MEDICAL CASE STUDY : COPD
EMILY BRANTLEY
DIETETIC INTERN
ANDREWS UNIVERSITY
INTRODUCTION
NM is a 62 year old white female who is 160.02 centimeters tall weighing 107.2
kilograms. She was admitted to Winter Park Memorial Hospital with shortness of breath,
respiratory abnormality, diarrhea and hypokalemia. I have chosen to conduct a case study on
this patient because of the multiple complications that she is facing such as Diabetes Mellitus,
Addison’s disease, Irritable Bowel Syndrome and IgA Deficiency. This case study began on
December 5, 2013 and ended two visits later on December 6, 2013. Although she has been
diagnosed with many health complications, the primary problem that NM has is Chronic
Obstructive pulmonary disease, or COPD. NM has other comorbidities that are comparable in
importance. Nevertheless, she is most often admitted to the hospital for exacerbation of COPD.
Therefore, COPD is the focus of this study.
SOCIAL HISTORY
NM is a Christian woman who lives at home with her husband and pet parakeet. She is
currently on Medicare. She is a retired RN. Her three children are all adults and live within the
region. NM is a former smoker but Medical records indicate that she does not smoke or drink
alcohol anymore.
NORMAL ANATOMY AND PHYSIOLOGY OF APPLICABLE BODY FUNCTIONS
COPD is characterized by slow, progressive obstruction of the airways. There are two
physical conditions that make up COPD. The first is known as Emphysema and it is characterized
by abnormal, permanent enlargement and destruction of the alveoli. The second is chronic
bronchitis where there is a progressive cough with inflammation of bronchi and other lung
changes. In both cases, the disease limits the airflow and frequently, both illnesses coexist as
part of this disorder.1&2
PAST MEDICAL HISTORY (INCLUDE PREVIOUS ADMISSIONS TO HOSPITAL)
Past medical history indicates that NM initially received the diagnosis of COPD in 1997.
According to the American Thoracic Society, comorbidities such as cardiac disease, diabetes
mellitus, hypertension, and psychological disorders are commonly reported in patients with
COPD, but with great variability in reported prevalence.
Along with the original diagnosis, NM also has also been diagnosed with Diabetes
Mellitus. The evidence for an interaction between diabetes and COPD is supported by studies
that demonstrate reduced lung function as a risk factor for the development of diabetes. In
fact, smoking has been established as a risk factor for both COPD and Diabetes Mellitus. 3
NM has been hospitalized six times within the past year for episodes of pneumonia.
When compared to other chronic diseases, COPD is more frequently associated with
pneumonia. Corticosteroids are standard of care for acute exacerbations of COPD, but their role
in the management of patients with COPD with pneumonia is less defined. 3
NM also suffers from Gastro-esophageal reflux disease (GERD). An increased prevalence
of GERD has been reported in patients with COPD. A recent study of 421 patients with severe
COPD using 24-hour esophageal pH monitoring showed that 62% had pathological GERD, and
notably 58% of the patients reported no symptoms of GERD.3
Besides COPD, Diabetes Mellitus and GERD as previously mentioned above, NM’s past
medical history also included other comorbidities. They are as follows:






Bronchial Asthma
Adrenal Insufficiency
Coronary Artery Disease
Trachaeomalacia
Addison’s disease
Hypothyroidism






Bipolar Disorder
Irritable Bowel syndrome
Vascular stent placement
Hyperlipidemia
Hyperthyroidism
Anemia
PRESENT MEDICAL STATUS AND TREATMENT
Theoretical Discussion of Disease Condition
COPD is the fourth leading cause of death in America. COPD is also more prevalent in
women.3&4 The primary risk factor in the development of COPD is smoking. Beyond the cessation of
smoking, it has been shown that the inflammatory stress continues to damage the lung tissue. Other
risk factors include air pollution, secondhand smoke, history of childhood infections, and occupational
exposure to certain industrial pollutants.
