Elizabeth Ho Moon Liang School Case Study

APN 2 Case Study Write Up: DKA

TABLE OF CONTENTS

TOPIC PAGE
Patient Profile 1
Health Assessment
 Demographic 2
 History Taking 2

 Past Family Medical History 3

3
 Medications and Drug Allergy
4
 Physical Examination
Diagnosis
 Provisional Diagnosis 5
 Investigations 7

 Epidemiology 12
12
 Pathologyphysiology
Management
 Medical Goals 13
 Pharmacological Agents 15

 Lifestyle Changes 17
21
 Special Issues in Adolescents
Conclusion 22
References 23

APN2 Case Study Page 1

Elizabeth Ho Moon Liang School Case Study

PATIENT PROFILE
Mr. Brandon Quek* is 16 years old. He went to National University of Singapore
(NUH) Accident and Emergency (A&E) department, on 5th December 2005 around
1114hrs.He was referred from the private family physician with chief complaint of
shortness of breath for 3 days and occasional “poking” mild chest pain. This was
accompanied with polydipsia, polyuria, sudden loss of weight and loss of appetite.
Physical examination showed no remarkable findings except dry tongue muscosae
by the accident and emergency doctor.

Clinical laboratory tests revealed the following significant findings: (1) high blood
glucose from bedside test and serum glucose (2) urine ketones and (3) metabolic
acidosis from arterial blood gases. He was subsequently diagnosed as Diabetes
Ketoacidosis by Endocrine team and admitted to the general ward. Subsequently
he was diagnosed having Type 2 Diabetes Mellitus as the cause of his condition.

This assignment will focus on (1) health assessment of Brandon (2) arriving at the
diagnosis (3) investigations arriving at the cause of the clinical problem and lastly
(4) management of the root problem. Due to the limitation of time, the acute
management of diabetes ketoacidosis will not be elaborated on.

APN2 Case Study Page 2

Elizabeth Ho Moon Liang School Case Study

HEALTH ASSESSMENT
Demographic
Brandon is 16 years old. He is an N-level student from Queensway Secondary
School, waiting for his N level results. He stays with his family in Telok Blangah and
has a younger brother. He hopes to enter into Information Technology course
offered by Institute of Technical Education.

History Taking
Brandon’s chief complaints were shortness of breath for 3 days with occasional
“poking” mild chest pain.

Details of Chief Complaints

Shortness of breath was sudden on onset and progressively becoming worse over
3 days. Shortness of breath was present while waking, sitting and even lying down.
No audible wheeze was heard. Shortness of breath was not relieved by positioning
or other factors. No known aggravating factors. There were no previous similar
episodes. He had fever for 1 day prior to admission but unable to quantify severity.
He also reported non-productive cough for a day. However, there was no reported
hemopytsis.

Chest pain was described as “poking” in nature. Pain was sudden on onset. It was
localized at the central region of the chest with no migration to other regions. Pain
score was 4 over 10. It was occasional in frequency on the day before admission
and duration for each episode was less than 2 minutes. Pain was aggravated when
he was “very short of breath and breathing hard”. No relieving factors were known
to him.

APN2 Case Study Page 3

Elizabeth Ho Moon Liang School Case Study

Symptoms were associated with nausea and vomiting of 1 episode in the accident
and emergency department of partially digested food. Vomitus is non-bilious and
bloody in nature. There is no accompanied abdominal pain.
He also had polydipsia and polyuria several days prior to admission. He reported
realizing having extreme thirst and had increased urinary frequencies about 5
times per night, 5 days before admission. There was no dysuria or haematuria. He
could not recall any event that trigger off these symptoms. He also noted loss of
appetite for 3 days and sudden loss of weight about 5 kg within a week.

There was no parasymal nocturnal dyspnea and swelling of the legs. No giddiness,
palpitations or syncope reported.

Review of Systems
Review of the neurological, musculoskeletal and haematological systems was
unremarkable.

Past Medical History

Brandon has a history of asthma since the age of five. However, he was not on any
inhalers or follow up for the management of his asthma. There is no past history of
cardiovascular diseases or recent surgery done.

Family History
Brandon has a strong family history of diabetes mellitus. His maternal
grandparents and his maternal grandmother had type 2 diabetes mellitus. His
mother had gestational diabetes and progression to diabetes at the age of 28. She
is currently on diet control and followed up by her workplace doctor.

Drug Allergy
Brandon has drug allergy to penicillin and ampicillin which will cause rashes, peri-
orbital edema and angioedema.

