What do these people have in common?
Candy Hull, PA-S
September 20, 2012

Case

CC: “2 weeks ago I cut my arm with a meat slicer and it hasn’t healed. I think
it may be infected.”

27 y/o presents with c/o right forearm laceration that occurred while using a
meat slicer on 8/14/12. The wound was cleansed with water and covered,
but has since developed some pain, swelling, and erythema around cut. No
discharge noted. He did have a fair amount of bleeding with injury that
eventually stopped with pressure. He did not seek any medical attention
until now. Last tetanus 5+ years ago.

Tried OTC Ibuprofen 800mg bid PRN and Tylenol 500mg qid PRN for pain and
swelling, but they did not help.
Abstract

Type 1 diabetes patients are insulin-dependent. “It accounts for approximately 5% to
10% of all cases, and is the most common subtype diagnosed in patients younger
than 20 years of age.” (Robbins & Cotran, 2009) With it come hormone imbalances
within the body that create long-term, even deadly situations. “The initial presentation is
usually subacute. Subacute features may include malaise and fatigue, recurrent
minor infections (e.g. paronychia, fungal diaper rash, or vaginal infection), weight
loss, polydipsia, polyuria, nocturia, secondary nocturnal enuresis, and polyphagia.”
(Levinson, Nelson, Scherger. 2007) However, it is the main reason for ESRD and most
diabetics die from CV disease. “Diabetes mellitus is a chronic disorder characterized
by hyperglycemia and the late development of vascular and neuropathic
complications. Regardless of its cause, the disease is associated with a common
hormonal defect—namely, insulin deficiency—that may be absolute or relative in the
context of coexisting insulin resistance. The effect of insufficient insulin plays a
primary role in the metabolic derangements linked to diabetes; hyperglycemia, in
turn, plays an important role in disease-related complications.” (Inzucchi & Sherwin,
2011)
Tests
 Random blood glucose >200mg/dL
 Fasting blood glucose >126mg/dL (8 hour fast) on >1 occasion
 OGTT >200mg/dL
 UA: Glucose >75mg/dL, Ketone +
 A1C: >7%
 Serum Insulin & C-peptide
 Antibody tests
Etiology of Type 1 DM
 CAUSES:
 Genetic - HLA markers
 Autoimmune – viral response
 Environment - triggers
Insulin Types
Restore blood glucose to the range of 72-180mg/dL
– Rapid-acting insulin (Lispro/Humalog, Aspart/Novolog)
• Reduce late postprandial hypoglycemia and temper early
post-meal glucose surges.
– Intermediate options (NPH)
• Cover lunchtime and noctural glucose excursions in twicea-day injection regimens
– Long-acting insulin (Glargine/Lantus, Detemir/Levemir)
• Basal insulin requirements for regulating hepatic glucose
production
– Continuous subcutaneous insulin infusion
PMH
DATE
ASSESSMENT
February 1995 Diagnosed with Type 1 Diabetes
March 1996
DKA, hospitalized for 2 days
PLAN
Disease mgmt via endocrinologist & CDE
Consider implantable infusion pump
May 1996
Continuous infusion pump implanted
Patient chose to remove pump. 18 y/o at this time, Daily insulin shots. BG < 100 = 7 units, BG >
pump was interfering with lifestyle as an active
100 =8 units Lantus at bedtime. Humalog
October 2003 teenager.
sliding scale 4-6 units before meals.
Cipro 750mg BID for 7 days given. Sliding scale
January 2004 Foot laceration, delayed healing. A1C 8.2
adjusted for Humalog, 6-8 units.
PCN 500mg BID for 10 days given. Humalog
December 2004 Strep throat. A1C 8.3
adjusted 8-10 units. f/u 3 mo
March 2005
Check-up. A1C 7.7
Continue insulin at current dosage. f/u 3 mo
June 2005
Check-up. A1C 7.4
Continue insulin at current dosage. f/u 3 mo
August 2005
Check-up. A1C 7.3
Continue insulin at current dosage. f/u 6 mo
PMH cont’d
DATE
ASSESSMENT
PLAN
Check-up. A1C 7.2. Patient admits to not taking his
insulin according to sliding scale. He usually needs 10
February 2006 units so he usually gives that.
Patient education. f/u 3 mo
April 2006
May 2006
Charles Cole ER – pneumonia
Clarithromycin 500mg BID for 7 days given.
Check-up. A1C 7.4
Certified Diabetic Educator counseling session
scheduled for June 2003.
June 2006
CDE counseling received
9/2006-1/2011 Check-ups all showed A1C < 7.0
Check-up. A1C 7.1. Patient admits to not taking his
April 2011
insulin according to sliding scale.
May 2011
Otitis externa
6/2011-7/2012 Check-ups all showed A1C < 7.0
8/2012
Infected arm laceration, not healing. A1C 7.3
Continue insulin at current dosage.
Patient education. f/u 3 mo
Cortisporin otic q6h
Continue insulin at current dosage. f/u 6 mo
Patient education, he would like to go back on
infusion pump. Will schedule for September.
Keflex 500mg BID for 10 days given.
Physical Exam
 Musculoskeletal:



