Discharge Checklist for 25yo AD Female with Resolved DKA, New Onset Diabetes, Anemia, and Other Conditions
The patient should be discharged tomorrow with a comprehensive diabetes management plan including basal-bolus insulin therapy, metformin, and close follow-up with endocrinology to ensure optimal glucose control and prevent complications. 1
Diabetes Management Plan
Insulin Regimen
- ✓ Lantus 35 units qAM and 40 units qPM (split-dose approach is appropriate)
- ✓ Aspart 25 units TID AC
- ✓ Correction factor 1:20 sliding scale
- ✓ Target blood glucose <250 mg/dL before discharge
The proposed insulin regimen is appropriate for a patient with significant insulin resistance and blood sugars in the 300s. The American Diabetes Association recommends basal-bolus insulin therapy for patients with severe hyperglycemia, especially following DKA 1.
Oral Medications
- ✓ Metformin 500mg daily, increasing to 500mg BID in 1 week, then 1000mg BID 1 week later
- This gradual titration will help minimize GI side effects
Glucose Monitoring
- ✓ Check blood glucose before meals and at bedtime
- ✓ Document results and bring to follow-up appointments
Follow-up Plan
- ✓ Endocrinology consultation if glucose not at goal tomorrow
- ✓ Endocrinology referral already placed (appropriate)
- ✓ Nutrition referral already placed (appropriate)
- ✓ PCM follow-up for LIMDU
- ✓ Follow-up on GAD65 and antibody testing to confirm diabetes type
Anemia Management
Current Plan
- ✓ Feraheme 510mg IV x1 today with Tylenol/Benadryl pretreatment
- ✓ Follow-up B12/folate testing
- ✓ Follow-up hemoglobin electrophoresis
- ✓ Transfusion threshold <7 g/dL
Monitoring
- ✓ Continue to monitor Hgb daily until discharge
- ✓ Document any ongoing vaginal bleeding
Cystitis Management
- ✓ Complete cefpodoxime 100mg PO q12h for 5 days (ending 9/22)
- ✓ Follow-up on urine culture from 9/17 (NGTD)
- ✓ Ensure adequate hydration
Vaginal Candidiasis Management
- ✓ Fluconazole 150mg PO x1 (appropriate for diabetic patients with vaginal candidiasis) 2, 3
- ✓ Discontinue nystatin powder as planned
Discharge Education
Diabetes Education
- ✓ Explain diagnosis of diabetes and importance of glucose control
- ✓ Demonstrate insulin administration technique
- ✓ Review signs/symptoms of hypoglycemia and hyperglycemia and appropriate management
- ✓ Explain relationship between diabetes and increased risk of infections, including vaginal candidiasis 3, 4
- ✓ Provide written instructions for insulin dosing and titration
Nutrition Education
- ✓ Basic carbohydrate counting
- ✓ Meal planning with consistent carbohydrate intake
- ✓ Importance of regular meals with insulin therapy
Sick Day Management
- ✓ Continue taking insulin during illness
- ✓ Increase fluid intake
- ✓ Check blood glucose every 4 hours
- ✓ When to seek medical attention
Additional Discharge Considerations
VTE Prophylaxis
- ✓ Not indicated (Padua <4)
GI Prophylaxis
- ✓ Not indicated
Disposition Plan
- ✓ Transfer to med/surg pending better glucose control
- ✓ Discharge home tomorrow if glucose <250 mg/dL
- ✓ DPOA: Husband (present in room)
Follow-up Appointments
- ✓ Schedule endocrinology appointment within 1-4 weeks 1
- ✓ Schedule primary care follow-up within 1-2 weeks 1
- ✓ Schedule hematology follow-up for anemia workup
Discharge Documentation
- ✓ Complete medication reconciliation
- ✓ Document diabetes education provided
- ✓ Include clear follow-up instructions
- ✓ Provide patient with glucometer and testing supplies
- ✓ Ensure patient has prescriptions for all medications
- ✓ Document DPOA information
Important Considerations and Pitfalls
Avoid abrupt discontinuation of insulin: The American Diabetes Association recommends continuing insulin therapy after DKA resolution with appropriate adjustments 1.
Monitor for hypoglycemia: The split-dose Lantus regimen reduces nocturnal hypoglycemia risk but requires careful monitoring.
Ensure proper transition of care: Schedule follow-up within 1-4 weeks to adjust therapy as needed 1.
Address all comorbidities: Treat anemia, cystitis, and vaginal candidiasis concurrently as these conditions can worsen with poor glycemic control 3, 4.
Consider psychosocial factors: Assess the patient's understanding of diabetes management and ability to perform self-care tasks.