1Type 1 DM Case Study

This case study is to be completed independently. Use valid resources and provide the citation for source(s) you use (class notes, online source, book). Please answer each answer thoroughly making sure you have thought through your answer and demonstrating what you’ve learned in class. Do not simply regurgitate information you find from other resources. You should type your answers using good writing mechanics and submit your final copy on Blackboard by Friday, December 5th at 5 PM. This case is worth 50 points; each question is marked with its point value.

Initial AppointmentJS is a twelve-year-old pre-teen within a family of 6 who enjoys sports of any kind and a variety of extra curricular activities offered at her middle school including journal club, cheerleading, and band. Per her parent’s report, she is very active and social and “never misses a beat”. They describe her as “very high energy and difficult to keep up with.” They claim that she has never had any serious medical issues; however, just two years ago she was diagnosed with type 1 diabetes and has been treated with Insulin Detemir injections once a day as prescribed by an endocrinologist. According to her parents, her blood glucose levels have been well controlled since. In fact, they were hoping she could go off her medicine because she just started playing soccer which they say seems to help lower her blood glucose levels.

They are in the pediatrician’s office because recently, over the last 6-9 months, JS has been experiencing episodes of fatigue, weakness, and weight loss, which especially concerns her parents as she is 5’3” and only 97 lbs. Two weeks ago in the first half of a soccer game, they said she had to sit the sidelines because she looked and felt weak, appeared pale, and was sweating profusely. After sitting for a minute, JS didn’t look any better (or JS’s condition was not improving) and complained of still feeling sick and shaky. The athletic trainer took her vitals during the game, in 87 degree heat, and noted she had a pulse of 54 and BP of 106/76. She had a temperature of 99.2 degrees Fahrenheit. With JS’s personal Accu-Check, she checked her blood glucose levels and told her mom it was 54 mg/dL. The ATC was immediately concerned that JS may be suffering low blood sugar and dehydration and urged her to quickly drink a soda and eat a Snicker’s bar.

Within 30 minutes of this episode, she was treated that afternoon in the local ER for ‘heat exhaustion’ per the nurse’s report. Since this episode, JS’s parents state that she hasn’t had any more reoccurrences but they are still concerned about their daughter’s health.

During the pediatric evaluation, JS admits to the doctor that she has been eating more junk food lately because she constantly feels hungry. She also admits to having more episodes like the one described above, but she hasn’t told her parents because she doesn’t want to miss more soccer. She denies any changes in bowel/bladder and vision and states that sometimes she feels great while other times she feels sick. When asked about her sleep schedule, she said that she sleeps normally but sometimes wakes up in the middle of the night though she thinks she has always done this.

Questions:

1. Based on only the above information, what do you think is going on with JS? Explain the physiology of why this is happening. Hint: why was her blood glucose level so low? (4)

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I think that JS is experiencing diabetic ketoacidosis (DKA). The pathophysiology is an increased catecholamine response without appropriate insulin compensation. In this case, I think the psychological stress of diabetes and the missed insulin doses are contributing to the DKA.

2. Name 3 of the signs/symptoms that lead you to your answer for question number one. Explain the physiology of these 3 symptoms. (3)Polyphagia, excessive hunger, is one noticeable symptom. This is associated with weight loss because the body is not properly absorbing them because of the absolute deficiency of insulin which prevents the uptake of glucose into insulin dependent tissues. Dehydration and weakness are two other symptoms.

3. What would you tell JS’ parents who think she can go off her insulin. Support your answer. In other words, is type 1 diabetes treatable without meds? (3)I would tell JS’s parents that it is not possible for her to go off insulin as a type 1 diabetic. Type 1 diabetes is the result of beta cell destruction and means that the patient is insulin deficient. Exogenous forms of insulin must be distributed by the patient or by an insulin pump for the body to be able to control blood glucose levels.

