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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.