|
Answer to #1
I would advise Matias to definitely keep snacks on him and to be able to recognize signs of mild hypoglycemia.
I would explain how exercise can cause hypoglycemia and that hypoglycemia can occur up to 24 hours after strenuous exercise such as biking 20 miles.
He should check his blood glucose prior to exercise to gauge how much insulin to give himself.
He should also check his blood glucose for signs of hypoglycemia after exercise.
If exercise is going to last longer than 30 minutes, a small snack is needed. Usually an additional 15 g of carbohydrates should be adequate for each hour of moderate physical activity.
For more strenuous exercise, 30 g of carbs per hour may be required. This would likely be the case for his tennis and bicycling activities.
Insulin will probably have to be reduced to potentially 1/3 to of original dosage for periods of exercise lasting a longer duration.
Adequate snacks will need to be consumed prior to exercise and insulin may not be needed to cover these snacks. Additional snacks may be needed post-exercise as well.
Suggest him to bring a kit with carbohydrate replacements (such as gels, tablets, or paste), glucometer (and testing strips), insulin/syringes, and ketone testing strips with him when playing tennis and get a pouch to carry these on his bike
Use medical ID.
Matias should inform his exercise partners about how to identify the signs and treat him for hypoglycemia.
Answer to #2
Date, Time
A: 32 YO Hispanic male
PMH: previous type 2 diabetes diagnosis
Family Hx: MIfather, type 2 diabetesmother, ovarian cancermother
Medications: None, discontinued use of metformin
Dx: Type 1 diabetes with DKA
Cardiac: tachycardia
Abdomen: non-distended, bowel sounds x 4 quadrants
Labs: glucose: 550 mg/dL, HbA1c: 10.2; CO2 31; osmolality 304.4; phosphate 2.1; Na 130; TG 175; cholesterol 210; LDL 137; HDL 38 . Antibodies present at diagnosis: ICA, IAA, GADA, c-peptide 0.09 consistent with T1DM/LADA.
D: Altered nutrition-related laboratory values related to lack of insulin production as evidenced by serum glucose of 550 mg/dL, HbA1C of 10.2, osmolality of 304.4 mOsm, +4 presence of urinary ketones, serum pH of 7.31, and C-peptide of 0.09 ng/mL
I: Goal: maintain optimal metabolic outcomes to prevent micro and macrovascular complications
Normalize glucose levels
Fasting: 80-110 mg/dL
Preprandial: 80-130 mg/dL
Postprandial: <180 mg> A1c: <7
Modify lifestyle habits including dietary intake and physical activity to prevent further complications
Patient will begin intensive insulin therapy with TDD 30 units, 15 units basal (glargine), and ICR 17 g:1 unit rapid-acting insulin Novolog (bolus insulin)
Provide education for carbohydrate counting using written materials, food labels, and restaurant menus.
Patient will incorporate physical activity such as walking, jogging, and other activities for 150 min./week.
Provide education to recognize and treat hypoglycemia.
M/E:
Patient will have new HbA1c measured in 3 months
Patient will adhere to SBMG by recording blood glucose levels pre and post meals.
Patient will correctly dose rapid acting insulin for carbohydrate in meals and snacks.
Patient will avoid any episodes of hypoglycemia and/or effectively manage any periods of hypoglycemia.
Signature (RD, LD)
Answer to #3
Using the ADA guidelines, for diabetics the following ranges are used:
Fasting: 80-120 mg/dL
Pre-prandial: 80-130 mg/dL
Post-prandial: <180 mg>
Answer to #4
2 slices of toast: 30 g carbs
1 cup OJ: 30 g carbs
2 T jelly: 28 g carbs
2 scrambled eggs: 0 g carbs
Total: 88 g carbs / 17 g carbs from ICR = 5.2 units of insulin or 5 units of Novolog rapid-acting insulin.
Answer to #5
Matias's estimated energy needs are 25-30 kcal/kg or 1865-2250 kcal/day, and it is estimated that carbohydrates should provide 50-60 of kcalories, depending on the individual and his or her personal lipid profile.
0.50 x 1875-2250 kcal = 938-1125 kcal from carbohydrates / 4 kcal/g = 234-281g of carbohydrates. To determine the number of carbohydrate choices per day: 234-281 g / 15 g carbs = 15-18 choices/day.
For Matias, the ICR was determined to be 17 g of carbs to 1 unit of insulin. Therefore, it could be determined that 234-281 g / 17 g carbs = 14-17 carb choices
Provide Matias written materials for carbohydrate counting along with sample meal plans or a food diary to assist in tracking his diet and blood glucose readings. Provide resources for CHO counting including label reading, eating out in restaurants, computer or Smart Phone applications.
Answer to #6
Energy: 25-30 kcal x 75 kg = 1875-2250 kcal (American Chest Physician's Equation)
Protein: protein ranges from 15-20 of daily calories. 0.15 x 1875 = 281 kcal / 4 kcal/g = 70 g protein, 0.20 x 1875 kcal = 375 kcal / 4 kcal/g = 94 g protein. Used the lower kcalorie range to maintain weight, since BMI is normal but on the upper end of the normal range. Therefore, protein needs range from 70-94 g/day.
Standards for this estimation were from the ADA guidelines that indicate that protein, carbs, total fat, sat. fat, cholesterol, fiber, vitamins, and minerals for diabetics are the same as for the rest of the population. If nephropathy is an issue, then protein needs are potentially decreased by10.
I would recommend that the patient maintain his current weight. His BMI of 23 is within the normal range. At this point, he should try to normalize his blood glucose values.
Answer to #7
HbA1c = 10.2 (high): Due to a chronic state of hyperglycemia. The more glucose in the blood, the more glucose that is glycated to the protein hemoglobin. HbA1c represents the average blood glucose over a period of about 3 months.
Glucose = 550 mg/dL (high): Hyperglycemia due to lack of insulin.
CO2 (high): Due to DKA; an indirect measure of acidity.
Blood and urinary pH (low): metabolic acidosis due to elevated ketone levels
Osmolality (high): Due to dehydration and hyperglycemia.
Phosphate (low): Electrolyte imbalance associated with dehydration or with kidney function.
Sodium (low): Due to dehydration and an electrolyte imbalance from DKA.
Triglycerides (high): Altered fat metabolism due to type 1 diabetes.
Cholesterol and LDL (high): Abnormal lipid profile.
HDL (low): Abnormal lipid profile
Ketones/protein/glucose in urine: Due to kidney's inability to prevent large molecules from spilling over into the urine. Due to hyperglycemia from type 1 diabetes; >180 mg/dL blood glucose values allow these to spill into the urine, which is abnormal.
Low c-peptide: Confirms that pancreas is not producing adequate amounts of insulin.
Antibodies ICA, IAA, GADA: Confirm autoimmune attack on beta cells consistent with T1DM.
|
Quick Reply