4. Pharmaceutical management:a. What is Insulin Detemir and what does it do? (2)

Insulin Detemir, or brand name Levemir, is a type of insulin that lasts for up to 24 hours each period of use. It is considered a long-acting insulin. Levemir is produced by a process that includes expression of recombinant DNA followed by chemical modification. This insulin is used to help control the blood sugar levels.

b. Name 2 other typical medical interventions that could have been used to treat JS. (2)Rapid acting analog insulin such as Lispro, Aspart, or Gluisine are one option. These require more daily injections because the duration's only 2-4 hours compared to 24 hours, but there is immediate release if taken with meals. These are rapid acting because they are onset in 15 minutes which is even faster than normal insulin. Another option would be neutral protamine hagedorn (NPH) which has an onset of 2-4 hours. The duration is 6- 10 hours.

c. How are these drugs administered? How frequently are they administered? (1)These drugs are administered through insulin injections. Many type 1 diabetics use an insulin pump that automatically injects the insulin into the blood stream at certain times depending on the type of insulin. Many times it is administered before a meal.

d. What are 2-3 side effects of this drug? (2)As with any RX drug, there are side effects. Side effects of Insulin Detemir can include redness, swelling, or itching at the site of injection, weight gain, changes in the feel of the skin (fat buildup or fat breakdown). Some serious side effects include wheezing, dizziness, shortness of breath, and or a rash/itching all over the whole body and not just site of injection.

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e. How do these drugs differ from those used to treat type 2 diabetes? (2)Type 2 diabetics are still able to produce insulin although the body does not respond well to it. Therefore, those with type 2 may only need to inject insulin at meal times to lower blood glucose levels after eating as opposed to a basal insulin that works for 24 hours.

5. Based on the information given, what test(s) specifically for her diabetes do you think should have been ordered in the ER? Give a brief rationale. (3)Glucose should have been monitored hourly, vitals should have been monitored every 1-2 hours, BMPs should have been monitored ever 4 hours, and ketones should have been monitored every 8-12 hours. All this would ensure that the DKA was managed properly and that the patient was back in a normal state.

6. Why do you think JS experiences these symptoms on a somewhat regular basis? Is this common? (2)I think she experiences these on a somewhat regular basis because she doesn't seem to eat right most of the time and continues to strain her body with high levels of physical activity for soccer. She isn’t managing her diabetes properly.

a. Why is she constantly hungry but losing weight? (2)JS is experiences polyphagia which is excessive hunger. Her body is not able to absorb the nutrients because she is insulin deficient as a type 1 diabetic. She is not able to uptake glucose into the insulin dependent tissues and is constantly eating to try and counteract this.

b. Provide 2 pieces of valid evidence (not a website but actual evidence) to support your answer (1)JS isn’t eating a proper diet to stay in control of her diabetes and she is working out on a moderate level which is not helping the situation of polyphagia. Not only does she need to eat more food to counteract her physical activity, she is not getting the proper nutrients to uptake glucose form the blood stream and deposit it in the proper tissues.

Upon retrieval of JS’s medical records from the ER, the doctor was able to find out that the following tests were ordered (with results listed):

CBC:Hgb: 12.7g/dLHct: 37.2%; WBC: 7,200 cmmRBC: 6.2 million cells/cmmPlatelets: 387,450/cmm

BMP:K: 3.8 mEq/L Na: 137 mEq/L Chloride: 102 mmol/L Creatinine: 1.1 mg/dL

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Calcium: 9.2 mg/dLBUN: 14 mg/dL Bicarbonate: 25 mmol/L

Glucose: 190mg/dLO2 Sat: 99%

Chol: 130 mg/dL

Questions:

1. JS’ blood glucose levels went from 54 mg/dL (as measured at the game) to 190 mg/dL (documented in the ER).

a. Explain why her blood glucose levels changed so drastically. (1)During the game when she was experiencing symptoms she was given a soda and a snickers bar. Both are sugary foods high in carbohydrates leading to an increase in blood sugar.

b. Is this drastic change unhealthy/bad? Why or why not? (2)This drastic change is both unhealthy and bad. The drastic change could have a negative effect on the body leading to shock.

c. What could have been done to prevent such a rapid change? (1)The “15” rule could have been applied here. 15 grams of carbohydrates every 15 minutes until blood glucose levels have reached a normal level.

2. Do you think the heat affected JS blood glucose level? What does research suggest? (3)I think heat affected JS blood glucose level because that would mean more sweat and more loss of fluids. She was active and sweating more than she would had she been not physically active. This cold promote polydypsia because of the loss of fluids.

