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Pediatric Type 1 DiabetesMINOR CASE STUDY
BY: AMANDA HUNTER, DIETETIC INTERN
Case Study Patient: BBADMITTING DX: DEPRESSION (SUICIDAL IDEATION)
HX: TYPE 1 DM (SINCE 2000), ADOLESCENT DEPRESSION, GAD (GENERAL ANXIETY DISORDER)
HEIGHT: 167CM WEIGHT: 73KG
AGE: 16YO SEX: FEMALE
Social History Parents: lives with father and step-mother
Biological mom has hx bipolar disorder
Siblings: 1 full sister, age 23. 1 half sister, age 6
Religion: Christian
Ethnicity: White/Caucasion
Education: 10th grade. Usually A, B student, but grades recently fell to C’s.
Marital Status: Single, recent break up with boyfriend of 2 months
Extracurricular Activities: No current. Past cheerleading
Hobbies: photography, pottery, cheerleading
Case study patient: BBOBJECTIVE:• WHY CHOSEN?
• FOCUS OF STUDY: ADOLESCENT DIABETES TYPE 1 IN A PATIENT WITH DEPRESSION
Pathophysiology of Type 1 Diabetes• CHRONIC ILLNESS / AUTOIMMUNE DISEASE THAT
ATTACKS PANCREATIC BETA CELLS
• PROGRESSIVE LOSS OF INSULIN PRODUCTION RESULTS IN HYPERGLYCEMIA
• CHILDREN AND ADOLESCENCE NEED EXOGENOUS INSULIN TO SURVIVE
• TYPE 1 DM IS 5-10% CASES
• GLOBAL INCREASE OF INCIDENCE PAST 30 YEARS
Disease Process: Type 1 DM• RAPID ONSET W/ FOLLOWING CLINICAL
SYMPTOMS:• Substantial weight loss
• Polyuria
• Polydipsia
• Hyperglycemia
• Ketoacidosis
Diagnosis of Type 1 Diabetes
DIAGNOSIS CRITERIA: (AMERICAN DIABETES ASSOCIATION, 2011)
•
A1C >/= 6.5%
• FPG (FASTING PLASMA GLUCOSE) >/= 126 MG/DL (7MMOL/L). THIS TEST IS DONE AFTER NO INTAKE FOR AT LEAST 8 HOURS
• SYMPTOMS OF HYPERGLYCEMIA (POLYURIA, POLYDIPSIA, AND UNEXPLAINED WEIGHT LOSS) AND A RANDOM GLUCOSE OF >200MG/DL
• OGTT (ORAL GLUCOSE TOLERANCE TEST). 2 HR PLASMA GLUCOSE = 200MG/DL
This test uses a glucose load of 75 grams anhydrous glucose dissolved in water, or 1.75g / kg body weight if weight is less than 40 pounds. (C)
Past medical history of BB
DM TYPE 1 DIAGNOSED IN 2000
ADOLESCENT DEPRESSION PAST 3-4 YEARS WITH MULTIPLE PREVIOUS PSYCHIATRIC HOSPITALIZATIONS
H/O CUTTING BEHAVIOR
COMPLETED OUTPATIENT PROGRAMS FOR DEPRESSION
Christ outpatient psych program in Summer 2013
St. Joseph in Joliet in 2012
Present Medical Status of BB
• PATIENT’S SYMPTOMS UPON ADMISSION:1. Suicidal Ideation
2. Abnormal serum glucose
3. Uncontrolled diabetes
Disease condition: Adolescent Depression w/ Type 1 DM • ADOLESCENTS W/ TYPE 1 DM 2X MORE LIKELY
TO HAVE DEPRESSION
• STUDY FOUND DEPRESSIVE SYMPTOMS INDIRECTLY RELATED TO A1C LEVEL
• TREAT DEPRESSION WITH MEDICATIONS AND/OR THERAPY
Treatment Plan for BB:
TREATMENT GOALS FOR AGE 13-19:
• BLOOD GLUCOSE BEFORE MEALS: 90-130MG/DL
• BEDTIME/OVERNIGHT BLOOD GLUCOSE: 90-150MG/DL
• A1C < 7.5%
• GLYCEMIC GOALS SHOULD BE INDIVIDUALIZED. A LOWER GOAL CAN BE ACHIEVED AS LONG AS THERE IS NO INCREASED RISK OF HYPOGLYCEMIA.
