12/8/2014

Case Study
Diabetes

Ashley Wilkins

Introduction
Pt was a 71-year-old patient admitted to the Hospital in June due to a poor healing wound and was
diagnosed upon admission with cellulitis and type 2 diabetes mellitus (T2DM). Pt was earlier diagnosed
with hypertension. This case study will discuss the patient social and medical history, nutrition diagnosis,
the etiology and treatment of T2DM.
Patient Profile and Social History
Pt was a 71-year-old female widow who was 50 and weighed 155 pounds. Pt clinic chart reports
complained about frequent bladder infections and tingling and numbness in feet. Pt has reported no use of
alcohol and/or drugs. Pt regularly attended the Senior Center birthday celebration.
Medical History
Pt was admitted to the hospital for surgical debridement of wound and unhealed ulcer, blurred
vision and a high blood glucose level. Patient had no allergies. Pt was taking capoten for hypertension and
claimed to never miss a day. Pt had a close family history of diabetes. Upon admission to the Hospital pt
was diagnosed with T2DM and cellulities. Many of the symptoms the pt was experiencing, like blurred
vision, slight tingling, and poor wound healing, may be related to the uncontrolled diabetes and
hyperglycemic hyperosmolar nonketotic syndrome (HHNS).
Nutrition Focused Physical Exam
The patients nutrition focused physical exam returned with mildly diminished in feet, a 2-3 cm ulcer
on the lateral left foot, pulse 2-bilaterally, cool, mild edema on peripheral vascular. Pts extremities and the
abdomen were normal.
Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) the bodys cells are insensitive to insulin or the body is not making
enough insulin, making it hard for glucose to enter the cells. This causes glucose to stay in the blood,
causing high blood glucose levels (1, 2). The cells that are not receiving glucose are sending signals to the
pancreas to release more insulin. Over time if the T2DM is uncontrolled or undiagnosed, the pancreas can
get worn out and insulin can be decreased (1). According to the Mayoclinic there are different factors that
affect ones risk of getting T2DM. Factors include excesses weight and genetics, but exactly why the body
reacts the way it does is still unknown (3).
The diagnosis criteria for diabetes mellitus (DM) is having glucose levels higher than 200 mg/dL for a
casual plasma test or a fasting glucose levels higher than 126 mg/dL (4). Tests done to determine if a
person has T2DM are blood glucose level tests, glucose tolerance test, and an HbA1c (1, 4). The HbA1c is
the amount of glucose the body has controlled over the past two to three months and must be about 7%
(4).
Type 2 diabetes affects approximately 8 percent of adults in the United States (5). Certain groups
of the population have been found to have increased risk of having T2DM. These groups are, overweight
and obese, certain minority races and the elderly, people with a family history of T2DM, sedentary lifestyle,
and those who have had gestational diabetes, and having a history of hypertension (1, 5, 6). Populations
that are at high risk of developing T2DM should know the signs and symptoms of T2DM and should
participate in prevention methods.
A study done by the New England Journal of Medicine showed that lifestyle changes have in impact
on the risk for T2DM (7). Increased exercise and healthier food choices can be a way to help control and/or
prevent T2DM. Theoretically by increasing exercise a person will decrease body fat, allowing the cells to be
more receptive to insulin, allowing glucose to enter (6).

Hyperglycemic Hyperosmolar Nonketotic Syndrome

Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) happens when a persons blood glucose
is greater than 600 mg/dL and occurs most often in people with T2DM (6). To have HHNS a persons blood
glucose must be extremely high, glucose levels are found to be that high in people with uncontrolled or
undiagnosed T2DM. Having glucose levels that high causes the body to filter the glucose out through the
urine, causing frequent urination, which can lead to severe dehydration and possibly death if untreated for
long periods of time (8). Treatment for HHNS is an IV saline solution and insulin (2).
Signs and symptoms of HHNS vary in their appearance and in their severity, but the person suffering
from HHNS will have extreme dehydration. To diagnose HHNS a blood glucose level test or a serum
osmolality test must be done.
Exchange List and Carbohydrate Counting
An exchange list is a diet that is meant to help control blood glucose levels by counting the amount
of carbohydrates each food groups gives you. The food groups are milk, starch, meat or meat substitutes,
fruit, vegetables, fat, and bean. The amount of food that is permitted is called an exchange and depending
on a persons needs determines how many exchanges they get from each group. The exchange list helps
control blood glucose by only allowing a certain amount of carbohydrates at certain times (10).
Carbohydrate counting is another way to control blood glucose levels by breaking down the allowed
amount of carbohydrates allowed throughout the day into portion. This method requires a lot of label
reading. The amount of carbohydrates eaten at each meal will determine the amount of insulin/
medication that would be needed (10). Both of the methods are effective ways to control blood glucose it
just depends on which method for glucose control. The method chosen are dependent on the patient and
which one will work best for them (11).

