Nhung Le
Xilan
Long tran
Case study 17 Adult Type 2 Diabetes
1.
What are the standard diagnostic criteria for T2DM? Which are found in Mitch’s medical
record?
The standard diagnostic criteria for T2DM:
·
Hgb A1C > 6.5 %
·
Or Fasting > 126
·
Or Casual Plasma Glucose > 200gm/dl
·
Or 2 hour postprandial > 200 after OGTT
·
And: Symptoms/Clinical manifestations of diabetes: Hyperglycemia, Glycosuria, polyuria,
polydipsia, weight loss, polydipsia, polyphagia, lipemia.
According to Mitch’s medical record, he was diagnosed with Type 2 DM uncontrolled with
HHS. For clinical manifestations of diabetes, he admitted with acute hyperglycemia and had
hyperlipidemia and shows sign of confusion. For laboratory results, his serum glucose is 1524
mg/dL, HbA1C is 15.2 % which is greater than 6.5 %. Also, his urinalysis shows positive on
glucose, ketones, and prot chk.
2. Mitch was previously diagnosed with T2DM. He admits that he often does not take his
medications. What types of medications are metformin and glyburide? Describe their
mechanisms as well as their potential side effects/drug-nutrient interactions.
·
Metformin is a biguanide. It works to decrease hepatic glucose production and making
tissues more sensitive to insulin. This does not cause in weight gain and no risk of hypoglycemia.
Metformin appears to have beneficial effects on lipid level and may help to protect the heart.
Metformin may use in combination with other drugs. There are potential side effects including:
metallic taste, gastrointestinal problems, interference with absorption with Vit B12 and folic
acid, and lactic acidosis.
·
Glyburide is a sulfonylurea. Sulfonylurea agents stimulate pancreatic insulin secretion..
Combination with other oral antihyperglycemic drugs like Metformin may increase their
benefits. This combination is available as Glucovance. People who are allergic to sulfa drugs
should not use sulfonylurea. Weight gain, water retention, and slight risk for cardiac events and
hypoglycemia are the side effects. Sulfonylurea has the high risk of hypoglycemia. Sulfonylurea
interacts with other drugs.
5. HHS and DKA are the common metabolic complications associated with diabetes. Discuss
each of these clinical emergencies. Describe the information in Mitch’s chart that supports the
diagnosis of HHS.
HHS (Hyperosmolar Hyperglycemic syndrome): in type 2 DM with extremely high blood
glucose levels (> 600 md/dL), increase of plasma osmolality, absent to ketosis ( not prone to
ketosis/acidosis) and altered mental status. High blood glucose can cause severe dehydration
and HHS.HSS has a slow onset and elderly especially prone.
DKA( Diabetic ketoacidosis): present with hyperglycemia, ketonemia and metabolic
secondary to relative insulin deficiency. Most patients with DKA have type 1 DM which
associated with insulin deficiency. Insulin deficiency will contribute to hyperglycemia; leading
to osmotic diuresis and hypotonic diuresis which results in dehydration and electrolyte depletion.
In addition, increase the lipolysis and causes acidosis. Therefore, the symptoms are polyuria,
polydipsia, weight loss, vomiting, abdominal pain hyperglycemia, and dehydration.
Based on Mitch Diagnosis, his information supports the diagnosis of HHS. His laboratory
results show his plasma glucose levels of 1524 mg/dL, dehydration and altered mental status(
confusion), hypoglycemia and hyperosmolarity ( 360 mOsm/kg)
9. Describe the insulin therapy that was started for Mitch. What is Lispro? What is Glargine?
How likely is it that Mitch will need to continue insulin therapy?
Lispro( Rapid acting insulin ): insulin response and allows greater flexibility in eating
schedule. Since this insulin release the bloodstream rapidly, the risk of hypoglycemic several
hours after meal is lessened. The onset to lower blood glucose is within 5 minutes. The peak time
for this insulin is 1-2 hour and duration is 3-4 hours.
Glargine (Extended Long acting): the most delayed onset and longest duration. Peaks are
not prominent or peakless.
The therapy insulin plan for Mitch is 0.5 units of Lispro for every 2 hours until glucose is
150-200 mg/dL. Glargine is 19 units at 9 pm. Lispro is progressed using ICR 1:15 and continue
bedside glucose checks hourly. If his blood glucose > 200 or < 80, notify his MD.
Since Mitch did not take his medications ( Glyburide and Metformin) and sent to ER for
Hyperglycemia with 1524 mg/dL. Therefore, he needs to continue with insulin therapy to control
his blood glucose to 150-200 mg/dL as recommended.
