Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New onset of symptoms suggestive of metformin toxicity (e.g., nausea, vomiting, abdominal pain, weakness, confusion)
History of Present Illness:
Onset, duration, and severity of symptoms.
Any potential precipitating factors (e.g., recent increase in metformin dose, dehydration, diarrhea, vomiting, underlying renal insufficiency).
Past Medical History:
Diagnosis of type 2 diabetes mellitus.
Duration of metformin therapy and current dosage.
Underlying medical conditions that may increase susceptibility to metformin toxicity (e.g., chronic kidney disease, heart failure, liver disease).
Medications:
List all current medications, including other medications that may interact with metformin.
Social History:
Recent alcohol intake (can worsen lactic acidosis).
Recent use of illicit drugs (e.g., cocaine can increase risk of lactic acidosis).
Family History:
Not typically relevant for metformin toxicity.
Physical Exam:
Vital signs: Assess for hypotension, tachypnea (rapid breathing), and altered mental status (confusion, lethargy).
General examination: Assess for signs of dehydration (dry mucous membranes) and illness (fever).
Abdominal examination: May reveal tenderness or distention.
Laboratory Tests:
Blood glucose level: May be normal, elevated (if metformin contributes to hyperglycemia), or low (if metformin overdose is suspected).
Serum electrolytes: Assess for electrolyte imbalances (e.g., hyperkalemia – high potassium – is a concern).
Lactate level: Elevated lactate suggests lactic acidosis, a potential complication of metformin toxicity.
Renal function tests: Evaluate kidney function, as impaired kidney function is a risk factor for metformin accumulation and toxicity.
Assessment:
Suspected metformin toxicity: Based on clinical presentation, recent metformin use, and laboratory findings (elevated lactate is a key indicator).
Severity of metformin toxicity: Evaluate the severity based on symptoms, laboratory abnormalities, and hemodynamic status.
Plan:
Immediate intervention is crucial:
Hold metformin therapy: Discontinue metformin use immediately.
Fluid resuscitation: Correct dehydration to improve perfusion and promote metformin excretion.
Electrolyte management: Address electrolyte imbalances based on laboratory findings.
Consideration of supportive measures: Depending on the severity, may include administration of sodium bicarbonate (cautiously) to correct severe acidosis and extracorporeal dialysis (hemodialysis) to remove metformin from the blood in critically ill patients.
Consultations: Depending on the severity, consultations with specialists (e.g., toxicology, nephrology) may be necessary.
Follow-up:
Close monitoring of vital signs, electrolytes, lactate levels, and renal function.
Reassessment of the need for metformin therapy once metformin toxicity resolves. Metformin may be safely restarted in patients with normal renal function after the episode.
Education:
Educate the patient about the importance of adherence to metformin dosing instructions and avoiding situations that increase the risk of metformin toxicity (e.g., dehydration, concurrent illnesses).
Discuss the importance of recognizing and reporting symptoms of potential metformin toxicity promptly.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Metformin toxicity is a serious but treatable condition. Early recognition and prompt intervention are crucial to prevent complications.