Last Name: ___Tam___

First Name: ______WaiSze _(Rickie)

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

Section:__(1)___

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 Normal: <100mg/dL, DM diagnosis > 125mg/dL PR p76 HgbA1c 8.1% fair : 7-8.9% (PR p.76) Tchol 152 Mg/dL PR p.82 HDL 62mg/dL PR p. 73 LDL 79 mg/dL PR p. 74 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.)

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Last Name: ___Tam___

First Name: ______WaiSze _(Rickie)

Section:__(1)___

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

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Last Name: ___Tam___

First Name: ______WaiSze _(Rickie)

Section:__(1)___

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 a 30 yo WDWN Asian American female with T1DM since diagnosed at 13 yo. Her insulin regimen is 50 units of insulin (Glargine) every evening and 3 units of Lispro with each meal. CAM using: ginseng tea and acupuncture. She has experienced hypoglycemia in the past few months and elevated HbA1c value. The last hypoglycemia experience caused her to lose consciousness and was delivered to the emergency room. Maternal aunt has T1DM. Grandfather died of CVD 2o to T2DM. Her parents, two siblings, and other grandparents are L&W. Pt reported she had varicella at age 7 and an appendectomy at age 12. O : (* see in calculator sheet) 30yo female. Dx: T1DM. PMH:NKA. *HT: 172.7cm, *CW: 65.9kgs (Higher than IBW), *IBW63.6kgs, *%IBW 103.57% (patient is 103.57% above ideal body weight), *BMI: 22.1 (Normal), BP:110/70 mm Hg (Normal). Lab data: FBG: 195 mg/dL (High) HgbA1c: 8.1% (High) Total CHOL=152mg/dL (Normal) HDL=62mg/dL (Normal) LDL=79mg/dL (Normal), TG=87mg/dL (Normal) TSH: 1.8mIU/L (below) Creatinine: 0.8mg/dL (Normal) 24 hr recall: Kcal = 2785.95 kcal (above required) CHO = 401.89 g (acceptable) PRO = 106.78 g (above required) FAT = 107.17 g (above required) SF = 34.67 g (10.41%) MUSF = 38.45 g (11.54%) PUSF = 21.92 g (6.58%) Requirement needs: *Kcal: 2522.4 kcal/day *PRO: 52.72 65.9 g/day *CHO: 321.16 556.68 g/day *FAT: 56.05 98.10 g/day *Fluid = 2854.76 3425.71 mL fluid/day A: (ND-6.2) Glargine dose change from 50 units to 40 units related to blood glucose management AEB low blood sugar level record causing constant hypoglycemia before breakfast. (ND-3.3.6) Discontinue Ginseng tea using in the evening related to decrease of blood glucose AEB hypoglycemia before breakfast.

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Last Name: ___Tam___

First Name: ______WaiSze _(Rickie)

Section:__(1)___

P Adjust the ginseng tea using or discontinue to use it in the evening to avoid Hypoglycemia in the next morning. Reduce the dose of Glargine from 50 units to 40 units to avoid Hypoglycemia. Set up a goal to maintain HgbA1c < 7% value to the target range over the next two weeks. Set up a goal to maintain Pre-prandial plasma glucose (FBG) 90-130 ml/dL and Post-prandial plasma glucose < 180 ml/dL. Provide diabetes education on blood glucose maintenance, self-blood glucose monitoring, and insulin treatment. Set up MNT with RD for a lasting 45 to 90 minutes within three to six months. Set up following appointment with RD to evaluate and monitor outcomes within a year. Encourage patient to increase physical activity as a daily basis helps to lower the weight. Avoid using acupuncture in the weekend to maintain more constant blood glucose level.

