Last Name ___________Ko___________

First Name________Nora_________ CASE STUDY #3 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 has T1DM, diagnosed at age 13. Insulin regimen is 50 units of insulin (Glargine) every evening and 3 units of insulin (Lispro) with each meal. Pt also has elevated HgBA1C and 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 an ambulance. Family history of T1DM and CVD second degree to T2DM.

O 30 yo female, Ht is 172.7cm, Wt 65.9 kg. BMI 22.1, %IBW is 103.6%. HgBA1C is 8.1%, FBG is 195 mg/dL, TSH 1.8 mlU/L, creatinine 0.8 mg/dL, BP 110/70 mmHg, T-Chol is 152 mg/dL, HDL 62 mg/dL, LDL 79 mg/dL, TG 87 mg/dL. Scar tissue in the abdomen to the left and right of umbilicus. kCal of energy requirement is 2287 to 2430 kcal. Protein needs are 52.72 gm/d. Fluid needs are 2287 to 2430 ml/d.

A Self-monitoring deficit (NI-1.4) r/t sometimes inconsistent timing of meals and lack of BG control AEB often extreme BG spikes and drops in the food record, and frequent manifestations of hypoglycemia. Inadequate energy intake (NI-1.2) r/t a caloric intake of ~1600 kcal when calculated energy requirement is ~2300 AEB her typical food intake records, her physical activity level, and frequent hypoglycemia episodes. Inconsistent carbohydrate intake (NI-5.8.4) r/t a breakfast relatively high in carbohydrate, 112g, without adequate insulin to correct for it AEB extreme BG spike after breakfast.

P 1. Teach advanced CHO counting to assist patient in achieving tight control of blood glucose. 2. Nutrition counseling goals: - Go over the importance of the timing of meals, insulin compensations, and corrections that needs to be made. - Suggest for PC to communicate to her colleagues so that they will understand that she must not work past her meal hours. - Talk about the new diet plan that includes more kcal, a better balance of nutrients based on recommendations, and a system that records PCs diet pattern using diabetes exchanges instead of only grams of CHO. - Suggest having eggs for breakfast, and more nuts for snacks to increase protein and fat kcal so there will be relatively less kcal from carbohydrate needed - Suggest logging and monitoring food, BG, and insulin intake on the weekends. - Suggest taking insulin for snacks too. Follow up in 2 to 3 weeks.

2. Compare PCs laboratory values with normal values. What does each value indicate? (4 points) Test Normal Patient Compare Meaning (+/-) FBG PCs FBG is very high, which indicates her < 100 195 diabetes, and that there has not been a tight control mg/dL mg/dL of her BG.

+
+

HgbA1c 5.5 % 8.1%

PCs BG is very high and has been that way for the past three months, or longer. It indicates that she has not been in good control of her diabetes for quite some time. PCs thyroid is working fine.

TSH 0.4-4.2 mU/L Creatinine 0.4-1.0 mg/dL 0.8 mg/dL Normal 1.8 mlU/L Normal

PCs kidneys are working fine.

(include references for values) 3. What does HbA1c measure? (1 point)

HbA1C is the glycosylated hemoglobin; it is basically a biomarker attached to hemoglobin in blood cells and reflects that average blood glucose over the past three months.

4. What are PCs goals for each of the following? (3 pts) HbA1c: A1C <7% Pre-prandial BG: 90 to 130 mg/dL Post-prandial BG: <180 mg/dL

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

The higher the HgbA1c values, the greater the risk for micro- and macro-vascular complications, which are symptoms of severe and uncontrolled diabetes. This is because HgbA1c reflects the average of a persons BG for three months, so this value directly affects the risk of these complications, as does the severity of this disease.

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. Glargine (Lantus) is long-acting. Onset: 6 to 10 hours. Peak: none Duration: 24 hours b. Lispro (Humalog) is rapid-acting. Onset: <15 min. Peak: 0.5 to 1.5 hours Duration: 2 to 3 hours

Lispro is short-acting and can be taken 15 minutes before her meals whereas Glargine will not take effect until 6 to 10 hours after consumption, so PC should not take Glargine right before meals because it will not work that quickly. Also, amounts of insulin taken must reflect the amount of CHO PC is consuming in order to have control of BG.

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) The extra tissue on PCs abdomen is likely because she frequently uses the same spot on her body to inject the insulin. This will cause the insulin to be more effective in the uptake of glucose in the cells of that region, and thus cause more fat to accumulate in that area. PC needs to be told to switch the insulin pump or her needle injections to different areas of her body to diminish this, and avoid this from happening again in the future.

8. You determine that PC needs ___2350___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 3 45 9 3 Fruit 1.3 20 0 0 Milk (circle: whole, 2%, 1%, or NF) 1.5 18 8 8 Meat (circle: very lean, lean, med or high fat) 3.0 0 14 12 Non-starchy vegetables 0 0 0 0 Fat 0 0 0 0 Morning Snack (list food groups) Fat 1 0 0 5 Milk, whole 1 12 8 8 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 Fat 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) Milk 2% Fat Total grams: kcal from each macronutrient: % kcal from each macronutrient: TOTAL KCAL:

3 1.3 1 1

45 20 5 0

6 0 2 7

3 0 0 3

1.5 1 1 3.5

22 15 0 53

2 0 0 0

0 0 5 0

2 2 2 4.3 2

10 0 0 50 0 315 X4 1260 55%

4 14 0 13 0 87 X4 348 15% ~2300kcal

0 14 5 0 11 76.5 X9 688.5 30% 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)

21 carbohydrate points or exchanges are in her daily diet from question 8, assuming her kcal needs remained the same.

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

The exchange based diet plan she was using only gave you the total carbohydrate intake at each meal in grams. It is much easier to use points or exchanges because then the patient will know exactly how many units of insulin is needed to compensate for the meal. In addition, the diet plan that PC was using before did not have enough kcal to compensate for her bodily requirements of energy.

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 93 138 111 2 89 100 95 3 159 106 97

HS Snack 110 69 99

a. What adjustment(s) should PC make if the values are above the desirable range? (1 point)

PC needs to calculate how much insulin she needs based on the meal, and her original BG. If the preprandial BG is 150 mg/dL for example, then she needs to 20/50 = 0.4 more units of insulin on top of that insulin which accounts for her meal.

b. What adjustment(s) should PC make if the values are below the desirable range? (1 point) If PCs BG values are below the desirable range, then PC will need to calculate the amount of insulin she needs at the next meal, and it should be less insulin needed. Or PC can take the same about of insulin planned, but increase her CHO intake to reach the BG target range.

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)

If PC follows the meal plan I have designed on question 8, she will need 5.54 units of insulin before breakfast. If she follows her old meal plan, then she will need 7.47 units of insulin. She should use rapid-acting insulin 15 minutes before her meal, since she has low BG level before breakfast, which means the long-acting insulin she took before bed did not last or is not enough.

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)

The amount of insulin need to cover this meal is 3 units. The amount of insulin need to compensate for the BG level is 210 130 = 80 / 50 = 1.6 units.