Cxxxxxx, Oxxxx Male 33 yo

Allergies: NKA Code: FULL Isolation: NONE

Pt. Location: RM 1307 Physician: J. Robinson Admit Date: 12/02/16

Pt Summary: O.C. is a 33 yo male admitted through the ED with c/o excessive thirst and
frequent urination of 2 wk duration, in addition to increased appetite and weight loss of 12
pounds in 3 weeks.

PMH: pt was product of normal pregnancy and delivery; had varicella at age 6, and an
appendectomy at age 15. No Medications. NKA.

FH: Parents L&W. Paternal uncle has Type 1 DM; Maternal grandfather died of CVD 2 to
Type 2 DM. Other grandparents L&W. Has 1 sibling, a younger brother, L&W.

Social Hx: 33 yo male, post-doc at UC Davis. Pt used to play soccer three times a week, but
says he now tires easily so he has not played in 3 weeks.

ROS:
GI: No hx of N/V, or diarrhea
GU: No hx of urgency, frequency, or burning urination except for present
complaint of polyuria
CNS: Alert and oriented, no hx of impaired LOC, convulsions, or difficulty
walking

PE:
General: Slightly underweight, tired appearing male; wt: 170# ht:
73
Vitals: T 98.2F; P 120; R 27 with fruity odor; BP 110/70 mm Hg
Lungs: Clear to percussion and auscultation
Heart: Normal sinus rhythm, no murmurs
HEENT: Non-contributory
Abdomen: Flat, non-tender, no liver enlargement
Genitalia: nl
Extremities: Non-contributory
CNS: Normal gait and deep tendon reflexes
Skin: Smooth, warm, dry, no edema
Peripheral Pulse +4 bilaterally
Vascular:
1
Laboratory Results
Ref. Range 12/02/16 1210
(non-fasting)
Chemistry
Sodium (mEq/L) 136-145 129 !!
Potassium (mEq/L) 3.5-5.5 3.6
Chloride (mEq/L) 95-105 101
Carbon dioxide (CO2, 23-30 32 !"
mEq/L)
BUN (mg/dL) 8-18 17
Creatinine serum (mg/dL) 0.6-1.2 1.1
Glucose (mg/dL) 70-110 372 !"
Phosphate, inorganic (mg/ 2.3-4.7 2.0 !!
dL)
Magnesium (mg/dL) 1.8-3 1.9
Calcium (mg/dL) 9-11 10
Osmolality (mmol/kg/H2O) 285-295 303 !"
Bilirubin total (mg/dL) 1.5 0.2
Bilirubin, direct (mg/dL) <0.3 0.01
Protein, total (g/dL) 6-8 6.9
Albumin (g/dL) 3.5-5 3.2 !!
Prealbumin (mg/dL) 16-35 14 !!
Ammonia (NH3, umol/L) 9-33 9
Alkaline phosphatae (U/L) 30-120 110
ALT (U/L) 4-36 6.2
AST (U/L) 0-35 21
CPK (U/L) 30-135 F; 55-170 61
M
Lactate dehydrogenase 208-378 229
(U/L)
Cholesterol (mg/dL) 120-199 180

2
Triglycerides (mg/dL) 35-135 F; 40-160 150
M
T4 (ug/dL) 4-12 8
T3 (ug/dL) 75-98 81
HbA1C (%) 3.9-5.2 8.55 !"
C-peptide (ng/mL) 0.51-2.72 0.52
ICA - + !"
GADA - + !"
IA-2A - -
IAA - + !"
tTG - -
Hematology
WBC (x 103/mm3) 4.8-11.8 10.6
RBC (x 106/mm3) 4.2-5.4 F; 5.8
4.5-6.2 M
Urinalysis
Collection method - Clean catch
Color - Yellow
Appearance - clear
Specific Gravity 1.003-1.030 1.008
pH 5-7 4.8 !!
Protein (mg/dL) Neg +1 !"
Glucose (mg/dL) Neg +4 !"
Ketones Neg +4 !"
Blood Neg Neg
Bilirubin Neg Neg
Nitrites Neg Neg
Urobilinogen (EU/dL) <1.1 Neg
Leukocyte esterase Neg Neg
Protein check Neg tr !"
WBCs (/HPF) 0-5 0

