Case Study #2



Name: Dawn Ortiz

Diabetes

Case Study: Millie R. is a 75 year old woman living with her 80 year old sister, for whom she is caring. They live in a low income urban community in a third floor walk up apartment. Millie comes regularly to the Medical Clinic. She complained at her most recent visit of blurred vision, symptoms of polydipsia and polyuria, and a weight loss of 6 lb. in the past two weeks.

On admission to the hospital, her blood glucose measured 888 mg/dl. A diagnosis of urinary tract infection and nonketotic hyperglycemia was made.

Medical History: Hypertension, congestive heart failure, asthma

Family History: Sister has had Type 2 Diabetes for 10 years

Current Medications: Digoxin, furosemide (Lasix), hydrochlorothiazide, propranolol, hydrochloride (Inderal), prednisone

Weight: 119 lb. (usual weight 125 lb.); Height: 4 ft. 11 in. BMI = 24

Additional nutrition related abnormal labs: Cholesterol 380 mg/dl

Patient Interview: "I’m the thinnest I’ve ever been and I’m too old to lose weight. I can’t be more active because my asthma kicks up. I know about diabetes. My sister has it and she eats the way I do."

On questioning, the following 24 hour recall information was obtained:

Breakfast

2 large shredded wheat biscuits

1 c. whole milk

1 slice toast with margarine, jelly

Snack

1/2 grapefruit, 1 tsp. sugar

Dinner

1 pork chop, approximately 4 oz., with fat

1 c. rice or potato with gravy

Greens with salt pork

2 slices bread with margarine

Snack

1/2 grapefruit, 1 tsp. sugar

Questions:

1. Explain the physiological difference between Type I and Type II diabetes.  How are each of these diseases treated?

Type 1 diabetes, also known as juvenile-onset or insulin-dependent DM, develops when the pancreas is no longer able to produce insulin due to loss of the insulin-producing pancreatic β-cells. Type 2 diabetes develops when the cell’s insulin receptors are no longer able to take in insulin and the glucose it is trying to carry into the cell. Both forms of DM result in high blood glucose levels. Type 1 is treated with multiple daily insulin injections. Type 2 can be managed with diet and exercise. In severe type 2 cases medication and/or insulin therapy may be necessary to manage blood sugar levels.

2. What are the criteria for diagnosing Type II diabetes?

Type 2 diabetes can be diagnosed with any of the following tests: Hemoglobin A1c, (HbA1c) test of 6.5% and above, a fasting plasma glucose (FPG) test of 126 mg/dL or above, or an oral glucose tolerance test (OGTT) indicating a 2-hour blood glucose level 140-199 mg/dL, followed by a second test indicating 200 mg/dL or above. Results should be confirmed with repeat testing.

3. Describe the risk factors for developing Type II diabetes.

A family history, being 45 years and over, race (greater in Hispanics, African-Americans, Native Americans, and Asians), low physical activity, metabolic syndrome, being overweight or obese (BMI of greater than 25 or 30), fat around the waistline, hypertension, abnormal lipid profile (HDL less than 35 mg/dL and/or triglycerides over 250 mg/dL), history of gestational diabetes and impaired glucose tolerance.

4. List 4 examples of OHA (oral hypoglycemic agents) and explain the mechanism of action for each.

1) Sulfonylureas- stimulate insulin secretion, which results in more insulin being released and therefore more glucose being absorbed into the cell.

2) Metformin- increases insulin action and reduces glucose output from the liver. It is most often used in combination with sulfonylureas to decrease blood glucose levels.

3) Thiazolidinediones- reverse insulin resistance by acting on muscle and fat to increase glucose utilization and decrease glucose production.

4) Alpha-glucosidase inhibitors- inhibit the gastrointestinal enzymes that convert dietary starch and complex carbohydrates into simple sugars, and therefore slows absorption into the cell.

5. What are the indications for using insulin in Type II diabetes?

When patients are unable to control their DM with diet, exercise or oral medications, physicians may prescribe insulin treatment. The following are scenarios requiring insulin; severe hyperglycemia (fasting blood glucose over 250 mg/dL), A1c over 10%, serious infection, concurrent illness, during and after major surgery, pregnancy and/or failure to maintain blood sugar levels using three or more oral medications.

6. What are the recommended guidelines for frequency of blood glucose monitoring for Type II diabetes on OHA?  Type II diabetes on insulin?

For Type 2 DM, patients that are on OHA medications should check their blood glucose levels periodically (about 3x/week) and keep a log for their doctor. Patients on insulin should check their glucose levels 1-3 times daily. They should check before meals, exercise, bed time and before driving.

7. Explain the mechanism by which the patient’s blood glucose level could become so high without producing ketosis (Hint: This is not DKA. This condition is abbreviated HHS).

According to the American Diabetes Association, hyperosmolar hyperglycemia (HHS) is a combination of ineffective insulin, along with an elevation in counterregulatory hormones production. This leads to increased hepatic and renal glucose production and impaired glucose utilization in peripheral tissues. The result is hyperglycemia and osmolality imbalances.