Although normal lung function gradually declines with age, individuals who are smokers have a
more rapid decline—twice the rate of nonsmokers. Low body weight has also been shown to be a risk
factor for the development of COPD even after adjusting for other potential risk factors including
smoking and age.2 Malnourished patients with COPD experience worsened respiratory muscle
strength, decreased ventilator drive and response to hypoxia, and altered immune function. 1, 5 & 6
Usual Treatment of Condition
An early and accurate diagnosis of COPD is the key to treatment. Quitting smoking is the single
most important thing that can be done to help treat COPD. 7 Once identified, the usual treatment of
COPD is composed of four main goals for effective management. They are to:
1. Assess and monitor the disease
2. Reduce risk factors
3. Maintain stable COPD and respiratory status
4. Manage any exacerbations
Once the disease progresses, rehabilitation programs along with oxygen therapy are used as
treatment. Additionally there are numerous medication prescriptions that include bronchodilators,
glucocorticosteroids, mucolytic agents, and antibiotics to treat infections. In cases where COPD may be
advanced, there is an option for surgical intervention, such as a lung transplant.1
Patient’s Symptoms upon Admission Leading to Present Diagnosis
NM was admitted with shortness of breath, cough, diarrhea, hypokalemia and fever. The
patient revealed that one of the possible causes of her diarrhea may be the fact that she had “been
around a couple of people with Clostridium Difficile.” NM also showed symptoms of hyperlipidemia
and hypertension – High blood pressure is a complication of COPD. 6 Hyperglycemia is a side effect of
steroid therapy for COPD. Steroids can increase the blood sugar making diabetes harder to control.8
Laboratory Findings and Interpretation
The lab values for NM on December 5th were as follows:
Lab Value
Normal Range
Sodium
138
135 to 145 milliequivalents per liter (mEq/L)
Potassium
3.5
3.7 to 5.2 mEq/L
BUN
16
7 to 20 mg/dL
Creatinine
0.69
0.6 to 1.1 mg/dL for women
Blood Glucose 152
70 to 100 milligrams per deciliter (mg/dL)
Accuchecks
70 to 100 milligrams per deciliter (mg/dL)
188, 130, 239, 282, 279, 233
1
Medications
Below is a table that explains the uses and purpose of NM’s medications along with their
food/drug interactions and side effects.
Drug Name
Dosage
Uses
Depakote ER
(Valproic Acid)
1000 mg
Lexapro
(Escitaloprem)
5 mg
Valproic acid is in the
anticonvulsant class of
medications. Valproic acid
is used to treat mania
(episodes of frenzied,
abnormally excited mood)
in people with bipolar
disorder. It works by
increasing the amount of a
certain natural substance
in the brain.
Escitalopram is in a class of
antidepressants called
selective serotonin
reuptake inhibitors (SSRI’s).
It is used to treat
depression and generalized
anxiety disorder. It works
by increasing the amount
of serotonin, a natural
substance in the brain that
helps maintain mental
balance.
Fludrocortisone is used to
treat Addison's disease and
syndromes where
excessive amounts of
sodium are lost in the
urine. It is a corticosteroid,
used to help control the
amount of sodium and
fluids in the body. It works
by decreasing the amount
of sodium that is lost
(excreted) in urine.
Fluticasone is in a class of
medications called
steroids. Salmeterol is in a
class of medications called
long-acting beta-agonists
(LABAs).
It works by relaxing and
opening air passages in the
lungs, making it easier to
breathe. The combination
of fluticasone and
salmeterol is used to
prevent wheezing,
Florinef
0.1 mg
(Fludrocortison
Acitate)
Fluticasone –
salemeterol
2 puffs
Food/Drug
interaction
Continue
normal diet
Continue
normal diet
Side Effects
Drowsiness, dizziness, headache,
diarrhea, constipation, changes
in appetite, weight changes,
back pain, agitation, mood
swings, abnormal thinking,
uncontrollable shaking of a part
of the body, loss of coordination,
uncontrollable movements of
the eyes, blurred or double
vision, ringing in the ears, hair
loss
Dizziness, sweating, nausea,
vomiting, tremor, drowsiness,
fast or pounding heartbeat,
seizures, confusion,
forgetfulness, fast breathing,
coma (loss of consciousness for a
period of time)
Doctors may
instruct to
follow a LowSodium, LowSalt,
PotassiumRich, or HighProtein diet.
