EXAMINATION

Mr. Q’s vital signs were 128/67, 79, 18, random glucose at the time of the visit was 122 mg/dL. Weight was 210 pounds. Height 5’9”, and body mass index was 31.

Physical exam revealed an obese man without signs of distress. The patient was alert, oriented, conversant, normocephalic and atraumatic; sclera white, oropharynx pink, tonsils without exudate, lungs clear to auscultation with equal expansion, respiration unlabored, no wheezing, well profused; heart rate regular, no murmur; abdomen large, soft, nondistended, nontender; no hepatosplenomegaly.

Mr. Q’s peripheral pulses were 2 plus, monofilament testing with normal peripheral sensation. His skin was intact with good turgor.


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RECOMMENDATION

The patient was instructed to hold oral antihyperglycemic agents (metformin and glimepiride) 24 hours prior to surgery. Mr. Q was also told to reduce insulin glargine injection to 15 units the night prior to surgery.

Steroid-induced hyperglycemia was anticipated postoperatively, creating a need for glycemic monitoring before meals and at bedtime.

The patient would likely to require an increase in insulin glargine beyond outpatient dose and was told to start insulin using supplemental insulin correction scale at meals and before bedtime.

Oral antihyperglycemic agents could be resumed 48 hours after surgery if the patient proved to be medically stable and tolerating oral intake, and with glycemic trend supportive of restarting outpatient oral antihyperglycemic agents.