3. Provide 2 lifestyle modifications you would recommend JS to make. Be specific. For example, don’t just say ‘eat better’. Instead, describe what better foods she should eat and how frequently she should do that. (2)Rather than grabbing a candy bar or any other junk food, JS could grab a healthy, low carb snack. Processed foods tend to be high in carbohydrates and low in dietary fiber which could promote hyperglycemia more often. I think JS should also join a diabetes self-management program that teaches her how to deal with her disease the consequences of not taking care of the body that is under the stress of diabetes.

4. Name and describe one biologically possible reason JS is consistently waking up in the middle of the night? Why does it occur? (3)JS may be consistently waking up in the middle of the night because she is often experiencing hypoglycemia, or low blood sugar. Hypoglycemia can lead to nightmares and night sweats. Daily physical activity can increase insulin sensitivity which may also lead to night time hypoglycemia.

5Type 1 DM Case Study

Follow-up Appointment6 months later, JS meets with her pediatrician again. Upon asking, she admits to not taking her medicine regularly. She says that sometimes she thinks she doesn’t need it and other times she “just doesn’t want to rely on a medicine to make her body normal”. Her parents also add that she was just recently diagnosed with depression, which really worries them. She says she feels like she doesn’t fit in and can’t always do what all of her friends are doing. This is another reason, she says, that she isn’t compliant with her meds.

Questions:

1. How does JS’ depression impact her diabetes? How does her diabetes impact her depression? (2)Depression can lead to lack of self-care because adjusting to the disease and dealing with the complications can be very stressful on a diabetes patient. Lack of self-care can lead to serious health risks such as anxiety, depression, eating disorders and medication issues. Antidepressants may increase the risk for diabetes by promoting weight gain, glucose intolerance, and insulin resistance. This can all lead to hyperglycemia, vascular disease, hypoglycemic episodes, and insulin resistance.

2. How does JS’ diabetes impact her family? Elaborate on financial and social aspects. (2).Parents often carry the blame when a child is diagnosed with type 1 diabetes. It is hard for the family to adjust to the diagnosis as well, leading to potential sabotaged dieting efforts and affects how the siblings are treated. Financially it may be an issue because insurance may not cover all the diabetes related supplies that are required. Eating a different diet from the rest of the family may also be a financial adjustment. A diabetes diagnosis can lead to the patient feeling left out because they are treated differently and not allowed to eat spontaneously if blood sugar levels are off.

3. Provide 3 ways in which her friends and family can show support for JS as she deals with diabetes and depression. (3)Family and friends can eat a similar diet as JS to show that it can be done and show that she isn’t being left behind because of her dietary and medical restrictions. The family could also learn her personal beliefs and how she feels about certain activities and dietary restrictions and make an effort to find out what is important to JS. Her family might be a little more restrictive with her diet in this case to show that they care about her health and well-being and to show that they are not trying to sabotage her efforts.

4. Provide 2 appropriate resources (could be websites, phone apps, books or other sources) JS could utilize to help better understand the disease and its potential complications if not well managed. These resources should have information to help convince JS of taking better care of herself and better manage her diabetes. (2)The American Diabetes Association has a great website for learning to manage diabetes and explaining the disease in terms that make it understandable. The website has online communities for those with diabetes or those that know someone with diabetes to help the patient connect with others in the same position. There is also an application on the

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website that helps those with diabetes plan means and log blood sugar levels to help keep track of daily readings and help your doctor track your progress. Another option is the phone app Diabetes Buddy. Like the American Diabetes Association application, it helps to track blood glucose levels and insulin injections all on a daily basis. The information can be easily shared with your doctor to keep track of medical progress and health records.

5. Put yourself in JS’ shoes. How do you think you would feel living with diabetes as a 12-year-old? What do you think would be most challenging for you? (2)I would feel very confused and agitated if I had diabetes as a 12-year-old, or at all. It is very frustrating to have to constantly monitor your body and what you are eating and how you are feeling. I can’t imagine having to actually deal with this every day. I would say it would be more stressful as a child because of things like the spontaneous eating of sweets and always having to be the friend checking blood sugar before meals. I believe the diet part of the disease is one of the most challenging sides of diabetes.

References:Mod 1, Lecture 1- Diabetes Classificationshttp://www.rxlist.com/levemir-drug.htmhttp://www.nlm.nih.gov/medlineplus/druginfo/meds/a606012.html#side-effectshttp://www.diabetes.co.uk/nocturnal-hypoglycemia.html