see below

UNIT 7 DISCUSSION - DIABETES TREATMENT

you have a newly diagnosed, type 2 diabetic, 16-year-old female in your clinic. The patient is the goalie of her high school soccer team. Her BMI is 37.

1. Your treatment plan for the new diagnosis of type 2 diabetes – structure your plan using the format outlined in the SOAP note assignment instructions (e.g. diagnostics, therapeutics, educational, consultation/collaboration)

2. Citations for each of the evidence-based practice (EBP) interventions included in your plan 3. For each article, you cited in support of an element of the plan, provide your thoughts about the strength of the evidence

presented in the article(s)

Subjective: the patient is a 16-year-old female goalie of her high school soccer team who presents in the clinic. Objective: BMI 37 Assessment: Type II DM Childhood obesity Plan Diagnostics The diagnostic criteria for DM are based on blood sugar measurement and the presence or absence of symptoms a fasting plasma glucose (FPG) of more than 126 mg/ dL (7.7 mmol/ l) on several occasions if without symptoms of polyuria, polydipsia, weight loss, a random plasma glucose sample ≥ 200 mg/ dL (11,1 mmol/ l) on several occasions if without symptoms, 2 hrs post glucose challenge ≥ 200 mg/ dL (11,1 mmol/ l) performed with 1,75 g glucose/ kg, max 75 g glucose dissolved in water and Hb A1c ≥ 6,5% (48 mmol/ l) (Temneanu et al., 2006). Therapeutic: The management of type II DM in children and adolescent is aimed at weight loss, physical activities, regulation of blood sugar and reducing the risk of complications and comorbidity (Temneanu et al., 2006). Metformin is currently the most widely used antidiabetic in pediatric with T2DM and is recommended for children over the age of 10 with therapy starting when the child is aged 10-16 years with 500 mg/ day (one tablet of 500 mg), which can be increased to 500 mg at every 1-2 weeks, depending on the glycemic profile, until a maximum dose of 2000 mg is reached (Temneanu et al., 2006). Metformin is effective in improving glucose tolerance and insulin sensitivity, lowering insulinemia, and reducing elevated androgen level (Stańczyk et al., 2008). The patient Hgb A1C should be rechecked 2weeks after start of new medication regimen and eGFR closely monitored. Also, non-pharmacological treatment with nutritional intervention and weight management is important in achieving optimal glycemic control in this child. The total amount of carbohydrate (CHO) consumed has the strongest influence on glycemic response, so limiting intake of refined CHO and consuming nutrient-dense carbohydrate sources that are high in fiber, such as vegetables, fruits, legumes, whole grains, as well as low fat dairy products are effective in glycemic control (Gray & Threlkeld, 2019). In addition, engaging in moderate physical activities will improve insulin sensitivity, bodyweight, as well as improves glycemic control in this patient which in turn reduce the risk of various cardiovascular events associated with DM (Raveendran et al.,2018). Educational: Patient education is crucial to the effective management of DM. Lifestyle modification adopting healthy eating habits is highly recommended. Education should include meal planning, weight loss strategies, stress coping mechanisms, how to monitor blood pressure and interpret readings. Patient should be encouraged to limit amount of meat and fried fatty food but increased intake of fruits, whole grains, as well be physically active. Patient should not be discouraged from continuing to play soccer. However, patient must be educated on the need for adequate treatment,

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increased carbohydrate intake and adequate hydration prior soccer activities, as hypoglycemia can ensue during prolonged and vigorous physical activities such as soccer (Yurkewicz et al., 2016). Patient should also be educated on the need of taking special care of her feet especially while playing soccer, and hand by wearing shoes or socks that always fit and not too tight and not to walk barefooted, trimming and filing nails carefully, hands and feet washing and moisturizing and checking for cuts, blisters, sore in between digits (Patient education: Nerve damage caused by diabetes (The Basics), 2020). Education that any injury sustained during soccer must be properly attended to by healthcare provider must be reinforced. Patient should also be educated on ways to manage sick days by continuing taking diabetic pills as usual when sick and trying to eat as much as possible and drinking extra calorie free liquids and monitoring for signs of infection (Center for Disease Control and Prevention, 2020). Patient should be educated on side effects, interactions, and warning signs of overdose of medications as well. Consultation/Collaboration: Managing diabetes mellitus requires a team-based approach that may involves multidisciplinary collaboration. Consultation may be made to an endocrinologist for better management and complication prevention if glycemic control does not improve after medication adjustment. Referral should be made to dietician and podiatrist to help the patient with nutritional to provide focused nutritional education and diabetic foot care.