Upset stomach, stomach
irritation, vomiting, headache,
dizziness, insomnia, restlessness,
depression, anxiety, acne,
increased hair growth, easy
bruising, irregular or absent
menstrual periods
Talk to doctor
about eating
grapefruit or
drinking
grapefruit
juice
runny nose, sneezing, sore
throat, throat irritation, sinus
pain, headache, nausea,
vomiting, diarrhea, stomach
pain, muscle and bone pain,
dizziness, weakness, tiredness,
sweating, tooth pain, red or dry
eyes, shaking of a part of the
body that cannot be controlled,
sleep problems
Metronidazole
Flagyl
500 mcg
Insulin lispro
(Humalog)
Medium
scale
Misoprostal
(Cytotec)
100 mcg
Monlelukast
(Singulair)
10 mg
shortness of breath,
coughing, and chest
tightness caused by asthma
and chronic obstructive
pulmonary disease. It
works by reducing swelling
in the airways.
Metronidazole eliminates
bacteria and other
microorganisms that cause
infections of the
reproductive system,
gastrointestinal tract, skin,
vagina, and other areas of
the body. Antibiotics will
not work for viral colds, flu,
or other viral infections.
Insulin lispro is used to
treat type 1 and type 2
diabetes. In patients with
type 2 diabetes, insulin
lispro may be used with
another type of insulin or
with oral medication(s) for
diabetes. Insulin lispro is a
short-acting, man-made
version of human insulin.
Insulin lispro works by
replacing the insulin that is
normally produced by the
body and by helping move
sugar from the blood into
other body tissues where it
is used for energy.
Misoprostol is used to
prevent ulcers in people
who take certain arthritis
or pain medicines,
including aspirin, which can
cause ulcers. It protects the
stomach lining and
decreases stomach acid
secretion.
Montelukast is in a class of
medications called
leukotriene receptor
antagonists (LTRAs). It
works by blocking the
action of substances in the
body that cause the
Continue
normal diet
Vomiting, diarrhea, upset
stomach, loss of appetite, dry
mouth; sharp, unpleasant
metallic taste, dark or reddishbrown urine, furry tongue;
mouth or tongue irritation,
numbness or tingling of hands or
feet
Important to
eat a
consistent
carbohydrate
diet. Skipping
or delaying
meals or
changing the
amount or
kind of food
eaten,
especially
carbohydrates
can cause
problems
with blood
sugar control.
Talk to doctor
about
decreasing
high acid
foods.
Redness, swelling, or itching in
the place where insulin is
injected. Changes in the feel of
skin such as skin thickening or
indentation in the skin, weight
gain, constipation
Continue
normal diet
headache, dizziness, heartburn,
stomach pain, tiredness
Diarrhea, headache, stomach
pain, upset stomach, gas,
vomiting, constipation,
indigestion
Pantoprazole
(Protonix oral)
40 mg
Potassium
chloride
40 mEq
RisperiDONE
(RisperDAL)
0.5 mg
Rosuvastatin
(Crestor)
5 mg
symptoms of asthma and
allergic rhinitis. Used to
prevent wheezing,
difficulty breathing, chest
tightness, and coughing
caused by asthma; prevent
bronchospasm during
exercise; relieve symptoms
of seasonal, and perennial
allergic rhinitis.
