Download Danielle Selden – Case Study #2 FINAL

Danielle Selden
2-13-2012
TR5320 Case Study #2 Type 2 diabetes
Follow all the instructions to be eligible to receive full credit.
 Use this format to submit your work.
 Use the formats indicated by the Annotated Sample SOAP using PES statements
A 45-year-old woman who has had the diagnosis of type 2 diabetes for 3 years is referred for
diabetes nutrition counseling. She works as the manager of a school cafeteria and is around food
all day long. Her mother and father both have been diagnosed with CVD. She does not smoke and
she has stable family life and a low stress lifestyle. Her current weight is 178 lb and her height is 63
inches. She has been at this weight for more than 6 months. She states that she doesn’t think
nutrition counseling can help her because the only advice she gets is to lose weight and to stay
away from sweets, neither of which is she has been able to do.
Rx: Glucophage 500mg twice a day. Occasionally takes the OTC drug Alli to try to lose weight but
she thinks it doesn’t work and costs too much.
Lab tests: A1C 8.6%, TC 234 mg/dl, HDL 53, TG 285 mg/dl, FBG: 120 mg/dl ,
Measurements: BP: 120/78 mm/Hg. Waist circumference = 38” and frame size = medium.
Look at her 24-hour diet recall. It has been analyzed and it provides approximately:

120 gm protein

220 gm carbohydrate

90 gm fat

2200 kcal
Calculate the percentage of kcals in her diet provided by:
(1 pt) Protein 120 x 4480/2200 x 10021.8% (22%)
(1 pt) CHO 220 x 4880/2200 x 100 40.0% (40%)
(1 pt) Fat 90 x 9810/2200 x 10036.8% (37%)
(3 pts) Compared to the AMDR and dietary goals for individuals with T2DM discuss the
significance of her dietary percentages for each macronutrient—protein, carbohydrate, fats.
The AMDR’s for people with T2DM have no specific differences from the normal individuals. Pt’s
calculated AMDR’s:
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Protein: 10-35% kcal from protein  pt AMDR 22%, within desirable range. Pt has elevated FBG,
120mg/dl and could benefit from increasing pt’s protein intake, as referenced to protein in diabetes
management (Diabetes 2, slide 15 Kazaks), “In individuals with T2DM, ingested protein can increase
insulin response without increasing plasma glucose concentrations.”
CHO: 45-65% kcal from CHO  pt AMDR 40%, below desirable range, pt needs adequate amount of
CHO’s in the diet. Pt should increase CHO intake slightly but pt’s main focus must be on CHO balance
and timing within the diet. In addition; goals of Medical Nutrition Therapy for Diabetes also states
(Diabetes 2, slide 3 Kazaks), “Attain and maintain optimal metabolic outcomes, by keeping blood
glucose normal or near normal range or as close to normal as possible.”
Fat: 20-35% kcal from fat  pt AMDR 37%, above desirable range. Pt needs to decrease fat intake as
indicated by fat in diabetes management (Diabetes 2, slide 3 Kazaks), “Limit saturated fat intake to
<7% of total calories, and intake of trans fat should be minimized. In addition pt’s BMI is 31.6, labeled
as obese, and pt’s percentage ideal body weight is at 155%, which is also elevated.
(2 pts) What are the significant DNIs and nutrition-related side effects for the OTC and Rx meds?
Glucophage (Metformin) 500mg: Antihyperglycemic agent. Potentiates the effect of insulin, lowers
GI glucose absorption, lower hepatic glucose production. DNI: Take with meals to lower GI distress.
Swallow SR form whole with evening meal. Prescribed diabetic diet. Lower calories if weight loss
needed. Take guar gum more than 6 hours after drug, lowers drug absorption. Nutr: Anorexia.
Stable weight or weight loss. Lower folate and vitamin B12 absorption. Oral/ GI: metallic taste,
dyspepsia, NAUSEA/ VOMITING, BLOATING, DIARRHEA, FLATULENCE. Constipation with XR form.
S/Cond: Avoid alcohol, increase risk of lactic acidosis. Blood/ Serum: LOWER GLUCOSE LEVELS,
LOWER HB A1C, lower cholesterol, lowers LDL, lowers TG, high HDL, Lower B12, increase
homocysteine. Possible- lowers folate.
Alli (Orlistat): Over the counter Weight Control Agent, Lipase inhibitor. Diet considerations: must
take 1 capsule with or within 1 hour of each meal containing fat. Adjust diet to reduce calories to less
than or equal to 30% of calories from fat. Distribute fat among three main meals. MVI is essential, and
take 2 hours before or after drug. Avoid Olestra, the fat substitute. Nutrition related side effects:
lowers weight, lowers fat absorption by 30%, lowers the absorption of fat soluble vitamins A,D,E, K,
lowers vitamin E absorption by 60%, lowers beta-carotene absorption by 33%. Oral/ GI side effects:
tooth/gum disorder, abdominal pain, fecal urgency, Increase defecation, oily spotting, fatty stool, fecal
inconsistence, FLATULENCE. S/Cond related to diet: >99% serum protein bound, but drug is
minimally absorbed from intestine. Do not take with chronic malabsorption. Blood/ Serum: lower
vitamin D levels, slightly lower cholesterol, lowered LDL, high HDL, high TG, lower fasting insulin, lower
Vitamin A, K, E, and lower beta-carotene levels. Monitor: vitamin D levels.
Calculate the following:
(1 point) IBW:
IBW100lbs for the first 60 inches + 5lbs/ each inch over 60 inches
100 + 5lbs(3in) 115lbs
+/-11 range (104-126)
(2 points) BMI and category:
Kg/M2 = BMI 63 inches x 2.54cm= 160cm/ 100m= 2.6m2
178lbs/ 2.2= 52.27kg
81 Kg/2.6m2= 31.6 BMI  Obese
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(4 points) Calculate the following (show calculations and factors used)
a. Estimated calorie needs—Use the Mifflin-St Jeor Equation this time:
Mifflin-St. Jeor
(10 x wt-kg) + (6.25 x ht-cm) – (5 x age) -161  REE (female)
(10 x 80.9kg) + (6.25 x 160.0cm) – (5 x 45yrs) – 161 REE
809 + 1000 – 225 – 161 REE 1423 kcal/day
1423 kcal (1.2 activity factor) 1707.6 1700 kcal/day
1423 kcal (1.3 activity factor) 1849.9 1800 kcal/day
b. Identify what percentage of estimated kcal needs your client’s current diet is providing:
Percentage of estimated kcal from current diet
Current calorie intake/ estimated calorie needs
2200 kcal/ 1700kcal x 100 129.41 129%
2220 kcal/ 1800kcal x 100 122.22 122%
(3 pts) Which of her lab tests could be directly related to her carbohydrate consumption and
why?
HbAiC: Pt’s HbA1C lab results are directly related to pt’s carbohydrate consumption. A1C test results
reflect average blood sugar levels over the past 2-3months by measuring what percentage of
hemoglobin is glycated. When this occurs, diabetes is uncontrolled and results with too much glucose
within the blood stream, binding to hemoglobin. Thus, this could indicate usual intake of carbohydrates.