APN2 Case Study Page 4

Elizabeth Ho Moon Liang School Case Study

Social and Lifestyle History

Brandon is an average teenager. His favorite pastime now during the holidays is
staying at home and playing computer games especially Play Station 2 computer
games. He seldom exercises and only does it during the Physical Exercise (P.E.)
lessons in school. He does not enjoy shopping or going out with friends as he has
limited allowances. His favorite food is Laksa and favorite snack is potato chips
“Lay” original flavor. He does not enjoy sweet desserts like cakes, ice-creams or
“sweet soups”. If he ever does drink sugary drinks, he prefers Pepsi. However,
right now his favorite drink is “Grass Power”.

In summary, Brandon’s lifestyle is sedentary for his age. His diet and favorite at a
glance seem to be high in saturated fat, cholesterol and salt content.

Physical Examination (done on the 7th December 2005, 3pm)

General Appearance
Brandon appears comfortable. There is no sign of respiratory distress. His reported
height is 1.84 meters and a reported weight of 85.6 kilograms. These give him a
body mass index of 25.3. His nail beds look pink and healthy. There is no clubbing
or cyanosis noted.

Vital Signs
His temperature is 37.2oC. His pulse rate is 78 beats/ minute. His respiration rate is
14 breaths/ minute. His blood pressure is 135/85 mmHg.

Head and Neck Examination

The neck veins are not distended. There is no cornea arcus and xantholoma. The
tongue is moist on the day of inspection and no central cyanosis noted. The tonsils
are not enlarged and dental hygiene is satisfactory. The thyroid is not enlarged.

APN2 Case Study Page 5

Elizabeth Ho Moon Liang School Case Study

(Brandon was noted to have dehydrated mucosae in the accident and emergency
department.)

Cardiac Examination
The radial pulse is strong and regular. There is no radial-radial or radial-femoral
delay. Collapsing pulse is also absent. Upon cardiovascular inspection, there are
no abnormalities noted. The apex beat is palpable at 5th intercostals space at mid
left clavicle line. It is not displaced. Thrills and heaves are absent. Dual heart
sounds heard with no additional heart sounds or murmurs.

Lung Examination
There are no surgical scars or abnormalities noted on inspection. Trachea is
central and not deviated. Chest expansion is bilaterally equal. Tactile fremitus and
vocal resonance are symmetrical and uniform throughout. Percussion tone is
symmetrical and normal. Breath sounds upon auscultation is clear and vesicular in
nature.

Lymph Nodes
The cervical, epitrochlear, supraclavicular and inguinal lymph nodes are not
palpable.

Abdominal Examination
The abdomen is not distended and has no scars or wounds on appearance. It is
soft and non-tender. There is no guarding and rebound tenderness. No lumps and
bumps felt. There is no shifting dullness. Upon auscultation, bowel sounds are
active and no renal bruits are heard. There is no hepatomegaly and splenomegaly.
Both kidneys are not ballotable. Rectal examination was not done.

APN2 Case Study Page 6

Elizabeth Ho Moon Liang School Case Study

Neurological Examination
Brandon is alert and orientated to time, place and person. Cranial nerves are
intact. Pupils are equal and reactive to light. There are no significant neurological
deficits found.

Joints
There are no joints swelling or tenderness.

DIAGNOSIS
Provisional Diagnosis and Differential Diagnoses
In summary, Brandon is a 17 year old gentleman was referred to the accident and
emergency department by the family physician. His chief complaints were
shortness of breath for 3 days with mild “poking” chest pain for a day, which were
accompanied by fever, vomiting, polydipsia, polyuria and sudden loss of weight.
His physical examination was not remarkable.

With a history of childhood asthma, a reasonable provisional diagnosis is

exacerbation of asthma. However, there was no presence of wheeze on
auscultation.

The second most probable diagnosis, given a strong family history of type 2
diabetes mellitus, is diabetes ketoacidosis (DKA) or hyperglycemic
hyperosmolar non-ketonic (HHNK). Signs and symptoms of hyperventilation
(shortness of breath), polydipsia, polyuria, sudden loss of weight, loss of appetite
and vomiting correlate with the symptoms of DKA.

Emergency diagnosis to be rule out that can present with shortness of breath and
chest pain for young people includes pneumothorax. Other diagnoses with lesser

APN2 Case Study Page 7

Elizabeth Ho Moon Liang School Case Study

probabilities due to his young age include pulmonary embolism, myocardial

infarction. Pericarditis as a low probability diagnosis also had to be considered.

Other differential non-emergency diagnoses that can account for his sign and
symptoms include:
(a) pneumonia - shortness of breath, fever and non-productive cough
(b) diabetes insipidus – polydipsia and polyuria
(c) adrenal insufficiency – a lesser probability due to the blood pressure of
135/85mmHg. However, other signs of weight loss, anorexia, fever, dehydration,
nausea and vomiting correlate with adrenal insufficiency.

