18 Oct Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting.
Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data:
Significant History
Type 2 DM x 4 years, HTN
Medications
Lisinopril 10 mg daily
Metformin 1000 mg po daily
Glipizide 5 mg po daily
Physical Exam
Pale, lethargic gentleman
Skin is very dry
VS 94/64 P 112 RR 30 T 99.4 wt 195 pounds ht 5’11 »
Lungs clear bilaterally, rapid respiration
CV : RRR, no murmurs or gallops
Abd: soft, non-tender, positive bowel sounds
Labs:
Hb 146 Hct 58% Cr 4.9 Bun 53 Cholesterol 238
Na 126 K 5.6 CL 95 Ca 8.8 Gluc 722 Phosphorus 5.8
Ketone Moderate AST 248 Alk Phos 132
ABG’s
ph 7.01
Pco2 20
Po2 100
Sat 98% (on room air)
HCO3 7.5
What is the “ corrected” sodium level for the hyperglycemia? What does this mean and how would it impact your treatment plan for this patient?
Question 2 Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data:
Significant History
Type 2 DM x 4 years, HTN
Medications
Lisinopril 10 mg daily
Metformin 1000 mg po daily
Glipizide 5 mg po daily
Physical Exam
Pale, lethargic gentleman
Skin is very dry
VS 94/64 P 112 RR 30 T 99.4 wt 195 pounds ht 5’11 »
Lungs clear bilaterally, rapid respiration
CV : RRR, no murmurs or gallops
Abd: soft, non-tender, positive bowel sounds
Labs:
Hb 146 Hct 58% Cr 4.9 Bun 53 Cholesterol 238
Na 126 K 5.6 CL 95 Ca 8.8 Gluc 722 Phosphorus 5.8
Ketone Moderate AST 248 Alk Phos 132
ABG’s
ph 7.01
Pco2 20
Po2 100
Sat 98% (on room air)
HCO3 7.5
What patient education would be important to provided related to sick day management of his diabetes (include management of insulin) ?
Question 3 A 44 year old female with history of type 2 diabetes taking metformin is admitted to the ICU following percutaneous placement of two coronary stents. Her chest pain is completely resolved. Twelve hours after the procedure the NP is contacted by the ICU nurse. The patient is experiencing shortness of breath, severe muscles pain, chilled, and a slow irregular heart beat. The patients ankles are swollen. The most recent labs show a Bun of 44 and Cr of 3.1. What do you suspect is happening with this patient?
Question 4 A 37 year old female with a 20 year history of DM is post cholecystectomy with complications. She has been on four time daily blood sugar testing with sliding scale insulin coverage. She is preparing for discharge and wanted to return to her previous blood sugar management. Her pre-hospitalization insulin regime included:
NPH insulin 16 units in AM and 8 units in PM
Regular insulin 8 units in am and 3 units in PM
She resumed this regime 2 days ago. Upon rounding this am, the patient tells the NP that she has woken up feeling awful. She is sweaty and shaky during the night and lethargic in the morning. The NP reviews her blood sugar readings and discovers this:
0300 0700 1200 1700 2100
62 196 109 90 146
64 203 82 100 150
What is your working diagnosis for this patient?
Question 5 How would you differentiate between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS)?
Question 6 Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data:
Significant History
Type 2 DM x 4 years, HTN
Medications
Lisinopril 10 mg daily
Metformin 1000 mg po daily
Glipizide 5 mg po daily
Physical Exam
Pale, lethargic gentleman
Skin is very dry
VS 94/64 P 112 RR 30 T 99.4 wt 195 pounds ht 5’11 »
Lungs clear bilaterally, rapid respiration
CV : RRR, no murmurs or gallops
Abd: soft, non-tender, positive bowel sounds
Labs:
Hb 146 Hct 58% Cr 4.9 Bun 53 Cholesterol 238
Na 126 K 5.6 CL 95 Ca 8.8 Gluc 722 Phosphorus 5.8
Ketone Moderate AST 248 Alk Phos 132
ABG’s
ph 7.01
Pco2 20
Po2 100
Sat 98% (on room air)
HCO3 7.5
What are the appropriate initial orders to treat this patient?
Question 7 A 56 year old male with an acute COPD exacerbation is admitted to the ICU. He has type I diabetes and utilizes NPR and regular insulin twice a day to manage his diabetes. He is currently taking very little orally due to his shortness of breath. What would the best way to manage his diabetes and insulin needs in the ICU?
Question 8 Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data:
Significant History
Type 2 DM x 4 years, HTN
Medications
Lisinopril 10 mg daily
Metformin 1000 mg po daily
Glipizide 5 mg po daily
Physical Exam
Pale, lethargic gentleman
Skin is very dry
VS 94/64 P 112 RR 30 T 99.4 wt 195 pounds ht 5’11 »
Lungs clear bilaterally, rapid respiration
CV : RRR, no murmurs or gallops
Abd: soft, non-tender, positive bowel sounds
Labs:
Hb 146 Hct 58% Cr 4.9 Bun 53 Cholesterol 238
Na 126 K 5.6 CL 95 Ca 8.8 Gluc 722 Phosphorus 5.8
Ketone Moderate AST 248 Alk Phos 132
ABG’s
ph 7.01
Pco2 20
Po2 100
Sat 98% (on room air)
HCO3 7.5
How and when would you switch the patient from IV insulin to SQ insulin?
Question 9 A 37 year old female with a 20 year history of DM is post cholecystectomy with complications. She has been on four time daily blood sugar testing with sliding scale insulin coverage. She is preparing for discharge and wanted to return to her previous blood sugar management. Her pre-hositalization insulin regime included:
NPH insulin 16 units in AM and 8 units in PM
Regular insulin 8 units in am and 3 units in PM
She resumed this regime 2 days ago. Upon rounding this am, the patient tells the NP that she has woken up feeling awful. She is sweaty and shaky during the night and lethargic in the morning. The NP reviews her blood sugar readings and discovers this:
0300 0700 1200 1700 2100
62 196 109 90 146
64 203 82 100 150
Describe how you would manage her insulin medications to improve her BS control
Question 10 Juan is a 42 year old male with complaints of nausea and vomiting for 3 days and has been unable to keep anything down in that time. He has not taken any of his medications due to the nausea and vomiting. Your assessment reveals the following data:
Significant History
Type 2 DM x 4 years, HTN
Medications
Lisinopril 10 mg daily
Metformin 1000 mg po daily
Glipizide 5 mg po daily
Physical Exam
Pale, lethargic gentleman
Skin is very dry
VS 94/64 P 112 RR 30 T 99.4 wt 195 pounds ht 5’11 »
Lungs clear bilaterally, rapid respiration
CV : RRR, no murmurs or gallops
Abd: soft, non-tender, positive bowel sounds
Labs:
Hb 146 Hct 58% Cr 4.9 Bun 53 Cholesterol 238
Na 126 K 5.6 CL 95 Ca 8.8 Gluc 722 Phosphorus 5.8
Ketone Moderate AST 248 Alk Phos 132
ABG’s
ph 7.01
Pco2 20
Po2 100
Sat 98% (on room air)
HCO3 7.5
What is the anion gap? What does this mean and how would it impact your treatment plan for this patient?
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