CASE STUDY #3 - NUT 116AL Diabetes Mellitus DUE Monday 12/9/13 (by 1:00pm in Meyer 3241)

Size: px

Start display at page:

Download "CASE STUDY #3 - NUT 116AL Diabetes Mellitus DUE Monday 12/9/13 (by 1:00pm in Meyer 3241)"

Julian Lawson
5 years ago
Views:

1 Last Name Reagan First Name Jason Section 2_ CASE STUDY #3 - NUT 116AL Diabetes Mellitus DUE Monday 12/9/13 (by 1:00pm in Meyer 3241) Patricia C. is a 30 yo Asian American woman with T1DM. She was diagnosed at age 13. Her insulin regimen is 50 units of insulin (Glargine) every evening and 3 units of Lispro with each meal. Her HbA1c is elevated and she has experienced several instances of severe hypoglycemia in the past few months, the last of which caused her to lose consciousness and she was taken to the emergency room by ambulance. FH: Parents L&W. Maternal aunt has T1DM; Paternal grandfather died of CVD 2 to T2DM. Other grandparents L&W. Has 2 siblings, two older sisters; both L&W. PMH: pt was product of normal pregnancy and delivery; had varicella at age 7, and an appendectomy at age12. NKA. Social Hx: pt married, without children. Works as an office manager. PE: General: WDWN 30 yo female; # Vitals: T 98.2 F; P 68; R 17; BP 110/70 mm Hg Chest/Lungs: Clear to percussion and auscultation Heart: Normal sinus rhythm, no murmurs HEENT: Non-contributory Abdomen: Scar tissue to the left and right of the umbilicus; otherwise non-tender, no guarding GI: No hx of N/V, or diarrhea GU: No hx of urgency, frequency, or burning urination except for present complaint of polyuria Extremities: Non-contributory Neurologic: Alert and oriented, LOC ā adm, no hx of convulsions, or difficulty walking Skin: Smooth, warm, dry, no edema Peripheral Pulse +4 bilaterally, warm, no edema Vascular: Labs: FBG: 195 mg/dl HgbA1c 8.1% Tchol 152 Mg/dL HDL 62mg/dL LDL 79 mg/dl TG 87 mg/dl TSH 1.80 mlu/l Creatinine: 0.8 mg/dl Rx: 50 units Glargine q pm & 3 units Lispro ac CAM: ginseng tea, acupuncture for pain r/t old sports injury Dx: T1DM Plan: No evidence of diabetes complications, though there is major concern about the increasing severity and frequency of hypoglycemia. Pt was seen by an endocrinologist who reduced the Glargine dose to 40 units. Pt referred to RD for diabetes education. (She has not had any diabetes education since her diagnosis 17 years ago.) 1

2 Dietary Assessment: After interviewing the client, the RD noted that PC: Typically eats 3 meals and 1 or 2 snacks each day. Eats breakfast at 7am on weekdays; she sleeps later on weekends but has low BG if she sleeps too late. Tries to eat lunch at around noon, but if work causes her to delay lunch until 2 pm, her blood sugar level drops. Eats a snack of fruit or pretzels on the drive home from work to make sure she does not get hypoglycemia when driving. If she has an early dinner, she also takes a bedtime snack. She takes Lispro with meals, but not with snacks. She checks her blood glucose 6 or more times a day. Takes Glargine at bedtime (between 10 pm and 12 am). Has hypoglycemia about twice a week with BG as low as 50 mg/dl. Lifestyle is relatively active, especially on the weekend when she plays either lacrosse or tennis. Uses alcohol occasionally, mostly on weekends. Treats hypoglycemia with regular soda or hard candy. PC s typical intake and blood sugar levels are shown in the table below. It should be noted that her breakfast is consistent on weekdays, but weekend breakfast and all lunches and dinners vary from day to day. Food Intake Blood Sugar CHO grams Level Pre-Breakfast 62 Breakfast Cereal 2 cups Milk 1.5 cups Banana, small Total CHO: 112 Two Hours PP 356 Pre-lunch 105 Lunch Tuna salad sandwich 1oz bag potato chips 1 apple Total CHO: 66 Two Hours PP 210 Snack 1oz bag pretzels 1 peach Total CHO: 37 Pre-dinner 250 Dinner Frozen cheese pizza, 2 slices 2 cups salad with oil & vinegar dressing Total CHO: 63 Snack 1 ½ cups frozen yogurt 50 Bedtime

