Case 1

By the end of the day, you receive Felicia’s laboratory results:

CBC

Patient values

Reference range

WBC/µl

18,000

5,500-19,500

Neutrophils /µl

16,000

2,500-12,500

Bands /µl

500

0-300

Monocytes /µl

700

0-900

PCV (%)

30%

30-45

Serum chemistry panel

Patient values

Reference range

BUN (mg/dl)

88

19-34

Creatinine (mg/dl)

2.4

0.9-2.2

Glucose (mg/dl)

341

60-120

Potassium (mg/dl)

5.7

3.7-6.1

Urinalysis

Urine specific gravity

1.016

WBC

0-1/hpf

RBC

0-1/hpf

Bacteria

None seen

pH

6

T4 = 1.5 µg/dl (reference range: 1-4 µg/dl)

The culture results are still pending. The neutrophilia with a left shift coupled with the azotemia and low urine specific gravity are highly suspicious of pyelonephritis.

QUESTION 7

Since an underlying infection is still on the differential list and we know that infections can cause insulin resistance, what is your plan for Felicia while we await the culture results?

a) No changes in her treatment at this time.

b) Increase the insulin dose to 3.5 U twice a day

c) Increase the insulin dose to 3.5 U twice daily and send her home on a broad-spectrum antibiotic.

d) Send her home on a broad-spectrum antibiotic with no changes in her insulin dose.

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