11. Outline the basic principles for Mitch’s nutrition therapy to assist in control of his DM.
● To consume a balance diet within adequate energy requirement
● Reduce foods that high in saturated fat and trans fat
● Monitor carbohydrate intake, and to have even distribution of carbohydrate foods
throughout the day
● To combine simple sugar and complex carbohydrate into diet
● Encourage to consume more dietary fiber and eat more fruit, vegetable and whole grain
products
● Adjust the amount of carbohydrate to glucose tolerate
● Encourage physical activity
● Continue nutrition counseling and monitor habit change.
12. Assess Mitch’s weight and BMI. What would be a healthy weight range for Mitch?
According to the report, the patient weighs 214 lbs and he is 5’9 tall. This patient’s BMI is 31.7,
which categorizes him as class I obese.
using Hamwi equation: Male: 106 lbs + 6 lbs (for every inch over 5 feet)
=106+ 6(9)
= 160 lbs x 0.45kg/lb = 73kg
A healthy weight range for Mitch is 73kg
13. Identify and discuss any abnormal laboratory values measured upon his admission. How did
they change after hydration and initial treatment of his HHS?
After hydration and initial treatments, his laboratory values improved. Hydration helped
improve his blood pressure, BUN level and overall circulation.
normal range measured upon admission
After initial treatment
BUN(mg/dL)
8-18
31
20 ( almost lowered back to nl)
Creatinine(mg/dL) 0.6-1.2
1.9
1.3(almost lowered back to nl)
Glucose(mh/dL) 70-110
1524
475(significantly lowered down
but still a lot higher than nl)
Osmolarity
(mmol/kg/H2O) 285-295
360
304(was able to bring down the
number but still a lot higher than nl)
HbA1c
3.9-5.2
15.2
15.2 is a good indication that he has
HHS with Type 2 DM. The HbA1c
level is used to measure long term
blood glucose control ( between 1- 3
month), so it is too soon to reeveluate.
Specific Gravity 1.003-1.030
1.045
Since his SG is high, it is too soon to
know the treatment. However, since
his osmolarity is decreased, so the SG
might decrease
14. Determine Mitch’s energy and protein requirements for weight maintenance. What energy
and protein intakes would you recommend to assist with weight loss?
Energy requirement for weight maintenance
Weight: 214 lbs = 97.3 kg
Height: 5’9” = 69”= 175.3 cm
Using Hamwi equation: Male: 106 lbs + 6 lbs (for every inch over 5 feet)
=106+ 6(9)
= 160 lbs= 73kg
REE=66.5 + 13.8 (72.7) + 5 (175.3)-6.8 (53)
=66.5 + 1003.26 + 876.5-360.4
=1585.86
1585.86 x 1.2= 1903 kcal/d--1585.86 x 1.3 = 2062 kcal/d
Protein requirement for weight maintenance
=72.7 kg x 0.8g/kg
=58g/day
In order to lose weight he needs to cut back around 500 calories
REE-500
1903-500=1403
= 1403 kcal/day
Energy intake to assist with weight loss
1403 x 0.5 = 702 kcal
Protein intake to assist with weight loss (his protein intake is lower than regular because he is
trying to lose weight)
1403 x 0.2 =280.6 kcal
15. Prioritize two nutrition problems and complete the PES statement for each.
PES # 1: Excess high calories dense fast food, poor eating habit,unhealthy dietary choices and
lack of nutrition education related to excessive energy store in the body as evidenced by showing
BMI is 32 which is classified as Obese.
Abnormal lab values related to Type 2 DM as evidenced by an high level of HbA1C with 12.5 %
and glucose serum with 1524.
PES# 2: Diet history with high saturated fats, cholesterol and sugar are the related to the lack of
nutrition knowledge. also lack of self-care, which is why the patient forget to take the prescribed
medication for glucose control, as evidence showed the discontinued use of medication and
blood glucose level of 1524 mg/dL.
16. Determine Mitch’s initial CHO prescription using his diet history as well as your assessment
of his energy requirements.
Mitch’s has to distribute his CHO intake throughout the day due to the fact he has Type 2
Diabetes Mellitus. So his CHO intake should be around 50%-60% of calories per day. Based on
Mitch’s initial CHO prescription using his diet history: estimated daily total CHO: 255 g,
estimated daily CHO kcal: 1020, and estimated daily kcal: 1315. As mention above his energy
requirement is 1903 kcal/day, but if he is plan to lose weight, 1403 kcal/day and 1653 kcal/day is
what he needs.
17. Identify two initial nutrition goals to assist weight loss.
Goal # 1: In order to lose weight it is important to reduce intake of fast-food sandwich. Instead,
consume more fruits, vegetables and whole grain products. Most important of all, meet up with
an RD to learn glycemic control and carbohydrate count because carbohydrate is a strong
predictor of glycemic response.
Goal #2: . Taking prescribed medication and incorporated a healthy meal plan with low fat and
low calories, will help to maintain blood glucose level. Furthermore, increase physical activities
such as walking and running will also help reduce the glucose level and promote insulin
sensitivity.