CASE STUDYType 1 Diabetes Mellitus

M.M., a 10 year old female, presents to the office with an approximate 10 lb. weight loss over the last few weeks, nausea, increased thirst and urination. She denies abdominal pain. Her father has had Type 1 DM for 14 years and one cousin was diagnosed with Type 1 DM at age 18 months. 1. What other history and PE exam would you perform? What further testing is required to confirm your diagnosis?

Physical exam reveals a thin, white female in no acute distress. Mucous membranes are dry. Rest of PE is normal. Lab studies reveal: Random blood sugar 411 (70-150mg/dl) BUN 24 (7-20) Sodium 129 (135-145) Chloride 93 (96-110) Potassium 5.4 (3.5-5.0) Bicarb 23 (21-28) CO2 23 (24-32) Serum Ketones Positive (Negative) WBC 11,600 (5,000-10,000) Hgb 13.7 (11-15) 2. What is your diagnosis and plan for this patient?

The child was admitted to the hospital for 24 hours and given sub-q insulin and oral fluids. Over the next 18 hours her blood sugars decreased to 140 mg/dl. Her last chem profile showed Sodium = 135, Potassium = 3.6, Chloride = 109, and CO2 = 25. She was seen by the dietitian and taught carbohydrate counting. Her discharge medication regimen was Humulin N Insulin 8 units in the morning with Humalog 3 units, LunchHumalog 3 units and Humulin N 4 units with 3 units of Humalog in the evening with addition of 3 units Humalog if pre-prandial Blood Sugars over 300 . 3. What is your nursing diagnoses for this patient? What teaching is appropriate during and after hospitalization for the newly diagnosed Type 1 patient?

The patient returned to the office the next day after discharge. She was using her fathers home glucose monitor 4 times/day and felt comfortable with technique. She was drawing up her insulin, but had not given a self-injection. Blood sugars per monitor were: FBS 9-20 9-22 311 186 Noon High 360 Supper 120 (walk) HS 95

5. How would you change her insulin?

After several days of fine tuning, M.M.s insuling regimen was: Morning : Humulin N 12 units Lunch: Humalog 3 units Evening: Humulin N 7 Humalog 5 units Humalog 3 She was back to school and giving her own insulin. She had a hypoglycemic reaction and responded appropriately. Activity varies with blood sugars lower after gym class and exercise with after school activities.

Blood Sugar record: 10-12 10-13 10-14 10-15 10-16 10-17 Avg FBS 230 206 189 245 131 160 193 Noon 221 110 139 192 100 152 Supper 182 266 145 91 93 155 HS 100 76 56 60 73

6. How would you change her insulin based on this record? What other data may be needed? Discuss the concept of Carbohydrate Counting? What foods are counted in the calculations? What are the dietary changes needed with increased activity?

CASE STUDY: Type 2 Diabetes Mellitus The client is a 44 year old female who presented as a new patient to the Family Practice office to have interpretation of her State of Michigan employee Health

Screening which revealed a borderline EKGand FBS = 132, Cholesterol = 232. Urine = 1+ Ketones. Client is married and is a secretary at the State Fish Hatchery with sedentary habits. Father has Type 2 DM. Physical exam is normal, Ht = 46, Wt. = 119#. 1. Discuss the pathophysiology of Type 1 vs. Type 2 Diabetes Mellitus. What are the risk factors seen in this case for Type 2 DM?

A stress thallium test was performed showing no previous MI and no evidence of ischemia. 3 Hour GTT = FBS = 156, 1 hr BS = 340, 2 hr BS = 306, 3 hr BS = 308, Glycohemoglobin = 6.5 (Normal = 4.1-7.2 %) confirming Type 2 DM. Client was referred to a dietician to be instructed on a 1000 calorie weight reduction diet, to the nurse educator for initial diabetic education and to the opthalmologist for initial diabetic exam. 2. Explain the diagnosis of Type 2 DM using GTT and FBS. Why are glycohemoglobin values obtained on an ongoing basis for Diabetes? Explain the difference between glycohemoglobin and HGB A1C.

3. Discuss importance of diet, weight loss, home glucose monitoring and the effects of exercise in treatment of Type 2 DM.

3 years later, client had 2 hour Post-Prandial Blood Sugar of 173 at office. Started on Glucophage and titrated dosage upward to 2000mg/day. Weight 116#. Trying to walk 2 miles, 4 times per week. Purchased home glucose monitor to check home blood sugars. Most post prandial blood sugars over 200. Diet recall = 1200-1500 cal/day.

The patient began seeing CNS for ongoing visits to normalize blood sugars and help with weight loss. Glycohemoglobin = 5.8. Cholesterol = 222, Triglycerides = 183, HDL = 40, LDL = 145. Yearly opthalmologic visits WNL. 4. Explain the rationale for yearly opthalmologic visits and close monitoring of lipids in the diabetic patient.

The client has been routinely following up with CNS. Weight 109#. Walking routinely at lunch hours for 20 minutes. Eating 3 meals per day but has trouble getting fruit and vegetable exchanges in at meals. Cholesterol = 153, Triglycerides = 133, HDL = 46, LDL = 80. On Zocor 10 mg q day. Glycohemoglobin = 10.1. After 3 months taking Glucophage 2000 mg daily (1000mg at breakfast, 1000mg at supper and restarted Glucotrol XL 5 mg q am. Glycohemoglobin 7.4, Weight = 105#. Urine for microalbuminurea = normal. 5. Discuss the role of oral sulfonylureas in the treatment of Type 2 DM. What is the rationale for using Metformin rather than insulin in Type 2 DM? Is she a candidate for other pharmacologic therapies?

6. Explain rationale for obtaining yearly urines for microalbuminuria in diabetics. What role do ACE inhibitors play in prevention of complications?

As of 6-18-96, this client has reduced her weight to 110#, walks 15 min./day, her last Hgb A1C = 6.2 (normal = <6.5) and 2 hour post-prandial BS range from 136-166 mg/dl. Her current drug regimen is Glucophage 1000 mg BID; Glucotrol XL 10 mg BID; and Zocor 10 mg q evening.