More Than Just the Numbers:

Transcription

1 More Than Just the Numbers: Individualising Patient Care ADEA-QLD Branch Conference 20 April 2018

2 Case Study 1 Child with Type 1 Diabetes 2 Background and Social History 10 year old female with T1DM since age 2 Lives with mother and 8 year old sister Seen by paediatric endocrinologist/consultant, diabetes educator, dietitian and referrals to CYMHS but not sure if they have engaged with this service family moves from town to town frequently as mother has DVO against partner no local family or social support

3 3 Child with Type 1 Diabetes Medical History very slim in 18 th BMI centile, weight 28.9kg, 143.5cm has Animas pump which is causing issues has anxiety, gastroparesis (not sure if this is confirmed diagnosis) says has coeliac disease, but in conversations with mother not sure if this is actual diagnosis, or they just prefer GF has had several admissions recently for mild DKA PT reported (unsure if formally diagnosed) & sensory autism

4 Child with Type 1 Diabetes 4 Medication ICR 1u:15g, mother doesn t correct fluvoxamine 525mg bd Osmolax 2 scoop od Recent Pathology HbA1c usually >10mmol/L.

5 Child with Type 1 Diabetes 5 Dietary History mother states she taught herself carb counting - is very anxious and defensive when questioned about anything (food, meds, living situation) child has regular meals, mother tries many different foods but the patient refuses them mother previously not engaged with Dietetics as she feels she hasn t found one that can deal with the carb counting child will only eat certain foods and textures and has wild tantrums when mum tries to introduce new foods has GF and lactose free diet unsure if tested for these intolerances

6 Case Study 2 - Latent autoimmune diabetes of adults (LADA) 6 Background male 34 year old BMI 24

7 Latent autoimmune diabetes of adults (LADA) 7 presents to RA3 ED at 3:30pm with: Severe blurry vision Generally unwell Polydipsia Polyuria BGL 26.9 initial bloodwork unremarkable, apart from hyperglycaemia fluids given in Emergency Department Medical Registrar contacted for support at RA2 hospital, advised probably Type 2 Diabetes but to test for IA2 and GAD antibodies

8 Latent autoimmune diabetes of adults (LADA) 8 BGL unchanged 6u Novorapid given at 2100hrs on the ward further 6u Novorapid given at 0700hrs discharged with script for metformin at 8.00am without meter advised to purchase at local chemist

9 Latent autoimmune diabetes of adults (LADA) 9 Wife concerned at 12.00pm BGL 10mmol/L 12u of Lantus given in Emergency Department out-patients at 1.00pm Libre applied - had access through CDE patient and wife nervous about starting insulin Also allowed for capillary ketone testing Returned home at 1:30pm C-Peptide added to pathology request

10 Latent autoimmune diabetes of adults (LADA) 10 BGL 19.9 at 3pm and trending up, Ketones 1.2 generally lethargic but otherwise well Return to hospital 6u Novorapid given sent home after 30 minutes Appointment with GP the next day Metformin and Novorapid prescribed in addition to Lantus Insulin titrated with confidence due to Libre

11 Case Study 3 Older Person 11 Background and Social History 76 year old lady living with husband who is 81 years old recently moved from NSW to QLD to live with daughter due to her frequent hypoglycaemia and admissions to hospital has hypoglycaemia about twice a week usually at night was told years ago she has to keep her blood glucose levels between 4-8 and she is very reluctant to reduce her insulin despite the hypos has chronic back pain so is very restricted with activities rely on the daughter to prepare meals non-drinker and has never smoked

12 Older Person 12 Medical History Diabetes for 15 years, she has always been on insulin, she is confirmed to have type 2 diabetes Osteoarthritis of the spine Chronic pain syndrome Hypertension Obesity Fatty liver

13 Older Person 13 Recent Pathology HbA1c 5% (13/10/17 5.1%, % and %) egfr 73 creatinine 70 Hb 126 Lipids, TC 3.3mmols/l, trigs 1.0mmols/L, Hdl 1.57 mmols/l, Ldl 1.3mmols/L Blood glucose levels 4-5mmols on waking, 5-10 before lunch and 5-10 before dinner, up to 16mmols before bed.

14 Older Person 14 Medications Novomix units mane and 35 units nocte Gabapentin 300mg 1 nocte Zanidip 20mg 1 nocte Crestor 10mg 1 daily Karvezide 300/25 daily Methadone 10mg 4 times daily