Profile review: Describe a prescription(s) with clinical issues that require an intervention
GR is a 66-year-old male, a former smoker, with a BMI of 35.73 and no known allergies. His
chief complaints include confusion and abnormal speech cadence reported by his family about
a week ago. He has had a decreased appetite, consuming only 500 calories per day, due to
dental issues. Additionally, he has recently experienced sleep problems exacerbated by the loss
of his son. His past medical history includes hypertension, hyperlipidemia, pulmonary
embolism, deep vein thrombosis, and osteoarthritis. His current home medications are
rosuvastatin 20mg daily, Xarelto 20mg daily, and Zaleplon 10mg daily.
During his hospitalization, he was newly diagnosed with type 2 diabetes, with a most recent A1c
of 13.4 and blood sugar of 447 on admission. His glucose levels were well controlled with the
following insulin therapy: Lantus 45 units nightly and Lispro 10 units daily with meals, along
with a low-dose correction scale. However, the original discharge plan prescribed Lantus 45
units nightly as outpatient antidiabetic to control his blood glucose level.
It was observed that under current recommendations, GR’s postprandial glucose level cannot
be adequately controlled without fast-acting mealtime insulin Lispro. Therefore, a modification
to his discharge plan was made for blood sugar control: insulin glargine 100 units/mL, 45 units
subcutaneously at bedtime, AND insulin lispro 100 units/mL, 10 units subcutaneously 3 times a
day 15 minutes before meals. We will also discharge him on a glucometer, strips, lancets, and
alcohol swabs to assist him check his blood sugar levels; glucose tabs and a glucagon
emergency kit are also suggested in case of hypoglycemia.
