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T Case Study #2 Kate Schlag 1.) Briefly describe the difference between Type 1 and Type 2 DM? How would you clinically distinguish between the two? (1.5 points) Type 1 diabetes occurs when the body does not make enough insulin because the immune system destroys islet cells, which produce insulin. Type 2 diabetes occurs when the body cannot use insulin properly. It often begins with insulin resistance, whereby the body needs more insulin to shuttle the same amount of glucose into cells; over time, the pancreas cannot keep up with the demand for insulin, leading to consistently elevated blood sugar levels. Type 2 diabetes is often associated with overweight and obesity as well as metabolic syndrome. Symptoms of T1D include significant weight loss, electrolyte disruption, and potentially ketoacidosis; biochemical signs include impaired fasting glucose (>126 mg/dl), impaired glucose tolerance (>200 mg/dl), HgbA1c >6.5%, random plasma glucose ≥200 mg/dl, and the occurrence of GADA, ICA, IAA, or C-peptide. Symptoms of T2D include central obesity, infection, dehydration, polyuria, polydipsia, polyphagia, and weight loss. Biochemical markers include blood glucose > 600 mg/dL, osmolality > 320 mOsm/kg, and an absence of ketoacidosis; blood tests for impaired fasting glucose, impaired glucose tolerance, HgbA1c, and random plasma glucose are the same as T1D. 2.) What are the common chronic complications associated with diabetes mellitus? Describe the pathophysiology associated with these complications, specifically addressing the role of chronic hyperglycemia. (4.5 points) Hyperglycemia can result in numerous chronic complications, affecting the eye, kidney, and nerves. DM can cause retinopathy, whereby blood vessels lose structure or function, leading to damaged blood vessels, fluid leakage, or blocked blood vessels. Eventually, this can lead to glaucoma, whereby new blood vessels grow and interfere with the normal flow of fluid out of the eye, thereby causing excess pressure, or blindness. Hyperglycemia can also results in nephropathy. Chronically elevated blood sugar levels tax the kidneys, resulting in leakage and loss of protein in the urine. Over time, this can lead to microalbuminuria or gross albuminuria, eventually leading to kidney failure. Chronically elevated blood glucose levels may also cause neuropathy, resulting in either peripheral or autonomic neuropathy. Peripheral neuropathy occurs when peripheral nerves are damaged by diseased blood vessels, results in tingling, pain, increased sensitivity, numbness and weakness. Autonomic neuropathy affects organs like the bladder, intestinal tract, and gallbladder. It can cause symptoms like urinary tract infections (from paralysis of the bladder), erectile dysfunction, diarrhea, gastroparesis, low blood pressure, and increased or decreased sweating as a result of damage to nerves that control these functions. DM also has macrovascular complications also. Hyperglycemia is proposed to thicken the basement membrane of both vessels of the circulatory system and the nervous system. The decreased flexibility and the decreased lumen size of the blood vessels lead to an acceleration of atherosclerosis, leading to cardiovascular disease. 3.) Identify at least four features of the physician’s physical examination as well as ED’s presenting signs and symptoms that are consistent with a diabetes diagnosis. Describe the pathophysiology that might be responsible for each physical finding. (4 points) Physical Finding Physiological Change/Etiology Mild retinopathy Hyperglycemia causes damage to blood vessels in the eye, leading to fluid leakage or blocked blood vessels and a loss in function Sensation mildly diminished in feet Hyperglycemia causes peripheral neuropathy, whereby diseased blood vessels damage peripheral nerves, resulting in tingling, numbness, weakness, or loss of sensation Frequent bladder infections Hyperglycemia causes autonomic neuropathy, whereby nerves to organs (including the bladder) are