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Case Study: A 44-Year-Old Woman With Type 1 Diabetes and a Recent History of Diabetes "Out of Control"

	Presentation

 
K.P. is a 44-year-old woman who was diagnosed with type 1 diabetes 22 years ago. She has been diagnosed with background retinopathy, which has been stable, and microalbuminuria, which is well-controlled on an angiotensin-converting enzyme (ACE) inhibitor. She has hypercholesterolemia, which is controlled with simvastatin (Zocor), and neuropathy. She has no history of hypertension, tobacco abuse, or cardiovascular disease.

She currently is treated with ultralente insulin and a rapid-acting insulin in boluses before each meal. She has had good control, as determined by HbA_1c levels averaging 7% over the past 2 years. Recently, however her HbA_1c increased to 9%.

K.P. is 5' 3'' tall, and her weight has recently decreased unintentionally from 115 to 110 lb. She works as a special education teacher and drives daily between two schools.

One week ago, she was found to be disoriented and hypoglycemic after her car ran into a curb while she was driving. Her blood glucose level was 26 mg/dl as measured by the paramedics who were called to the scene. After treatment, she stated that she had eaten lunch 2 h before the accident and that her blood glucose before lunch had been 130 mg/dl. She had taken her normal rapid-acting insulin bolus and had no exercise that day or the day before. Her carbohydrate intake for lunch and the amount of rapid-acting insulin that she injected seemed appropriate (1 unit for every 15 g carbohydrate). She was referred to a dietitian certified in diabetes education for evaluation.

	Questions

 

1. What is causing K.P.’s postprandial hypoglycemia?
   
2. Why has her diabetes been so difficult to control recently, with unexpectedly high and low blood glucose levels after meals?
   
3. What is the cause of her unintentional weight loss?
   

	Discussion

 
The dietitian asked K.P. to fill out a questionnaire at the beginning of her visit. She indicated the . . . [Full Text of this Article]

	Clinical Pearls

 

	Footnotes

 

	REFERENCES

 

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