What do these people have in common?Candy Hull, PA-SSeptember 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

twice-a-day injection regimens – Long-acting insulin (Glargine/Lantus, Detemir/Levemir)

• Basal insulin requirements for regulating hepatic glucose production

– Continuous subcutaneous insulin infusion

PMHDATE ASSESSMENT PLAN

February 1995 Diagnosed with Type 1 Diabetes Disease mgmt via endocrinologist & CDE

March 1996 DKA, hospitalized for 2 days Consider implantable infusion pump

May 1996 Continuous infusion pump implanted

October 2003

Patient chose to remove pump. 18 y/o at this time, pump was interfering with lifestyle as an active teenager.

Daily insulin shots. BG < 100 = 7 units, BG > 100 =8 units Lantus at bedtime. Humalog sliding scale 4-6 units before meals.

January 2004 Foot laceration, delayed healing. A1C 8.2Cipro 750mg BID for 7 days given. Sliding scale adjusted for Humalog, 6-8 units.

December 2004 Strep throat. A1C 8.3PCN 500mg BID for 10 days given. Humalog 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

February 2006

Check-up. A1C 7.2. Patient admits to not taking his insulin according to sliding scale. He usually needs 10 units so he usually gives that. Patient education. f/u 3 mo

April 2006 Charles Cole ER – pneumonia Clarithromycin 500mg BID for 7 days given.

May 2006 Check-up. A1C 7.4Certified Diabetic Educator counseling session scheduled for June 2003.

June 2006 CDE counseling received

9/2006-1/2011 Check-ups all showed A1C < 7.0 Continue insulin at current dosage.

April 2011Check-up. A1C 7.1. Patient admits to not taking his insulin according to sliding scale. Patient education. f/u 3 mo

May 2011 Otitis externa Cortisporin otic q6h

6/2011-7/2012 Check-ups all showed A1C < 7.0 Continue insulin at current dosage. f/u 6 mo

8/2012 Infected arm laceration, not healing. A1C 7.3

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

DM2

Eating Disorder

Malabsorption/Celiac

Not likely, he had both HLA-DR3 & DR4 haplotypes

No s/sx of eating disorder. Patients kept food diary for 10 days and calories >2000/day.

No s/sx diarrhea, bloating, flatulence, steatorrhea

Likely, goes with type 1 diabetes

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=978-1-4377-1604-7&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/353303328-2/1345190464?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