3
RBCs (/HPF) 0-5 0
Bacteria 0 0
Mucus 0 0
Crys 0 0
Casts (/LPF) 0 0
Yeast 0 0

Dx: New Onset Type 1 Diabetes Mellitus

MDs Plan: Admit, achieve glycemic control with Regular Insulin then adjust to daily therapy
with mixed insulin therapy; initiate DSM training; nutrition consult for hospital and home
diet planning and pt. education.

You are the in-patient RD.

You meet with O.C. to do a nutrition assessment and begin a general introduction to dietary
management of diabetes. You take a diet history (listed below) as part of your assessment.
O.C. states that these are the types of foods that he usually eats, but the quantity is much

4
greater than usual because he has felt so hungry lately. O.C. is Muslim and follows Islamic
dietary laws.

Breakfast (eaten at home):

1 c. oatmeal with brown sugar and cup of 2% milk
1 c. juice (orange, apple, or cranberry)
Toast (2 slices or English muffin) w/ butter & jelly
Coffee with sugar and 2% milk
(occasionally 2 scrambled eggs instead of the cereal)

Lunch (eaten at the CoHo/Silo on weekdays):

2 slices of cheese pizza with a small salad or
Grilled cheese and French fries or
Meal from Shahs Halal Food cart Gyro or Rice Plate (lamb/chicken)
16 oz of sweetened iced tea
dessert such as cookies or a brownie
(sometimes 8 oz of 2% milk instead of the iced tea)

Mid afternoon:
medium mocha or latte,
A cookie or a piece of fruit

Dinner:
~6 oz. meat (chicken/lamb/beef, occasionally fish)
1 cup of rice
Vegetables in season (will eat w/ salt & butter)
12 ounces of 2% milk
or
A vegetarian sandwich and chips and soda if he does not have time to cook

HS:
O.C. eats one of the following:
Bag of microwave popcorn w/ 1-12 oz can of regular soda
2 scoops of ice cream
1 c 2% milk and 4-5 cookies
2 oz. cheese and 12 Wheat Thin crackers

5
First Name: Sidra Last Name: Ansari ID: 998113960

1. Compare O.C.s admission laboratory values with normal values. What does each value
indicate, based on the hospitals lab value reference ranges above? Use your texts for non-
fasting BG values. (5 pts)
Test nl Values O.C.s Comparison What do O.C.s lab values suggest
Values : about his metabolic state?
</=/> nl
values
BG 70-110 mg/ 372 mg/dL Higher than His non-fasting glucose levels are well
dL nl above the DM diagnosis criteria of
more than or equal to 200 mg/dL

NTP p. 481
Urinary Negative +4 Higher than Since he has a lot of glucose in his
glucose nl urine this means that he has too much
glucose in his blood and his body is
trying to compensate by putting the
extra glucose in urine

NTP p.481
Urinary Negative +4 Higher than Ketones in the urine means that O.Cs
ketones nl body has an increased production of
keto acids past what could be used for
energy. So the extra ketones are being
put out in the urine

NTP p.481
PreAlb 16-35 mg/ 14 mg/dL Lower than Pre albumin can decrease with
dL nl conditions such as inflammation,
metabolic stress or diseases of the
liver meaning that O.C. could be
suffering from one of the above and
not necessarily from an inadequate
diet

NTP p.59

6
HbA1C 3.9-5.2% 8.55% Higher than HbA1c increases when a lot of
nl hemoglobin is being glycated. This
means that his blood glucose must be
high

NTP p.487

2. What is HbA1C and what does HbA1C measure? (1 pt)

HbA1c is hemoglobin that has had a glucose molecule added to it. A HbA1c test is a
measure of the amount of hemoglobin that has been glycated. Furthermore, since RBCs
have a life span of 120 days the HbA1c test is good for testing blood glucose from the past
2-3 months. Therefore, not only can it be used to test for diabetes but also to check how
well a patient has been managing their blood glucose.

