Case Study BMIs in the range of are considered overweight. Therefore, F.V. s usual BMI indicates that she was overweight.

Transcription

1 Morgan McFarlane February 26 th, 2013 HHP 439 Professor White Case Study What is your interpretation of F.V. s clinical data? F.V. s clinical data includes chronic abdominal pain, loose stools, unintentional weight loss, anorexia, nausea, vomiting, lack of stamina, a mild fever, and oily/foul smelling stools. The vomiting is causing her to lose electrolytes and unintentionally lose weight along with the nausea which decreases her appetite. F.V. s lack of stamina and anorexia is due to malabsorption of nutrients. The oily/foul smelling stools is due to unabsorbed fat.¹ 2. What is your interpretation of her usual BMI? BMI= Weight(lbs)/ Height² (in²)*703 BMI= (165 / 67²) * 703 BMI= 25.8 BMIs in the range of are considered overweight. Therefore, F.V. s usual BMI indicates that she was overweight. 3. What is your interpretation of her percent weight change? % weight change= Weight Change/Usual Weight * 100 =(3/165) * 100 =1.81% F.V. s weight loss is not significant but she should not lose this amount of weight in one week, especially unintentionally. Her weight loss is most likely due to her vomiting and steatorrhea. 4. What is your interpretation of F.V. s blood test results? F.V. s blood ALT and AST concentrations are both high which are indicators for numerous disease states such as liver and pancreatic disease. Her blood ALP concentration is also high, which could indicate cholestasis. Cholestasis is defined as little to no bile secretion or obstruction of the flow of bile into the digestive tract. F.V. s blood GGT concentration is slightly high which can indicate liver disease. Her blood amylase and lipase concentrations are both high

2 which indicate pancreas problems. F.V. s blood albumin concentration is in the normal range which is g/dl but it is on the lower end of the normal range. Her white blood cell count is high which indicates an infection or inflammation in the body. F.V. s fasting serum glucose and blood A1c concentrations put her in the prediabetic category since they fall into the ranges mg/dl and %, respectively. Since F.V. has a serum osmolality of higher than 295 mosm/kg this indicates dehydration (most likely from vomiting). F.V. s serum sodium concentration is low and this is also due to her vomiting.¹ 5. What disease condition(s) do you think F.V. has, based on the above data? Justify your answer. Based on F.V. s clinical data and blood test results, F.V. has acute pancreatitis. Acute pancreatitis is sudden swelling and inflammation of the pancreas ² F.V. has several clinical manifestations of acute pancreatitis including her vomiting, nausea, abdominal pain, and steatorrhea. F.V. stated that food worsened her symptoms and this is another common problem with acute pancreatitis.¹ F.V. s serum amylase and lipase concentrations are both high. When the pancreas is diseased or inflamed, amylase and lipase both release into the blood ² causing an increase in serum amylase and lipase concentrations. 6. Does F.V. suffer from viral hepatitis? Why or why not? I do not believe F.V. suffers from viral hepatitis. I believe that F.V. has acute pancreatitis. While she has some of the symptoms of hepatitis, she doesn t have some of the major symptoms which include dark urine and jaundice.¹ 7. Is F.V. s disease condition caused by alcohol abuse? Explain your position. Alcohol abuse is a pattern of drinking that results in harm to one s health, interpersonal relationships, or ability to work. ³ F.V. s disease condition is not caused by alcohol abuse. F.V. only socially drinks no more than once a month and has done so for the past five years. 8. Describe the medical nutrition therapy appropriate to help F.V. manage her disease condition. In the hospital F.V. should be administered her nutrition via enteral nutrition in order to achieve pancreatic rest while still using the gut. If the GI tract is not used, this could worsen the disease severity. The tube feeding should include medium chain triglyceride oils since her pancreas is not able to use lipase to break down fats. The tube feeding should also include supplemental pancreatic enzymes, fat-soluble vitamins, and B12 vitamin. Overfeeding needs to be avoided so that there is no refeeding syndrome. Fluid and electrolyte balance needs to be maintained. After sufficient time has been allowed to let the pancreas rest, oral nutrition should be reintroduced. Oral nutrition should entail six small meals that are easily digestible, low-fat, have adequate protein, and increased calories along with pancreatic enzymes. Vitamin supplementation should