Pantoprazole is in a class of
medications called protonpump inhibitors. It works
by decreasing the amount
of acid made in the
stomach. Pantoprazole is
used to treat symptoms of
(GERD), allow the
esophagus to heal, and
prevent further damage to
the esophagus; Used to
treat conditions where the
stomach produces too
much acid, such as
Zollinger-Ellison syndrome.
Electrolyte mineral in
tablet form used to treat
deficiency.
Risperidone is in a class of
medications called atypical
antipsychotics. It works by
changing the activity of
certain natural substances
in the brain. It is used to
treat the symptoms of
schizophrenia, episodes of
mania or mixed episodes in
bipolar disorder.
Risperidone is also used to
treat behavior problems
such as aggression, selfinjury, and sudden mood
changes in teenagers and
children 5 to 16 years of
age.
Rosuvastatin is in a class of
medications called HMG-
Continue
normal diet
headache, dizziness, nausea,
vomiting, gas, joint pain
Doctor may
recommend
foods high in
potassium
foods such as
bananas
Continue
normal diet
Muscle cramps or spasms,
abnormal heart rhythms, fatigue,
constipation
Low
cholesterol or
Constipation, heartburn,
dizziness, difficulty falling asleep
Drowsiness, dizziness, nausea,
vomiting, diarrhea, constipation,
heartburn, dry mouth, increased
saliva, increased appetite,
weight gain, stomach pain,
anxiety, agitation, restlessness,
dreaming more than usual,
difficulty falling asleep or staying
asleep, decreased sexual interest
or ability, breast milk
production, vision problems,
muscle or joint pain, dry or
discolored skin, difficulty
urinating
NaCl
1 gm
Tolterodine
(Detrol LA)
2 mg
Voriconazole
200 mg
CoA reductase inhibitors
(statins). It works by
slowing the production of
cholesterol in the body to
decrease the amount of
cholesterol that may build
up on the walls of the
arteries and block blood
flow to the heart, brain,
and other parts of the
body. It is used together
with diet, weight-loss, and
exercise to reduce the risk
of heart attack and stroke
and to decrease the chance
that heart surgery will be
needed in people who have
heart disease or who are at
risk of developing heart
disease.
Combination of sodium
and chloride in tablet form
to assist with hydration and
elecrolyte balance.
Tolterodine is in a class of
medications called
antimuscarinics. It is used
to relieve urinary
difficulties, including
frequent urination and
inability to control
urination. It works by
preventing bladder
contraction.
Voriconazole is in a class of
antifungal medications
called triazoles. It works by
slowing the growth of the
fungi that cause infection.
It is used to treat serious
fungal infections such as
invasive aspergillosis and
esophageal candidiasis.
low saturated
foods diet.
or staying asleep, depression,
joint pain, cough, memory loss
or forgetfulness, confusion
Caution with
foods high in
sodium,
restrict use of
table salt.
No side effects known.
Dry mouth, blurred vision, upset
stomach, headache,
constipation, dry eyes, dizziness
Talk to doctor
about eating
grapefruit and
drinking
grapefruit
juice while
taking this
medicine
Blurred or abnormal vision,
difficulty seeing colors,
sensitivity to bright light,
diarrhea, vomiting, headache,
dizziness, dry mouth, flushing
9
Observable Physical and Psychological Changes in Patient
Upon observation, Nm physically looked well nourished. She did not appear to have difficulty
breathing until after she spoke for a long period of time. She did have a severe cough that she tried to
conceal. NM was a very agreeable patient for both psychological interviews. In spite of her COPD
diagnosis and all of the multiple medical comorbidities that NM faced, she still presented a positive
attitude and spoke openly about her faith.
Treatment
NM received a chest x ray that revealed consolidation in the left lung and midline lung level.
Once this was identified, she was admitted to the hospital from the Emergency room for treatment.
She was started on IV steroids, IV antibiotics, flagyl and nebulizers around the clock to see how she
progressed.