Investigations
The aims of the investigations are (1) to confirm diagnosis (2) to rule out differential
diagnoses (3) to guide management plan and (4) to find out the underlying cause
of the illness. This assignment will only discuss briefly the investigations done in
the emergency department for Brandon to rule out differential diagnoses. The main
discussion will focus on a few areas of concern (1) investigations done for
hyperglycemic emergencies - differentiating between DKA and HHNK (2) how
investigations guide acute management of hyperglycemic emergencies and (3)
investigations for hyperglycemic emergencies.

Investigations to rule out Differential Diagnoses

Chest x-ray was done to rule out pneumothorax and pneumonia. His chest x-ray
results revealed a normal chest x-ray. There was no consolidation (pneumonia) or
separation of lung margins from the rib cage (penumothorax).

Electrocardiogram (ECG) was also done. The investigation revealed no

abnormalities, a normal cardiac axis and sinus tachycardia.There was no ST-
depression or elevation, Q wave, inverted T wave or a left bundle branch block
impression to suggest myocardial infarction. There was also no ECG signs to

APN2 Case Study Page 8

Elizabeth Ho Moon Liang School Case Study

suggest pericarditis and pulmonary embolism. Troponin T test was done, with a
result of less than 0.1, to rule out myocardial infarction.

Investigations done for Hyperglycemic Emergencies

Beside capillary blood glucose test was done with a reading of 26.8mmol/L. Urine
ketones was positive 3+. Serum ketones test was not done on the day of
admission. Arterial blood gases were done with the results shown in Table 1. Urea
and electrolytes results are shown in Table 2.

The differences between diabetes ketoacidosis (DKA) and hyperglycemic

hyperosmolar non-ketonic state (HHNK) include (1) the presence of elevated
serum ketones in DKA (2) metabolic acidosis in DKA (3) significant higher anion
gap in DKA and (4) significant higher serum osmolality in HHNK (Davidson, 1986
and Gale & Anderson, 2002).

5th Dec 2005 (Normal) 11.39hrs 1257hrs

pH 7.35 - 7.45 7.1 7.078
PaCO2 (mmHg) 35 – 45 16.5 16.3
PO2 (mmHg) 75 – 100 146 165
BEecf (mmol/L) -2.5 to 2.5 -25 -25
HCO3 (mmol/L) 22-26 5.1 4.8
TCO2 (mmol/L) 6 5
Sa02 98% 99%
Table 1: Arterial Blood Gases Results

APN2 Case Study Page 9

Elizabeth Ho Moon Liang School Case Study

5th Dec 2005 (Normal) 1157hrs

Sodium 135-150 127

Potassium 3.5-5.0 4.9

Urea 2.5-7.5 4.9

Creatinine 65-125 120

Glucose 3.0-6.0 29.8

Table 2: Urea and Electrolytes Results

Brandon’s arterial blood gases results revealed metabolic acidosis with respiratory
compensatory. Anion gap was unable to be calculated as chloride levels were not
obtained. Another way to confirm presence of acidosis is to calculate the pH using
Henderson Hasselbach Equation. Serum osmolality can be calculated from the
urea and electrolyte profile with the urea and electrolyte results. The formula for
calculating serum osomolality is 2(Sodium + Potassium) + glucose (mmol/L) + urea
(mmol/L), 2 (127 + 4.9) + 29.8 + 4.9, which gives 298.5 mOsm/kg (Davidson,
1986). The value falls within the normal serum osmolality ranges from 278 to 302
mOsm/kg.

In summary, Brandon had diabetic ketoacidosis from the arterial blood gases,
although calculating the anion gap and pH will give a more accurate picture of the
acidosis. There was no evidence of hyperosmolality state to suggest a mixed state
of HHNK and DKA.

Other investigations that were done for Brandon included full blood count,
coagulation profile and liver enzymes. Though abnormalities were present in his
test results, however, the exploration of these abnormalities were not within the
scope of this assignment. Slight elevation of white blood cells was expected due to
accumulation of ketone bodies or even presence of ongoing infection (Casteels

APN2 Case Study Page 10

Elizabeth Ho Moon Liang School Case Study

and Mathieu, 2003). Ongoing monitoring of fever, deterioration of symptoms and

repeated full blood count profile to detect escalating sepsis that will complicate the
diabetic ketoacidosis state. If sepsis is suspected, appropriate and prompt
antibiotics treatment had to be initiated.

Role of Investigations and Acute Management

Investigations especially the arterial blood gases and urea and electrolytes profile
serve as not only a diagnostic tool, they were equally important in guiding the acute
management of DKA.

Diabetes ketoacidosis can result in death. Basic stabilization of maintaining airway

and oxygenation is important. Oxygen therapy can be guided by pulse oximetry
reading and saturation of oxygen. The main components of the acute management
of DKA include active fluid replacement and insulin administration. Correction of
acid-base balance and replacement of electrolytes according to the blood results
are also necessary.

