JS, a 12-year old girl with type 1 diabetes, has been experiencing episodes of fatigue, weakness, and weight loss. During a soccer game, she felt sick and her blood glucose level was found to be low. She was treated for heat exhaustion. The doctor thinks she may be experiencing diabetic ketoacidosis. Proper management of type 1 diabetes requires lifelong insulin administration, monitoring of blood glucose and ketone levels, and maintenance of a healthy diet and activity levels to prevent dangerous fluctuations.

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Type 1 DM Case Study
Thiscasestudy isto be completedindependently. Usevalidresources andprovide
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each answerthoroughly making sureyouhavethoughtthroughyouranswerand
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Thiscaseis worth50 points;eachquestionismarkedwith its pointvalue.
Initial Appointment
JS is a twelve-year-oldpre-teenwithinafamilyof 6 who enjoys sports ofany kind anda variety
of extracurricular activities offeredat her middleschoolincludingjournalclub, cheerleading,
andband. Per herparent’s report,she is very active andsocialand “nevermisses abeat”.They
describe her as “veryhighenergyand difficult to keep up with.” Theyclaimthat she has never
hadany serious medicalissues;however,justtwo years ago shewas diagnosed withtype1
diabetes andhas beentreatedwith InsulinDetemirinjections once a dayas prescribed by an
endocrinologist.According to herparents,herbloodglucose levels havebeenwellcontrolled
since. Infact, they werehopingshecouldgo off her medicinebecause shejust startedplaying
soccer whichthey sayseems to helplowerher bloodglucose levels.
Theyare in thepediatrician’s office because recently, overthe last6-9months,JS has been
experiencingepisodes offatigue,weakness,andweightloss,whichespeciallyconcerns her
parents as she is 5’3” andonly97 lbs. Two weeks ago in thefirst halfof a soccer game,they
saidshe hadto sit thesidelines because shelookedandfelt weak, appeared pale,andwas
sweating profusely.Aftersittingfor a minute,JS didn’t lookany better(orJS’s conditionwas
not improving) andcomplained ofstillfeelingsick andshaky.The athletictrainer tookher
vitals duringthe game,in 87 degreeheat,and notedshehada pulseof 54 and BP of 106/76.
She hada temperature of 99.2degrees Fahrenheit.WithJS’s personalAccu-Check, shechecked
her blood glucoselevels andtoldhermomit was 54mg/dL.TheATC was immediately
concerned that JS maybe sufferinglowbloodsugaranddehydrationandurgedherto quickly
drink a sodaandeat a Snicker’s bar.
Within 30 minutes of this episode,shewas treated that afternoonin thelocal ERfor ‘heat
exhaustion’perthenurse’s report.Since this episode,JS’s parents statethat shehasn’thad any
morereoccurrences but theyare still concerned abouttheir daughter’s health.
Duringthe pediatricevaluation,JS admits to the doctorthat shehas beeneating morejunk
foodlatelybecause she constantlyfeels hungry.She also admits to havingmoreepisodes like
the onedescribed above,butshehasn’ttold her parents because shedoesn’twantto miss more
soccer. Shedenies any changes in bowel/bladderandvisionandstates thatsometimes she
feels great whileothertimes shefeels sick. Whenasked abouthersleepschedule,shesaid that
shesleeps normallybutsometimes wakes upin the middleof thenight thoughshethinks she
has always donethis.
Questions:
1. Based on only the above information, what do you think is going on with JS?
Explain the physiology of why this is happening. Hint: why was her blood
glucose level so low? (4)