MEDICAL NUTRITION THERAPY
Nutrition History
NM stated that beginning in March 2012, she began intentionally losing weight by following a
PCP prescribed commercial diet known as Optifast. Optifast offers shakes, protein bars and soups. With
this regimen, NM has lost 70 pounds since March 2012. At home, NM usually sticks to her Optifast
food items for breakfast, lunch and snacks between meals. For dinner, however, she shares a meal
with her husband. He is a professional chef who is control of purchasing groceries and prepares dinner
most nights.
Analysis of Previous Diet
Below is an example of a typical day for NM with her Optifast products incorporated multiple
times during the day.
Time
Meal
8:00
Breakfast
AM
Food Item
1 cup Oatmeal
160
31
5
3
160
20
14
3
108
10
0
3
0
0
12
0
1 large apple
110
29
1
0
Optifast 800 Bar
Optifast 800 Ready to
Drink Shake
Optifast 800 Soup
8 Wheat Thins
¾ cup Raw Carrots
1 Tbs Ranch dressing
170
21
14
5
160
20
14
3
170
60
25
71
20
10
5
1
14
1
1
0
4
2
0
8
170
21
14
5
2 Tbs Alfredo Sauce
¾ cup Yellow Squash
¾ cup Green Beans
220
125
25
25
43
1
5
5
8
3
1
1
1
0
0
0
½ cup Grapes
104
27
1
0
3 oz Cheddar
147
2020
2
264
21
113
6
52
Optifast 800 Ready to
Drink Shake
3 tsp Margarine
3 packets Splenda
11:00 Mid-morning
AM snack
1:30
Lunch
PM
4:30 Mid-afternoon
PM snack
7:00
Dinner
PM
9:30
HS Snack
PM
Totals for the Day
Calories Carbohydrates Protein Fat
(kcal)
(grams)
(grams) (grams)
Optifast 800 Bar
1 cup Spaghetti
1& 11
Current prescribed diet
NM was on steroid therapy to treat her COPD. Because of the steroid therapy, NM was
admitted with consistently high blood glucose levels. For this reason, doctor’s orders were given for an
Average Diabetic Diet for the duration of her stay at Winter Park Memorial Hospital. An Average
Diabetic Diet allows the patient to select up to 60-75 grams of carbohydrates for each meal. NM’s diet
order remained the same for her entire stay.
Objectives of dietary treatment
The objective of the Average Diabetic diet is to maintain NM’s blood sugars within normal limits
or as close as possible to normal levels. This may have proved an arduous task given the steroid
therapy that NM was undergoing to treat her COPD. Finger-stick blood sugar levels referred to as
“Accuchecks” ranged inconsistently from 130 to 289 as seen on the lab values table above.
Patient’s Physical and Psychological Response to Diet
NM stated that at home, she followed an eating pattern similar to that of the Average Diabetic
Diet but with the addition of snacks in between meals. She denied facing vomiting or constipation
while on this diet. She did admit to experiencing diarrhea and nausea upon admission to the hospital.
As previously mentioned, NM believed she was exposed to Clostridium Difficile, to which she attributes
to the cause of having diarrhea.
List nutrition-related problems with supporting evidence
COPD: Increased energy expenditure related to increased energy requirements during COPD
exacerbation as evidenced by estimated resting energy expenditure greater than predicted needs.
Evaluation of Present Nutritional Status
According to the diet analysis table above, NM was meeting her increased caloric needs for COPD.
Additionally, her diarrhea subsided by day two of hospitalization. Per lab values as those noted above
in the table, there did not appear to be any indication of dehydration.
Kcal/Protein Guidelines
Nutritional needs are often increased in COPD due to the increased work of breathing. Optimal
nutritional status plays an important role in maintaining the integrity of the respiratory system and in
allowing maximal participation in daily living.1 Caloric requirements for COPD should be individually
determined based on patient age, weight and gender, the extent of protein energy malnutrition loss of
lean body mass, current medications and other acute or chronic medical conditions.