Waisze Tam R.D. 12/09/13 01:00pm 2. Compare PCs laboratory values with normal values. What does each value indicate? (4 points) Test Normal Patient Compare Meaning (+/-) It means pt has hyperglycemia. It indicated FBG <100 mg/dL 196 mg/dL Patients pt was diagnosed as diabetes, at risk of (PR p.76) value was above normal CVD, comorbidies !included macrovascular (HTN and atherosclerosis) and microvascular complications (blindness, kidney failure, amputation) HgbA1c 4.5-9.0% (PR p.76) 8.1% Patients value was above normal Patients value was below normal It means patients had high blood sugar level over a period to weeks or months. Pt has high potential to develop eye disease, heart disease, kidney disease, nerve disease, and stroke. It means patients thyroid secretion has not working properly. Abnormal TSH value could worsen hyperglycemia, changing the carbohydrate metabolism, affecting gastrointestinal glucose absorption, and might be also increase insulin resistance. It means the renal system of pt was working properly. Diabetes disease and the medication did not affect or damage the normal function of patients kidney.

TSH

2-10 mlU/L (NTP p.786)

1.80mlU/L

Creatinine

Female: 0.51.1 mg/dL (NTP p.A-91)

0.8 mg/dL

Patients value is within normal

(include references for values) 3. What does HbA1c measure? (1 point) HbA1C measures the amount of glycosylated hemoglobin. It reflects average blood glucose level over the past 8 to 12 weeks or 2 to 3 months.

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Last Name: ___Tam___

First Name: ______WaiSze _(Rickie)

Section:__(1)___

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

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Last Name: ___Tam___

First Name: ______WaiSze _(Rickie)

Section:__(1)___

5. What is the relationship of HgbA1c values to the micro- and macro-vascular complications of diabetes? (3 points) High HgbA1c values have high correlations with the risk of macrovascular complications cardiovascular disease, and microvascular complications nephropathy, retinopathy, and neuropathy. Hyperglycemia causes blood vessel prone to endothelia damage, leading to thickening and changing the composition of subendothelial layer. It can result in dyslipidemia, hypertension, and atherosclerosis lesion that increase the risk of cardiovascular disease. The increased HgbA1c increase the risk of the microvascular complications. It can cause nerve problems, blindness, and renal 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. b. Lispro: (NTP p.488) Glargine (NTP p.488) Onset: 5-15 minutes Onset: 2-4 hours Peak: 30-90 hours Peak: Peakless Duration: 3-5 hours Duration: 20-24 hours Lispro has a rapid acting result, it start working 5-15 minutes, once it acting, the insulin in the body would allow to works with carbs turned into blood sugar and being uptake to the cells. Within the 3-5 hours duration, insulin would be able to works in the body. Glargine has a peakless long-acting result, it start to work in 2-4 hours, it can only start working after 2-4 hours and it would be good for using at evening so the blood glucose from the dinner can still be able to deliver to cells and it does not have peak time, it is relative more stable. 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 scaring can be the result by insulin injection. Since type 1 diabetes patient need insulin to maintain life. They might need to use insulin injection for a long time. Injection medicines into the body causes mild injury might affect the local immune system and have the reaction at the injection site. It might not be a big concern because the injury usually heals in a very short time without consequences. However, if the same site has been repeatedly administered, it can be result in constant inflammation. Also, it might affect the insulin absorption level into the bloodstream. PC can rotate the injection site and avoid injecting insulin for at least one month at the same site.

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Last Name: ___Tam___

First Name: ______WaiSze _(Rickie)

Section:__(1)___

8. You determine that PC needs _2522.4__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 0 Fruit 2 30 0 0 Milk (circle: whole, 2%, 1%, or NF) 1 12 8 8 Meat (circle: very lean, lean, med or high fat) 0 0 0 0 Non-starchy vegetables 3 15 6 0 Fat 4 0 0 20 Morning Snack (list food groups) Fruit 3 45 0 0

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) Fruit

Lunch 2 3 1 2 1 4 3

30 45 12 10 0 0 45

6 0 8 4 7 0 0

0 0 8 0 3 20 0

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) Fruit

1 2 1 2 0 2 2

15 30 12 10 0 0 30

3 0 8 4 0 0 0

0 0 8 0 0 10 0

Total grams: kcal from each macronutrient:

371 X4 1484 !"#$%&'%(')!

60 X4 240

77 X9 693

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Last Name: ___Tam___

% kcal from each macronutrient: TOTAL KCAL:

First Name: ______WaiSze _(Rickie)