NTP p.487

3. List the following HbA1C ranges. (2 pts)

Normal non-diabetic: 4-6%

116AL MNT for Diabetes Slide 26

NTP p.503
Pt w/ controlled <7%
diabetes:
116AL MNT for Diabetes Slide 26
NTP p.503
Pt w/ fair to poorly Fair 7.0%-8.5%
controlled diabetes: Poor >8.5%

CDC Associations Between Colorectal Cancer Screening and

Glycemic Control in People With Diabetes, Boston,
Massachusetts, 2005-2010
https://www.cdc.gov/pcd/issues/2011/jul/10_0196.htm

7
4. Explain the role/relationship of HbA1C in the development of micro- and macro-vascular
complications of diabetes. (2 pts)
As discussed earlier, HbA1c tests measures how much hemoglobin in the blood has an
added molecule of glucose to it. If the results are high, then that means that patient has a
high blood glucose concentration. A high blood glucose concentration that isn't controlled
or is allowed to become chronic can result in macro and microvascular problems.

Macrovascular Too much glucose in the blood can cause blood vessels to be more prone
to damage, which in turn causes them to become thicker and less flexible leading to high
blood pressure.

Microvascular High blood glucose can also alter the kidneys filtering abilities (can lead
to HTN) and cause damage to blood vessels in the eye (also caused by high blood pressure).
In addition, glycated proteins (glycated hemoglobin) along with other substances can cause
cellular damage and lead to complications in the nervous system.

NTP p.487,507-508

5. What are three metabolic reasons for O.C.s weight loss (number each for full credit). (2
pts)
1) Muscle Wasting Because O.C. has T1DM and his bodys cells are not taking amino
acids. So the body compensates breaking down proteins from muscles thus causing
muscle wasting and contributing to weight loss.
2) Decreased Adipose Again because of O.Cs T1DM, he has a lack of insulin but an
overproduction of other hormones such as glucagon that contributes to the break down
fat from adipose tissue and decreased fat storage in general. As a result the decrease in
adipose could be contributing to O.C.s weight loss.
3) Hypovolemia One of the manifestations of T1DM is polyuria because the body is
attempting to put out extra glucose in the urine. However, the polyuria also contributes
to increased fluid loss and decreased blood volume. The resulting hypovolemia
contributes to weight loss

NTP p.481, 482

116A Diabetes Mellitus Slides 19, 20, 21
6. Describe and explain Islamic dietary laws and any dietary restrictions you would need to
consider when counseling O.C. (2 pts)

8
Islamic dietary laws state that meat is halal if hand slaughtered in the name of Allah
(God). It cannot have been slaughtered some other way and the animal should not have
been already dead for some other reason. However, there are animals that are not
considered halal even if slaughtered according to Islamic rule. Non-halal meat includes
all pork and pork products, predatory land animals, and animals without external ears
such as some birds and reptiles. But all animals from the sea is considered halal. Also
muslims do not consume any alcohol. Therefore, any food products that contain the
forbidden foods or its extracts cannot be eaten. For example, if yogurt has gelatin from
an animal that isnt considered a halal meat or wasnt slaughtered properly cannot be
consumed. Another example is cheese that has animal enzymes from a non-halal source.

Todays Dietitian Understanding Muslim Fasting Practices

http://www.todaysdietitian.com/newarchives/072709p56.shtml

7. Based on O.C.s diet history information and what you know about MNT management of
Type 1 DM, name 3 nutrition-related topics that are important to discuss in educating O.C. as
he prepares to head home from the hospital. (3 pts)
1) O.C. should not be afraid of carbohydrates and should be educated about switching
from simple carbs to complex ones. Also he should try to aim to have 40-50% of his
calories coming from carbohydrates
2) Since O.C. is suffering from unintended weight loss that may be due to muscle wasting
caused by T1DM, he should make sure he is taking adequate amounts of protein. This
could be 20% of his calories or at the very least 0.8g of his ideal body weight. He should
be educated about the adjustments that can be made based on the amount of weight
he lost and his activity levels
3) O.C. should keep his fat levels between 30-40% of his calories as part of a generalized
dietary strategy.