The strength of most of the article cited is the submission that support physical activities in diabetic patients. The articles opined that physical activities can lead to improved metabolic control of diabetic patients. Thus, the use of physical activity in addition or oral antidiabetic agents and diet is strongly recommended in the treatment of diabetes mellitus.

References Center for Disease Control and Prevention. (2020). Managing sick days.

https://www.cdc.gov/diabetes/managing/flu-sick-days.html Gray, A., & Threlkeld, R. J. (2019). Nutritional recommendations for individuals with diabetes.

https://www.ncbi.nlm.nih.gov/books/NBK279012/ Horowitz, G. L. (2021). Hemoglobin A1c testing.

https://emedicine.medscape.com/article/2049478-overview Raveendran, A. V., Chacko, E. C., & Pappachan, J. M. (2018). Non-pharmacological treatment

options in the management of diabetes mellitus. European endocrinology, 14(2), 31–39. https://doi.org/10.17925/EE.2018.14.2.31

Patient education: Nerve damage caused by diabetes (The Basics). (2020). https://www.uptodate.com/contents/nerve-damage-caused-by-diabetes-the-basics? topicRef=15751&source=see_link

Stańczyk, J., Otto-Buczkowska, E., Jarosz-Chobot, P., & Nowowiejska, B. (2008). Used of oral antidiabetic agents in pediatric patients - own observations. Endokrynologia Polska, 59(5), 434–443.

Temneanu, O. R., Trandafir, L. M., & Purcarea, M. R. (2016). Type 2 diabetes mellitus in children and adolescents: a relatively new clinical problem within pediatric practice. Journal of medicine and life, 9(3), 235–239.

Yurkewicz, M., Cordas, M., Jr, Zellers, A., & Sweger, M. (2016). Diabetes and sports:

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Managing your athlete with type 1 diabetes. American journal of lifestyle medicine, 11(1), 58–63. https://doi.org/10.1177/1559827615583648

Daija

Lifestyle modification especially healthy eating and weight loss for diabetic patient can never be overemphasized. Like you submitted, the patient must be educated on the importance of weight loss in improving prognosis of treatment. Studies have shown that there is a strong correlation between increased glucose, obesity, and cardiovascular events. According to Reusch (2003) an increased in body weight, elevated blood sugar with elevated hemoglobin A1C increases the atherosclerotic plaque burden in patients which predisposes the patients to cardiovascular accidents”. Not only that, but hyperglycemia also has disastrous “effects on vascular endothelial function that could account for the correlations between hyperglycemia and poor vascular outcomes” (Reusch, 2003).

References

Reusch J. E. (2003). Diabetes, microvascular complications, and cardiovascular complications:

what is it about glucose? The Journal of clinical investigation, 112(7), 986–988. https://doi.org/10.1172/JCI19902

Marenda. I agree with you that mental health referral may be necessary for this patient with diabetes mellitus. Studies have shown that depression is common among people with serious medical disease that has a lifetime prevalence such as diabetes mellitus. Bădescu et al. (2016) submitted that the prevalence of depression has increased in prediabetic and undiagnosed diabetic patient, including children, as well as markedly increased in the previously diagnosed diabetic patients compared to normal glucose metabolism individuals. Not only is depression likely to be three- times higher in patients with type 1 diabetes and twice as high in people with type 2 diabetes compared with the general population worldwide, but also anxiety is also noted to be on the increase appearing in about 40% of patients with type 1 or 2 diabetes (Bădescu et al., 2016). With the presence of anxiety and depression in diabetic patients, the prognosis is worsened which increases noncompliance with medication and lifestyle modification thereby decreases life expectancy and increases mortality.

References Bădescu, S. V., Tătaru, C., Kobylinska, L., Georgescu, E. L., Zahiu, D. M., Zăgrean, A. M., & Zăgrean, L. (2016). The association between diabetes mellitus and depression. Journal of medicine and life, 9(2), 120–125.

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