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Mini Case

Study
October 9, 2015

Amanda Lambrechts
Illinois State University Dietetic Intern

Objectives

Provide thorough pt history and overview

Discuss unique pt with hypoglycemic events and COPD

Provide background on COPD

Discuss the MNT of pt with hypoglycemic events and COPD

Patient Introduction

Patient Name: J.K.

Age: 57 y.o.

Height: 51

Weight: 86#

BMI: 16.28 kg/(m^2)

Family Responsibility:
independent,
widowed

Date of Admission:
9/14/15 at 2310

Attending
Physician(s): Dr.
Jaydev Jani and Dr.
Jerry Antonini

Unit: FCC (Medical)

Previous Medical History//Disease & Conditions

T2DMdt removal of part of pancreas for


a cyst and stone. 2010

Asymmetrical sensorineural hearing loss

Meningiomaprobable meningioma left


inferior posterior cranial fossa

Pancreatic cyst and stoneremoved at


Barnes Jewish, July 2010. Non
cancerous

Essential HTN, benign

Vertigo

Diverticular ds

Asthma

Diverticulosis

Obstructive chronic bronchitis

Colon Cancer Screening

Pancreatitis

Non-compliance

Osteopenia10/13

COPD

Previous Medical History//Hospitalizations

Colon Surgery for diverticulitis2007

Cholecystectomy, laparoscopy2010

Cataract removal

Laser surgery of eye

Exploratory of abdomen, pancreas


2010

Cesarean section1979, 1976

Pancreas surgery, cyst and stone--2010

Present Admission

Admit Date: September 14, 2015

Diagnosis/Problem List:

Acute exacerbation of chronic obstructive pulmonary disease (COPD) and


hyponatremia

Physical Examination

No edema, skin wounds, or any other notable physical abnormalities

Cachexia

Other Significant Data:

Pt is a current 1 ppd smoker who comments that she has cut back a lot recently

Trends in Lab ValuesNa and K Balance


Sodium

Potassium

15-Sep

125

4.1

16-Sep

133

4.6

25-Sep

135

5.1

Normal Ranges:

Sodium: 136-145 mmol/L

Potassium: 3.5-5.1 mmol/L

Trends in Lab ValuesAlb, BUN, Cr, BUN/Cr


Ratio
BUN

Creatinine

15-Sep

11

0.6

18

16-Sep

0.58

14

0.56

14

25-Sep

Normal Ranges:

BUN: 10-20 mg/dL

Creatinine: .60-1.00 mg/dL

BUN/Cr Ratio: 12-20

Albumin: 3.5-5.0 g/dL

BUN/Cr Ratio

Albumin
3.5

Trends in Lab ValuesPOCT


9/17

9/15
0511
0817
1316
1752
2122

81
133
159
141
97

0814
0838
1248
1756
2132

63
126
135
173

0854
0917
0933
1243
1703

9/16
0819
1321
1629
2112

66
82
164
211
132

9/18
65
82
88
145
118

Hypoglycemic Consults

First Hypoglycemic consult on 9/17

PharmacyNoted Metformin d/cd on 9/16 and thought should add back in since
doesnt significantly contribute to hypoglycemia, plus pt is on steroid

Diabetic Educator/Dietitianencouraged nutrition intervention because slightly


early dinners ordered and mostly simple sugars; encouraged 3-4 CHO choices at
meals with 3 meals and HS snack

Second Hypoglycemic consult on 9/18

Pharmacysame recommendations

Dietitiannoted refusal of breakfast initially; pt ordering adequate CHO at D and


HS snack; recommended larger lunch and earlier breakfast; consider dextrose
based IVF at night and questioned whether SSI necessary

Nutrition Assessment: 9/15 New Pt Visit

Triggered by low BMI and cachexia

78% IBW

Barriers: c/d, SOB while eating secondary to COPD, difficulty chewing food

Estimated needs

1750-2000kcal/day (35-40kcal/kg)

60g Protein/day (1.2g/kg)

1750-2000mL fluid/day (1 mL/kcal)

Pertinent Interview Data:

So-so appetite, pt does shopping and lives alone, unintentional wt loss post 2010 surgery

Malnutrition Diagnosis:

Other protein malnutrition given Alb 3.5 and 99% UBW. BMI is 16.28 which is severe
underweight, which appears to be normal for pt.