damaged, resulting in a loss in function Hypertension (150/97 mm Hg) High blood pressure can result from nephropathy, as damage to kidneys can cause high blood pressure due to fluid imbalance and altered hormonal actions. It may also result from damage to the arteries 4.) Briefly describe hyperglycemic hyperosmolar nonketotic syndrome (HHNS). How is this syndrome different from ketoacidosis? What factors may lead to HHNS? Is ED at risk? (4 points) Hyperglycemic hyperosmolar nonketotic syndrome occurs when blood sugars rise heavily; as a result, a patient’s body tries to get rid of the excess sugar by excreting it into urine. In addition, there is simultaneous loss of electrolytes (especially Na+, K+, and phosphate). Fluids are pulled from individual body cells by the increasing serum hyperosmolality and extracellular fluid loss, causing intracellular dehydration. This results in severe dehydration and, in some cases, coma and death. HHNS differs from DKA in that individuals with HHNS produce adequate amounts of insulin to prevent lipolysis and ketogenesis. In addition, serum glucose levels in HNNS are extremely elevated (they’re not in ketoacidosis). Factors that lead to HHNS include renal dysfunction, congestive heart failure, certain drugs (alcohol, corticosteroids, beta blockers, histamine-receptors blockers), TPN, noncompliance with medicines or insulin therapy, or other complications that result in a reduction in fluid intake, an increase in glucose, or an increase in osmolarity. Mrs. Douglas is at risk due to her prolonged hyperglycemia and signs/symptoms of dehydration. 5.) Calculate Mrs. Douglas’s energy (using the Mifflin-St. Jeor equation), protein, and fluid needs. Please show all work. (3 points) MSJ: (10 x 70.45 kg) + (6.25 x 152.4 cm) - (5 x 71) - 161 = 1141 kcal x IF of 1.1 (wound healing) x AF of 1.3 = 1,631 kcal/day Based off of IBW: (10 x 45.5 kg) + (6.25 x 152.4 cm) – (5 x 71) – 161 = 891.5 x IF of 1.1 x AC of 1.3 = 1,274 kcal/day Protein: 0.8-1.2 g/kg = 56.4 g - 84.5 g/day (based off of UBW) OR 36.4 g - 54.5 g/day based on IBW Fluids: 25 ml/kg/d = 1136.25 ml/day 6.) Compare ED’s laboratory values that were out of range on admission with normal values. How would you interpret this patient’s labs? Make sure explanations are pertinent to this situation. (12 points) Parameter Normal Value Patient’s Value Reason for Abnormality Nutritional Implications Glucose (mg/dL) 64-128 325 There is not enough insulin to shuttle all of the circulating glucose into cells, resulting in hyperglycemia r/t insulin resistance Monitor CHO intake, reduce saturated fat intake; may result in weight loss HbA1c (%) 4-5.6% 8.5% A higher percentage of circulating glucose molecules are attached to RBCs, indicating a higher blood glucose Monitor CHO intake, monitor serving sizes Cholesterol (mg/dL) <200 300 Obesity; high-fat diet; HTN; dyslipidemia; metabolic issues Increase MUFAs in diet; moderate alcohol consumption; choose reduced or low-fat dairy; limit pastries, cakes, other sweets; limit processed meats; increase fiber; reduce intake of saturated fat/trans fat LDL-cholesterol (mg/dL) <100 140 Hyperglycemia reduces ability of body to remove cholesterol; LDL receptors in liver are coated in sugar, impairing liver’s ability to remove LDL from Moderate alcohol consumption; choose reduced or low-fat dairy; limit pastries, cakes, other sweets; limit processed meats; bloodstream increase omega3s; reduce intake of saturated/trans fat; increase exercise; weight loss HDL-cholesterol (mg/dL) >60 35 Low fiber diet; association with high triglycerides; insulin resistance Add soluble fiber; increase intake of F/V and foods rich in plant sterols Triglycerides (mg/dL) <150 400 Insulin resistance; buildup of glucose and triglycerides in blood Moderate alcohol consumption; reduce intake of simple carbohydrates; increase omega-3 intake 7.) Write two appropriate PES statements for two of the patient’s nutrition problems. (6 points) Undesirable food choices r/t lack of knowledge of appropriate diet/nutrition AEB altered labs [high PG (325 mg/dL), cholesterol (300 mg/dL), LDL-cholesterol (150 mg/dL), low HDL-cholesterol (35 mg/dL), high TG (400 mg/dL), and high HbA1C (8.5%)], diet recall of frequent intake of processed foods, high-fat meats and low intake of fruits and vegetables. Impaired nutrient utilization r/t new onset/uncontrolled type 2 diabetes AEB high PG (325 mg/dL), high HbA1C (8.5%), s/s vascular complications (mild retinopathy, frequent bladder infections, and delayed wound healing). 