Subjectively, patient isn't complaining of symptoms associated with hyperglemia.
Patient denies polyuria, polydypsia, or vomiting.
Patient states poor compliance is secondary to unaffordable cost of medication.
Objectively, patient's blood glucose in the last 24 hours has been as high as 505 and as low as 94
Qualitatively, relevant physical exam findings at this time are not concerning.
Patient has no changes in sensorium which would be suggestive of a hyperosmolar syndrome
Quantitively, Relevant laboratory findings at this time are not concerning.
Most recent HbA1c on file is 14.2
Patient is showing no signs of hyperglyemic findings such as:
Rales or signs of pneumonia
No acute changes in serum potassium which would occur after administration of insulin or correction of acidosis.
No acute changes in serum sodium which is a possible sequelae associated with hyperglycemia.
No abnormalities in serum phosphate which may fall with treatment of hyperglycemia.
In conclusion, my assessment is that the patient is presenting good tolerance to treatment with absence of complications.
Our goals for today are the following:
1. Monitor glucose with goal of maintaining the glucose at 100-200 mg/dL. Some studies recommend decreasing the insulin drip & changing IV fluids to D5 half-normal saline. Other studies recommend discontinuing the continuous drip, resuming the patient's home insulin regimen, and using half-normal saline with potassium to continue fluid electrolyte repletion.
2. Lantus 6 IU twice daily with Lispro 8 IU three times daily with meals; sliding scale insulin with meals as well. Evidence suggests that close management of diabetes will lower the incidence of complications. Current recommendations for patients with diabetes are to maintain the glucose of 80-120 mg/dL before meals and a hemoglobin A3 level less than 6.5%. Such tight control necessitates self monitoring of finger stick glucoses, multiple insulin administrations per day, or use of a continuous infusion insulin pump. Additionally, studies suggest that maintaining near normal glucose levels with insulin reduces morbidity in patients with severe acute illness during the perioperative period. Current recommendations are to consider IV insulin in such setting. One protocol is as follows:  Initial units of insulin per hour in infusion = (plasma glucose - 60) x 0.03  Measure glucose hourly; recalculate and adjust insulin infusion rate hourly: if plasma glucose is more than 140 mg/dL, increase formula multiplier by 0.01; if plasma glucose less than 100 mg/dL, decrease multiplier 0.01; Treat hypoglycemia if plasma glucose is less than 80-100 mg/dL, give D50 using formula: 100 - plasma glucose x 0.3 = #cc D50 to be given IV push. Re-measure plasma glucose in 30 minutes and repeat D50 treatment if needed.
3. Social work consult. Anticipated barrier to long term care appears to involve social determinates of health. Therefore, social work may be able to help patient with medication affordability.
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