Active fluid replacement is divided into 2 stages replacing the extracellular

compartment and then replacing the intracellular compartment when the glucose
level reaches near normal (Frier and Fisher, 2002). The choice of using 0.9% or
0.45% NaCl intravenous infusion for the initial fluid replacement is dependent on
the serum sodium. Brandon’s serum sodium was 127mmol/L thus he was replaced
with 0.9% of NaCl intravenous infusion initially. Subsequently with alternating
dextrose 5% and sodium chloride 0.9% 500mls with 5mls of 7.45% potassium
chloride at 4 hourly interval for a day.

Though the potassium level for Brandon was normal, the potassium level will
decrease with the correction of the hyperglycemic state with insulin due to the shift
of potassium ions into intracellular space with insulin. Thus, a constant monitoring

APN2 Case Study Page 11

Elizabeth Ho Moon Liang School Case Study

of urea and electrolytes of potassium is necessary to prevent extreme

hyperkalemia or hypokalemia which both will result in cardiac arrhythmias.

Glucose monitoring is essential in administration of insulin. Insulin was infused

intravenously to Brandon at 5units/hr with the bedside glucose test of 26.8mmol/L.
Although it is preferred that insulin is administered at a bolus of 0.15U/kg, followed
by a continuous infusion of 0.1U/kg/hr (Casteels and Mathieu, 2003). Maybe due to
a glucose level of 26.8mmol/L, the physician decided to maintain at 5units/hr
instead of 8 units/hr based on Brandon’s weight of 85.8kg. Continuous hourly
monitoring of the blood glucose is necessary as it not only guide insulin
administration but also fluid replacement therapy.

The use of bicarbonate in DKA management is controversial (Casteels and

Mathieu, 2003). However, if intravenous bicarbonate has to be administered, it had
to be guided by pH level. In Brandon’s case, his pH did not fall below 7.0 thus there
was no indication for the administration of bicarbonate.

In summary, the acute management of Brandon according to his investigations

results is adequate which resulted in a lowering of his blood glucose level and
correction of his ketoacidosis state. Brandon’s beta-hydroxybuterate is 4.2 which is
normal about 6 hours after admission. The clinical picture will definitely be much
more accurate if beta-hydroxybuterate was being done on admission. It will also be
good if phosphate levels were also monitored.

Investigations for the underlying cause of DKA

After the acute management of DKA, cause of DKA has to be established to
administer appropriate medical management. Primary causes of diabetes,
determination between Type 1 and Type 2 diabetes were explored. Anti-islet cell
antibodies, C peptide test and glutamic acid decarboxylase (GAD) auto antibodies
were done. Secondary causes to diabetes were also explored. Liver function tests,

APN2 Case Study Page 12

Elizabeth Ho Moon Liang School Case Study

thyroid function tests and cortisol tests were done (All blood results can be found in
Appendix A). The final diagnosis for Brandon is Type 2 diabetes.

Epidemiology
Classically Type 2 diabetes mellitus (T2DM) was considered a disease of the
adults and elderly. However, over the last decade, internationally there had been
an increasing trend of T2DM in children and adolescent (Piscopo et al, 2005).
Although there are no specific figures in Singapore on T2DM in youth and its
impact, this increasing trend is reported to be correlated with sedentary lifestyle
and obesity (Bloomgarden, 2004 and Piscopo et al, 2005). Pathogenesis of T2DM
in the young include (1) genetics – this include beta-cell defects such as maturity-
onset diabetes of the young (MODY) (2) familial factors and intrauterine growth
retardation – family history is evident in Brandon’s case study. Both grandparents
from paternal and maternal side have T2DM and his mother also have diabetes
and on diet control. (3) Obesity, which is also evident in Brandon with a BMI of
25.3. Obesity in children and young adolescent blunt the growth hormone and
epinephrine responses to exercise and causes insulin resistance in the body
(Bloomgarden, 2004).

In general, T2DM, as a whole, is a burden for healthcare in Singapore. Diabetes

was ranked the 8th leading cause of death with 3.0% of all deaths being attributable
to this disease (Ministry of Health, 2005). Due to the difference in age stratification
in both National Health Surveillance Surveys 2001 and 2004, comparisons on
diabetes and obesity could not be made for the age group between 18 years to 29
years. However, in general the prevalence of obesity among Singapore residents
as a whole rose from 6% in 1998 to 6.9% in 2004. This increasing trend is even
more significant in the abdominal fatness from 8.1% in 1998 to 11.9% in 2004 as
reported in the survey. Central obesity had been reported for pathogenesis of
T2DM in the young (Piscopo et al, 2005, Bloomgarden, 2004 and Davidson, 1986).

