CASE STUDY # 5 Diabetes Mellitus



Last Name ______Xie_____________First Name____Yuchen_____________ Section___01__ CASE STUDY #3 - NUT 116ALDiabetes MellitusDUE 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; 5’8” 145#Vitals:T 98.2°F; P 68; R 17; BP 110/70 mm HgChest/Lungs:Clear to percussion and auscultationHeart:Normal sinus rhythm, no murmurs HEENT:Non-contributoryAbdomen:Scar tissue to the left and right of the umbilicus; otherwise non-tender, no guardingGI:No hx of N/V, or diarrheaGU:No hx of urgency, frequency, or burning urination except for present complaint of polyuriaExtremities:Non-contributoryNeurologic:Alert and oriented, LOC ā adm, no hx of convulsions, or difficulty walkingSkin:Smooth, warm, dry, no edemaPeripheral Vascular:Pulse +4 bilaterally, warm, no edemaLabs:FBG:195 mg/dLHgbA1c8.1%Tchol152 Mg/dLHDL62mg/dLLDL79 mg/dLTG87 mg/dLTSH1.80 mlU/LCreatinine:0.8 mg/dLRx: 50 units Glargine q pm & 3 units Lispro acCAM: ginseng tea, acupuncture for pain r/t old sports injuryDx: T1DMPlan: 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.)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 IntakeBlood Sugar LevelCHO gramsPre-Breakfast62BreakfastCereal – 2 cupsMilk – 1.5 cupsBanana, small741820Total CHO:112Two Hours PP356Pre-lunch105LunchTuna salad sandwich1oz bag potato chips1 apple301620Total CHO:66Two Hours PP210Snack1oz bag pretzels1 peach2215Total CHO:37Pre-dinner250DinnerFrozen cheese pizza, 2 slices2 cups salad with oil & vinegar dressing5310Total CHO:63Snack1 ? cups frozen yogurt50Bedtime298Based 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 OAPCompare PC’s laboratory values with normal values. What does each value indicate? (4 points)TestNormalPatientCompare (+/-)MeaningFBG<90mg/dl*195mg/dl+Fasting Plasma Glucose is the major measurement of Diabetes. 100-125mg/dl is prediabetes, 126mg/dl is diabetes, 195mg/dl above mean the patient have diabetes.HgbA1c~5%*8.1%+5.7-6.4% is prediabetes, patient have 8.1% means she have diabetes.TSH0.4-4.0mlU/L**1.80mlU/LNormalThyroid gland produce enough thyroid hormone, works normal, Creatinine0.6-1.1mg/dL**0.8mg/dLNormalKidney function normal(include references for values)* NDIC: ** MedlinePlus: does HbA1c measure? (1 point)An HbA1c test is also called glycohemoglobin test, and it’s used to specifically measure type 2 diabetes and prediabetes, although it’s not recommended to detect type 1 diabetes or gestational diabetes.At A1C below 5% is normal, an range of 5.7-6.4% means prediabetes, and 6.5% or above indicates diabetes. (NDIC)What are PC’s goals for each of the following? (3 pts)HbA1c: <7%Pre-prandial BG:90-130 mg/dlPost-prandial BG:<180mg/dlWhat is the relationship of HgbA1c values to the micro- and macro-vascular complications of diabetes? (3 points)Multiple large-scale clinical trials, including the Diabetes Complications and Control Trial (DCCT)?in type 1 diabetes and the United Kingdom Prospective Diabetes Study (UKPDS)?in type 2 diabetes, provide evidence that the risk for macrovascular and microvascular complications begins to increase at an HbA1c level of 6.5%. In the (UKPDS), a 1% rise in HbA1c was associated with a 37% increase in microvascular disease, and increased incidence of cardiovascular and peripheral vascular disease. Reference1. DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in IDDM. N Eng J Med. 1993;329: 977–983.2. Stratton IM, Adler AI, Neil HA, et al. Association of Glycaemia With Macrovascular and Microvascular Complications of Type 2 Diabetes (UKPDS 35): Prospective Observational Study. BMJ. 2000;321:405–412.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. GlargineOnset: 6-10 hrPeak: no peakDuration: 24hrb. LisproOnset: <15minPeak: 1-2hrsDuration: 4-6hrsWhat 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) You determine that PC needs __2094.05__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 groupNumber of ExchangesCHO gramsProtein gramsFat gramsBreakfastStarch46080Fruit1.32000Milk (circle: whole, 2%, 1%, or NF)1.518123Meat (circle: very lean, lean, med or high fat)0000Non-starchy vegetables0000Fat----Morning Snack (list food groups)Sweets22030LunchStarch46080Fruit1.32000Milk (circle: whole, 2%, 1%, or NF)0???Non-starchy vegetables42000Meat (circle: very lean, lean, med or high fat)40288Fat----Afternoon Snack (list food groups)starches11520Fruit11500DinnerStarch46080Fruit----Milk (circle: whole, 2%, 1%, or NF)Non-starchy vegetables4800Meat (circle: very lean, lean, med or high fat)302115Fat----HS Snack (list food groups)Milk 1%11282Total grams:3289828X4X4X9kcal from each macronutrient:1312392252% kcal from each macronutrient:672012TOTAL KCAL:1956You 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 self-care more flexible and achieve tighter glucose control.You begin teaching PC about carbohydrate counting.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)1 unit of insulin for every 15g of CHO (handout)for question 8, her daily intake of CHO is 328g, so 328/15=21.9 unitDescribe briefly how this will differ from the exchange-based diet plan that she was using. (2 points)Carb Counting is particularly important for people who take insulin because their dosage is dependent on the amount of carbohydrate they need to offset. Since PC has a various schedule and can not keep her activity and intake constant, she has to determine the number of carbs she will eat in a particular meal, calculate the amount of insulin she will need to clear those carbs from their blood, then give herself an injectionHowever, the food-exchange system organizes foods according to their nutritional content: Starch, Fruit, Vegetable, Fat-Free/Reduced-Fat Milk (including milk and yogurt), Very Lean Meat, Lean Meat, Medium-Fat Meat, High-Fat Meat, and Fat.PC brings her SBGM record in for review when she comes for nutrition counseling. The pre-prandial BG goal is 70-130 mg/dl. Several pre-meal entries are listed below.Circle the values below that are outside the desirable range. (1 point)PP BG mg/dLDayBreakfastLunchDinnerHS Snack193138111110289100956931591069799What adjustment(s) should PC make if the values are above the desirable range? (1 point)Increase the insulin doseIf the high values occur before dinner, the morning insulin can be incresed If the high values occur in the early morning, the evening insulin can be increaseIf the value are high before the bedtime snack, increase the dinner rapid-acting or regular insulinWhat adjustment(s) should PC make if the values are below the desirable range? (1 point)Reduce insulin doseIf the low values occur before dinner, the morning insulin can be reduced by 1 or 2 unitsIf the low values occur in the early morning, the evening insulin can be reduced by 1 or 2 unitsIf the value are still low the next day, reduce the insulin again.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)Her total breakfast CHO is 98g. unit: 98g/15g/unit= 6.5unitShe should use LisproIf 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)Turkey Sandwich: 2 svg bread=30gA piece of fruit: 1 svg fruit=15gTotal CHO: 45g45g/15g/unit=3 unitCorrection does: 210mg/dL-130mg/dL=80mg/dL80mg/dL/50pts=1.6unitTotal insulin unit: 3 unit+1.6unit=4.6 unit ................
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