116Al MNT for Diabetes Slide 40

8. You determine that O.C. needs 3000-3300 kcals/day based on EER calculations and the
fact that O.C. needs to gain weight to achieve his normal weight. You want to follow his
normal eating pattern as much as possible while still meeting his protein requirements and
keeping the kcal from fat at 30-40% of total kcals. Using the Exchange Lists, develop a
pattern for O.C.s diet. (15 pts)

9
 Food group Number of CHO grams Protein Fat grams
Exchanges grams
Breakfast
Starch/CHO 3 45 9 3
Fruit 2.5 37.5 0 0
Milk & Subs.(skim, 1%, 2%, or
whole) 1 12 8 5
Protein (lean, med- or high-fat) 2 0 14 10
Fats 2 0 0 10
Morning Snack
None
Lunch
Starch/CHO 4 60 12 4
Fruit 2 30 0 0
Milk & Subs.(skim, 1%, 2%, or
whole) 1 12 8 5
Non-starchy vegetables 4 20 8 0
Protein (lean, med- or high-fat) 3 0 21 6
Fats 2 0 0 10
Afternoon Snack
Starch/CHO 2 30 6 2
Milk (2%) 1 12 8 5
Fat 2 0 0 10
Dinner
Starch/CHO 3 45 9 5
Fruit 1 15 0 0
Milk & Subs.(skim, 1%, 2%, or
whole) 1 12 8 5
Non-starchy vegetables 4 20 8 0
Protein (lean, med- or high-fat) 4 0 28 8
Fats 2 0 0 10
HS Snack
10
Milk (skim, 1%, 2%, or whole) 1 12 8 5
Starch/CHO 2 30 6 2
Fats 1 0 0 5
Total grams 392.5 161 110
X4 X4 X9
kcal from each macronutrient 1570 644 990
TOTAL KCAL: 3204 49% 20% 31%

116AL MNT for Diabetes Slides 40 - Generalized Dietary Strategies

What I used to Estimate How Many Carbs, Protein and Fat I Should Give
Protein Requirements: 20% 0.20 x 3000 = 600 kcal / 4 kcal = 150g
0.20 x 3300 = 660 kcal / 4 kcal = 165g
CHO Requirements: 40-50% 0.40 x 3000 = 1200 kcal / 4 kcal = 300g
0.40 x 3300 = 1320 kcal / 4 kcal = 330g
0.50 x 3000 = 1500 kcal / 4 kcal = 375g
0.50 x 3300 = 1650 kcal / 4 kcal = 412.5g
Fat Requirement: 30-40% 0.30 x 3000 = 900 kcal / 9 kcal = 100g
0.30 x 3300 = 990 kcal / 9 kcal = 110g
0.40 x 3000 = 1200 kcal / 9 kcal ~ 133g
0.40 x 3300 = 1320 kcal / 9 kcal ~ 147g

9. O.C. is taught about his diet, insulin injections, SMBG, and other self-care issues prior to
discharge. He is discharged on a basal injection of Levemir, with bolus injections of Novolog
regular insulin at mealtimes. Provide the generic name and indication of each medication
and its effects. Also note any dietary recommendations, contraindications/precautions, and
interactions. What effect will these medications have on his nutritional care? Refer to the
medication information in the FMI text. (3 pts)
Levemir
Generic name: insulin detemir FMI p.196
Classification: Antidiabetic, Hypoglycemic FMI p.196
Onset of Action: 0.8-2 hour dose dependent FMI p.180
Peak: no peak FMI p.180
Duration: 12-24 hour FMI p.180

11
Novolog
Generic name: insulin aspart FMI p. 179
Classification: Antidiabetic, hypoglycemic FMI p. 241
Onset of Action: 10-20 minutes FMI p.180
Peak: 40-50 minutes FMI p.180
Duration: 3-5 hour FMI p.180