The Mifflin St. Jeor equation can be used to estimate the REE. In patients with COPD, this
calculation may underestimate the caloric requirements because of the caloric increase from
metabolically active tissue in COPD. To compensate for this underestimation, a stress activity factor
may be added according to the degree of stress. Furthermore, in most cases the total calorie intake of
the COPD patient is more important than the source from calories. For maintenance 1.33 x REE or
25/35 calories per kilogram is appropriate for the needs of the COPD patient. Protein is recommended
at 1.0-1.5 grams per kilogram of body weight for maintenance.1
Below is a chart of how NM’s needs were clinically calculated during her hospital admission on
December 5th through the 6th.
Kcal calculations
Protein calculations for adjusted body weight
Fluid requirements
1926-2408
66-79
1500 ml per
physician
Need for Alternative Feeding Methods and the Patient’s Nutrition Education Process
Since NM was in fact meeting the additional needs required for COPD, I do not believe that
there was any need for alternative feedings such as tube feeding. Moreover, in explaining the
prescribed diabetic diet to NM, no type of barrier to learning was identified.
PROGNOSIS
NM expressed her motivation to continue to follow a diet similar to that of the Average
Diabetic Diet upon her return home as long as her increased COPD needs were met. She was aware of
the effects of steroid therapy on her blood sugar levels. In fact, NM clearly verbalized her
understanding on the use of steroids, their effects on increasing blood sugar levels and the importance
of meal planning especially around carbohydrates. This was more of a motivating factor for her to
continue monitoring her diet on discharge.
SUMMARY
From this study, I learned how very serious COPD is. It was once explained to me some time ago
that COPD was like a gradual suffocating in a pillow. Seeing NM experiencing shortness of breath
during the interviews or when speaking to me during the interviews made me realize that even the
slightest amount of energy requires oxygen. Imagine not being able to breathe to conduct the simplest
activities of daily living! In addition to other medical issues as NM had, it made me realize how
important nutrition energy is needed for healing.
BIBLIOGRAPHY
1. Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food, Nutrition and Diet Therapy, 13th Edition,
Philadelphia, Pa: Elsevier; 2012
2. Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy and Pathophysiology, 2nd Edition. Cengage
Learning, Inc: 2010.
3. Chatila WM, Thomashow BM, Make BJ. Comorbidities in Chronic Obstructive Pulmonary Disease. Journal
of the American Thoracic Society. 2008 May 1; 5(4): 549-555
4. Centers for Disease Control. Chronic Obstructive Pulmonary Disease (COPD) Data and Statistics.
Available at: http://www.cdc.gov/copd/data.htm. Accessed December 29, 2013.
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Nutrition Therapy. Available at: http://www.nutritioncare.org/index.aspx?id=5696. Accessed January 5,
2014.
6. Mayo Clinic. Disease and Conditions: COPD. Available at: http://www.mayoclinic.org/diseasesconditions/seo/basics/symptoms/con-20032017. Accessed January 8, 2014.
7. National Institutes of Health: National Heart Lung and Blood Institute. How Is COPD Treated? Available
at: http://www.nhlbi.nih.gov/health/health-topics/topics/copd/treatment.html. Accessed January 8,
2014.
8. British Lung Foundation. Steroids. Available at: http://www.blf.org.uk/Page/Steroids. Accessed
December 29, 2013.
9. MedlinePlus: A service of the U.S. National Library of Medicine From the National Institutes of
HealthNational Institutes of Health. Drugs and Supplements. Available at:
http://www.nlm.nih.gov/medlineplus/druginfo/drug_Ca.html
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https://www.nlm.nih.gov/learn-about-drugs.html. Accessed January 8, 2014.
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Januery 7, 2014.
Images
1. http://sciencelife.uchospitals.edu/2013/05/07/qa-dr-christopher-wigfield-on-the-future-of-lungtransplantation/
2. http://www.nlm.nih.gov/medlineplus/ency/imagepages/19376.htm
3. http://www.cdc.gov/copd/data.htm
4. http://www.optifast.com/Pages/index.aspx