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Type 1 DM Case Study
I think that JS is experiencing diabetic ketoacidosis (DKA). The pathophysiology is an
increased catecholamine response without appropriate insulin compensation. In this case, I
think the psychological stress of diabetes and the missed insulin doses are contributing to the
DKA.
2. Name 3 of the signs/symptoms that lead you to your answer for question number
one. Explain the physiology of these 3 symptoms. (3)
Polyphagia, excessive hunger, is one noticeable symptom. This is associated with weight
loss because the body is not properly absorbing them because of the absolute deficiency
of insulin which prevents the uptake of glucose into insulin dependent tissues.
Dehydration and weakness are two other symptoms.
3. What would you tell JS’ parents who think she can go off her insulin. Support
your answer. In other words, is type 1 diabetes treatable without meds? (3)
I would tell JS’s parents that it is not possible for her to go off insulin as a type 1
diabetic. Type 1 diabetes is the result of beta cell destruction and means that the
patient is insulin deficient. Exogenous forms of insulin must be distributed by the
patient or by an insulin pump for the body to be able to controlblood glucose levels.
4. Pharmaceuticalmanagement:
a. What is Insulin Detemir and what does it do? (2)
Insulin Detemir, or brand name Levemir, is a type of insulin that lasts for up
to 24 hours each period of use. It is considered a long-acting insulin. Levemir
is produced by a process that includes expression of recombinant DNA
followedby chemicalmodification. This insulin is used to help controlthe
blood sugar levels.
b. Name 2 other typical medical interventions that could have been used to
treat JS. (2)
Rapid acting analog insulin such as Lispro, Aspart, or Gluisine are one option.
These require more daily injections because the duration's only 2-4 hours
compared to 24 hours, but there is immediate release if taken with meals. These
are rapid acting because they are onset in 15 minutes which is even faster than
normal insulin. Another option would be neutral protamine hagedorn (NPH)
which has an onset of 2-4 hours. The duration is 6- 10 hours.
c. How are these drugs administered? How frequently are they
administered? (1)
These drugs are administered through insulin injections. Many type 1 diabetics
use an insulin pump that automatically injects the insulin into the blood stream at
certain times depending on the type of insulin. Many times it is administered
before a meal.
d. What are 2-3 side effects of this drug? (2)
As withany RX drug, there are side effects.Side effectsof Insulin Detemir
can include redness, swelling, or itching at the site of injection, weight gain,
changes in the feel of the skin (fat buildup or fatbreakdown). Some serious
side effectsinclude wheezing, dizziness, shortness of breath, and or a
rash/itching all overthe wholebody and not just site of injection.

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Type 1 DM Case Study
e. How do these drugs differ from those used to treat type 2 diabetes? (2)
Type 2 diabetics are still able to produce insulin although the body does not
respond well to it. Therefore, those with type 2 may only need to inject insulin at
meal times to lower blood glucose levels after eating as opposed to a basal
insulin that works for 24 hours.
5. Based on the information given, what test(s) specifically for her diabetes do you
think should have been ordered in the ER? Give a brief rationale. (3)
Glucose should have been monitored hourly, vitals should have been monitored every 1-2
hours, BMPs should have been monitored ever 4 hours, and ketones should have been
monitored every 8-12 hours. All this would ensure that the DKA was managed properly
and that the patient was back in a normal state.
6. Why do you think JS experiences these symptoms on a somewhat regular basis?
Is this common? (2)
I think she experiences these on a somewhat regular basis because she doesn't seem to eat
right most of the time and continues to strain her body with high levels of physical
activity for soccer. She isn’t managing her diabetes properly.
a. Why is she constantly hungry but losing weight? (2)
JS is experiences polyphagia which is excessive hunger. Her body is not able to
absorb the nutrients because she is insulin deficient as a type 1 diabetic. She is
not able to uptake glucose into the insulin dependent tissues and is constantly
eating to try and counteract this.
b. Provide 2 pieces of valid evidence (not a website but actual evidence) to
support your answer (1)
JS isn’t eating a proper diet to stay in control of her diabetes and she is working
out on a moderate level which is not helping the situation of polyphagia. Not
only does she need to eat more food to counteract her physical activity, she is not
getting the proper nutrients to uptake glucose form the blood stream and deposit
it in the proper tissues.
Upon retrievalof JS’s medicalrecords from the ER,the doctorwas ableto find out thatthe
following tests wereordered (withresults listed):
CBC:
Hgb: 12.7g/dL
Hct: 37.2%;
WBC: 7,200 cmm
RBC: 6.2 million cells/cmm
Platelets: 387,450/cmm
BMP:
K: 3.8 mEq/L
Na: 137 mEq/L
Chloride: 102 mmol/L
Creatinine: 1.1 mg/dL

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Type 1 DM Case Study
Calcium: 9.2 mg/dL
BUN: 14 mg/dL
Bicarbonate: 25 mmol/L
Glucose: 190mg/dL
O2 Sat: 99%
Chol: 130 mg/dL
Questions:
1. JS’ blood glucose levels went from 54 mg/dL (as measured at the game) to 190
mg/dL (documented in the ER).
a. Explain why her blood glucose levels changed so drastically. (1)
During the game when she was experiencing symptoms she was given a soda and
a snickers bar. Both are sugary foods high in carbohydrates leading to an increase
in blood sugar.
b. Is this drastic change unhealthy/bad? Why or why not? (2)
This drastic change is both unhealthy and bad. The drastic change could have a
negative effect on the body leading to shock.
c. What could have been done to prevent such a rapid change? (1)
The “15” rule could have been applied here. 15 grams of carbohydrates every 15
minutes until blood glucose levels have reached a normal level.
2. Do you think the heat affected JS blood glucose level? What does research
suggest? (3)
I think heat affected JS blood glucose level because that would mean more sweat and
more loss of fluids. She was active and sweating more than she would had she been not
physically active. This cold promote polydypsia because of the loss of fluids.
3. Provide 2 lifestyle modifications you would recommend JS to make. Be specific.
For example, don’t just say ‘eat better’. Instead, describe what better foods she
should eat and how frequently she should do that. (2)
Rather than grabbing a candy bar or any other junk food, JS could grab a healthy, low
carb snack. Processed foods tend to be high in carbohydrates and low in dietary fiber
which could promote hyperglycemia more often. I think JS should also join a diabetes
self-management program that teaches her how to deal with her disease the consequences
of not taking care of the body that is under the stress of diabetes.
4. Name and describe one biologically possible reason JS is consistently waking up
in the middle of the night? Why does it occur? (3)
JS may be consistently waking up in the middle of the night because she is often
experiencing hypoglycemia, or low blood sugar. Hypoglycemia can lead to nightmares
and night sweats. Daily physical activity can increase insulin sensitivity which may also
lead to night time hypoglycemia.

