Care Plan
Introduction
Kevin U. is a 54-year-old divorced male who presents for his three-month diabetes evaluation. Kevin is a high school graduate who previously worked as a self-employed logger but now raises beef cows and does some crop farming on the family farm. Kevin’s main complaint today is the burning and tingling sensation he is experiencing in his hands and feet. Has been using gabapentin with minimal relief, applies CBD oil twice daily which he reports provides immediate short-term relief. Kevin does use marijuana daily for pain control.
History
Kevin was diagnosed with type 1 DM at the age of 18 months. He denies any hospitalizations for hypoglycemia or hyperglycemia/DKA other than his first diagnosis. Currently, he is experiencing hypoglycemia unawareness, so he limits his driving to only local areas and will check his BG before starting the vehicle; glucose tablets and glucagon are readily available. Two surgeries are documented with one being a same day surgery 14 years ago to repair an inguinal hernia and most recently had a cataract removed from his LT eye. Right eye is free from cataracts currently. Immunizations are up to date, last pneumococcal vaccine documented as 2015, Tdap 03/14/2014, and influenza vaccine received every year. Kevin reports as a child he did experience chicken pox, strep throat, and viral illnesses. Review of medical record shows a positive titer for mumps and rubella. No known tick exposure, but due to his history of working as a logger, a Lyme titer should be considered. Colonoscopy completed in 2014. Diverticulitis was present with one polyp removed. Last PSA was in 2016 with result of 3.0. Kevin denies any immediate family members who have mental illness or substance abuse. Denies tobacco use presently; however, he did chew tobacco when he was in his early 20’s.
Occasional alcohol intake in the form of beer once every two weeks and reports smoking marijuana for the past ten years every evening to help with the neuropathy pain in hands and feet. CAGE is negative. Blood glucose meter was down loaded, and readings are reviewed. Patient on average has been monitoring his blood glucose one to three times a day with average reading being 197.
Current Medications
Lantus 65 units SQ twice daily
Humalog- insulin to carb ratio of 1:6 with a correction scale of 2 units for every 50 above BG of 150. Administer SQ thirty minutes before each meal
Atorvastatin 80 mg daily
Lisinopril 20 mg one daily
Multivitamin daily
Mega Red 500 mg daily
Aspirin 81 mg daily
Gabapentin 300 mg one tablet three times a day
Melatonin 6 mg by mouth every evening
Glucagon kit to be used as needed for hypoglycemia
Viagra 100 mg ½ – 1 tablet as needed
Care Plan
Review of lab work shows elevated cholesterol, A1c, glucose, RUMAL, creatinine/GFR and liver labs. Total cholesterol is with the recommended range of <200. However, the LDL is out of range at 140. Recommended level for LDL is <100. LDL is also known as the “bad cholesterol” which also has a genetic component. Better diet control and exercise can assist the atorvastatin in lowering the LDL and raising the HDL to a level of >50. “People with high blood triglycerides usually also have lower HDL cholesterol. Genetic factors, type 2 diabetes, smoking, being overweight and being sedentary can all lower HDL cholesterol.” (heart.org, 2018)
On average for past three months, Kevin’s glucose has been in the range of 180-200. This is documented by his A1c. The A1c is an average of glucose readings over the past 2-3 months. It is measured by the amount of glucose that is attached to red blood cells circulating in the body. This is an acceptable A1c reading for a brittle type 1 diabetic who is experiencing hypoglycemic unawareness. Adjusting insulin to lower the A1c could have a detrimental effect on the individual, so no changes will be recommended regarding insulin. In the future, if the A1c continues to rise, the base insulin (Lantus) could be increased, but caution needs to be taken due to his hypoglycemia unawareness.
Kevin has been a diabetic for over fifty years and his kidneys are being stressed. This is based on his RUMAL (the amount of albumin/protein released in system when kidneys are stressed) Kevin’s results are >300 which is considered moderate kidney disease. Normal RUMAL is up to 30, mild kidney disease is 30-300, and >300 shows moderate kidney disease. Consider increasing the dose of his ACE inhibitor to 40 mg once daily. The creatinine is elevated at 1.9, normal range being 0.5-1.5. The creatinine shows how kidneys are functioning, but the GFR which shows how the kidneys are filtering is diminished at 45. Any result <60 is considered a sign of kidney disease. If the dose of ACE inhibitor is increased, careful monitoring of renal functions and electrolytes is needed. A common side effect of ACE inhibitors is elevated potassium levels. If the Ace inhibitor is increased, Kevin should present for a potassium and creatinine level at two-week intervals, times two for monitoring.
