tenderness with
evidence of mild hepatomegaly and mild sclera icterus. The
patient admitted to a history of moderate alcohol intake (1012 drinks/week for the past several years). He stated that he
had also recently been taking approximately 8 tablets of
Extra-Strength Tylenol (500 mg acetaminophen each) over
the course of the day, every day, for the past 2 weeks for
pain relief from a recent knee injury sustained during a fall.
Laboratory analysis revealed markedly elevated serum ALT
(535 IU/L) and AST (430 IU/L) levels (normal values: 4-51
IU/L and 15-45 IU/L, respectively), increased bilirubin (41
mol/L; normal: < 17 mol/L), a serum glucose level of 2.0
mmol/L (normal: 3.9-5.8 mmol/L), and a blood
acetaminophen concentration of 58 g/mL. The patient was
admitted to the hospital and administered an intravenous
infusion that included glucose and N-acetylcysteine (NAC).
1

2. A 53-year old male (height: 5 feet, 10 inches; weight 265

pounds) was diagnosed with insulin resistance and type 2 diabetes
mellitus. His fasting plasma glucose (FPG) level was 174 mg/dL
(normal 70-110 mg/dL) and his hemoglobin (Hb) A1c value was
suboptimal at 8.4%. The patient had normal renal and hepatic
function. The patient stated that his consumption of alcohol was
moderate and that he was not currently taking any medications
other than an occasional ibuprofen. He stated that he had gained a
significant amount of weight over the past 2 years, and he largely
attributed this to both his increasingly stressful workload and
sedentary lifestyle since switching jobs. He was instructed by his
physician to modify his diet, increase his level of activity as much
as possible, and was prescribed oral metformin (500 mg bid) to be
taken with meals.

At a follow-up examination 3 months later, the patient's status had

not really changed that significantly; he weighed 260 pounds, his
FPG was 157 mg/dL, and his HbA1c was 8.0%. He admitted that
he had not really increased his level of exercise or modified his diet
that much, but insisted that he was taking his metformin every day.
The physician considered adding an oral sulfonylurea to the
patient's regimen, but first decided to check further if the patient
had been taking his metformin as prescribed. He instructed the
patient to bring his current prescription bottle with him for his next
visit in 2 weeks. When his office contacted the local pharmacy
where the patient had his prescriptions filled, the pharmacist
informed the physician that the patient's metformin prescriptions
appeared to have been refilled in a timely manner.
At his next office visit, the patient brought his current prescription
bottle that still contained metformin tablets, but should have been
empty. The patient admitted that he had not been taking his
metformin twice everyday. He stated that he sometimes only took
the medication once a day, and occasionally missed a day
completely because he forgot or was too tired". He also stated the
he had "a few more" metformin tablets in his medicine cabinet at
home which were stored in a non-prescription container.
2.