Lauren Pavone
Diabetes Case Study
NFSC460
Type 2 Diabetes Mellitus
Adapted from Nelms and Anderson, Medical Nutrition Therapy: A Case Study Approach,2nd
Ed.
And
Lisa Hark and Gail Morrison, Medical Nutrition & Disease, A Case-Based Approach, 4th Ed.
Show all calculations in your answers. (These may be hand-written, legibly.)
Objectives
After completing this case, the student will be able to:
1. Collect pertinent information and use nutrition assessment techniques to determine
baseline nutritional status.
2. Evaluate laboratory indices for nutritional implications and significance.
3. Integrate working knowledge of pathophysiology with nutrition care of type 2 diabetes
mellitus.
4. Develop appropriate behavior outcomes for the patient.
5. Determine appropriate nutrition requirements.
6. Identify appropriate MNT goals.
7. Complete appropriate documentation in the medical record.
Eileen Douglas is a 71-year-old woman who was admitted for surgical debridement of a nonhealing foot wound. On admission, Mrs. Douglas was found to be hyperglycemic, and a
diagnosis of type 2 diabetes mellitus was determined.
Client name: Eileen Douglas
DOB: 7/27
Age: 71
Sex: Female
Education: Less than high school - What grade/level? 10 th grade
Occupation: Homemaker
Hours of work: N/A
Household members: Sister, age 80, Dx with type2 DM 10 years ago. Mrs. Douglas cares for
her sister.
Ethnic background : African American
Religious affiliation: Protestant
Referring physician: Richard Case, MD (internal medicine); Dennis Shyne, MD (general
surgery)
Chief complaint:
"This cut on my foot happened over two months ago and has not healed. And I don't think I see
well. Maybe I need my eyes checked again. I have been having trouble reading the newspaper
for the past few months."
Patient history:
Onset of disease: Mrs. Douglas is a 71-year-old widow, who lives with her 80-year-old sister,
whom she cares for. They live in low-income housing in a third-floor walk-up apartment. In
addition to the unhealed wound and blurry vision, Mrs. Douglas complains of frequent bladder
infections, which are documented in her clinic chart, and a slight tingling and numbness in her
feet. On admission to the hospital, her blood glucose measured 325 mg/dL. Surgical debridement
of wound is indicated, along with normalization of blood glucose and alleviation of blurred
vision.
Type of Tx: Surgical debridement of wound, sliding scale insulin, 1200-kcal diet, DM selfmanagement education
PMH: HTN
Meds: Capoten (captopril), 50 mg PO bid
Smoker: No
Family Hx: What? DM
Who? Sister, for 10 years
Physical exam:
General appearance: Overweight elderly African American female
Ht: 5’0”
Wt: 155 lbs
Vitals: Temp 99.2oF, BP 150/97 mm Hg, HR 75 bpm, RR 12 bpm
Heart: Regular rate and rhythm, no gallops or rubs, point of maximal impulse at the fifth
intercostals space in the midclavicular line
HEENT:
Head: Normocephalic
Eyes: Wears glasses for myopia, mild retinopathy
Ears : Tympanic membranes normal
Nose: Dry mucous membranes w/out lesions
Throat: Slightly dry mucous membranes without exudates or lesions
Genitalia : Normal without lesions
Neurologic: 'Alert and oriented. Cranial nerves II-XII grossly intact, strength 5/5
throughout, sensation to light touch intact in hands, mildly diminished in feet, normal
gait, normal reflexes
Extremities: Normal muscular tone for age, normal ROM, nontender
Skin: Warm and dry, 2X3 cm ulcer on lateral left foot
Chest/lungs: Respirations normal; no crackles, rhonchi, wheezes, or rubs noted
Peripheral vascular: Pulse 2 + bilaterally, cool, mild edema
Abdomen: Audible bowel sounds, soft and non tender, without masses or organomegaly
Nutrition Hx:
General: Because her sister "has sugar," Mrs. Douglas does not purchase cakes, candy, and other
desserts. In fact, Mrs. Douglas reports that she and her sister try to avoid "all starchy foods"
because that's what they were told to do when her sister received a printed diet sheet from her
MD (10 years ago). Once a month, though, she and her sister have cake and ice cream at the
Senior Center birthday party.
