The patient reported a sedentary lifestyle due to chronic back pain that limited activity of daily living and exercise. He consumed two meals daily, usually breakfast and dinner, without snacks in between. The patient described his meal size as “regular,” and his meals included baked lean meats, and “special rice for diabetes.” He reported avoiding desserts and sweet drinks.

The patient had followed his internist’s advice and took insulin detemir 65 units at bedtime the night prior to surgery and insulin detemir 22 units the morning of surgery. The patient withheld all other antihyperglycemic agents.


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On the day of surgery, the patient was euglycemic with a glucose range of 90 to 155mg/dL. The surgical team further reduced his insulin regimen postoperatively. By postoperative day one, his glucose range from 247 to 375 mg/dL.

On postoperative day two, patient remained hyperglycemic with glucose range of 262 to 332 mg/dL. Otherwise, his inpatient medication regimen was notable for initiation of dexamethasone 6 mg intravenously every 6 hours on postoperative day one, narcotics, a bowel regimen, and an antiemetic.

The patient reported mild incisional back pain when he used his prescribed opioid regimen but otherwise felt okay. He reported feeling thirsty with frequent urination, which he dismissed as baseline. The patient denied blurred vision, chest pain, palpitations, shortness of breath, and cough. He reported a normal appetite without nausea, vomiting, constipation or diarrhea.

Physical examination

The patient was a well-nourished elderly male resting in bed without any sign of distress. He was alert and oriented, conversant, and appropriate with normal affect in stable mood.

The patient’s injection sites were sclerae anicteric and conjunctivae pink and moist. There was lipohypertrophy at the insulin injection sites. Acanthosis nigricans was noted at cervical area. Auscultation of lungs revealed normal breath sounds.

The patient’s vital signs were as follows:

  • Blood pressure: 127/99 mm/Hg
  • Pulse: 92 beats per minute
  • Temperature: 99.1 degrees Fahrenheit
  • Breathing: 18 breaths per minute
  • Weight 102.5 kg
  • Height: 5 feet 8 inches
  • Body mass index (BMI): 34.37

Select pertinent recent labs:

  • Hemoglobin A1C: 10.1%
  • Blood urea nitrogen (Bun): 34
  • Creatinine: 1.6
  • Glucose: 281
  • Aspartate aminotransferas (AST): 17
  • Alanine aminotransferase (ALT): 23