The liver functions test AST is used to detect a liver injury or active or chronic liver problem. The normal range for males is 8-46. The ALT which is mildly elevated at 51. This test is used to detect liver injuries or long-term liver disease. Normal range is 5-40. The slight elevation could be related to use of atorvastatin or could be related to “fatty liver.” Monitoring should be completed every three months and include an ultrasound of the liver to check for any physical abnormalities.
Encourage Kevin to continue to see the Podiatrist every three months for foot exams and nail care. Educate on how to complete a daily home foot exam with a mirror and stress the importance of always wearing some foot cover even when in the house. It is essential for patients who suffer from diabetic neuropathy to be seen frequently by a Podiatrist. Regular foot examinations and frequent educational messages on foot care will significantly reduce the occurrence of ulceration and even amputation. One could consider a referral to a vascular surgeon for ABI assessment which is an evaluation for peripheral vascular disease. Further referrals for Neurology, massage therapist, acupuncture or physical therapy should be considered. Medication change from gabapentin to Lyrica could also be considered along with adding B vitamins which in studies has shown to reduce paresthesia. Topical therapy with capsaicin or transdermal lidocaine can be used for individuals who may have more localized discomfort, Kevin is currently using CBD cream with short term relief. Tramadol and narcotics could be added in the future for pain control, however, with Kevin experiencing hypoglycemia unawareness and driving farm machinery, this should be avoided at this time if possible.
The benefits of diet and exercise and how simple changes can improve blood pressure, glucose readings and cholesterol results should be reviewed in detail with Kevin. Attempt to have Kevin set a daily goal for exercise, review chair exercises and provide handouts. Encourage to take 6 10-minute exercise breaks during the day and evening with goals to increase exercise to 30-60 minutes daily. A referral to a dietician should be considered due to Kevin cooking quick processed meals. Healthy, quick nutritious meals and snacks should be the focus when visiting with the dietician.
Consider Penicillin testing for the questionable penicillin allergy. One can question if the rash was related to the strep infection or the medication. Completing a penicillin challenge could prove beneficial in the future if he should develop a foot ulcer which needs antibiotic coverage. A Lyme titer should be completed to determine if Lyme disease is enhancing his neuropathy pain in hands and feet. Encourage Kevin to continue to monitor blood glucose before driving farm equipment or his vehicle. Review automobile and farm equipment safety. Blood glucose should be monitored before meals and at bedtime, minimum of four times a day. Although Kevin continues to refuse wearing a continuous glucose monitor, (CGM) information and review of the benefits of the monitor along with the benefits of an insulin pump should be reviewed. Complete prior authorization to insurance company and review the minimal cost it will be to him out of pocket along with the beneficial data to be received. EKG should be completed for baseline comparison and then yearly thereafter and as needed. Reinforce the need for dental exam every six months along with regular Ophthalmologist visits for dilated eye exams.
Summary
There are a few medication adjustments which could be completed in the future, but all will come with the need for increase monitoring. One of the easiest and most simple is to improve diet and exercise. This will benefit his cholesterol, hypertension and glucose readings. Improved glucose readings are important for slowing the progression of neuropathy. Exercise and diet will help him maintain a healthy weight which will also assist with better blood glucose control. Follow up visits should be scheduled every 6 weeks to 3 months with the Diabetes Educator to monitor blood glucose readings, diet, weight loss and to encourage and keep patient motivated with his lifestyle changes. Assistance scheduling appointments with the recommended referrals, such as Neurology to assist with his diabetic neuropathy, Podiatry for nail care and foot assessment along with Ophthalmology for eye care.
Encouragement and frequent assessments of blood glucose will hopefully keep Kevin in his current state of health and slow the progression of the diabetes disease process.