FBG: Pt’s FBG lab results are elevated at 120mg/dL. The normal range for a fasting state is at 7099mg/dL. Her diet is full of heavy processed CHO’s and simple surgers, which is evident by her FBG
results. The main concern is her CHO timing that can be contributing to the problem of blood glucose
regulation.
TG: Pt’s TG lab results are elevated at 234 mg/dL. The normal TG levels should be <150ng/dL. Pt’s
high TG levels reflect poor blood glucose regulation. When there is excess CHO in the diet it can be
directly converted into triglycerides, as a result her TG are going to be elevated. Or most likely in her
case, her CHO intake may not be excessive but it’s that she is not spreading out her CHO intake
throughout the day. This behavior pattern could mean excess CHO at one point in the day, thus, in turn
would be converted to triglycerides and show as an increase on the lab test.
(6 points) What are 3 specific nutrition concerns you have for this client based on her diagnosis
and her current diet? Justify your answers.
My first nutritional concern for this pt is the pt’s uncontrolled glucose levels related to her inconsistent
CHO intake. Pt has had T2DM for the past 3 years and pt’s glucose levels are still extremely elevated.
If this continues, it could lead to more serious complications, such as kidney failure, declining vision,
declining nerve function, etc.
The second nutritional concern I have is the pt’s weight related to her excessive calorie intake. With
her current diet she is consuming 129% of her calorie needs. Pt is currently and has been obese for at
least the past 6 months. Furthermore, with the pt’s current T2DM condition, being obese could bring
further problems to pt’s T2DM condition.
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The third nutritional concern I have is the pt’s family history of CVD. The pt’s risk of a chronic disease
in conjunction with her high fat intake concerns me. The fact that CVD runs in both sides of the family
puts pt at a higher risk for developing a disease such as CVD, that pt is already predisposed to.
(26 pts total) Write a SOAP note for this patient. Include 2 of the problems you identified as PES statements.
Use Annotated Sample SOAP using PES statements format for the SOAP note.
You do not have to list the foods in the diet recall this time.
(2 points) S: Pt referred to nutrition diabetes counseling for management of T2DM. GI: none Med
Hx: none FHx: Pt mother and father both have been diagnosed with CVD. Wt Hx: 178 lbs for more
than 6 mo. Social Hx: Works as manager of a school cafeteria and is around food all day long.
Stable family life and a low stress lifestyle. Pt states “I don’t think nutrition counseling can help me
because the only advice I get is to lose weight and to stay away from sweets, neither of which I
have been able to do.” Food/Nutrition Related Hx: Occasionally takes the OTC drug Alli to try to
lose weight but pt “thinks it doesn’t work and costs too much.” Activity:  Tobacco. OTC: Alli
(Orlistat)
(8 points) O: 45 yo ♀ Dx: T2DM/3yr Ht: 63’’ (160.0 cm) Wt: current: 178# (80.9 kg); UBW: 178#
(80.9 kg); UBW% 100%; IDW (103.5-126.5#); IBW% 155%; BMI: 31.6 = obese; Waist
circumference = 38”; frame size = medium; A1C 8.6%; TC 234 mg/dl; HDL 53; TG 285 mg/dl; FBG
120 mg/dl; BP: 120/78 mm/Hg
Rx Meds: Glucophage (Metformin) 500mg 2x/day
Nutrition Prescription of Estimated Energy Needs: REE 1423 kcal (AF: 1.2) 1707.6 1700
kcals/d.
Protein: (0.8g x 81kg)  65g/d. (1.0g x 81kg)  81g/d  Range of 65– 81g/d.
Fluid: 35 ml/kg: 2832 ml / day.
NIA: 120 g protein, 220 g CHO, 90 g fat, 2200 kcal
(8 points) A: Include two PES statements
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1. Inconsistent carbohydrate intake (NI-5.8.4) r/t food and nutrition related knowledge deficient
concerning appropriate timing of carbohydrate intake AEB 24 hr. diet recall, HbA1C level of 8.6,
FB level of 120mg/dL. and TG level of 285mg/dL.
2. Excessive energy intake (NI-1.5) r/t food and nutrition-related knowledge deficit concerning
energy intake AEB 24 hr. diet recall.
Readiness for change: Low-medium
Clinical observations related to probability of goal achievement: Pt’s lack of self-efficacy and
motivation to make appropriate changes in diet. Pt needs a more structured coordination of care
plan and specific nutritional education to be successful.
(8 points) P: (Include interventions and goal for each PES)
1. Coordination of Care: Discussed the importance of carbohydrate management and the significance of
balancing out carbohydrate intake throughout the day to control blood glucose levels. Refer pt to
consult with a certified diabetes educator about blood glucose management. Goal: On f/u in one week,
pt will report following through with referral plan to meet with certified diabetes educator to review blood
glucose monitoring.
3. Nutrition Education: Reviewed estimated energy needs of pt and discussed alternative low-fat and
sugar-free options for diet replacement in an effort to bring down caloric intake. Goal: On f/u in one
week, pt’s typical day will reflect a decreased caloric intake meeting estimated energy needs on current
24 hr. recall.
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