To determine how many carbohydrates a person can have first their estimated needs must be
determined, and for and exchange list the amount of protein and fat needs must also be determined. Once
determined split the amount between the amounts of meals throughout the day. Most important thing is
to never exceed the maximum carbohydrate limit.
Treatment and Progress
Pt was admitted for the treatment lesion on foot and high blood glucose levels. The treatment plan
for pt was to deride the wound, normalize blood glucose levels through nutrition education with menu
planning and other lifestyle changes associated with T2DM and HHNS, signs and symptoms (s/s) of T2DM
and HHNS, and medication. Pt decided on the exchange list diet as the option for controlling carbohydrate
intake. After determining patients estimated needs, using the Harris-Benedict equation, of 1432 Calories.
Patients exchange diet is listed below and gave patient an appropriate amount of calories according to their
estimated needs on the day of admission.
Pt was sent to a Registered Dietitian before being discharged and was giving nutrition education
related to their diagnoses of hypertension, T2DM, and cellulitis. Pt was also educated on how to use the
exchange diet and food and drug interactions.
Diet Evaluation and Exchange Diet
Pt usual diet before being admitted contained three full meals and one snack ate night. Pt had a
diet high in saturated fat and cholesterol and contained about 1417 Calories, just below patients estimated
needs. The pt diet order while at the hospital was a 1200 Calorie diet from the American Diabetes
Association (ADA) exchange diet.

The following was an exchange list diet for pt provided by the Registered Dietitian (RD) after the
estimated needs were calculated. Pts estimated needs were calculated because the 1200 Calorie diet
seemed to low and could cause metabolic syndrome.

Starch (5)
Meat (4)
Milk (3)
Fat (6)
Veg (3)
Fruit (2)
Bean (1)
Total
B
S
L
S
D
S

CHO
74
0
45
0
15
30
15
179

Starch (5)
1
1
1
1
1

PRO
15
33
24
0
6
0
7
85

FAT
5
8
3
30
0
0
2
48

Kcal
400
180
300
270
75
120
125
1470

Meat (3)

Milk (3)

Fat (6)
1

1
1

2
1
2
1

3
1

Veg (3)

1
2

Fruit (2)
1
1

Bean (1)

B: Waffle with fruit

S: Granola with small fruit
L: Grilled cheese sandwich and milk to drink
S: Crackers with cheese
D: Corn tortilla with beans, hamburger, and lettuce
S: Carrots and ranch dressing with milk to drink
Medications
Patient was prescribed 10 mg gd Lipitor and was told to continue taking 50 mg bid Capoten. Both
medications are used to lower risk for cardiovascular disease (9). These medications may be the reason for the slight
improvement between the lab reports.

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Lab Data and Interpretation

Lab
Normal
Albumin
3.5-5
Total Protein
6-8
Prealbumin
16-35
Transferrin
250-380
Sodium
136-145
Potassium
3.5-5.5
Chloride
95-105
PO4
2.3-4.7
Magnesium
1.8-3
Osmolality
285-295
Total CO2
23-30
Glucose
70-110
BUN
8-18
Creatinine
0.6-1.2
CHOL
120-199
HDL-C
>55
LDL
<130
LDL/HDL ratio
<3.22
TG
35-135
HbA1c
3.9-5.2
HGB
12-15
HCT
37-47
Red= High, Blue= Low

Admit
4.0
7
23
310
140
4.2
103
3.6
2.1
315H
25
325H
26H
1.2
300H
35L
140H
4.0H
400H
8.5H
9.9L
30.4L

d/c
4.1
7.2
24.5
305
145
4.5
100
3.2
1.8
314H
26
121H
26H
1.2
250H
37L
138H
3.7H
300H
10.1L
27.7L

Units
g/dL
g/dL
mg/dL
mg/dL
mEq/L
mEq/L
mEq/L
mg/dL
mg/dL
mmol/kg/H2O
mEq/L
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
%
g/dL
%

All of her labs are improving except the BUN and the HCT. Overall it would appear that ED is
improving. This could be due to the medications and the controlling of the diabetes. ED admission labs are
probably the way they are because the patient had uncontrolled T2DM and once it was diagnosed the
blood levels are starting to return to normal.
Anthropometrics
Pt was 152.4 cm in height and 70.45 kg in weight. Pts ideal body weight (IBW) was 45.45 kg. Pts
weight was 155% of her IBW. Body Mass Index (BMI) is not an appropriate measurement for this patient
because she was African American, therefore a BAI would be the most appropriate way to determine body

fat percentage. Did not have enough information to perform the BAI. The pts BMI was 30.3, pt was in the
overweight/ obese category.
Conclusion
Pt was admitted to the Hospital for a sore on the left foot that was not healing. Upon discharge pt
received nutrition education for T2DM and an exchange list meal plan.
Many of the pts labs were starting to improve after blood glucose levels were starting to be controlled.
With the exchange list diet and the diabetes education pts glucose levels will hopefully regulate.