APN2 Case Study Page 13

Elizabeth Ho Moon Liang School Case Study

Pathophysiology
Classically, it is believed that Type 2 diabetes develops into HHNK and Type 1
diabetes develops into DKA. The pathphysiology section in this assignment will
explore the hyperglycemic states and answer the question “Is it possible for Type 2
diabetes to develop into DKA?” Yes. The factors that can contribute a Type 2
diabetes presenting with DKA are (1) undiagnosed diabetes as in Brandon’s case
(2) non-adherence to prescribed therapy (diet or medication) (3) alcohol abuse
(Davidson, 1986). However the presentations of hyperglycemic states, of T2DM
patients once they started on therapy, range from the spectrum of pure HHNK state
to mixed HHNK state with DKA. This is due to the complex interplay between the
compensating and de-compensating mechanisms in renal, gastrointestinal, buffers,
respiratory and cardiovascular systems (Davidson, 1986).

The simple diagram shown in Figure 1 from Frier and Fischer (2002) explained the
pathophysiology processes during the lack of insulin resulting in the signs and
symptoms that Brandon had experienced.

MANAGEMENT
There are 2 basic goals for Brandon’s diabetes management. (1) Reaching optimal
glucose control and (2) prevent macrovascular and microvascular complications of
diabetes mellitus. The goals will be reached by a holistic team approach involving
the physician in charge and multi-disciplinary health care team. The methods
achieving and maintaining the goals require patience, cooperation and open
communication between the patient and all the healthcare professionals who
participate in his care.

The specific medical goals that we hope to achieve for Brandon according to the
clinical guidelines from Ministry of Health (MOH), Singapore (1999) for managing
diabetes mellitus include:

APN2 Case Study Page 14

Elizabeth Ho Moon Liang School Case Study

• Glucose control: Achieve and maintain at optimal HbA1C% 6.5 to 7%.

Frequency to check 2 to 4 times a year. Optimal preprandial blood glucose
of 6.1 to 8.0 mmol/L and optimal two-hour postprandial glucose of 7.1 to
10.0 mmol/L.

Lack of Insulin

Decreased Increased
anabolism Increased secretion of: catabolism
Glucagon
Cortisol
Growth hormone
Catecholamines

Fatigue Glycogenolysis
Hyperglycaemia Wasting
Gluconeogenesis
Lipolysis Loss of weight
Vulvitis Glycosuria
Balanitis
Hyperketonaemia
Polydipsia Osmotic diuresis
Polyuria Hyperventilation
Acidosis Peripheral
vasodilation
Salt and water Diabetic
depletion Ketoacidosis

Tachycardia
Hypotension Hypotension
DEATH Hypothermia

Figure 1: Pathophysiological processes in hyperglycemic state.

* Words in purple were symptoms experienced by Brandon.

APN2 Case Study Page 15

Elizabeth Ho Moon Liang School Case Study

• Lipids control: As Brandon has diabetes mellitus which is also a

cardiovascular heart disease equivalent risk factor. It is important that he
maintains total cholesterol level lesser than 4.1, low density lipoprotein
cholesterol of lesser than 2.6 mmol/L, triglycerides level lesser than 1.8 and
high density lipoprotein cholesterol higher than 0.9. Frequency to check lipid
profile at least annually.
• Blood pressure control: Maintain his blood pressure reading not higher
than 130/80 mmHg. Frequency to check blood pressure at least quarterly.
• Body weight: Achieve and maintain a BMI of 22.9 and prevent increase
central obesity. Frequency to check body weight as least quarterly.
• Renal function: Maintain normal serum creatinine levels, normal urine
albustix, urine protein or urine microalbumin levels. Frequency to check at
least annually.

These medical goals will be achieved in due time by pharmacological agents and
lifestyle changes.

Pharmacological Agents
Brandon was discharged with subcutaneous insulin injection Mixtard 30/70 with the
dosage 35 units every morning and 20 units every night. He was prescribed this
regimen upon before his C peptide results were out. The question whether should
Brandon have invasive or non-invasive (oral) medication regimen since it has been
confirmed that he has Type 2 diabetes mellitus is a concern. In United States
clinical practice, approximately one-half of young patients with type 2 diabetes
receive insulin and the other half oral medications agents, most commonly
metformin, for their treatment.

According to Bloomgarden (2004), it is reasonable to start the youths with Type 2

diabetes mellitus with insulin with a few reasons. First, the physician is familiar with

APN2 Case Study Page 16

Elizabeth Ho Moon Liang School Case Study

insulin and it is effective in treating acute metabolic de-compensatory state

especially if the diagnosis is still uncertain between a Type 1 and Type 2 diabetes
mellitus. Furthermore, starting off with insulin might able to convey a message of
the seriousness of the illness and perhaps improve compliance.