• IF THERE IS A DIFFERENCE BETWEEN PREPRANDIAL GLUCOSE LEVELS AND A1C, POSTPRANDIAL GLUCOSE SHOULD BE MEASURED TO DETERMINE THE APPROPRIATE AMOUNT OF BASAL/BOLUS INSULIN.
• CHILDREN WHO EXPERIENCE FREQUENT HYPOGLYCEMIA SHOULD HAVE A HIGHER GLYCEMIC GOAL. (C )
Patient’s Diagnosis and Lab FindingsDX: ADOLESCENT DEPRESSION, TYPE 1 DIABETES MELLITUS
Lab 1/06/2015 High / Low
Possible Indications
Glycemic Control
Blood glucose
Alb 4.4 WNL n/a 1/6 240, 191, 264, 331
TP 7.2 WNL n/a 1/7 288, 274, 219, 290
HbA1c 9.5% High Uncontrolled Diabetes
1/8 193, 272, 303, 189
Est ave gluc
226 High Uncontrolled Diabetes
1/9 241, 272, 317, 179
UA glucose 4+ High Diabetes 1/10 189, 287, 191, 287
UA ketones 1+ High Uncontrolled diabetes, fasting
1/11 217, 194, 343, 271
UA protein Trace Diabetes 1/12 261, 246, 241, 272
1/13 215, 184
MedicationsMedication Dosage Use Interactions
Prozac (Prior to admit)
10mg /day SSRI antidepressant
Alcohol, no food interactions
Escitalopram (Lexapro)
10mg @ bedtime
SSRI antidepressant, anxiety
Alcohol, no food interactions
Insulin detemir (Levemir)
30 units subQ @ bedtime
Long lasting insulin for Insulin-dependent diabetes
Alcohol, no food interactions.Gatafloxacin
Insulin lispro (HumaLOG)
subQ w/ meals Fast acting insulin for Insulin dependent diabetes
Alcohol, no food interactions.Gatafloxacin
Medical Nutrition Therapy NUTRITION HISTORY:
HOME DIET: REGULAR
SPECIAL CONSIDERATIONS: PATIENT STATES SHE WILL EAT LESS SUGARY FOODS – SODA, CANDY, ICE-CREAM – WHEN BLOOD GLUCOSE READINGS ARE HIGHER (> 200MG/DL)
DIET PATTERN: 3 MEALS, 2 SNACKS
Analysis of diet (24 hr recall)BB’s Diet Hisotry
5:45am – Wake up 6:00am – Breakfast
Goal: 3-4 carbs
2 eggs2 sausage links
1 slice toast2 cups milk, 1%
3 carbs4 protein
2 fats
11:30am – Lunch
Goal: 4-5 carbs
1 ½ cups salad2 TB ranch dressing
1 cup grapes1 granola bar
1 can diet coke
2 ½ carbs0 protein
2 fats
2:30pm – Afternoon snack
Goal: 1-2 carbs
1 whole fruit or chips1 can diet coke
1-2 carb0 protein
0 fat
6:00pm – Dinner
Goal: 4-5 carbs
4oz chicken breast1 cup mashed potatoes
2 cups milk, 1%1 cup salad
2 TB ranch dressing
4 carbs4 protein
2 fat
9:00pm – PM snack
Goal: 1-2 carbs
1 banana 2 carbs 0 protein
0 fat
Medical Nutrition Therapy CURRENT PRESCRIBED DIET: THE CURRENT DIET IS DIABETIC 2000KCAL, CONTROLLED CARBOHYDRATE, NO CAFFEINE.
