[Answered]: Chief Complaint: According to the patient’s son, the…

Chief Complaint: According to the patient’s son, the patient cannot speak and has reduced movement of her right arm and leg. History of Present Illness: KL is a 79 year old Caucasian female brought to the hospital by her son, who is her primary caregiver. The son states that things were normal during breakfast at 0700. At lunch, around 1130, KL seemed tired and did not want to eat. When he came back to check on her at 1200, she was having difficulty speaking and holding her fork. He thought she would be better after lunch, but her symptoms became progressively worse over the afternoon. He waited until he could discuss it with his sister and they decided to bring her to the hospital at 1730. Allergies: NKDA Past Medical History: Hypertension, type 2 diabetes, diabetic neuropathy, and stomach ulcers Medications: Metformin extended release 1500 mg daily, Levemir 10 units QHS daily, Accupril 20 mg daily, Neurontin 900 mg TID, esomeprazole 20 mg daily, aspirin 81 mg daily Pertinent Physical Exam / Vitals: Height: 5’5″ Weight: 121 pounds BP: 176/96 mmHg HR: 91 BPM RR: 15 BPM Temp: 100.8deg F Pain: 5/10 O2 Sat: 96% on room air Labs: Na (mEq/L) = 140 (135 – 145) WBC (cells/mm3) = 10.8 (4 – 11 x 103) K (mEq/L) = 4.7 (3.5 – 5) Hgb (g/dL) = 12.4 (13.5 – 18 male, 12 – 16 female) Cl (mEq/L) = 101 (95 – 103) Hct (%) = 38.1 (38 – 50 male, 36 – 46 female) HCO3 (mEq/L) = 28 (24 – 30) Plt (cells/mm3) = 145 (150 – 450 x 103) BUN (mg/dL) = 22 (7 – 20) AST (IU/L) = 42 (10 – 40) SCr (mg/dL) = 1.9 (0.6 – 1.3) ALT (IU/L) = 35 (10 – 40) Glucose (mg/dL) = 192 (100 – 125) Albumin (g/dL) = 2.8 (3.5 – 5) Ca (mg/dL) = 8.7 (8.5 – 10.5) PT (sec) = 10 (10 – 13) Mg (mEq/L) = 2.0 (1.3 – 2.1) aPTT (sec) = 23 (22 – 38) PO4 (mg/dL) = 3.9 (2.3 – 4.7) INR = 0.9 (0 – 1.2) A1C (%) = 8.1 Tests: CT head: infarct of the middle cerebral artery (MCA). No signs of hemorrhage. Echocardiogram: EF 30% Toxicology screen: negative for all screened substances. Plan: Stroke team present in ED to determine management. Question While hospitalized, KL is prescribed the following regimen to control her blood glucose: Levemir – continue home dose Humalog 3 units TID-AC (hold if patient not eating) Correction doses as follows: Blood Glucose Reading (mg/dL) Correction Dose (Insulin Lispro) < 60 Hold insulin; contact MD 140-180 Give 2 units 181-220 Give 4 units 221-260 Give 6 units 261-300 Give 8 units 301-340 Give 10 units 341 and above Call MD Instructions: calculate the total amount of correction dose insulin administered in 24 hours. Increase the basal-bolus insulin as follows: 50% to the basal insulin and 50% to the bolus insulin Question: During morning rounds, the pharmacist calculates that KL received 36 units of insulin lispro from correction doses in the past 24 hours. Which basal-bolus insulin regimen should be recommended to the medical team? Answer A Levemir 46 units QHS and Humalog 21 units TID-AC B Levemir 36 units QHS and Humalog 18 units TID-AC C Levemir 36 units QHS and Humalog 9 units TID-AC D Levemir 28 units QHS and Humalog 9 units TID-AC E Levemir 18 units QHS and Humalog 6 units TID-AC