Home

Pearls

More
Features     

More
Reviews     

Opportunities

Editor in Chief    

Order
Form

Site Map

Contact Me 

1. A 37-year-old female who is previously healthy presents with complaint of a dark skin lesions that she has noted on her posterior neck and bilateral axilla.  They don’t bother her, but she feels they are cosmetically unsightly.  She denies weight loss, rather weight gain and her periods have been irregular.  On physical exam she has central obesity and the areas of hyper pigmentation have a velvety feel and are hyperkeratotic.   What is the most likely diagnosis.

a.        seborrheic keratosis

b.       insulin resistance

c.        gi malignancy

d.       simple mole

2.        A type one diabetic patient has been on regular insulin, but would like to try a new insulin called lispro.  He asks what to expect in terms of onset of action.  How would you advise?

a.        1hour

b.       15 minutes

c.        45 minutes

d.       1.5 hours

3.        You are consulted on the 18^th of the month to manage the diabetes of a 67 year old female type 2 diabetic.  The patient had an incision and drainage of her left knee on the 14^th of the month due to MRSA of the knee that developed after a previous knee surgery.  She has been nauseated since the surgery and has not eaten well.  Intially she was on D5W1/2 normal saline after the surgery but her IV was saline locked on the 17^th.  She has been afebrile with stable vital signs and is taking NPH 16 units sq every a.m. since the 15^th and a regular insulin sq sliding scale which is listed below. Her blood glucose reading that are checked four times a day before meals and at before bed are listed below.  Some of her blood glucose reading are missing from the computer report.

Regular insulin sq sliding scale (the bedtime glucose is not covered by the sliding scale)

Blood Glucose      Insulin dose in units

Less than 60          Give juice and call the physician

60-200                               Do nothing

201-250                            2

251-300                            4

301-350                            6

351-400                            8

                        Over 400                Call the physician

Blood Glucose report

DATE     AM         NOON    5PM        9PM

15^th          NO INFORMATION AVAILABLE (N/A)

16^TH        N/A        320          300          350

17^TH        315          334          285          368

What is the best way to treat her diabetes?

a.        Make no changes.

b.       Keep the NPH at the current dose and add schedule regular insulin 6 units before breakfast and dinner in addition to the current sliding scale

c.        Change the NPH to 16 units sq before breakfast and dinner.

d.       Change the NPH to 16 units sq before breakfast and dinner and change the regular to 6 units sq before breakfast and dinner in addition to the current sliding scale.

e.        Change the NPH to 16 units sq before breakfast and dinner and change the regular to 22 units sq before breakfast and dinner in addition to the sliding scale.

BIBLIOGRAPHY:

Up-to-date, 2003 edition; key word:  Diabetes

Q1.  answer :  The patient presents with a picture of insulin resistance, no historical features suggest gi malignancy. 

Q2.  answer:  onset of action is typically 15 minutes which allows for greater flexibility in dosing since the half-life is also less than with regular insulin.  Thus the patient can have take the medication just before meals allowing for fewer hypoglycemic episodes.