Endocrinology Case Study

CHIEF COMPLAINT

Elevated blood sugars uncontrolled by high-dose outpatient insulin.

HISTORY AND PHYSICAL FINDINGS

The patient is an 80-year-old white male with history of type 2 diabetes, intermittently requiring insulin, with recent flare-up of his chronic congestive heart failure and bronchitis, which resulted in an elevation of blood sugars.  He has been on Glucotrol 15 mg b.i.d., but blood sugars were going over 400 on his Glucometer at home for the last week and a half.  He was started on insulin and this dose increased to 90 units per day, given concomitantly with the Glucotrol.  He was also given some Zaroxolyn for the flare-up of congestive heart failure he had last week.  As a result, his blood sugars have not come down significantly, still running frequently off the scale on the Glucometer at home and running as high as 557 two days ago at a laboratory.  His sodium has dropped from the mid to high 120s down to low 120s, and BUN and creatinine have risen secondary to Zaroxolyn as in the past.  He has been treated with ampicillin for his bronchitis.  The patient also has a history of permanent left nephrostomy tube for ureteropelvic junction dysfunction.

MEDICATIONS

Allopurinol 100 mg b.i.d.; Lasix 160 mg a.m., 120 mg p.m.; Feldene 20 mg q.a.m.; Metamucil 2 tablespoons h.s.; Darvocet-N 100, 1 every 4 to 6 hours p.r.n. pain; Dalmane 15 mg h.s.; nitroglycerin 0.4 mg sublingually p.r.n. chest pain; Micro-K
10 mEq 1 to 3 times per day; Cardizem 60 mg q.i.d.; Isordil 30 mg q.i.d.  He had 95 units of insulin the day prior to admission and, I believe, 80 units of combined NPH and regular insulin the day of admission.

PHYSICAL EXAMINATION

Vital signs include temperature 97.7, pulse 72, respirations 28, blood pressure 120/70.  General examination reveals an obese white male.  HEENT reveals PERRL.  Normal fundi.  TMs normal.  Pharynx clear.  Neck without JVD.  Coronary examination reveals a regular rate and rhythm.  Lungs are clear.  A few coarse bibasilar rales.  Abdomen is obese without masses.  Back with left nephrostomy tube.  Genital examination indicates an uncircumcised male.  Testicular edema that was noted last week in the office prior to Zaroxolyn therapy is now resolved.  Extremities show 1+ edema extending all the way to the thighs and presacral area.  Is wearing TED hose.  Right leg is worse than left per usual.

LABORATORY

CBC reveals white blood count is 7000 with 66 polys, no bands,
23 lymphs, 8 monos, 3 eosinophils.  Hematocrit 45.0.  Blood sugar on admission 445.  Electrolytes reveal sodium 115, potassium 3.2, chloride 72, CO2 32.  BUN 73, creatinine 2.6.

IMPRESSION

1. Type 2 diabetes — flare-up secondary to congestive heart failure and bronchitis.

2. Recent exacerbation of congestive heart failure — resolved.

3. Hyponatremia, probably secondary to hyperglycemia (artificial) and Zaroxolyn.

4. Acute exacerbation of chronic renal failure secondary to Zaroxolyn.

5. Recent history of decreased auditory acuity — probably secondary to Lasix and Zaroxolyn, although Lasix dose has been chronically the same.

PLAN

The patient will be given subcutaneous and IM insulin as required to bring his blood sugars down to a more acceptable range, and then NPH and regular insulin will be given on a split-dose b.i.d. dosing regimen.

FOOTNOTE

Line 33 (Page 1).  Alternative:  4-6.

Line 35 (Page 1).  Alternative:  1-3.

Line 40 (Page 1).  Exam was expanded in the heading.

Line 42 (Page 1).  BP was expanded to blood pressure for clarity.

Line 1 (Page 2).  The dictation error was corrected; TED’s was changed to TED.

Line 18 (Page 2).  In the Impression, the dictated number 4 was corrected to be numeral 5.

Line 23 (Page 2).  The slang term subcu was expanded to subcutaneous.

Line 23 (Page 2).  Alternative:  I.M.

All the abbreviations were expanded for clarity.