Although having insulin injections have its flexibility in terms of the dosage and can
result in better control. Other things that have to be considered and balance
against the risk benefit ratio especially the issue of compliance. Insulin injections
can also result in weight gain and higher frequencies of hypoglycemic symptoms.
Oral medications might be more easily acceptable to patients. However they do
have some adverse effects on organs that metabolize or eliminate the drugs
involve in long term. Not only that, as Brandon gets older, he will most probably be
on more medications and with polypharmcy, drug and drug interactions will
definitely be of concern. Furthermore, “poor adherence to oral therapy among
relatively asymptomatic young persons with type 2 diabetes may be a major barrier
to improvement in outcome” (Bloomgarden, 2004, p. 1004).

The decision on the type of pharmacological agents to use should not be made by
the physician alone. Open communication on informing Brandon on what the
physician think is best, the other options available and the long term effects on him
is necessary. Trust between the physician and patient has to be built for the
effective management for Brandon. As long as mutual trust is established between
both parties, and that they are responsible for the achievement and maintaining the
medical goals together, will ensure more open communication.

The tailoring of the pharmacological agents and medical regimen should be

monitored with serum HbA1C% levels and preferably Brandon’s own self glucose
monitoring readings.

APN2 Case Study Page 17

Elizabeth Ho Moon Liang School Case Study

Lifestyle Changes
Diet (Medical Nutrition Therapy)
Brandon has been seen by the hospital dietician before his discharge. It is
important to stress to Brandon that the “diabetic diet” is principally a “healthy diet”
that is also recommended to the population in general. As Brandon is overweight
with a BMI of 25.3, he needs to lose around 8 kg for his height to reach a BMI of
22.9. Gradual weight reduction of 1 to 2 kg in a month or maintenance of current
weight could be a short term goal till Brandon is more used to the changed lifestyle.
According to MOH, (1999), there is clear evidence of the effect of weight loss and
diet modification in obese T2DM patients on restoring normal carbohydrate
metabolism.

Counseling of the diet not only has to focus on the reduction of the overall caloric
intake as well as the basics of a “diabetic diet”. These basics include saturated fats
not exceeding 10%, with carbohydrate 50-60%, and protein 15-20% of the total
caloric intake (MOH, 1999). Other recommended dietary points include daily
consumption of cholesterol less than 300mg and 20 to 35 grams of dietary fiber.
Diet should also include a variety of foods from each basic food groups and contain
adequate vitamins and minerals.

Besides the basics, Brandon also has to learn to be sensitive to the pattern and
portion of his meals. Ideally, other skills that the dietician should equip Brandon
include food label reading, carbohydrate counting, food exchange, glycemic index,
insulin to carbohydrate ratio and moderating food portions using blood glucose
results. Unfortunately, not all skills will be imparted to Brandon, it depends on
Brandon’s motivation and even health literacy level and a lot of patience and
encouragement from the healthcare professionals involve.

APN2 Case Study Page 18

Elizabeth Ho Moon Liang School Case Study

“Eating”, a simple act which most of us take for granted everyday has become a
“medication” to Brandon. The consciousness and self awareness of every portion
of food he is going to take can be tiring and requires a lot of discipline. Needing to
reduce or even abstain from his favorite food and drinks like Laksa (high in
saturated fats and cholesterol), potato chips and pepsi and “Grass Power”. (Grass
Power is a wheatgrass drink which contains 45grams of carbohydrates in 1
serving). It is definitely a challenge for both the patient and healthcare
professionals to find substitutes for these favorite food and drinks which can fit into
his diet. Substitutes, which he can enjoy as “favorites”. Although most of the time,
conveniently most healthcare professionals request that patients stay away from
these food items.

Exercise
To achieve an ideal BMI of less than 22.9 and prevent weight gain from insulin
injections, exercise is a must. Exercise had been reported by studies having a
positive impact on the glucose level of Type 2 diabetes patients by improving
insulin sensitivity and insulin-mediated glucose utilization (Devlin, 2000). The
recommended exercise regimen for diabetes mellitus patients should be tailored
according to Brandon’s aptitude, fitness and interest (MOH, 1999). Although earlier
studies reported that strength training improved glucose tolerance comparable to
aerobic exercise training. However, the mechanisms of aerobic exercise improve
insulin sensitivity whereas strength exercises increase total muscle volume with
unchanged insulin sensitivity (Devlin, 2000). Thus, it will definitely be appropriate to
encourage Brandon to take up some aerobic exercise regimen.

