Hyperglycemia # Diabetes-mellitus HHNS

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On December 19, 2016, Novo Nordisk announced that the FDA approved an expanded indication for Tresiba® (insulin degludec injection 100 U/mL, 200 U/mL), once-daily, long-acting basal insulin, to be used in children and adolescents with diabetes. Trial, first approved by the FDA in September 2015, is now indicated to improve glycemic control in patients with type 1 and type 2 diabetes from the age of one through adulthood, making it the only basal insulin approved for both type 1 and type 2 diabetes in patients as young as 1 year old. Tresiba® is a long-acting insulin that is released over time, has a 25-hour half-life and has a consistently flat and stable profile at steady state. Todd Hobbs, MD, US Chief Medical Officer, Novo Nordisk said that "we are seeing a rise in the number of children and adolescents with diabetes in the US, especially those with type 2, and are proud to support these patients by offering new and effective treatment options". The great challenge is children with type 1 diabetes and their parents to manage blood sugar levels and keep up with multiple injections throughout an already busy day. With this approval, they now have another option of a long-acting insulin that is dosed once daily.

Patient us a 50 y/o diabetic male is noncompliant with diet and medication and had been out of Humalog for 1 week. Previous insulin regimen was Levemir 50U BID and Humalog "sliding scale" per patient, typically around 120U before meals. BP 160/108 pulse 108 resp 20 BMI 28.19. Patient in no acute distress, no altered consciousness, no nausea, no weakness or malaise at visit. Initially seen in the outpatient clinic where labs were ordered. Here are the results. What would you do?

44 y/o M DM type 2. Dx approx 2 yrs ago. Current meds humulin 70/30 20 u bid and #Metformin 500 mg qid. Low reading was false low. Any suggestions to improve BS? Per pt, moderate activity 2-3x week.

I was at work this evening and had a patient with DM controlled with insulin. Daily they take Lantus 16 units in the morning and then Apidra 7u with meals. This evening their BG was 81 and they refused their apidra, also, prior to being seen by the endocrinologist there were parameters in the apidra - hold of BG less than 90. So that being said I faxed the endocrinologist and asked them if they would like to reinstate the parameters of the apidra, and also made them aware she refused her dinner dose. His response was that she should still get it (yes, but she refused) and then he stated that if her BG is less than 80 to give her 15g of sugar and then give her her apidra dose. Is this common practice to bump up a diabetic just to give them insulin? And if so, why? Her BG at HS was 188 even without the dinner apidra. Just curious why she should be given sugar just to get insulin. Thoughts?

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A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis. He had a history of hypertension, long-term smoking, and a sedentary lifestyle. On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.

A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets. Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.

A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.

patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family, are there any features in this ekg that would warrant further work-up or is this just a pediatric ekg?