Decreasing right wrist ROM (secondary to pain) with slight numbness on
ulnar side.
Full ROM on remaining MS exam
No decreased circulation visible, no edema, no foot ulcers or lesions
 Neuro:



Motor grossly intact, sensory grossly intact
Cranial Nerves: I – XII intact
Not ataxic, Romberg and Pronator drift negative
 Endocrine:

No diaphoresis, hot/cold intolerance, polyuria, polydipsia, polyphagia
Assessment
 Infected right forearm laceration
 Uncontrolled diabetes
 Immunocompromised, delayed wound healing
Diff Dx
Immune Deficiency
Likely, goes with type 1 diabetes
DM2
Not likely, he had both HLA-DR3 & DR4 haplotypes
Eating Disorder
No s/sx of eating disorder. Patients kept food
diary for 10 days and calories >2000/day.
Malabsorption/Celiac
No s/sx diarrhea, bloating, flatulence,
steatorrhea
Plan
 Keflex 500mg BID for 10 days for arm infection
 Adjust Humalog insulin (10-12 units)
 Schedule infusion pump counseling for September. Follow-up after
insertion
 Educate on s/sx of DKA (vomiting, low muscle tone, seizures,
lightheadedness, drowsiness, slow or shallow breathing) and
hypoglycemia (hallucinations, seizures, high fever, low BP, increased
rebound spasticity) and when to go to the ER. Importance of adhering
to insulin regiment as prescribed an follow a healthy diet.
Summary
 Most uncontrolled Type 1 Diabetic patients are at an increased risk of
recurrent infections.
 Most uncontrolled Type 1 Diabetic patients will experience an episode
of DKA and need to know the s/sx.
 If sugars cannot be controlled with current insulin regimen, the units
must be increased - based on each patient’s A1C.
 Consistent follow-up is needed for A1C checks and regular physical
exams.
 Long term control can often be achieved through continuous insulin
pump infusions when diabetes is not controlled with shots.
An 11 year-old’s story
 http://youtu.be/ISSo2RfCcmA
References
•
Inzucchi, S.E., Sherwin, R.S., (2011). Type 1 Diabetes Mellitus. [ONLINE] Available at:
http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4377-1604-7..00561-3&isbn=9781-4377-1604-7&sid=1352421040&uniqId=360865981-3#4-u1.0-B978-1-4377-1604-7..00561-3-s0010
•
Levinson P., Nelson, B.A., Scherger J.E. (2007). Diabetes mellitus type 1 in children. [ONLINE]
Available at: http://www.mdconsult.com/das/pdxmd/body/3533033282/1345190464?type=med&eid=9-u1.0-_1_mt_1016295#Contributors. [Last Accessed 2012
August 23].
•
Mitchell R.N., Kumar V., Abbas A.K., Fausto N., Aster J.C., (2012). Pathologic Basis of Disease.
8th ed. Philadelphia: Elsevier-Saunders.
•
MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2012 Sept
4]. Diabetes Type 1. Available from: http://www.nlm.nih.gov/medlineplus/diabetestype1.html
•
JNJ Health. (2012, March 15). Type 1 Diabetes: An 11 year-old’s story. Retrieved from
http://www.youtube.com/watch?v=ISSo2RfCcmA