A 56-Year-Old Man Comes to the Emergency Department with Retrosternal

question 107

Multiple Choice

A 56-year-old man comes to the emergency department with retrosternal chest pain that began when he was cleaning his backyard a few hours ago.  His medical problems include type 2 diabetes mellitus, hypertension, hypercholesterolemia, and obesity.  Three weeks ago, his hemoglobin A1C was 9.6% and glyburide was added.  He has no overt chronic complications of diabetes.  His medications include metformin, glyburide, ramipril, amlodipine, simvastatin, and low-dose aspirin.
His blood pressure is 140/80 mm Hg, pulse is 70/min, and body mass index is 38 kg/m².  The patient appears a little apprehensive, but the examination otherwise shows no abnormalities.
Electrocardiogram shows normal sinus rhythm and non-specific ST-T changes in the lateral chest leads.  The initial levels of cardiac troponin I are normal.  Chemistry profile is normal except for blood glucose of 266 mg/dL.  Chest x-ray is unremarkable.
The patient is admitted to a telemetry bed for monitoring, and serial cardiac enzymes are ordered.  He is allowed to eat a diabetic diet.  Finger-stick blood glucose measurement before meals and bedtime is ordered.
Which of the following is the best way to manage this patient's diabetes mellitus during hospitalization?

• A)Continue his home regimen and start a long-acting basal insulin
• B)Continue his home regimen and start a sliding scale of short-acting insulin
• C)Stop oral diabetic agents and start a basal-bolus regimen
• D)Stop oral diabetic agents and start intravenous insulin infusion
• E)Stop oral diabetic agents and start a sliding scale of short-acting insulin

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Definitions:

Hammond Postulate

A principle stating that the transition state of a chemical reaction resembles the structure of the closest stable species.

Free Radical Bromination

A chemical reaction process involving the substitution of hydrogen atoms in organic molecules with bromine atoms, initiated by free radicals.

Free Radical Chlorinations

A reaction involving the substitution of hydrogen by chlorine in a hydrocarbon through the action of free radicals.

Hammond Postulate

A principle in organic chemistry that proposes the structure of a transition state is more similar to the structure of the reactants or products to which it is more similar in energy.