7 : A 19-year-old with insulin-dependent diabetes mellitus is taking 30 units of NPH insulin each morning and 15 units at night. Because of persistent morning glycosuria with some ketonuria, the evening dose is increased to 20 units. This worsens the morning glycosuria, and now moderate ketones are noted in urine. The patient complains of sweats and headaches at night. The next step in management is: a. Increase the evening dose of insulin b. Change to premixed 30:70 Insulin c. Increase the morning dose of insulin d. Switch from human NPH to pork insulin e. Obtain blood sugar levels between 2:00 and 5:00 A.M.
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Answer: E The patient sounds hypoglycemic, due to the adrenergic symptoms of sweats and headache, so the immediate next step should be confirmation of low blood sugar levels in the middle of the night. Then the next step after that would be to shift the dose of intermediate acting insulin closer to bedtime, hence ensuring a later peak of insulin just before breakfast.
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