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References
1. Oral Diabetes Medications for Adults with Type 2 Diabetes: An Update. AHRQ. 2011;1.
http://www.effectivehealthcare.ahrq.gov/ehc/products/155/644/type-2-diabetes-medications-report130911.pdf. Accessed December 5, 2014.
2. Porter RS, Kaplan JL, eds. The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Sharp
and Dohme Corp; 2011
3. Mayo Clinic Staff. Disease and Conditions: Type 2 Diabetes. http://www.mayoclinic.org/diseasesconditions/type-2-diabetes/basics/causes/con-20031902. Updated July 24, 2014. Accessed December 5,
2014.
4. Desai SP. Clinicians Guide to Laboratory Medicine. Huston TX: MD2B; 2009.
5. Diabetes Prevention Program Research Group. Reduction in the Incidence of Type 2 Diabetes With Lifestyle
Intervention or Metformin. NIC 2002. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1370926/pdf/nihms5217.pdf. Accessed on December 5, 2014.
6. Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA: Cengage
Learning; 2007.
7. Tuomilehto J, Lindstrom J, Eriksson J, Valle TT, Hamalainen H, Ilanne-Rarikka P, etc. Prevention of Type 2
Diabetes mellitus by Changes in Lifestyle Among Subjects With Impaired Glucose Tolerance. The New
England Journal of Medicine. 2001; 1343. http://www.nejm.org/doi/pdf/10.1056/NEJM200105033441801.
Accessed December 5, 2014.
8. Mayo Clinic Staff. Diseases and Conditions: Diabetic hyperosmolar syndrome.
http://www.mayoclinic.org/diseases-conditions/diabetic-hyperosmolar-syndrome/basics/definition/con20026142. Updated June 20, 2012. Accessed December 5, 2014.
9. Pronsky ZM, Crowe SJP. Food Medication Interactions. 17th ed. Birchrunville, PA: Food-Medication
Interactions; 2012.
10. Mayo Clinic Staff. Diabetes diet: Create your healthy-eating plan. http://www.mayoclinic.org/diseasesconditions/diabetes/in-depth/diabetes-diet/art-20044295. Updated April 4, 2013. Accessed December 7,
2014
11. Carbohydrate Counting. American Diabetes Association. http://www.diabetes.org/food-andfitness/food/what-can-i-eat/understanding-carbohydrates/carbohydrate-counting.html. Updated
September 15, 2014. Accessed December 7, 2014.

Nutrition Care Process and Note

A: Pt was a 71 y/o female pt w/ HTN, cellulitis, and T2DM; 152.4 cm and weighed 70.45 kg. Pt body mass index of 31.
The following labs were elevated: BUN, glucose casual diet, HgbA1c, cholesterol serum, LDL:HDL, triglycerides serum,
low labs: , cholesterol LDL, hemoglobin, and hematocrit. Total energy intake (FH-1.1.1.1) seem low w/ 1200 kcals
compared to estimated energy needs of 1432. Has a sister with DM for ten years and has had DM education.
Nutrition focused physical exam included mild retinopathy, mild diminished sensation in feet, ulcer and laceration on
left foot and mild edema in the peripheral vascular. Patient diagnosed with Type 2 Diabetes Mellitus.
D: Inadequate oral intake (NI-2.1) r/t Mayoclinic exchange list diet AEB actual intake.
I: Modify composition of meals/snacks (ND-1.2) and Nutrition relationship with health/disease (E-1.4)
Goals: pt will follow the exchange list diet for two weeks to help increase caloric intake up to the recommend amount
of 1432 Calories.
M/E: RD will f/u in two weeks and check glucose, casual diet (BD-1.5.2) and total energy intake (FH-1.1.1.1).
Anticipate stabilization of blood glucose and improved wound healing.

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ESHA Report
ED- food All Days
Female

71 Yrs.

5 ft. in.

155.00 lb.

