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Case Study 23 Mylena Dominguez

Type 2 Diabetes Mellitus 10/22/2012

1. What is the difference between type 1 diabetes mellitus and type 2 diabetes mellitus?

Type 1:

- 5%-10% of diagnosed cases.

- Individuals present a lack of production of insulin due to a destruction of ß-cells in pancreas.

- 50% acquired before 20 years old. 50% develop as adults.

- Most frequent in children and adolescents but increasing in adults.

- Cellular-mediated autoimmune destruction of ß-cells of the pancreas.

- Genetic predisposition and environmental factors seem to contribute.

Type 2:

- 90%-95% of diagnosed cases.

- Due to insulin resistant in tissues and ß-cell failure.

- May be due to heredity and environmental factors.

- Obesity, particularly central distribution of adiposity and sedentary may play a role in developing T2DM.

2. How would you clinically distinguish between type 1 and type 2 diabetes mellitus?

- T2DM: hyoerglycemic hyperosmolar syndrome (HHS), which is characterizied by a serum glucose level of >600 mg/dL, and a serum osmolality >320 mOsm/kg pf water and absence of ketoacidosis.

- T1DM: serum glucose of > 200 mg/dL, fasting plasma glucose of > 126 mg/dL and symptoms such as unexplained weigh loss, polydipsia, polyuria.

3. What risk factors for type 2 diabetes does Mrs. Douglas present with?

- Older age: 71 years old

- Obesity: BMI

- Family Hx: Siter Dx with T2DM 10 years ago

- Race/ethinicity: African American

4. What are the common complications associated with diabetes mellitus? Describe the phatophysiology associated with these complications, specifically addressing the role of chronic hyperglycemia?

- Cardiovascular Disease (Macrovascular complication): hyperglycemia makes the blood vessels prone to endothelial damage. This leads to thickening and changes in the composition of the subendothelial layer.

- Nephropathty (Microvascular complication): hyperglycemia changes the structure of the glomerulus’ blood vessels and capillaries which result in a increase of permeability and decreses in filtering ability.

- Retinopathy (Microvascular complication): hypergycemia affects the blood vessels.

- Peripheral neuropathy: hyperglycemia causes an abnormal accumulation of sorbitol and glycated proteins resulting in cellular damage, disrupting normal nervous system pathways.

5. Does Mrs. Douglas present with complications of diabetes mellitus? If yes, which ones? Yes, hyperglycemia 325 mg/dL, hypertension 150/97 mm Hg, blurry vision (retinopathy), tingling and numbness in her feet (peripherial neuropathy), dyslipidemia, and dehydration.

6. Identify at least four features of the physician’s physical examination as well as her presenting signs and symptoms that are consistent with her admitting diagnosis. Describe the pathophysiolgy that might be responsible for each physical finding.

|Physical finding |Physiological Change/Etiology |

|Unhealed ulcer on leg |Hyperglycemia damaged blood vessels preventing proper flow of blood |

| |and subsequently slowing down healing. |

|Mild edema |Diminished elasticity of blood vessels |

|Mild Retinopathy |Microvascular damage due to hyperglycemia. |

|Dry mucous membranes |Could be a sign of dehydration, possibly due to polyuria. |

|Slightly diminished sensation on feet |Sign of neuropathy due to changes in the nervous system pathways. |

7. Prior to admission, Mrs. Douglas had not been diagnosed with diabetes mellitus. How could she present with complications?

12. Calculate Mrs. Douglas BMI.

BMI= 70.45/(1.5) =31.73 Obesity Class1

13. What are the health implications for a BMI in this range?

Obesity has been correlated to T2DM. Excess body fat elevates fasting and postprandial levels of serum free fatty acids, which is a risk factor for metabolic syndrome. High serum free fatty acids can stimulate the secretion of insulin potentially leading to insulin resistance in the peripheral tissues, inhibit cellular uptake of glucose, reduce glycogen storage, and increase hepatic glucose production, eventually developing T2DM.

14. Calculate Mrs. Douglas’s energy needs. Use HB with appropriate stress factor. What is the appropriate weight to use in the equation?

Ideal body weight: 100lb for 5 foot = 5ft-100lb

655.1+9.6(45.45)+1.99(152)-4.7(71)= 1060.2 kcal

Stress factor: 1.3

1060.2x1.3=1278.26

15. Calculate Mrs. Douglas’s protein needs.

45.45 kg x 1.3=59.08g

1278 x .20= 255.6/4=63.9g

Protein needs=61g

16. Is the diet order of 1,200 kcal appropriate?

Yes, the pt is obese and therefore a 1,200 kcal diet would be appropriate

19. Calculate kcals, protein, fat, and cho. Of Mrs. Douglas’s diet. Use

|Food/Portion |Kcal |Protein g |Fat g |CHO g |

|1 egg |92 |6.3 |7 |.4 |

|2 strips bacon |92 |6.3 |7.1 |.2 |

|½ c orange juice |112 |1.7 |.5 |25.8 |

|1 slice bologna |88 |2.9 |7.9 |1.1 |

|2 slices white bread |48 |1.6 |.6 |8.8 |

|1 slice American cheese |68 |4 |5.6 |.3 |

|1 c turnip greens |29 |1.6 |.3 |6.3 |

|1 oz fatback |256 |2.8 |.2 |0 |

|2 sm potatoes |245 |2.8 |.2 |23.9 |

|2-inch corn bread |188 |4.3 |6 |28.9 |

|1tsp butter |34 |.03 |.03 |.03 |

|¾ beans |100 |6.4 |0.3 |18.4 |

|1 oz ham |45 |4.6 |2.4 |1.1 |

|2 vanilla wafers |35 |0.25 |125 |5.5 |

|Total |1432 |43.35 |195.13 |120.73 |

20. How would you compare Mrs. Douglas’s “usual” dietary intake to her current nutritional needs.

- Caloric intake is higher of her needs.

- Protein intake of lower than her needs.

- Fat intake: 195.13 g

Recommendation: 1278kcal x .35=447.3/9=49.7 g

- Fat intake is higher than needs.

22. Identify two lab values that should be monitored regularly.

- Lipids

- Glycated hemoglobin

30. Select two high-priority nutrition problems and complete the PES statement for each.

Inadequate nutritional intake related to newly diagnosed T2DM as evidenced by serum glucose level of 325 mg/dL and high intake of carbohydrate.

31. What was the most important nutritional concern when the patient was originally admitted to the hospital (time of Dx)?

Normalize blood glucose

33. For each of the PES statement that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology).

Ideal goal would be to stabilize blood glucose and maintain a Hgb A1C >7.

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