50 yr old african american male patient c extensive medical hx of heart disease. Pt initially suffered from CHF due to ASD and abnormal Mitral valve which were surgically repaired back in 1/08. A few months later, pt suffered from subacute bacterial endocarditis that led him to cardiomyopathy resulting in heart transplant in 7/08.
While having a surgery, pt was revealed to have high blood sugar level. Pt was on IV insulin to control the sugar level. At the time of discharge, pt was given 25 units of lantus c sliding scale of novolog. Pt was instructed to give meal bolus of 4 units with each meal three times a day.
Pt came to see me first time a month ago with very high sugar level c A1C of 10 %.
SCr level was 2.1 which ruled out conventional medical treatment options but the insulin regimen.
I instructed pt to increase lantus level 3 units per 5 days till AM BG turns below 120mg/dL.
Type II DM: since 5/08
SMBG: 3x/d
Lows: None
Last A1C: 9%
Ophtho: Needs
Renal: SCr 3.1, GFR 22%
CV : AICD, Heart transplant, functional class II, No CAD
POD: Needs
VASC: No PVD
Flu Vax: Need
Labs:
Regimen:
Lantus 60 units qHS
Novolog: 10 units c meal TID
Current meds
1. Lantus
2. Novolog
3. Bactrim
4. Calcium carbonate
5. Prograf
6. Hydralazine
7. Cell Cept
8. Norvasc
9. Pepcid
10. Pravastatin
11. Torsemide
12. Multivitamin
13. Prednisone
PMH
1. ASD
2. AICD implant
3. MVR
4. Cardiomyopathy 2ndary to SBE
5. Heart transplant
6. CHF
7. TIA
8. OSA
9. HTN
10. Hyperlipidemia
Surgical Hx
Corrective surgery for ENT for OSA
ASD/MV repair
Heart transplant
AICD (medtronic)
Family Hx
Grandpa deceased from AMI at 68
Uncle, sister c DM
Mother deceased from brain aneurysm
Social Hx
Smoking 1PPW for 20 yrs, quit 10yrs ago.
Married
No exercise
No alcohol
Sexually active
Occupation: Stock clerk. Now disabled.
Allergy: NKDA
Hospitalizations: See above
Diagnostic Procedure: See above
ROS
Not contributory.
Vitals
Ht 64.75, Wt 229, BMI 38.40, BP 142/108, HR 100, RR 20
Assessment
1. Type II DM
2. Hyperlipidemia
3. HTN
4. Tinea Corporis
5. Heart transplant
6. Proptosis
7. Acute renal failure.
Tx..........??
Pt came back a month later with A1C >14% c SCr 3.1.
I discussed the matter with one of the NPs at the hospital where he had a surgery done.
I also discussed with my immediate supervisor.
The help was not much different from what I was planning to do since pt cannot take any other meds anyway.
The problem was in spite of increasing lantus from 25 units to 60 units, pt kept getting higher AM BG level upto 400 to 500 everyday.
I gave 8 different new instructions to this patient.
Remember this is a new type II diabetes patient.
What would those instructions be you think??