8.) For each of the PES statements that you have written, establish an ideal goal and an appropriate intervention. (5 points) Goal: Provide nutrition education addressing healthy eating/lifestyle strategies that promote positive diabetes management and general health outcomes. Recommendations: 1) New Diet Rx: 1,250 kcal/day, 140 g carbs spread out throughout the day 2) Educate on food items rich in carbohydrates and relationship of intake with blood glucose levels 3) Educate on the importance of consuming a balanced, healthful diet by increasing intake of fruits and vegetables and decreasing intake of largely processed, high fat meals 4) Educate on importance of modifying current diet intake to reduce risk of cardiovascular disease by reducing total fat intake (<7% SF, 0-2% trans fat), improving sources of dietary fat (increase PUFA and MUFA intake), reducing cholesterol intake (<200 mg), increasing fiber intake (at least ~2g/day of soluble fiber from plant sterols), increasing fish consumption to twice a week, and limiting sodium to <2400 mg/day 5) Educate on relationship between physical activity and blood glucose levels Goal: Provide nutrition education, focusing on the importance of diabetes management in the context of nutrition. Recommendations: 1) New Diet Rx: 1,250 kcal/day, 140 g carbs spread out throughout the day 2) Provide education on relationship between food components and blood glucose levels 3) Provide education on long-term consequences of hyperglycemia 4) Provide education on s/s of hyper/hypo-glycemia and what food items help to alleviate these s/s 3) Provide education on carbohydrate counting/exchange system 4) Educate on importance of modifying current diet intake to reduce risk of cardiovascular disease by reducing total fat intake (<7% SF, 0-2% trans fat), improving sources of dietary fat (increase PUFA and MUFA intake), reducing cholesterol intake (<200 mg), increasing fiber intake (at least ~2g/day of soluble fiber from plant sterols), increasing fish consumption to twice a week, and limiting sodium to <2400 mg/day 5) Educate on relationship between physical activity and blood glucose levels 6) Provide education on SMBG and recording BG, food intake, and physical activity 7) Provide education on potential food-drug interactions with Capoten and Lipitor 9.) Please use the next page to write an ADIME note for this patient. (10 points) A: 71 YOAAF who pw with c/o blurry vision, frequent bladder infections, and tingling/numbness in feet; now s/p debridement of un-healed wound x2 months. Nutrition was consulted to provide diabetes selfmanagement training for new nutrition prescription, meal planning, signs/symptoms and treatment of hypo/hyper-glycemia, SMBG, appropriate exercise, and potential food-drug interactions. Medical Dx: Cellulitis; Type 2 Diabetes Mellitus Significant PMHx: HTN Social Hx: Lives and cares for 80 YO sister; purchases and prepares all food Pertinent meds: Capoten (captopril), 50 mg PO bid Anthropometrics: Ht: 5’ (152.4 cm) Wt: 155 lb (70.45 kg) Obesity-adjusted ideal body weight: 113.75 lb BMI: 30.3 (obese) IBW: 90.1 lb - 110.1 lb %IBW: 140-170% (obese) % Obesity-adjusted ideal body weight: Significant Labs: BUN (26 mg/dL) high Hgb (9.9 g/dL) low Hct (30.4%) low Osm (315 mmol/kg/H2O) high Glc (325 mg/dL) high HgbA1c (8.5%) high Chol (300 mg/dL) high LDL (140 mg/dL) high HDL (35 mg/dL) low TG (400 mg/dL) high Nutrition Hx: No previous MNT; reports she follows sister’s previous MNT to avoid “all starchy foods” ENN: (MSJ x 1.3IF x 1.3AF) = 1928 kcal/day Protein: 0.8-1.2 g/kg = 56.4 