It is also important exercise precaution information on proper footwear, adequate

hydration and avoidance of exercise during periods of severe hypoglycemia and
hyperglycemia be imparted to Brandon as part of the exercise program. According
to the MOH (1999) guidelines on diabetes management, it is important that
patients on insulin treatment be specially warned on prevention of exercise-

APN2 Case Study Page 19

Elizabeth Ho Moon Liang School Case Study

induced hypoglycemia. The prevention of the symptoms can be achieved with the
following steps: (1) Appropriate reduction of medication prior to exercise (2)
consume some carbohydrate 30-60 minutes before exercise especially if
blood glucose <5.5 mmol/L, and after every 30 minutes of moderately
intense exercise (3) have a gradual progression of exercise intensity and lastly (4)
avoid late-night exercise.

Brandon is not a very physically active teenager. When he was asked if he had any
physical activities he enjoys most, he was not able to give an answer. It is a
challenge for healthcare professionals to finally engage Brandon in an exercise
regimen.

Self Management
Effective self management for Brandon can be achieved by education given by the
diabetes nurse educator. Components of effective self management include the
following:
• Knowledge on diabetes pathophysiology, medical management and
medications actions and side effects.
• Knowledge on diet, exercise and other related factors (e.g. alcohol)
relationship to diabetes.
• Self blood glucose monitoring and insulin injection skills.
• Skills in identification of hyperglycemia and hypoglycemia symptoms.
• Foot care skills.
• Regular follow up with specialist doctor and other healthcare professionals.
Remembering to do annual foot screening, eye screening, doing laboratory
tests on lipids, electrocardiogram and urine microalbuminia.
• Psychosocial coping skills, learning to deal with festive seasons,
depression, anger, guilt, etc.

APN2 Case Study Page 20

Elizabeth Ho Moon Liang School Case Study

An exploration study by Weijman et al (2004) reported that patients with avoidance

as a coping style and patients with lower levels of self efficacy, find self-
management tasks a burden and frustrating. According to Rubin (2000),
interventions that can help to raise self efficacy include skills mastery, modeling,
role-playing, re-interpreting of symptoms and setting short-term achievable goals
through therapy groups, support groups, diabetes camp, self-help groups etc.

Effective self-management is a complex task involving making the right choices in

elements of self care amidst in one’s environment, psychological and sociological
domains. Educating Brandon is only the stepping stone for its success but not the
end. Empowering Brandon to take responsibility of his medical condition is the key
to effective self-management. Self-empowerment according to Anderson et al
(2000) has 2 domains. The first domain is knowledge and the second domain is
self-awareness about own values, needs, goals and aspiration regarding diabetes
care. Anderson et al (2000) believed that empowerment is necessary for diabetes
self management because of the nature of this medical condition. (1)The most
important choices that affect health of a person with diabetes are made by the
person with disease. (2) Patients are in control of their diabetes self-management
and lastly (3) consequences of choices patients make every day accrue first and
foremost to patients themselves.

Thus, it will come a time in the care of Brandon that monitoring behaviors is more
important than monitoring medical goals. Models and theories on health behavior
will come in useful for assessment and working out implementation strategies.
Prochaska and DiClemente’s Transtheoretical Model of Behavior Change, Becker’s
Health Belief Model, Lazarus and Cohen’s Transactional Model of Stress and
Coping and Bandura’s Social Cognitive Theory are some of the models and
theories that can be used as a framework to use during consultation process to
seek understanding about patient’s behaviors and modify undesirable behaviors
(Glanz, Rimer and Lewis, 2002).

APN2 Case Study Page 21

Elizabeth Ho Moon Liang School Case Study

Rollink and Miller’s motivational interviewing which is defined as a “directive, client-

centered counseling style for eliciting behavior change by helping clients explore
and resolve ambivalence” (Miller and Rollnick, 2002). The key elements include (1)
motivation to change is elicited from the person not the health care professionals,
(2) it is the person’s task not the health care professional’s to identify and resolve
ambivalence, (3) direct pressure is not useful in resolving ambivalence, (4)
counseling style employed is quiet and eliciting, (5) readiness to change is not a
“trait” but fluctuates over time.
It is also important, during consultation, healthcare professionals should not focus
on self-management activities only but how Brandon think of these self-
management activities. It might be even necessary to refer Brandon to a
psychologist to make these self-management tasks more manageable if need
arises.

Special Issues in Adolescents

Adolescence is a period of transition from childhood to adulthood. It is also a period
of time which adolescents find themselves seeking their own identities and defining
their own territories. It is a time when peer influence is stronger than parental
guidance. It is a time when teenagers want to “break free” from the care of
authoritative figures. Healthcare professionals like physicians, nurses are viewed
as authoritative figures to the adolescents. It is a stressful period of time when
teenagers experience stress from puberty, love relationships and friendships, yet at
the same time deal with their school work and plan for their future as adults.

