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

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Eunice Manning
5 years ago
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1 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 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 Living & Well. 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 chickenpox at age 7, and an appendectomy at age12. No Known Allergies. 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. 12/5/13 10:49 AM S: PC has normal feeding abilities and eating habits which include approximately 3 meals & 2 snacks/day. Pt reports no known allergies. CAM practices include consumption of ginseng tea. PC is able to and educated about packing snacks throughout the day. Previous nutrition counseling on diabetes was at age 17. Pt is married with no children, and is relatively active. Currently pt is employed as an office manager. Parents and siblings are living and well. However, maternal aunt has T1DM and paternal grandfather died of CVD 2 to T2DM. Other grandparents are living and well. Diagnosed with T1DM. Acupuncture use present due to pain r/t sports injury. Rx includes 50 units Glarcine which was recently adjusted to 40 units & 3 units Lispro ac. Recent episodes of hypoglycemia. O: 30 yo Asian American female Ht. 5 8 Wt. 145# BMI: 22.1kg/m2 EER: kcal IBW: 63.6 kg % IBW: 104% EPR:52.7 gm/day 65.9 gm/day Fluid Needs: 1977 ml/day Present complaint of Polyuria. No edema. FBG: 195 mg/dl HgbA1c: 8.1% Tchol: 152 Mg/dL HDL 62mg/dL LDL: 79 mg/dl TG: 87 mg/dl Creatinine: 0.8 mg/dl Diagnosed w/t1dm; Diet Order: foods and insulin that maintains stable BG levels esp. to prevent further hypoglycemic episodes. Based on Blood sugar levels collected during interview, pt needs tighter Glycemic Control. A: P: 1. A1C<7, Preprandial plasma glucose (FBG) mg/dl, Postpranidal plasma glucose <180 mg/dl F/U 2-3 weeks, bring food and SMBG logs Signature: 3

4 2. Compare PC s laboratory values with normal values. What does each value indicate? (4 points) Test Normal Patient Compare Meaning (+/-) FBG mg/dl (Lab) mg/dl HgbA1c 4-6% 8.1% + (Lab) TSH miu/l (TSH) Creatinine mg/dl (Lab) 1.80 miu/l 0.8 mg/dl (include references for values) 3. What does HbA1c measure? (1 point) Glycated hemoglobin assays measure the amount of glucose bound to hemoglobin protein. This allows for the measurement of average glycemia over preceding 2-3 months (NTP 492). 4. What are PC s goals for each of the following? (3 pts) (NTP) HbA1c: <7% Pre-prandial BG: Post-prandial BG: mg/dl <180 mg/dl 4

5 5. What is the relationship of HgbA1c values to the micro- and macro-vascular complications of diabetes? (3 points) 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. b. 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) 5

6 8. SLIDE 59 & find diabetes case studyyou determine that PC needs 1977 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 Breakfast Starch 2 cups? 65 Fruit 1 Milk (circle: whole, 2%, 1%, or NF) 1.5 cups? Meat (circle: very lean, lean, med or high fat) 0 Non-starchy vegetables 0 Fat 0 Morning Snack (list food groups) 15 CHO grams Protein grams Fat grams Lunch Starch 80 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) 17 Dinner Starch 100 Fruit Milk (circle: whole, 2%, 1%, or NF) Non-starchy vegetables Meat (circle: very lean, lean, med or high fat) Fat 20 HS Snack (list food groups) Total grams: X4 X4 X9 kcal from each macronutrient:

7 % kcal from each macronutrient: 60% 25% 15% TOTAL KCAL: 1977 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) b. Describe briefly how this will differ from the exchange-based diet plan that she was using. (2 points) 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) Increase insulin delivered b. What adjustment(s) should PC make if the values are below the desirable range? (1 point) Decrease insulin delivered 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) 7

8 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) 8

9 CITATIONS: "Lab Values." Lab Values. University of Missouri, n.d. Web. 05 Dec "TSH Test: MedlinePlus Medical Encyclopedia." U.S National Library of Medicine. U.S. National Library of Medicine, n.d. Web. 05 Dec

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

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