Very Active

BMI: 30.27

Diet

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Diet cont.
Item Name
Ham, smoked,
1 Ounce-w...
spiral cut
Coffee

Quantity

Measure

1 Cup

Evening Snack

Cookie, vanilla
wafer
Recommendations
Nutrients

Rcmd

Basic Components
Calories (kcal)

2396.14

Calories from Fat (kcal)

670.92

Calories from SatFat (kcal)

Protein (g)
Carbohydrates (g)
Dietary Fiber (g)

Nutrients
Biotin (mcg)

215.65
56.25
329.47
33.55

Soluble Fiber (g)

Vitamin C (mg)
Vitamin D - mcg (mcg)

20.00

Vitamin E - Alpha-Toco (mg)

15.00

Folate (mcg)

400.00

Folate, DFE (mcg)

400.00

Pantothenic Acid (mg)

Monosaccharides (g)

75.00

Vitamin D - IU (IU)

Vitamin K (mcg)

Total Sugars (g)

Rcmd
30.00

90.00
5.00

Minerals

Disaccharides (g)

Calcium (mg)

Other Carbs (g)

Chromium (mcg)

1200.00
20.00

Fat (g)

74.55

Copper (mg)

0.90

Saturated Fat (g)

23.96

Fluoride (mg)

3.00

Iodine (mcg)

150.00

Mono Fat (g)

Poly Fat (g)

26.62
23.96

Trans Fatty Acid (g)

Cholesterol (mg)
Water (g)

300.00
2700.00

Iron (mg)

8.00

Magnesium (mg)

320.00

Manganese (mg)

1.80

Molybdenum (mcg)

45.00

Vitamins

Phosphorus (mg)

Vitamin A - IU (IU)

Potassium (mg)

4700.00

Selenium (mcg)

55.00

Vitamin A - RAE (RAE)

700.00

Carotenoid RE (RE)

Sodium (mg)

Retinol RE (RE)

Zinc (mg)

Beta-Carotene (mcg)
Vitamin B1 (mg)

700.00

1200.00
8.00

Poly Fats
1.10

Omega 3 Fatty Acid (g)

2.40

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Recommendations cont.
Vitamin B2 (mg)

Nutrients

Rcmd
1.10

Vitamin B3 (mg)

14.00

Vitamin B3 - Niacin Equiv (mg)

Nutrients
Omega 6 Fatty Acid (g)

Rcmd
21.30

Other Nutrients

14.00

Alcohol (g)

Vitamin B6 (mg)

1.50

Caffeine (mg)

Vitamin B12 (mcg)

2.40

Choline (mg)

425.00

Weight Gain/Loss
N\A

N\A

Multi Column: ED | All Days

Nutrients

Value

Basic Components

Nutrients
Biotin (mcg)

Value
9.52

Gram Weight (g)

1646.93

Vitamin C (mg)

90.25

Calories (kcal)

1415.47

Vitamin D - IU (IU)

94.10

Calories from Fat (kcal)

670.43

Vitamin D - mcg (mcg)

2.36

Calories from SatFat (kcal)

228.38

Vitamin E - Alpha-Toco (mg)

3.43

Protein (g)
Carbohydrates (g)

47.69
127.78

Dietary Fiber (g)

19.77

Soluble Fiber (g)

0.66

Total Sugars (g)

Monosaccharides (g)
Disaccharides (g)

24.15

Folate (mcg)
Folate, DFE (mcg)
Vitamin K (mcg)
Pantothenic Acid (mg)

170.18
163.58
152.17
1.70

Minerals

6.50

Calcium (mg)

5.17

445.94

Chromium (mcg)

1.16

Other Carbs (g)

83.80

Copper (mg)

0.31

Fat (g)

74.56

Fluoride (mg)

49.86

Saturated Fat (g)

25.38

Iodine (mcg)

31.47

Mono Fat (g)

25.91

Iron (mg)

5.13

Poly Fat (g)

9.53

Magnesium (mg)

49.79

Trans Fatty Acid (g)

0.65

Manganese (mg)

0.32

Cholesterol (mg)

317.25

Molybdenum (mcg)

Water (g)

917.76

Phosphorus (mg)

460.08

Potassium (mg)

737.65

Vitamins
Vitamin A - IU (IU)

7514.45

Selenium (mcg)

Vitamin A - RAE (RAE)

484.74

Sodium (mg)

Carotenoid RE (RE)

689.71

Zinc (mg)

Retinol RE (RE)

139.89

Beta-Carotene (mcg)

4039.49

12.41

34.10
3730.66
2.22

Poly Fats
Omega 3 Fatty Acid (g)

0.79

13
Vitamin B1 (mg)
Vitamin B2 (mg)

0.30

Omega 6 Fatty Acid (g)

0.44

8.12

Other Nutrients

Vitamin B3 (mg)

4.17

Alcohol (g)

Vitamin B3 - Niacin Equiv (mg)

8.11

Caffeine (mg)

306.22

Vitamin B6 (mg)

0.45

Choline (mg)

189.66

Vitamin B12 (mcg)

1.29
Multi-Column