61.40 2,417

Section:__(1)___
9.93 28.67

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) 1 CHO serving = 15 g CHO 371g CHO / 15g = 24.73 servings b. Describe briefly how this will differ from the exchange-based diet plan that she was using. (2 points) Exchanged-based diet plan consist of the foods that the value of serving can be exchanged in different macronutrients value. All of the exchange values of the food intake are showed in the exchange list. While carbohydrate counting consists of a fixed amount of carbohydrate for each day. It reflects the overall CHO consumptions for each day and seems like more flexible than the exchange-based diet list because it represent in the consumption of different diet groups. 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 should increase her insulin dose and match the dose of her food intake to maintain the serving of CHO for each day.

b. What adjustment(s) should PC make if the values are below the desirable range? (1 point) It is recommended PC should increase snack consumption between meals or reduce insulin dose to raise blood glucose level to desirable range.

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Last Name: ___Tam___

First Name: ______WaiSze _(Rickie)

Section:__(1)___

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) Insulin using before consuming usual weekday breakfast: 112g / 15 = 7.47 unit Rapid-Acting Insulin analogs should be used after her usual weekday 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) Turkey sandwich = 7 PRO 2 FAT Fruit = 15 CHO Diet soda = free serving 15g CHO / 15 = 1 unit of insulin would be used to cover the meal. She should use more than 1 unit of insulin to reduce the above value of BG level.

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Last Name: ___Tam___

Calculation:

First Name: ______WaiSze _(Rickie)

Section:__(1)___

Height: 58 = (5x12 = 60 + 8 = 68) x 2.54cm = 172.7cm = 1.727m Weight: 145# / 2.2# = 65.9kgs BMI: 65.9kgs/ (1.727m)2 = 22.0953 ~ 22.1 kg/m2 IBW Hamwi for IBW Female: 100# for first 5 + 5 # for every inch over 5+/- 10% Patricia C: 58 5 = 100# + 8 x 5# = 140# IBW = 140#/2.2# = 63.6kgs % IBW: 145#/140# x 100% = 103.57%IBW (PR p.10) (PR p.31) (PR p.32)

(PR p.34)

Estimated Energy Requirement (EER): Female: EER = 354 6.91 x Age + PA x (9.36 x weight + 726 x Height) (NTP p.242) PA = 1.27 for active (relatively active lifestyle and plays either lacrosse or tennis on the weekend) EER = 354 6.91 x 30yo + 1.27 x (9.36 x 65.9kgs + 726 x 1.727m)= 2522.4 kcal/day Estimate Protein needs: Based on Normal nutrition for Healthy adults: 0.8 1.0g/kg/day Protein: (0.8 1.0 g/kg/day x 65.9kgs) = 52.72 65.9 g/day Estimate Carbohydrate needs Estimate Energy requirement: 2522.4 kcal/day Based on USDA recommended 45-65 %of daily calories for a 30yo female 2522.4kcal/day x 45% = 1134.9 kcal/day / 4 g/kcal = 283.73 g/day 2522.4 kcal/day x 65% = 1639.56 kcal/day / 4 g/kcal = 409.89 g/day CHO requirement: 283.73 409.89 g/day Estimated Fluid Requirement: Fluid requirements: 1ml fluid/1kcal intake Energy requirement: 2522.4 kcal/day (2522.4 kcal / day) x (1ml / 1 kcal) = 2522.4 mL fluid/day Fluid requirements: 2522.4 mL fluid/day Estimate Fat needs Estimate Energy requirement: 2522.4 kcal/day Based on USDA recommended 20-35 %of daily calories for a 30yo female 2522.4kcal/day x 20% = 504.48 kcal/day / 9 g/kcal = 56.05 g/day 2522.4kcal/day x 35% = 882.84 kcal/day / 9 g/kcal = 98.10 g/day Fat requirement: 56.05 98.10 g/day Website: HgbA1c: http://www.nlm.nih.gov/medlineplus/ency/article/003640.htm DRI macronutrient: http://www.iom.edu/Global/News%20Announcements/~/media/C5CD2DD7840544979A549EC47E56A 02B.ashx (NTP p.123) (PR p.22) (PR p.44)

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