Usual dietary intake:
AM: One egg, fried in bacon fat, 2 strips of bacon or sausage, 1 cup coffee, black, 1/2 cup orange
juice (unsweetened)
Lunch: Lunchmeat 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 cup turnip greens seasoned with 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 I tsp butter, 1 cup beans and ham (Great Northern beans cooked with ham,
approximately 1/4 cup beans and 1/4 cup or 1 oz ham), 1 cup coffee, black
Snack: 2 vanilla wafers
24-hr recall: N/A
Food allergies/intolerances/aversions: N/ A
Previous MNT? No
Food purchase/ preparation: Self
Vit/min intake: None
Current diet order: 1200 kcal ADA exchange diet
Tx plan:
Debride wound
Normalize blood glucose levels
Provide adequate kcalories and nutrients to meet Pt's needs
Begin self-management training on nutrition prescription, meal planning, signs/symptoms, and
Tx of hypo-hyperglycemia, SMBG, appropriate exercise, potential food-drug interaction
Initiate Lipitor 10 mg gd, continue Capoten 50 mg bid
LABS: Mrs. Douglass Labs PDF Document
Diabetes Case Study Questions:
1)
What is the difference between type 1 and type 2 diabetes mellitus? (2)
Type 1 is an auto-immune disease where the beta cells in the pancreas are unable to make
insulin. Type 2 diabetes mellitus is caused by life-style factors such as obesity that result in
insulin resistance.
2)
How would you clinically distinguish between type 1 and type 2 diabetes mellitus? (2)
In Type 1 Diabetes, destruction of Beta cells leaves a marker of islet cell autoantibodies. Also
patients with Type 1 Diabetes will have no insulin in their blood. Test for insulin in the blood
and also the prescience of islet cell autoantibodies.
3)
List the chronic complications of diabetes mellitus. (2)
Chronic elevation of blood glucose can cause damage to the blood vessels (angiopathy). This is
turn can lead to damage of small blood vessels known as microangiopathy. Microangiopathy can
cause the following due to chronic elevation of blood glucose. Cardiomyopathy, which is
damage to the heart. Nephropathy (kidney disease), which can lead to renal failure., Neuropathy,
which can lead to damaged nerves and amputations contributing to decreased sensation. This is
also connected to diabetic foot including ulceration, sores and infection. Retinopathy affecting
the eyes and especially eye sight, it can lead to blindness.
4)
What risk factors does Mrs. Douglas have for developing diabetes? (2)
She is over 45 years of age at 71, she has family history of diabetes, she is at increased race by
her African American ethnicity. Mrs. Douglass has a BMI of 30.2 indicating that she is Obsese,
Class 1, and she is diagnosed with Hypertension. Her casual blood glucose is (>120mg/dL), her
LDL is (>130 mg/dL), HDL is (<40mg/dL), TG is (>150), and HbA1c is (>6.4)
5)
a. Does Mrs. Douglas present with any complications of diabetes mellitus? If yes, which
ones? (1)
Yes, she has a sore on her foot that is not healing, she complains of having multiple UTI,
and blurry vision.
b. How does the pathophysiology of the disease relate to her signs and symptoms? (2)
The sore on her foot is caused by vascular neuropathy which lead to damaged nerve and
faulty nerve signaling. Her multiple UTI may be cause by vascular nephropathy. Blurred vision
is caused by retinopathy.
6)
Compare the patient'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. (4)
Parameter
Normal Value
Goal with DM
Admitting Lab Values
Glucose
HbA1c
Cholesterol
LDL-Cholesterol
HDL-Cholesterol
Triglycerides
70-99
<4-6
<200
<100
40-85
35-150
70-130
<7.0
<200
<70 or <100
>50 female
<150
325
8.5
300
140
35
400
The patient has hyper-increased glucose levels. This signifies that she has Type 2 Diabetes and
since her plasma glucose is >250, she is at risk for DKA. Other signifiers of Type 2 Diabetes is
indicated by her HbA1c of 8.5. Her increased level of total cholesterol, increased LDL decreased
HDL and hyper-lipedemia of Blood TG at 400 mg/dL are significant of insulin resistance which
can increase her risk of metabolic syndrome as well as Type 2 Diabetes Mellitus.
7).
Calculate Mrs. Douglas's body mass index (BMI). What are the health
implications of this? (1)
155 LB
60 INCHES
BMI = [155/(60^2)] = 30.2
BMI >30 indicated Obesity, Class 1.
This puts her at risk for Type 2 Diabetes, Metabollic Syndrome, Coronary Heart Disease,
Atherosclerosis, Myocardial Infarction and Stroke, Deep Vein Thrombosis, Pulmonary
Embolism.
8)
Calculate Mrs. Douglas's energy needs using the Mifflin St. Jeor equation and her
actual body weight. If you want Mrs. Douglas to lose weight, how would you
adjust her kcal recommendation based upon the Mifflin St. Jeor equation? (2)
RMR= (10*kg) + (6.25*cm) – (5 * yrs) – 161
RMR = (10*70.45)+(6.25*152.4) – (5*71) – 161 = 1141 kcal
Stress Factor; 1.3
RMR*1.3
1141*1.3 = 1483.3 kcal
Since Mrs. Douglass is Obesity Class 1, weight loss, deficit of 500 kcal/day
1483.3 – 500 = 983.3 kcal/day
9)
Calculate Mrs. Douglas's protein needs using her actual body weight. Note that
she has skin ulcer on her foot. (1)
70.45 kg
1.5g/kg (stress factor)
Because Mrs, Douglass has a skin ulcer, she needs increased protein needs.