Levemir & Novolog

Indication: Antidiabetic, hypoglycemic FMI p. 179
Diet: Diabetic meal plan to balance carbs with insulin FMI p.179
Possible FMI: Use alcohol with caution and under physician advice b/c alcohol
can increase insulin hypoglycemic effect
FMI p. 179
Potential Nut/ increase in weight (but not in T1DM w/ insulin detemir)
Oral/GI Side caution w/ severe hypoalbuminemia (O.C. has low albumin from
Effects: lab results)
FMI p.179

12
10. Write an ADIME note for O.C., using the information that you have obtained up until this
point. Base your note on the pertinent information given in the presentation data, diet
history, and questions above. Write the ADIME note below and attach a separate sheet with
all calculations. Include two PES statements. (8 pts)
A:
Pt Hx: 33 yo M admitted through ED for polydipsia & polyuria of 2 wk duration, polyphagia
& 12# wt loss in 3 wks. Dx TDM1 & FH uncle has Type 1 DM, grandfather died of CVD 2 to
Type 2 DM
MD Diet Order/Rx: Glycemic control w/ regular insulin, then adjust to daily therapy w/
mixed insulin therapy. DSM training & nutrition consult for hospital & home diet planning &
pt. education.
Anthropometrics:
Ht: 185.42 cm PG p.2
CBW: 77.3 kg PG p.2
IBW: 83.6 kg (92% IBW) PG p.2
BMI: 22.5 kg/m2 (Normal) PG p.1
Wt Hx: 12# or 7% wt loss in 3 wks
Overall Appearance: Slightly Underweight
Biochemical Data: (12/02/16) Non-fasting Glucose 372 mg/dL (high), HbA1c 8.55% (high),
Urine glucose +4 (high)
Medications: Levemir, Novolog
Estimated Nutrient Needs (based on IBW 83.6 kg):
Energy: BEE = 1835 kcal x AF 1.5 - 1.75 PG p. 3,5
Protein: 84 - 167 g/day (1.0-2.0 g/kg) PG p.5
Fluid: 2753 - 3211 mL PG p.6
Food and Nutrition Hx: O.C. follows Islamic dietary laws & plays soccer 3x a wk. Eating a
lot lately d/t polyphagia. NKFA. Will be getting diet exchange list and nutrition consult at
home. O.C.s current typical diet is more than what he would normally eat and includes a
lot high carb foods.
See attached paper for calculations

D:
Unintended wt loss (NC-3.4) r/t muscle wasting caused by T1DM AEB by wt loss of 12#.

Inconsistent carbohydrate intake (NI-5.8.4) r/t polyphagia AEB high simple carb food
choices found on diet hx.

13
I:
Overall goal is to achieve glycemic control & prevent further wt loss while regaining/
maintaining optimal wt.

Recommendations
for wt regain needs 2735-3211 kcal/d, 84-167 g Pro/d, & 2735-3211 mL fluid/d
should aim for 40-50% CHO, 20% PRO, 30-40% fatG

Goal of HbA1c<7%
Emphasize complex carbs and limit simple sugars (<10%)
Eat fiber from F/V, whole grains and legumes (30-38g/d)

Discussed w/ pt to follow exchange lists & educate about nutrition facts panels from
food labels and how to measure food

Pt is expected to comply with diet since he will most likely want to regain wt and energy
to continue playing soccer. Support/education may be needed at first to make sure pt
understands exchange lists, CHO counting in future, and proper insulin administration. A
SMBG log may help pt to understand importance to stabilize BG levels.