8. What is HbA1c and what is the goal patient’s should try to maintain?

Glycated hemoglobin assays measure the amount of glucose bound to hemoglobin protein in the blood. HbA1c is a good indicator of regular blood glucose levels. People with diabetes should try to maintain HbA1c of less than 7% to avoid complications from the disease.

9. Evaluate the patient’s diet, based on the 24 hour recall. Give estimated calories, carbohydrate, protein, and fat. Comment on meal patterns and portions.

Breakfast

2 large shredded wheat biscuits – 190 kcal, 28g CHO, 6g PRO, 7g fat

1 c. whole milk- 150 kcal, 12g CHO, 8g PRO, 8g fat

1 slice toast with margarine, jelly- 70 kcal, 13g CHO, 2g PRO (bread), 1g fat (toast) + 100 kcal, 0g CHO, 0g PRO, 11g fat (1 tbsp margarine) + 50 kcal, 13g CHO, 0g PRO, 0g fat (1 tbsp jelly)

Total: 560 kcal, 66g CHO, 16g PRO, 27g fat

Snack

1/2 grapefruit, 1 tsp. sugar- 60 kcal, 16g CHO, 1g PRO (grapefruit) + 16 kcal, 4g CHO, 0g PRO, 0g fat (1 tsp sugar)

Total: 76 kcal, 20 CHO

Dinner

1 pork chop, approximately 4 oz., with fat- 256 kcal, 0g CHO, 32g PRO, 16g fat

1 c. rice or potato with gravy- 200 kcal, 44g CHO, 4g PRO, 0g fat (rice) + 120 kcal, 11g CHO, 9g PRO, 5g fat(gravy)

Greens with salt pork- 75 kcal, 8g CHO, 4g PRO, 4g fat

2 slices bread with margarine- 140 kcal, 26g CHO, 4g PRO, 2g fat (bread) + 100 kcal, 0g CHO, 0g PRO, 22g fat (1 tsp margarine)

Total: 891 kcal, 89g CHO, 53g PRO, 49g fat

Snack

1/2 grapefruit, 1 tsp. sugar- 76 kcal, 20g CHO total

Total: 76 kcal, 20 CHO

DAILY TOTAL: 1603 kcal, 195g CHO, 69g PRO, 76g fat

According to the USDA DRI’s, a 75 year old lady should be consuming the following macronutrient amounts per day: 130g CHO, 56g PRO and 20-35g fat. Although Millie is not consuming too many calories in her diet, she is eating foods which are too high in all of the macronutrients. Her meal patterns are somewhat sporadic and she does not eat lunch. She is eating large amounts in one sitting and adding unnecessary sugar and fat to her foods. She should work to reduce portion sizes, spread her meals throughout the day, reduce the total carbohydrates, protein and fat that she is consuming. She should also practice carbohydrate counting to spread out the amount of sugar she is getting throughout the day. She needs to add more variety to her diet to ensure she is receiving adequate vitamins, minerals and fiber.

10. What diet would you recommend for this patient?

I would recommend Millie start to follow a diabetic, 1600 kcal, heart healthy (low sodium) diet. She should also try to consume more calcium and potassium based on the medications she is currently taking. Millie should work to reduce her fat and sodium intake, spread her carbohydrate intake out throughout the day and eat more vegetables and whole grains for fiber.

11. Make a diet plan and write one day’s sample menu.

Millie’s diet should consist of eating small frequent meals throughout the day. She should practice carbohydrate counting to make sure she is not consuming too many carbohydrates at once.

Guidelines:

1600 Kcal ADA and Heart Healthy Diet

55% CHO (1600x0.55) / 4 kcal per g = 220 g

20% Pro (1600x0.20) / 4 kcal per g = 80g

25% Fat (1600x0.25) / 9 kcal per g = 44g

Breakfast

Egg white

1 slice whole wheat toast (1)

1 cup fat free milk (1)

½ banana (1)

Lunch

3 oz. grilled chicken on a green salad with carrots, tomatoes, cucumbers, beets and quinoa with olive oil and vinegar (1)

Small wheat roll (1)

Snack

1/2 grapefruit (1)

Dinner

3 oz. grilled salmon

½ cup brown rice with garlic and olive oil (1)

½ cup broccoli

½ cup carrots (1)

1 cup fat free milk (1)

Snack

3 prunes (1)

12. Which items in her present diet would you like to replace with foods more appropriate for this patient?

I would replace Millie’s entire breakfast and do away with the carbohydrate overload, margarine and whole milk, have her stop adding sugar to fruit, start eating lunch, switch the pork chop for a lean meat/fish, change the way she prepares her vegetables, take away the gravy and two pieces of toast and give her a different fruit to snack in the evening.

Patient follow-up: Millie is not able to achieve adequate glucose control using OHA and diet. Her physician recommends that she start taking insulin for better blood sugar control.