THIS DIET ORDER IS IN PLACE DUE TO THE PATIENT’S DIAGNOSIS OF UNCONTROLLED DIABETES. THE CALORIE ALLOWANCE IS BASED ON THE PATIENT’S ESTIMATED ENERGY NEEDS. THE CARBOHYDRATE EXCHANGES OF 5 CARBS FOR BREAKFAST, 6 CARBS FOR LUNCH AND 6 CARBS FOR DINNER ARE GUIDELINES FOR THE PATIENT’S MEALS TO HELP KEEP HER CARBOHYDRATE INTAKE CONSTANT IN ORDER TO STABILIZE HER BLOOD SUGAR. THE CAFFEINE RESTRICTION IS DUE TO HER INSOMNIA AND ANXIETY.
PATIENT’S RESPONSE TO THE DIET: COMPLIANT.
Medical Nutrition Therapy NUTRITION RELATED PROBLEMS: UNCONTROLLED DIABETES, OVERWEIGHT
PRESENT NUTRITIONAL STATUS: OVERWEIGHT, HYPERGLYCEMIA
EER: 2000KCAL / DAY
PROTEIN REQUIREMENTS: 15-20% =75-100G = 10-14OZ / DAY
FLUID REQUIREMENTS: 1620ML (1500ML + 20ML FOR EVERY INCH OVER 60INCHES)
Patient’s Nutrition Education Process• NUTRITION CONSULT FOR ABNORMAL SERUM GLUCOSE
AND UNCONTROLLED DIABETES.
• NUTRITION ASSESSMENT AND EDUCATED ON CARBOHYDRATE COUNTING AND MENU SELECTION.
• THE PATIENT AND THE PATIENT’S FATHER EXPRESSED NO NEED OR DESIRE FOR FURTHER DIABETIC EDUCATION.
• THE PATIENT WAS COOPERATIVE IN PROVIDING INFORMATION ON HER HISTORY OF DIABETES, MEDICATION, AND DIET RECALL.
• FEEDBACK WAS PROVIDED ON HER DIET RECALL
• STRESSED IMPORTANCE OF FOLLOWING A CONSTANT CARBOHYDRATE DIET IN ORDER TO MANAGE BLOOD SUGAR WAS STRESSED.
Prognosis• MANAGEMENT OF DEPRESSION, THE PATIENT’S
PROGNOSIS IS GOOD
• follows medication regimen and continues to see her therapist
• MANAGEMENT OF DIABETES, PT’S PROGNOSIS IS FAIR TO GOOD
• The success of using insulin therapy to manage diabetes is dependent on her knowledge, self-management skills, and support system. E
Bibliography 1. DIABETES MELLITUS TYPE 1. (2015, JANUARY 1). RETRIEVED JANUARY
15, 2015, FROM HTTP://WWW.NUTRITIONCAREMANUAL.ORG/TOPIC.CFM?NCM_CATEGORY_ID=13&LV1=144621&LV2=144762&NCM_TOC_ID=144762&NCM_HEADING=NUTRITION CARE
2. COUPER JJ, HALLER MJ, ZIEGLER A-G, KNIPM, LUDVIGSSON J, CRAIG ME. PUBLISHED IN PEDIATRIC DIABETES 2014: 15(SUPPL. 20): 18–25.
3. LANGE K, SWIFT P, PANKOWSKA E, DANNE T. PUBLISHED IN PEDIATRIC DIABETES 2014: 15(SUPPL. 20): 77-85
4. MCGRADY, M. E., & HOOD, K. K. (2010). DEPRESSIVE SYMPTOMS IN ADOLESCENTS WITH TYPE 1 DIABETES: ASSOCIATIONS WITH LONGITUDINAL OUTCOMES. DIABETES RESEARCH AND CLINICAL PRACTICE, 88(3), E35–E37. DOI:10.1016/J.DIABRES.2010.03.025
5. HOOD, K. K., RAUSCH, J. R. AND DOLAN, L. M. (2011), DEPRESSIVE SYMPTOMS PREDICT CHANGE IN GLYCEMIC CONTROL IN ADOLESCENTS WITH TYPE 1 DIABETES: RATES, MAGNITUDE, AND MODERATORS OF CHANGE. PEDIATRIC DIABETES, 12: 718–723.