116A MNT for Diabetes Slides 28,29, 31, 38, 40, 67

M/E
Follow up 2-3 weeks & pt should bring SMBG log including 2 hr PP BGs
Also bring diet hx/food log to ensure wt regain goals are being met along with CHO,
Pro, fat, & fluid
Check CBW, & fasting BG levels
Schedule follow up if necessary to ensure understanding and to address any concerns

116A MNT for Diabetes Slides 48, 50 86

11. O.C. does well over the next few months in learning to manage his diabetes. However,
he is finding it difficult to keep his activity and intake constant due to the fact that his
schedule is variable, and he wants to resume playing soccer. He and the health care team
agree to use an insulin pump with intensive therapy in order to make his self-care more
flexible and achieve tighter glucose control. You begin teaching O.C. about carbohydrate
counting. Describe briefly how this will differ from the exchange-based diet plan that he was
using. (1 pt)

14
 Carbohydrate counting involves counting foods that contain 15g of carbohydrates. The
amount of carbohydrates is converted to glucose and the proper amount of insulin needed
is determined. Carbohydrate counting focuses more on the amount of carbs eaten in a day
rather than the source. Foods included in carbohydrate counting are fruits, milk, yogurt,
sweets and starches. Non-starchy vegetables are not included unless more than 15g is
consumed. Also, it helps with maintaining a consistent amount of carbs throughout the day
at meals. Since carbohydrate counting is more focused on the carbohydrates found in food
O.C. will have to become familiar with which food portions that contain 15g of
carbohydrates and decide how much to eat in order to be balanced and still be satisfied.
Also he will need to learn how to adjust insulin units based on his diet or learn how many
carbohydrates his insulin covers.

NTP p. 501,502
116Al MNT for Diabetes Slides 62, 63, 66

12. O.C. brings his SMBG record in for review when he comes for nutrition counseling. The
pre-prandial BG goal is 70-130 mg/dl. Several pre-meal entries are listed below.
Day Breakfast Lunch Dinner HS Snack
1 94 152 110 100
2 90 106 97 69
3 142 108 95 102

a. Circle/highlight the values that are outside the desirable range. (1 pt)
b. What adjustment(s) should O.C. make if the values are above the desirable range? (1 pt)
If the pt is experiencing increased blood glucose levels outside of the 70-130 mg/dL range
in the morning then he may need to take into account his bed time snacks and make sure
they are not high in carbs or adjust his insulin accordingly to the snack. Otherwise the pt
needs to adjust insulin with the food intake and make sure he is taking the proper amount
of insulin units to cover the food he is eating. He should consult with an MD or RD if he
doesn't understand how much insulin he should take with a certain meal or snack

116A Diabetes Mellitus - Part 2 Slide 55

NTP p.505

c. What adjustment(s) should O.C. make if the values are below the desirable range? (1 pt)
When blood glucose levels are below 70 mg/dL that means that the pts blood glucose is
low and could indicate hypoglycemia as a side effect of using insulin. Therefore, the pt
should consume 15-20g of a fast acting carbohydrate and then check after 15 minute if
blood glucose levels are back in the range. If not then the pt should consume another
snack.

NTP p. 505
15
13. What adjustments should O.C. make on the days when he plays soccer? (1 pt)
If the pt exercise for more than one hour, which I am assuming he is, then he needs to
account for decreased blood glucose levels. O.C. can reduce his insulin levels before
exercise to make up for the eventual decreased blood glucose levels. He should also eat a
snack higher in carbohydrates depending on how long and strenuously he plays soccer. This
may mean having a snack with 15-30g of carbohydrates.

NTP p. 504-505

14. O.C. has caught a cold and has a fever of 102 F. He feels miserable and is not eating
much. He calls you to ask if he should reduce his insulin dose since his diet is just a few
foods (chicken noodle soup and diet 7-up). What advice would you give him and why? (2
pts)
O.C. will still need to take insulin and may need to increase insulin levels because he
has a fever. He should continue testing his blood to make sure his glucose levels are not
too high. Then he should adjust accordingly. He can continue to eat chicken noodle
soup but he should try to eat every 3-4 hours and keep carbohydrate levels 45-60g at
each meal. Furthermore, if he wants something else other than what he is eating right
now he should again make sure his meal choices have sufficient carbs and are soft. It is
also very important that O.C. makes sure he is drinking adequate amounts of fluid
whether it is from water or the soup. In addition, O.C. should discontinue the diet 7 up
and switch to regular 7 up if he wants to continue drinking it. Or he can have another
soft drink with sugar to maintain his electrolytes

NTP p. 508
116A Diabetes Mellitus Slide 55

16