g - 84.5 g/day (based off of UBW) OR 36.4 g - 54.5 g/day based on IBW Fluids: 25 ml/kg/d = 1136.25 ml/day 24-Hour Recall: AM: One egg (fried in bacon fat), 2 strips of bacon or sausage, 1 cup coffee (black), 1⁄2 c orange juice (unsweetened) Lunch: Sandwich (2 slices enriched white bread, 1 slice (1 oz) bologna, 1 slice (1 oz) American cheese, mustard), 1 glass (8 oz) iced tea (unsweetened) PM: 1 c turnip greens seasoned with (1 oz) fatback, salt, and pepper (simmered on stove top for at least 3 hours); 2 small new potatoes, boiled, seasoned with salt and pepper; 2-inch square of cornbread with 1 tsp butter; 1 c beans and ham (Great Northern beans cooked with ham, approximately 3⁄4 c beans and 1⁄4 c or 1 oz ham); 1 c coffee (black) Snack: 2 vanilla wafers Diet recall provides 1,379 kcal, 55g protein, 108g carbs, 19g fiber, 28g sugar, 70g fat, 3265mg sodium Diet meeting 85-108% ENN (depends on if using UBW or IBW) Pt at moderate nutritional risk D: Undesirable food choices r/t lack of knowledge of appropriate diet/nutrition AEB altered labs [high PG (325 mg/dL), cholesterol (300 mg/dL), LDL-cholesterol (150 mg/dL), low HDL-cholesterol (35 mg/dL), high TG (400 mg/dL), and high HbA1C (8.5%)], diet recall of frequent intake of processed foods, high-fat meats and low intake of fruits and vegetables. I: Goal: Provide nutrition education addressing healthy eating/lifestyle strategies that promote positive diabetes management and general health outcomes. Recommendations: 1) New Diet Rx: 1,250 kcal/day, 140 g carbs spread out throughout the day 2) Provide education on the importance of consuming a balanced, healthful diet by increasing intake of fruits and vegetables and decreasing intake of largely processed, high fat meals 3) Provide education on relationship between food components and blood glucose levels 4) Provide education on long-term consequences of hyperglycemia 5) Provide education on s/s of hyper/hypo-glycemia and what food items help to alleviate these s/s 6) Provide education on carbohydrate counting/exchange system 7) Educate on importance of modifying current diet intake to reduce risk of cardiovascular disease by reducing total fat intake (<7% SF, 0-2% trans fat), improving sources of dietary fat (increase PUFA and MUFA intake), reducing cholesterol intake (<200 mg), increasing fiber intake (at least ~2g/day of soluble fiber from plant sterols), increasing fish consumption to twice a week, and limiting sodium to <2400 mg/day 8) Educate on relationship between physical activity and blood glucose levels 9) Provide education on SMBG and recording BG, food intake, and physical activity 10) Provide education on potential food-drug interactions with Capoten and Lipitor M/E: 1) Continuous glucose monitoring before meals (8AM, 12PM, 6PM and before bedtime via glucose, food, physical activity log Goals: Preprandial glucose: 70-130 mg/dL Postprandial glucose: <180 mg/dL 2) Check long-term glycemic control in 3 months Goals: A1C: <7.0% Preprandial plasma glucose: 90-130 mg/dL Peak postprandial plasma glucose: <180 mg/dL 3) Continue checking fasting lipid profile every three months Goals: LDL: <100 mg/dL HDL: >50 mg/dL TG: 150 mg/dL 4) Check electrolytes every three months Goals: potassium 3.5-5.0mEq/L sodium 135-145mEq/L chloride 98-106mEq/L calcium 8.7-9.2mg/dL phosphate 2.5-4.5mg/dL 5) Check adherence to consistent carb diet at next visit via glucose, food, physical activity log Outcome: Meet Diet Rx of 1925 kcal with 40-45% of kcal from CHO, 15-20% of kcal from protein, 30-35% of kcal from fat; SFA<7%, chol<200mg, MUFA 20% total kcal, PUFA 10% total kcal, 20-35g fiber. 6) Record weight and BP at monthly intervals Goals: Weight Loss 5-10% CBW BP: <130/80 mm Hg F/U in outpatient clinic in one week Kate Schlag 2/27/15 References Hemphill RR. Hyperosmolar hyperglycemic state. Medscape. http://emedicine.medscape.com/article/1914705-overview#aw2aab6b2b3aa Mayo Clinic: Diabetic retinopathy. Accessed from: http://www.mayoclinic.org/diseases-conditions/diabeticretinopathy/basics/complications/con-20023311.