Skinner, Channon, Howells and McEvilly (2000) believed that, first; clinicians must
maintain contact with the young people. Maintaining contact Brandon using other
means such as emails, mobile phone messaging etc. is necessary even if face to
face contact is not possible. This is because without this contact, an honest, open
and trusting relationship which the foundation of diabetes care is built will be

APN2 Case Study Page 22

Elizabeth Ho Moon Liang School Case Study

difficult to maintain. Second; when contact is established, try not to make diabetes
the be-all and end-all exchange. Example, Brandon was actually anxious about his
N level results at that time when I did the history interviewing. After the history
interviewing, we explored on the pros and cons of different education institutions
and career paths.

Although at that time, I have tried to assess Brandon’s negative feelings towards
himself because of diabetes such as feelings of sadness, guilt, anger, anxiety or
frustration, I was not able to elicit much information. Still helping Brandon to make
the distinction between their emotional responses to their diabetes and those that
are natural part of the adolescent being when need arises can help him to live
successfully with diabetes (Skinner, Channon, Howells and McEvilly, 2000).

Lastly, involving the family in the care of Brandon and yet at the same time to have
an open communication with Brandon’s family to help them interplay between a
“gate-keeper” role and “friend” role. Helping the family members to tide over the
negative feelings towards diabetes like feelings of guilt is also necessary for
effective holistic management

CONCLUSION
Managing diabetes mellitus in adolescence is a delicate task. Brandon has a long
road to go, much longer than someone who is diagnosed with diabetes at the age
of 50. Patience, perseverance, faith and passion are essential qualities of an
Advanced Practice Nurse involve in the care of an adolescent with diabetes
mellitus.

APN2 Case Study Page 23

Elizabeth Ho Moon Liang School Case Study

REFERENCES

Anderson, R. et al (2000). Facilitating self-care through empowerment. In F.J.

Snoek and T.C. Skinner (Eds), Psychology in diabetes care (pp.69 - 89). England:
John Wiley and Sons, Ltd.

Bloomgarden, Z.T. (2004). Type 2 diabetes in the young – the evolving epidemic.
Diabetes Care, 27 (4), 998-1010.

Casteels, K. and Mathieu, C. (2003). Diabetic ketoacidosis. Reviews in Endocrine

and Metabolic Disorders, 4, 159–166.

Davidson, J. (1986). Diabetic ketoacidosis and the hyperglycemic hyperosmolar

state. In J.K. Davidson, Clinical diabetes mellitus – a problem oriented approach
(pp. 300 – 316). New York: Thieme Inc.

Devlin, J.T. (2001). Exercise therapy in diabetes. In J.L. Leahy, N.G. Clark and W.T.
Cefalu (Eds). Medical management of diabetes mellitus (pp. 255 – 266). United
States of America: Marcel Dekker.

Fier, B.M. and Fisher, B.M. (2002). Diabetes mellitus. In C.Haslett, E.R.Chilvers,
N.A.Boon and N.R.Colledge (Eds), Davidson’s principles and practice of medicine
(pp. 641-682). Philadelphia: Churchill Living Stone

Gale, E.A.M. and Anderson, J.V. (2004). Diabetes mellitus and other disorders of
metabolism. In P. Kumar and M. Clark (Eds.), Kumar and Clark clinical medicine
(pp. 1069-1120). United Kingdom: Saunders

Glanz, K., Rimer, B.K. and Lewis, F.M.(Eds).(2002). Health behavior and health
education – theory, research and practice (3rd ed.). San Francisco: Jossey-Bass.

Miller, W. and Rollinick, S. (2002). Motivational interviewing – preparing people for

change (2nd ed.). New York: The Guilford Press.

Ministry of Health, Singapore. (1999). Clinical practice guidelines for diabetes

mellitus.

Ministry of Health, Singapore. (2005). National health survey 2004. Singapore:

Epidemiology and disease control.

Piscopo et al (2005). Type 2 diabetes mellitus in childhood. In F.Chiarelli, K.Dahl-

Jorgensen and W. Kiess (Eds). Diabetes in childhood and adolescence (pp. 347 –
360). Switzerland: Karger.

APN2 Case Study Page 24

Elizabeth Ho Moon Liang School Case Study

Rubin, R.R. (2000). Psychotherapy and counseling in diabetes mellitus. In F.J.

Snoek and T.C. Skinner (Eds), Psychology in diabetes care (pp.235-264). England:
John Wiley and Sons, Ltd.

Skinner, T.C., Channon, S., Howells, L. and McEvilly A. (2000).Diabetes during

adolescence. In F.J. Snoek and T.C. Skinner (Eds), Psychology in diabetes care
(pp.25 - 60). England: John Wiley and Sons, Ltd.

Weijman et al (2005). The role of work-related and personal factors in diabetes

self-management. Patient education and counseling, 59(1), 87-96.

APN2 Case Study Page 25