(70.45 * 1.5g) = 106g of protein/day
10)
Use Diet Analysis Plus or Supper Tracker to calculate the kcal, protein, fat, CHO, fiber,
cholesterol, and Na content of Mrs. Douglas' diet. How does her diet compare to her
estimated needs for these dietary components. Does Mrs. Douglas's "usual"
dietary intake meet the Food Guide Pyramid guidelines? If not, in which areas
does her diet need improvement? (6)
Based on SuperTracker diet analysis and nutrient food report of Mrs. Douglas’s diet, she
is consuming 1212kcal/day, 44g (14.5%kcal) of protein, 144g (46.5%kcal) CHO, 414g (38%
kcal) fat, and 14% sat fat. Her sodium intake is 3182mg. Her dietary fiber intake is 12g, and her
cholesterol is 334mg
Her usual dietary intake does not follow the Food Guide Pyramid, because she is
consuming too much fat (20-35%), saturated fat (<10%) and sodium (<2300mg) and she is also
not consuming enough fiber in her diet (25g).
Based on Mrs. Douglas’s current nutritional status an optimal diet for her would be to
decreases her energy intake and increase her protein intake. We calculated that she should be
consuming 983 kcal/day and 106g protein/day, which would be account for 42% kcal. She
should lower her fat intake, and choose foods that are higher in dietary fiber such as whole
grains, beans, and vegetables that are cooked with no fat.
11)
What is the MNT goal at this time? (Note the reason she was admitted to the
hospital.) (2)
MNT goals will include, lowering and stabilizing blood glucose due to her T2DM. Lower
her total cholesterol, LDL cholesterol, and increase HDL cholesterol, and stabilize her blood
pressure. She will incorporate an exercise regimen into her daily life-style.
Also, create a diet plan including patient education. This education may include CHO counting, a
list of exchanges, an overview of the amount of each nutrient to be taken daily and what types of
foods qualify for each nutrient. Education will also include facts about new diabetes medication,
how to use them and the adverse effects of food/drug interactions. She will also learn how to
recognize chronic and acute diabetes signs and symptoms and be aware how to monitor and
regulate her blood glucose.
Currently, her primary MNTgoal is to lower her blood glucose by managing her Obesity by
decreasing her total kcal intake and total fat intake.
12)
Is the diet order of 1200 kcal appropriate? Justify your answer. (2)
No, the diet order of 1200 kcal would be appropriate based on calculating her Total Estimated
Energy, however, since Mrs, Douglass is Obese, we need to create a deficiet of 500ckal per day
to get on a weight-loss regimen of 1#/week. Because of this a 983 kcal diet order is appropriate.
13)
Review the following initial nutrition note written for this patient. Is this progress
note complete? Do you note any errors? Any omissions? Explain. (4)
Subjective; “sugar” should say “diabetes,” it should include her past medical history and
her primary complaints such as blurred vision and foot sore.
Her dietary intake calculation are not accurate. She is consuming 1212kcal, 44g protein,
144g CHO, 38% fat, and 14% sat fat, 111% cholesterol, 138% Na, and she does not have
adequate fiber intake at (12g).
Objective: Ideal Body Weight should be 100# The diagnosis should be in Assessment not
objective.
Assessment: Missing how her dietary intake compares to her usual intake and how her
lab values compares to normal values. The Assessment should also include the diagnosis.
Plan: It wasn’t really complete; it only had 2 non- specific goals.
6/8, 1300 hr Nutrition Note
S:
O:
A:
Patient lives with 80 yo sister for whom she cares. Sister has had “sugar" for 10
years and Pt is responsible for shopping & meal preparation. Usual dietary intake
reflects an intake of -1700 kcal, 59 g protein, 142% fat rec, 151% Na rec, 126%
cholesterol rec, and a more than adequate fiber intake.
71 yo f, ht 5'0", wt 155#, ABW 106#
Dx: Unhealed foot ulcer, type 2 DM
PMH: HTN
Meds: Cipro, Cardizem
Glucose and HbA1c high due to DM. Pt will need education appropriate for
understanding level prior to and follow-up after discharge
P:
1) Recommend Pt ed on appropriate food choices or diet for glucose control
2) Dietitian to follow daily. Monitor for adequate oral intake
14)
Identify two lab values that should be monitored regularly in a DM patient. Why
is regular follow-up with an MD, CDE or RD important? (2)
1. HbA1c for long-term blood glucose levels
2. Insulin to monitor blood glucose and regulate it depending on the SMBG reading.
Regular follow-up is extremely important in preventing chronic and acute complications.
Diabetes is a progressive disease and medications and types of insulin may have to be changed.
Monitoring allows amending plans with evidence- based analysis.