3 still be included with proper amounts of vitamin C, B-complex vitamins, folic-acid, and vitamin B12. 4 F.V. should now avoid alcohol, smoking, and fatty foods.¹ 9. What is your interpretation of F.V. s more recent clinical and biochemical data? F.V. s hepatic enzyme levels have all lowered but all still higher than normal which indicates that her acute pancreatitis more than likely has become chronic pancreatitis. F.V. s blood amylase and lipase concentrations have both significantly dropped which are improvements. However, F.V. s blood glucose concentrations indicate a problem. F.V. s fasting serum glucose is 324 mg/dl and this is significantly over the normal range of mg/dl and indicates that she has diabetes. Her postprandial serum glucose concentration is 508 mg/dl which is extremely high and another indicator of diabetes. F.V. s A1c level is 17.4% and this is very high and indicates diabetes. F.V. states that she is now experiencing dehydration, weight loss, and polyuria which are all symptoms of diabetes.¹ 10. What disease condition(s) do you think F.V. now has, based on the new data? Justify your answer. Since F.V. s blood work still shows indicators of pancreatitis, her acute pancreatitis is now considered chronic since she has had this condition for twelve years (more than six months). F.V. s high blood glucose concentrations indicate that she has developed type I diabetes. F.V. has several symptoms of type I diabetes including weight loss, dehydration, and excessive urination. F.V. s diabetes most likely developed from her chronic pancreatitis because immunemediated diabetes mellitus results from an autoimmune destruction of the β-cells of the pancreas, the only cells in the body that make the hormone insulin. ¹ 11. How should F.V. manage her condition at this point? In order to manage her type I diabetes, F.V. needs to implement an insulin regimen into her schedule. F.V. also needs to count her carbohydrates in order to be able to administer the proper amount of insulin. F.V. should follow a diabetic diet and cut down on sugary foods and starches. F.V. should increase her physical activity in order increase her sensitivity to insulin. To manage her chronic pancreatitis, F.V. should supplement pancreatic enzymes, fat-soluble vitamins, and B12 vitamins.¹

4 ADIME A D I M E Patient is 27yo, Caucasian female. (CH-1.1) Patient is mother of two young children. (CH-1.1) Patient is a social drinker. (CH-3.1) Patient states she has been experiencing chronic abdominal pain, loose stools, unintentional weight loss, pain worsened by food, anorexia, nausea, vomiting, oily/foul-smelling stools, mild fever, and loss of stamina. (PD-1.1) Ht: 5 7 Wt: 162lb BMI: 25.8 UsualBW: 165lb UsualBMI: 25.8 Weight Change: 3lb loss %WtChange: 1.81% Blood ALP: 136 units/l Blood AST: 56 units/l Blood ALT: 37 units/l Blood GGT: 27 units/l Blood amylase: 276 units/l Blood lipase: 220 units/l Fasting serum glucose: 114 mg/dl Fasting blood A1c: 6.3% Serum osmolality: 303 mosm/kg Serum sodium: 133 meq/l (BD-1.11) (BD-1.9) (BD-1.7) (BD-1.5) (BD-1.4) (BD-1.2) (AD-1.1) Impaired nutrient status related to pancreatitis as evidenced by steatorrhea, vomiting, and dehydration. (NC 2.1) Unintentional weight loss related to pancreatitis as evidenced by nausea, vomiting, dehydration, and anorexia. (NC 3.2) Stop oral food and fluid to limit activity of pancreas. Provide patient with enteral nutrition. (ND-2.1) Enteral nutrition should be an elemental formula with MCT oils. (ND-3.1) Eventually reintroduce oral nutrition with six, small meals a day of meals that are easily digestible, low-fat, have adequate protein, and increased calories. (ND-1) Provide patient with supplemental pancreatic enzymes, fat-soluble vitamins, vitamin B12, and vitamin C. (ND-3.2) Educate patient about avoidance of alcohol, smoking, caffeine, and fatty foods.(e-1) Monitor patient s tube feeding, hepatic enzyme levels, blood glucose levels, blood protein levels, hydration status, sodium levels, weight, stool output, and vitamin intake (FH-1.3.1) (BD-1.4) (BD-1.5) (BD-1.11) (FH-1.2.1) (BD-1.2) (AD-1.1) (FH-1.6.1) Improved nutritional status demonstrated by 1. Increased appetite (FH-1.2.2) 2. Improved hydration and electrolyte balance (FH-1.2.1) (BD-1.2) 3. Decreased blood glucose levels (BD-1.5) 4. Decreased hepatic enzyme levels (BD-1.4) 5. Weight maintenance (AD-1.1)

5 References 1. Escott-Stump S, Mahan LK, Raymond JL. Krause s Food and the Nutrition Care Process. 13 ed. St. Louis, Mo: Elsevier; Acute Pancreatitis. Updated January 20, Accessed February 22, Alcohol and Public Health. Accessed February 22, Escott-Stump, S. (2008) Nutrition and Diagnosis-Related Care, 6 th Ed, Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia, PA.