13. List the types of insulin available, the onset, peak and duration of action for each type. Include at least one brand and/or generic name for each type of insulin.

According to the American Diabetes Association:

Rapid-acting insulin-- starts to lower blood glucose within 5 to 10 minutes. It peaks after 1 hour and is effective 2-4 hours. Types: glulisine (Apidra), lispro (Humalog), and aspart (NovoLog).

Regular or Short-acting insulin-- starts to lower blood glucose within 30 minutes after injection and has its strongest effect 2 to 5 hours after injection. It is effective for 3 to 6 hours. Types: Humulin R and Novolin R.

Intermediate-acting insulin-- reaches the bloodstream within 2 to 4 hours and peaks 4 to 12 hours after the injection. It is effective for about 12 to 18 hours. Types: NPH (Humulin N, Novolin N).

Long-acting insulin-- starts to lower blood glucose within 4 to 6 hours and has strongest effect 10 to 18 hours after injection. It continues to lower glucose levels fairly evenly over a 24-hour period. Types: detemir (Levemir) and glargine (Lantus).

14. What is CGM? How does it differ from accuchecks / fingerstick measurements?

Continuous glucose monitoring (CGM) measures interstitial fluid glucose, which correlates with blood glucose, in a continuous and minimally invasive manner. This helps diabetics on intensive insulin therapy monitor how foods, exercise and medication effect their glucose levels throughout the day. CGMs have a sensor right under the skin attached to a transmitter which relays the information to a handheld receiver or an insulin pump. CGMs have alarms for hypo and hyperglycemia, which help diabetics avoid these extreme blood glucose levels. CGMs check the fluid right beneath the skin while fingersticks check actual blood glucose levels. Therefore, CGMs are more convenient but fingersticks are more accurate.

15. Briefly describe the insulin pump and the type of patient that may benefit from its use. Can the pump be combined with CGM? What are advantages / disadvantages?

Insulin pumps deliver rapid/short-acting insulin 24 hours a day through a catheter placed under the skin. The doses are separated into: basal rates, bolus doses to cover carbohydrates in meals and correction/supplemental doses. Basal insulin is delivered continuously (programed based on needs), which keeps your blood glucose levels in range between meals and overnight. The insulin pump can give additional insulin called a bolus before meals. Corrective doses can be taken if glucose levels are too low or high. Some advantages of using the pump is that injections are not necessary, HbA1c levels may improve, allows for exercise without having to consume large amounts of carbohydrates, helps keep blood sugar levels more consistent and allows for more flexibility in the diet. Some disadvantages of using the pump is that it is expensive, may cause weight gain, can be bothersome and may cause diabetic ketoacidosis if it comes out. Some insulin pumps have CGM technology incorporated into the device. If it is not incorporated, it may be a good idea to use both.

16. Outline the information that you would want to include in your education to the patient and her family prior to discharge.

Goals for Millie:

• Follow meal plan provided

• Count carbohydrates at meals and snacks (spread out daily healthy carb intake)

• Increase fiber, calcium and potassium intake (fruits, low/non-fat dairy, vegetables and whole grains)

• Decrease refined sugar and sodium intake

• Drink plenty of water

• Visit with an exercise physiologist

• Follow up call in 1 week to check if Millie is following her diet plan and ask for a 24 hour recall

• Refer Millie to a diabetes educator to make sure she is monitoring blood sugar and insulin treatment correctly.

• Follow up MD visit to check glucose levels in 3 weeks

• Recommend MD lower dose of prednisone if possible, which may be elevating Millie’s blood sugar levels.

17. What is Carbohydrate Counting and how does it differ from the traditional exchange system?

Carbohydrate counting helps diabetics manage blood glucose levels through careful meal planning. Carbohydrates consist of 4 kcals, and since about half of intake should be carbohydrates, divide total allotted kcal intake by 2 and then divide by 4 to figure how many grams of carbs to consume in 1 day. The total carbs should then be evenly distrusted throughout the day to maintain blood glucose levels. The traditional exchange system allows for switching up foods throughout the day based on a list which categorizes them based on similar calories, as well as carbohydrates, protein and fat. It is more complicated than carbohydrate counting because every macronutrient is taken into account, instead of only carbs.

18. What is Diabetic Ketoacidosis (DKA)? How is it diagnosed? What are the symptoms and treatment?

When the cells are not getting energy from glucose, mainly due to lack of insulin production or resistance fatty acids are is broken down instead. Acidic ketones, a byproduct of fat breakdown are then found in the urine. DKA may result from poor diabetes management and/or insulin therapy. Symptoms include; vomiting, dehydration, gasping breaths, confusion and in very severe cases, coma. DKA is diagnosed with blood and urine tests; it is distinguished by very high blood sugar levels. Treatment involves intravenous fluids to correct dehydration, insulin to suppress the production of ketone bodies, treatment for any underlying causes/infections, and close observation to prevent complications.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download