When Board Type Questions Turn into Reality

Dx: DM Type II Uncontrolled, ESRD

Doctor’s order from different time periods

  • CBG q12
  • Give RI 6 ‘U’ if ≥180 mg/dL, refer if ≥250 and ≤70mg/dl
  • Give 1600kcal of Nutren DM in 6 divided feedings(266cc q4)
  • Glargine 18 ‘U’ @HS
  • Give 5 ‘U’ RI pre meals

Dilemma

  • CBG monitoring is q12, you will have to give 5 ‘U’ of RI pre meals without the immediate knowledge of current CBG level, what if hypoglycaemic? Will you  still give or withhold?

Analysis

GIVE

HOLD

If CBG is normal at the time. Feeding will increase blood glucose level, with insulin glucose will be absorbed. YEY!

If hypoglycemic

  • RI will take effect after ½ to 1hr while gastric emptying in 1-3 hours; monosaccharides is transported from intestinal villi to the liver then converted to glucose finally be transported to the general circulation
  • Giving RI may lead to further hypoglycemia: mild: sweating, tachy, palpitations

Moderate:change in sensoruim plus all symptoms of mild

Severe: Coma seizure

*q4 naman ang feeding mo so lesser and tedency for hypoglycemia but still you don’t know kasi wala ka ngang CBG at the time

*mabuti kung nag check ka muna ng NGT patency at residual bago mag bigay ng RI, safe ka. Eh panu kung nauna ka mag bigay tas greater than 100cc ang residual mo, meaning wala kang gastric emptying eh may ongoing kang Glargine (very long acting; 24 hours) ka

*from 4pm na bigay mo ng RI 8pm ka pa pwedeng mag check ng CBG as ordered kung nacheck mo at madami ang residual pwede ka naman mag refer so taking note sa referral na given na ang RI 5 ‘U’; intay ka ng orders habang anxious ka na baka hypo gly na ang patient mo from 12nn na huling nagbigay ng feeding,

 

If hypoglycemic then feed may be it will normalizeIf normal

  • Feed-> hyperglycemia

Mamimili ka ngayon will it be DKA or HHNS

To consider na Type 2 sya so malamang HHNs saka mag DKA ka lang kung walang insulin present eh di ba nga may glargine ka.

Kung HHNS: electrolyte imbalance, decrease in BP, tachy, decrease in sensoruim

*aabot ka ba sa  HHNS? Hindi may CBG monitoring ka ng q12 by 8pm kung hyper glecemic sya may 6 ‘U’ka on the look out, problem mo lang dito ay yung hyperosmolarity na madudulot ng hyperglycemia lalo sya magmamanas

  • Lesser evil ang ihold safest ang iggiit in a nice way nag gawing CBG q4 follow up question: Do you have the guts to win a Yes, if he says no, ihohold mo for how long? Will you have the sufficient know hows to defend what you did when the next endorsement comes?

Sa board exam kahit tumambling ka ng pabaliktad may nag isip na ng problema,  pati ang gagawin mo pipili ka na lang. Sa totoong buhay kaylangan mong madistinguish ang totoong problema sa hindi in matter of less than one minute and to think for the most effective  action to be done, executed in a fast efficient manner dahil maraming patients pa ang nag iintay. Masarap isipin at hilingin to the heavens above na maging staff, bukod sa mas malaki ang sweldo, credited ang experience mo sa ibang bansa in the right time pwede ka ng mag fly away and at mag gapas ng dolyares in greener pastures. Pero sa mga sitwasyong hawak mo ang ikabubuhay at ikakamatay ng pasyente, take note madami sila, mapapatanong ka naman eh,  “kaya ko na ba?”

 

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