3 1. Based on the information above, write a SOAP note, including a PES statement for PC. (8 points) (include references for equations; include calculations on an attached sheet) S- Patient diagnosed with T1DM. She was diagnosed at age 13. Her insulin regimen is 50 units of insulin (Glargine) every evening and 3 units of Lispro with each meal. Her HbA1c is elevated and she has experienced several instances of severe hypoglycemia in the past few months, the last of which caused her to lose consciousness and she was taken to the emergency room by ambulance. FH: Parents L&W. Maternal aunt has T1DM; Paternal grandfather died of CVD 2 to T2DM. Other grandparents L&W. Has 2 siblings, two older sisters; both L&W. PMH: pt was product of normal pregnancy and delivery; had varicella at age 7, and an appendectomy at age12. NKA. Social Hx: pt married, without children. Works as an office manager. Plan: No evidence of diabetes complications, though there is major concern about the increasing severity and frequency of hypoglycemia. Pt was seen by an endocrinologist who reduced the Glargine dose to 40 units. Pt referred to RD for diabetes education. (She has not had any diabetes education since her diagnosis 17 years ago.) O-30 yo Asian American woman. PE: General: WDWN 30 yo female; # Vitals: T 98.2 F; P 68; R 17; BP 110/70 mm Hg Chest/Lungs: Clear to percussion and auscultation Heart: Normal sinus rhythm, no murmurs HEENT: Non-contributory Abdomen: Scar tissue to the left and right of the umbilicus; otherwise non-tender, no guarding GI: No hx of N/V, or diarrhea GU: No hx of urgency, frequency, or burning urination except for present complaint of polyuria Extremities: Non-contributory Neurologic: Alert and oriented, LOC ā adm, no hx of convulsions, or difficulty walking Skin: Smooth, warm, dry, no edema Peripheral Pulse +4 bilaterally, warm, no edema Vascular: Labs: FBG: 195 mg/dl HgbA1c 8.1% 3

4 Tchol 152 Mg/dL HDL 62mg/dL LDL 79 mg/dl TG 87 mg/dl TSH 1.80 mlu/l Creatinine: 0.8 mg/dl Rx: 50 units Glargine q pm & 3 units Lispro CAM: ginseng tea, acupuncture for pain r/t old sports injury Dx: T1DM A: (NB-1.4) Self-monitoring deficit r/t inadequate insulin monitoring AEB checking blood glucose about 6 times a day. (NB-1.1) Food- and nutrition-related knowledge deficit r/t diabetes education AEB lack of diabetic education since she was diagnosed, low CHO intake, Pre-Breakfast blood glucose level of 62 mg/dl and Pre-Lunch blood glucose level of 105 mg/dl. P: Provide diabetic education and emphasize on normal amounts of CHO intake, and proper insulin monitoring. Monitor BG levels to avoid hypoglycemia. Setup follow-up appointment with patient after 1 month. 4

5 2. Compare PC s laboratory values with normal values. What does each value indicate? (4 points) Test Normal Patient Compare Meaning (+/-) FBG mg/dL 195 mg/dl +65 mg/dl Fasting hyperglycemia. HgbA1c 6-6.9% (NTP pg 76) 8.1% +1.2% Possible inadequate blood glucose control 2-4 months prior. TSH mlu/l 1.80 mlu/l Normal range Normal activity of thyroid gland Creatinine mg/dl (NTP pg 74) (include references for values) 0.8 mg/dl Normal range Normal levels of nitrogenous by-product, as a result of the breakdown of muscle creatinine phosphate for energy metabolism 3. What does HbA1c measure? (1 point) HbA1c measures the amount of circulating glucose that is able to bind to hemoglobin within the circulating red blood cells. 4. What are PC s goals for each of the following? (3 pts) HbA1c: <7% Pre-prandial BG: Post-prandial BG: mg/dl <180 mg/dl 5

6 5. What is the relationship of HgbA1c values to the micro- and macro-vascular complications of diabetes? (3 points) PC s A1c levels show poor glycemic control over a 3 month time period. This poor glycemic control contributes to both micro- and macro-vascular complications such as MI, stroke, heart failure, hypertension, and hyperglycemia. 6. What is the difference between the onset, the peak, and the duration of the two types of insulin that PC is taking? How does this relate to her food intake? (3 points) a. Lispro- Is a rapid-acting insulin. It has an onset of 15 minutes, a peak of 30 to 90 minutes and a duration of 3 to 5 hours. -PC takes Lispro before her major meals because it has a short onset and will begin to work by the time she eats. This will keep her BC levels under control during and after her meal. b. Glargine- Is a long-acting insulin. It has an onset of 1 hour, is peakless and has a duration of 20 to 26 hours. -PC takes Glargine before she sleeps because it is a long-acting insulin. It does not need to be taken with any meals and will work up to 24 hours. This will keep her BC levels under control while she sleeps. 7. What is the cause of the scaring that has been noted on PC s abdomen? What impact does this have on insulin activity? What information should she be given in relation to this? (3 points) This scaring is due to the appendectomy that PC had at the age of 12. This can result in some insulin resistance in cells. In relation to this, an increase in insulin to compensate for the resistance may be needed. 6

