Last Name Hirata________________

First Name_Miles_______________ 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 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; 58 145# Vitals: T 98.2F; 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 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.)

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. PCs 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 74 Milk 1.5 cups 18 Banana, small 20 Total CHO: 112 Two Hours PP 356 Pre-lunch 105 Lunch Tuna salad sandwich 30 1oz bag potato chips 16 1 apple 20 Total CHO: 66 Two Hours PP 210 Snack 1oz bag pretzels 22 1 peach 15 Total CHO: 37 Pre-dinner 250 Dinner Frozen cheese pizza, 2 slices 53 2 cups salad with oil & vinegar dressing 10 Total CHO: 63 Snack 1 cups frozen yogurt 50 Bedtime 298

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 Pt is T1DM diagnosed at 13. Pt has elevated A1C levels and has experienced several instances of hypoglycemia over the past few months causing her to lose consciousness and been taken to the emergency room. Paternal grandfather died of T2DM. Pt takes 50 units of Glargine every evening and 3 units of Lispro at each meal.

O Pt is 30yo female, 68 inches, wt 145#, FBG 195 mg/dL, A1C 8.11%, kcal requirement 2,240.1kcal, protein requirement 98.9g, fluid requirement 2,240.1 mL.

Protein NTP pg 61, EER NTP pg 242, Fluid Requirement NTP pg 123, Insulin NTP pg 493.

A NI-5.8.4 Inconsistent Carbohydrate intake r/t variation in schedule AEB PCs typical blood glucose and carbohydrate intake levels.

P Increase physical activity and nutritional education regarding carbohydrates in foods and carbohydrate counting.

2. Compare PCs laboratory values with normal values. What does each value indicate? (4 points) Test Normal Patient Compare Meaning (+/-) FBG 195 + FBG measures blood glucose. PCs value is above mg/dL normal limits, indicating her to be diabetic. < 100 mg/dl

HgbA1c

<6.5%

8.1%

A1c levels measures glucose levels over the last 3 months. Elevated A1c levels indicate a high blood glucose over the past 3 months.

TSH

1.2-3.4

1.8

Normal

A low TSH level could lead to weight gain. However, PC is within normal limits.

Creatinine

0.5-1.1

0.8

Normal

Increased or decreased creatinine levels signify impaired kidney function or kidney disease. PC is within normal limits though.

(include references for values) 3. What does HbA1c measure? (1 point) HbA1c is glycosylated hemoglobin and measures the average blood glucose over the past 3 months.

4. What are PCs goals for each of the following? (3 pts) HbA1c: < 6.5% Pre-prandial BG: Post-prandial BG: 70-130mg/dL <180mg/dL

5. What is the relationship of HgbA1c values to the micro- and macro-vascular complications of diabetes? (3 points) As HbA1c levels increase, risk of Nephropathy, Retinopathy, and Neuropathy increases. A build up of glycolysis intermediate products cause changes in cell signaling which can lead to inflammation and metabolic changes, leading to CVD, atherosclerosis, and hypertension.

HbA1c info NTP pg 496

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: Onset of action: 5-15min Peak: 30-90min Duration: 3-5 hours b. Glargine: Onset of action: 2-4 hours Peak: no peak Duration: 20-24 hours

Lispro (short acting) allows PC to consume carbs without her blood glucose from fluctuating rapidly. Glargine (long acting) allows PC to regulate her blood glucose particularly while she sleeps. Lispro/Glargine info NTP pg 488 7. What is the cause of the scaring that has been noted on PCs abdomen? What impact does this have on insulin activity? What information should she be given in relation to this? (3 points) Scaring occurs when the same spot is used for insulin injection. This can lead to a build up around the injection site, thereby decreasing the insulin activity. PC should be told to switch areas of injection frequently to avoid this.

8. You determine that PC needs 2,240.6__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 PCs diet. (15 points) Food group Number of CHO Protein Fat Exchanges grams grams grams Breakfast Starch 2 30 6 2 Fruit 1 15 3 1 Milk (circle: whole, 2%, 1%, or NF) 1 12 8 3 Meat (circle: very lean, lean, med or high fat) 2 0 14 6 Non-starchy vegetables Fat Morning Snack (list food groups) Starch 2 30 6 2 Meat, medium fat 2 0 14 6 Lunch Starch 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 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) Sweets, desserts, and other carbohydrates Starch Total grams: kcal from each macronutrient: % kcal from each macronutrient: TOTAL KCAL:2,251

3 1 1 1

45 15 5 0

9 3 2 7

3 1 0 3

1 1

15 15

3 0

1 0

30

2 2 1 3 2

10 0 0 45 30 327 X4 1308 58%

4 14 0 9 0 112 X4 448 19%

0 10 5 8 2 55 X9 495 22% 6

You review PCs 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)

24 servings

b. Describe briefly how this will differ from the exchange-based diet plan that she was using. (2 points)

By keeping track of protein and fat intake, PC can take into account the effects of fat and protein on blood glucose. Fat will decrease insulin activity and raise blood glucose. Protein will provide another source of glucose but will be created at a slower rate.

10. 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. a. Circle the values below that are outside the desirable range. (1 point) PP BG mg/dL Day Breakfast Lunch Dinner 1 93 111 138 2 89 100 95 3 106 97 159

HS Snack 110 69 99

a. What adjustment(s) should PC make if the values are above the desirable range? (1 point) PC could increase her insulin amount, increase her physical activity, and decrease carbohydrate intake from her last meal.

b. What adjustment(s) should PC make if the values are below the desirable range? (1 point) PC could increase carbohydrate intake by eating a snack between meals.

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)

Assuming an insulin to carb ratio of 1:15, PC should take 7.5 units of insulin. Although her pre-breakfast blood glucose is low, she could take 7 units of insulin. She should take fast acting insulin before consuming breakfast.

12. If PCs 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) PC should take 3 units of insulin to cover her lunch. To compensate for her elevated blood glucose level, she should take an additional 2 units of insulin.