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Type 1 DM Case Study
Follow-upAppointment
6 months later,JS meets with herpediatricianagain.Upon asking,she admits to not taking her
medicineregularly.She says thatsometimes shethinks she doesn’tneedit andothertimes she
“justdoesn’twantto rely ona medicineto make herbodynormal”.Herparents also addthat
shewas justrecently diagnosed withdepression,whichreallyworries them.Shesays she feels
like shedoesn’tfit in andcan’t always do whatall of herfriends aredoing.This is another
reason,shesays,thatshe isn’t compliantwithher meds.
Questions:
1. How does JS’ depression impact her diabetes? How does her diabetes impact her
depression? (2)
Depression can lead to lack of self-care because adjusting to the disease and dealing with
the complications can be very stressfulon a diabetes patient. Lack of self-care can lead to
serious health risks such as anxiety, depression, eating disorders and medication issues.
Antidepressants may increase the risk for diabetes by promoting weight gain, glucose
intolerance, and insulin resistance. This can all lead to hyperglycemia, vascular disease,
hypoglycemic episodes, and insulin resistance.
2. How does JS’ diabetes impact her family? Elaborate on financial and social
aspects. (2).
Parents often carry the blame when a child is diagnosed with type 1 diabetes. It is hard
for the family to adjust to the diagnosis as well, leading to potential sabotaged dieting
efforts and affects how the siblings are treated. Financially it may be an issue because
insurance may not cover all the diabetes related supplies that are required. Eating a
different diet from the rest of the family may also be a financial adjustment. A diabetes
diagnosis can lead to the patient feeling left out because they are treated differently and
not allowed to eat spontaneously if blood sugar levels are off.
3. Provide 3 ways in which her friends and family can show support for JS as she
deals with diabetes and depression. (3)
Family and friends can eat a similar diet as JS to show that it can be done and show that
she isn’t being left behind because of her dietary and medical restrictions. The family
could also learn her personal beliefs and how she feels about certain activities and dietary
restrictions and make an effort to find out what is important to JS. Her family might be a
little more restrictive with her diet in this case to show that they care about her health and
well-being and to show that they are not trying to sabotage her efforts.
4. Provide 2 appropriate resources (could be websites, phone apps, books or other
sources) JS could utilize to help better understand the disease and its potential
complications if not well managed. These resources should have information to
help convince JS of taking better care of herself and better manage her diabetes.
(2)
The American Diabetes Association has a great website for learning to manage diabetes
and explaining the disease in terms that make it understandable. The website has online
communities for those with diabetes or those that know someone with diabetes to help the
patient connect with others in the same position. There is also an application on the

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Type 1 DM Case Study
website that helps those with diabetes plan means and log blood sugar levels to help keep
track of daily readings and help your doctor track your progress. Another option is the
phone app Diabetes Buddy. Like the American Diabetes Association application, it helps
to track blood glucose levels and insulin injections all on a daily basis. The information
can be easily shared with your doctor to keep track of medical progress and health
records.
5. Put yourself in JS’ shoes. How do you think you would feel living with diabetes
as a 12-year-old? What do you think would be most challenging for you? (2)
I would feel very confused and agitated if I had diabetes as a 12-year-old, or at all. It is
very frustrating to have to constantly monitor your body and what you are eating and how
you are feeling. I can’t imagine having to actually deal with this every day. I would say it
would be more stressfulas a child because of things like the spontaneous eating of sweets
and always having to be the friend checking blood sugar before meals. I believe the diet
part of the disease is one of the most challenging sides of diabetes.
References:
Mod 1, Lecture 1- Diabetes Classifications
http://www.rxlist.com/levemir-drug.htm
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a606012.html#side
-effects
http://www.diabetes.co.uk/nocturnal-hypoglycemia.html