7 8. You determine that PC needs 2498 kcals/day based on EER calculations. You want to follow her normal eating pattern as much as possible while still meeting her protein requirements and keeping the kcal from fat at 30% or less of total kcals. Using the Diabetes Exchange Lists that can be found in NTP Appendix L-1 and the worksheet below, develop a pattern for PC s diet. (15 points) Food group Number of Exchanges CHO grams Protein grams Breakfast Starch Fruit Milk (circle: whole, 2%, 1%, or NF) Meat (circle: very lean, lean, med or high fat) Non-starchy vegetables Fat Morning Snack (list food groups) Starch Fruit Lunch Starch 3 1/ Fruit Milk (circle: whole, 2%, 1%, or NF) Non-starchy vegetables Meat (circle: very lean, lean, med or high fat) Fat Afternoon Snack (list food groups) Starch 1 1/ Fruit Dinner Starch Fruit Milk (circle: whole, 2%, 1%, or NF) Non-starchy vegetables Meat (circle: very lean, lean, med or high fat) Fat HS Snack (list food groups) CHO Fat Fat grams Total grams: X4 X4 X9 kcal from each macronutrient: % kcal from each macronutrient: TOTAL KCAL:

8 You review PC s diet, insulin injections, SBGM, and other self-care issues. She continues on injections of Glargine and Lispro. She does well over the next few months in managing her diabetes. However, she is finding it difficult to keep her activity and intake constant due to the fact that her schedule is variable. She and the health care team agree to use an insulin pump with intensive therapy in order to make her selfcare more flexible and achieve tighter glucose control. 9. You begin teaching PC about carbohydrate counting. a. Assume that her kcal needs have remained the same. How many CHO points or servings are in her daily diet from question 8? (1 point) 387g in PC s diet / 15g CHO/ CHO point = 25.8 CHO points b. Describe briefly how this will differ from the exchange-based diet plan that she was using. (2 points) Giving 26 servings of CHO assumes each serving contains 15g CHO. This is not true in all cases such as dairy and non-starchy vegetables. 10. PC brings her SBGM record in for review when she comes for nutrition counseling. The pre-prandial BG goal is mg/dl. Several pre-meal entries are listed below. a. Circle the values below that are outside the desirable range. (1 point) PP BG mg/dl Day Breakfast Lunch Dinner HS Snack a. What adjustment(s) should PC make if the values are above the desirable range? (1 point) Some adjustments that PC could make to reduce some of the above values could be: 1. Skip the snack that is ate before bedtime to reduce PP BG before breakfast. 2. Decrease the portion size of items ate at breakfast to reduce PP BG before lunch. For example, reduce the portion of cereal consumed to 1.5 cups instead of 2 cups. 8

9 b. What adjustment(s) should PC make if the values are below the desirable range? (1 point) An adjustment that PC could make to increase the value that is below the desirable range would be by increasing the amount that is consumed before the HS snack. 11. Assuming an insulin to CHO ratio of 1:15 how much insulin should PC be taking before consuming her usual weekday breakfast? Which type of insulin should it be? (2 points) PC consumes about 112 grams of CHO during her usual weekday breakfast. This would equal about 7.5 units of insulin. The type of insulin that should be used before consuming breakfast would be the rapidacting, Lispro. 12. If PC s BG was measured at 210 mg/dl just before lunch, which was to be a turkey sandwich, a piece of fruit and a diet soda, how much insulin should she take to cover the meal, and how should it be adjusted to compensate for the BG level? (2 points) = 80 mg/dl Turkey sandwich = 30g CHO 1 fruit = 15g CHO Diet soda = 0g CHO In order to cover the meal, PC would need to take 3 units of insulin. But based on her high blood glucose level before the meal, the amount of insulin would need to be increased. 9

CASE STUDY Diabetes Mellitus FH: PMH: Social Hx PE: Labs: Rx: CAM: Dx: Plan:

CASE STUDY Diabetes Mellitus FH: PMH: Social Hx PE: Labs: Rx: CAM: Dx: Plan: CASE STUDY Diabetes Mellitus Patricia C. is a 30 yo Asian American woman with T1DM. She was diagnosed at age 13. Her insulin regimen is 50 units of insulin (Glargine) every evening and 3 units of Lispro