Answer Guide for Medical Nutrition Therapy: A Case Study ...



Amee Gloyn

Case Questions for Medical Nutrition Therapy: A Case Study Approach 4th ed.

Title: Case 17 – Adult Type 2 Diabetes Mellitus: Transition to Insulin

Instructions: Answer the questions below. Please print the questions out with your answers and bring to class on the due date.

Questions:

1. What are the standard diagnostic criteria for T2DM? Which are found in Mitch’s medical record?

Standard diagnostic criteria for T2DM is A1C > 6.5, FBG > 126 or Oral Glucose Tolerance Test >200. Mitch’s medical record shoes A1C= 15.2, and a BG of >1524. And while the test is not fasting, he reported not eating or drinking for at least 12 hours.

2. Mitch was previously diagnosed with T2DM. He admits that he often does not take his medications. What types of medications are metformin and glyburide? Describe their mechanisms as well as their potential side effects/drug–nutrient interactions.

Metformin is an antihyperglycemic. It potentiates the effect of insulin. Decreases GI glucose absorption and hepatic glucose production. Side effects include headache, fatigue, muscle pain, flu like symptoms, dyspnea, rash, sweating, chills, chest discomfort, palpitation, dizziness, asthenia, and, very rarely, lactic acidosis. Potential drug-nutrient interactions include decrease in weight, decrease in folic acid and B12 absorption. It is recommended that the patient wait 6 or more hours after taking the medication to consume guar gum, as this decreases absorption.

Glyburide is a sulfonylurea, an oral hypoglycemic. It increases insulin release from beta cells in the pancreas. Side effects include dyspepsia, nausea, diarrhea, constipation, hypoglycemia, dizziness, headache, drowsiness, blurred vision, and skin reactions. Potential drug-nutrient interactions include a decrease or increase in appetite.

3. What other medications does Mitch take? List their mechanisms and potential side effects/drug–nutrient interactions.

Dyazide is a diuretic and antihypertensive combination drug. Triamterene (diuretic) is a weak dihydro-folate reductase antagonist. Hydrochlorothiazide (diuretic, antihypertensive). Side effects include taste changes, nausea, vomiting, diarrhea, dizziness, headache, photosensitivity, hyperkalemia, constipation and GI irritation. Possible drug-nutrient interactions: avoid excess potassium intake, avoid natural licorice (triamterene) and possible need for potassium supplement, avoiding excess calcium and vitamin D, increase magnesium, decrease sodium (hydrochlorothiazide).

Lipitor (HMG-CoA Reductase inhibitor) is an antihyperlipidemic. It works by inhibiting HMG-CoA reductase in the liver, which is a key synthesizer of cholesterol. Side effects include nausea, dyspepsia, abdominal pain, constipation, diarrhea, chest pain, insomnia, bronchitis, myopathy, back pain, weakness, headache, rash, dizziness, and flatulence. Possible drug-nutrient interactions include decreasing fat in diet, dietary cholesterol, and avoiding grapefruit and related citrus.

4. Describe the metabolic events that led to Mitch’s symptoms and subsequent admission to the ER with the diagnosis of uncontrolled T2DM with HHS.

Mitch was diagnosed with T2DM a year ago and did not make the necessary changes to his diet to lower his blood glucose levels. He also did not take his medication as prescribed to lower his blood glucose. So with a continued diet high in carbs and improper medication intake, his blood glucose continued to rise. Eventually, his blood glucose reached a point his body could no longer handle. The HHS manifested when he was sick with nausea and vomiting for 12-24 hours and he had little to nothing to drink (fluid intake) leading to dehydration without diabetic ketoacidosis.

5. HHS and DKA are the common metabolic complications associated with diabetes. Discuss each of these clinical emergencies. Describe the information in Mitch’s chart that supports the diagnosis of HHS.

HHS is diagnosed by blood glucose higher than 600, serum osmolality greater than 320 mOsm/kg, absence of ketoacidosis, infection, and dehydration. Often seizures may be present.

DKA develops rapidly. Polyuria, polydipsia ad weight loss may be present for several days. Vomiting and abdominal pain are frequently the presenting symptoms. Dehydration is found upon physical examination. Mental status can vary from fully aware to profound lethargy. Acetone on the breath is often present upon admission. It is diagnosed by blood glucose higher than 250, moderate degree of ketonemia, serum bicarbonate of ................
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