Follow-up: 9/18

Consistent wt

Diet changed to regular per pt request on 9/16

Orders varied from 477kcal/15g Pro to 2292kcal/60g Pro

Pt experiences AM hypoglycemia at home; never experiences highs

Constipation

Missed Rockford dental surgery

Hopeful that rescheduled appointment will help solve chewing difficulties and
enjoy food more

Reinforced COPD meal tips

Study of Disease: COPD

Definition: (American Thoracic Society, 2004)

Chronic Obstructive Pulmonary Disease

Characterized by progressive increase in obstruction of airflow to lungs

Abnormal inflammatory response to noxious gases

Occurrence

6.3% of US adults with COPD (15 million)CDC, 2012

3rd leading cause of death in USCDC 2013

Definition of New Words:

Dyspnea: shortness of breath, difficulty breathing

Orthopnea: shortness of breath when lying fown flat

Cyanosis: blue-colored mucous membranes d/t lack of O2 supply

COPD (continued)

Etiology

Cigarette smoke, secondhand smoke, air pollution, chemical


fumes (National Heart, Lung, and Blood Institute, 2014)

Emphysema and chronic bronchitis contribute

Symptoms:

Dyspnea, hypoxemia, fatigue

Like breathing through a staw

Treatmentmedical and nutritional

Smoke cessation, meal habit modifications, bronchodilators,


steroids, O2 therapy, pulmonary rehab

Related Diseases

Emphysema

Chronic bronchitis

What does the AND EAL say about COPD?

Factors Affecting Energy Needs

Inflammation increases resting energy expenditure

Physical activity will increase needs

Limited research on influence of thermic effect of food, breathing efficiency and


medicaitons

Relationship between Wt Loss and pts with COPD

18 studies reviewed

Prevalance of malnutrition (BMI<20) may be as high as 30%

Risk of COPD-related death doubles with wt loss

Effect of consumption of milk and milk products on mucus production

2005 Review study, no significant effect of milk on mucus production

Effect of Omega-3 Fatty Acids

Six studies

Inconsistent findingsmore studies needed

Effects of antioxidantsvitamins A, C, and E

Eight studies

Six report reduced serum and/or tissue levels of vitamins A, C and/or E in people
with COPD

Insignificant effects from supplementation in three studies

Medical Treatment of Pt.

Medications:

Metformin (daily w/breakfast), Zofran (PRN), SSI, steroid

Cortrosyn, DUO-NEB, Solu-Medrol, Norvasc, Symbicort, Wellbutrin, Lovenox,


Neurontin, Lisinopril, Toprol-XL, deltasone, Zoloft

IV: NaCl @ 2000mL/hr

Medical and/or surgical measures:

PT 5x week

Respiratory Therapy

General progress:

Breathing progress, intake progress

Next StepsAfter Discharge

Follow-up Plans

OSF-Homecarecurrent documentation of compliance

Respiratory therapy and O2 at home

What I Would have Done Differently

Problems with fat digestion d/t pancreatic surgery?

Found a handout on COPD for pt

Worked more with the hypoglycemic consults

References

Academy of Nutrition and Dietetics. 2014. Evidence Analysis LibraryCOPD.

American Thoracic Society / European Respiratory Society Task Force. (2004). Standards for the
diagnosis and management of patients with COPD (Version 1.2). New York: American Thoracic
Society.

Centers for Disease Control and Prevention. (2012). 6.3% of U.S. adults report having COPD.
Retrieved from http://www.cdc.gov/Features/COPDAdults?

Centers for Disease Control and Prevention. (2013). Deaths and mortality. Retrieved from
http://www.cdc.gov/nchs/fastats/death/htm

National Heart, Lung, and Blood Institute. (2013). How is COPD treated?. Retrieved from
http://www.nhlbi.nih.gov/health/health-topics/topics/copd/treatment.

National Heart, Lung, and Blood Institute. (2014). What causes COPD?. Retrieved from
http://www.nhlbi.nih.gov/health/health-topics/topics/copd/causes

Questions??

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