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Case History

Case History. 52 y.o. Native American female History Type 2 DM, onset 1993 Chronic Pancreatitis HTN Bigeminy/Trigeminy with bradycardia Depression Etoh (recovered). Case History (cont.) . Asthma B12 deficiency Benign positional vertigo GERD. Medications. HCTZ KCl Multivitamin

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Case History

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  1. Case History • 52 y.o. Native American female • History • Type 2 DM, onset 1993 • Chronic Pancreatitis • HTN • Bigeminy/Trigeminy with bradycardia • Depression • Etoh (recovered)

  2. Case History (cont.) • Asthma • B12 deficiency • Benign positional vertigo • GERD

  3. Medications • HCTZ • KCl • Multivitamin • Albuterol • Paroxetine • Gabapentin • Asthmacort • Loperamide

  4. Medications • 70/30 45-0-25-0 • Simvastatin • Valsartan • Celebrex • ASA • Prempro • Buspiron

  5. February 2005 • 2/11/2005 • PCP Visit • a.m. blood sugars 40-90s • a.c. lunch 40-80s • Pt adjusting 70/30 based on blood sugars • Taking evening dose at bedtime instead of at suppertime • A1C: 8.0%

  6. What would you do???

  7. What was done… • 70/30 D/C’d • Started on NPH 32-0-0-8 • Given appt to see PCP in 2 wks

  8. February 25, 2005 • PCP and DCOE Visit • “I hated to call you because I would bother you” • Blood sugars 26-300s • Self-adjusted bedtime insulin from 8 to 15 units • 23 episodes of hypoglycemia documented by meter (70 mg/dl or less) • Occurring all times of the day and night

  9. What would you do??

  10. What was done… • D/C’d NPH • Started on Lantus 20 units at HS • Agreed to phone call the following week • F/U with PCP 4 wks

  11. February 28, 2005 • Phone call to DCOE • “I’ve had a bad weekend with blood sugar” • FBS 121, 301, and 287 mg/dl • Midday 422 and 421 • ac supper 596 and 540 • PP supper “hi”

  12. What would you do??

  13. What was done… • Increased Lantus 30 units • Added Regular insulin 5-5-5-0

  14. March 2, 2005 • Phone call • “I’m a little better” • Increased Lantus to 33 units • FBS 390 mg/dl • Lunch 138 mg/dl • Midday 378 mg/dl

  15. What would you do??

  16. What was done….. • Told her to keep a food diary • Increased Lantus to 35 units • Increased Regular insulin to 5-8-8-0

  17. March 3, 2005 • Phone • “I don’t like waking up at 225 mg/dl” • Bedtime 317 mg/dl • ac lunch 187 mg/dl • pp lunch 151mg/dl • Lantus increased to 37 units • Regular increased to 5-8-10

  18. Interim • 3/10/05 • Cancelled appt due to flat tire • 3/16/05 • Falls in hole and fx Left Patella • 3/18/05 • PCP phone • Taking Regular insulin 5/10/10 • Had lows, but related to taking regular without eating

  19. March 28, 2005 • DCOE office visit • “I woke up to the paramedics trying to help me last week”. Refused to go to hospital • Blood sugar 22 mg/dl • Still taking regular without eating or stacking them (i.e. taking it at 9a.m. and again at 12N) • Blood sugars fasting 22-470 mg/dl • Lunch 99,177, 313, 217, and 425 mg/dl • p.m. 219,78, 404, 270 and 66 mg/dl

  20. What would you do??

  21. What was done…. • Instructed to bring food log • Eat if taking regular insulin or don’t take insulin at all • Appt in 2 days with PCP and DCOE

  22. March 30, 2005 • DCOE Office Visit • “Under a lot of stress and I throw up from stress” • Blood sugar range 23-470mg/dl • Switched to Lispro • 5-5-10-0

  23. April 8, 2005 • PCP Visit and DCOE Visit • Nighttime sugar 20mg/dl • FBS 137, 95 mg/dl • Pre-lunch 112, 237, 155 mg/dl • Changed Lispro 5-5-5-0 • Taking Lispro after eating • Blood sugar range 20-407 mg/dl

  24. April 14, 2005 • DCOE • “My blood sugars are better, but had 37 this a.m.”. • “Thinks she may have taken 2 Lispro injections with supper the night before” • No change in medications • Phone call in 2 wks

  25. May 2005 • Pt reportedly found down at home • Pulse 10, low blood sugar • Hospitalized Good Samaritan – records requested; never received. • Patient reportedly left Good Sam against medical advice

  26. May 19, 2005 • DCOE • Now still on Lantus 37 units q hs, Lispro 5-5-5-0 • “I want pills” • A1c is 8.3%, BS range 50-413 mg/dl • “I do not care about carb counting” • Told patient needs to carb count, patient registered for carb counting class, Lispro increased 5-5-6-0

  27. May 20, 2005 • PCP visit • Patient complains generalized body pain, depression, anxiety • Patient refused mental health consult • Increased Lantus 40 units q hs

  28. June 17, 2005 • PCP- • Smoking 2 packs/day • Again declines referral to Behavioral Health • Depression meds changed • DCOE • Introduce concept of small vs big meals with holding Lispro dose with small meal • Carb counting class scheduled 6/22/05

  29. July 8, 2005 • PCP Visit • 15 episodes of hypoglycemia noted • a.m. blood sugars 48-372 mg/dl • At bedtime, if blood sugar is 100 mg/dl, then pt eats • If blood sugars are low, pt ate no CHO with supper, but took insulin • Pre-lunch blood sugars 33 & 56 mg/dl • After lunch 59-371 mg/dl • After dinner 31-338 mg/dl

  30. July 8, 2005 (cont.) • Pt taking insulin without eating • Recognizes that a low blood sugar may occur if she does this • Plan • Food log (1 wk) • Lispro 5-5-0-0

  31. Future • DNKA carb counting class 6/22/05 • Has not returned DCOE phone calls • DCOE 7/19/05

  32. Other Points of Discussion • Pt has erratic and inconsistent diet • Compliance issues • Multiple co-morbid conditions • Gives inconsistent messages to M.D. & DCOE • Seeing a separate CIGNA M.D. • CIGNA Case Manager

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