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OSTEOMYLETIS WITH SECONDARY DIABETES AND RENAL FAILUREEmily KruegerApril 15, 2016Case Study IntroductionThis paper will cover and discuss a medical case observed at LDS Hospital, located in Salt Lake City, Utah. Osteomyelitis with complications of diabetes and renal failure is the case that will be discussed in detail. This will include the patient’s profile and illness. Also, medical nutrition therapy for this specific patient and their situation will be reviewed and it will be discussed on how well it was received and functioned.Patient ProfileNS is a 45 year old, Caucasian, female from the Utah county area. She is the mother of three children and is currently separated from her husband. The patient reported that she works in security so she is on her feet much of the time. She also reports that she is not religious.NS has a medical history of endometritis, fibromyalgia, and diabetes. She was diagnosed with diabetes in 2003. A year ago, May of 2015, NS was admitted to the hospital for wounds on her right foot and left foot. The right foot wound occurred from being scratched on the coral reef while in Hawaii for vacation. The left foot is a seashell injury from the same trip. NS received irrigation and debridement treatments on both wounds. Other surgeries NS has had were a tubal ligation and an ACL surgery.Patient Illness NS has a history of poorly controlled diabetes. She was admitted to the hospital with her right, great toe exhibiting redness, swelling, pain, and discoloration. She reported that it had been like that for the past week. NS also said upon admittance that she had been experiencing nausea, vomiting, fever, and chills in the past eight days. She also reported that she was having difficulty urinating and was experiencing constipation. She was diagnosed with osteomyelitis and cellulitis. Other problems that were also noted were hyponatremia, DVT prophylaxis, diabetes, and renal failure.Osteomyelitis is an infection of the bone. Some infections can travel through the bloodstream and spread to nearby tissue such as bone. The abscess starts in the bloodstream and grows, destroying the surrounding tissue faster than osteoblast can rebuild the bone. The infection tears down surrounding tissue breaking through the skin. It kills the healthy cells, causing the red and black discoloration seen in this patient. It is not uncommon for diabetics to develop osteomyelitis, it is common to happen the foot ulcers that develop in many diabetics. NS had poorly controlled diabetes, so a development of osteomyelitis is not uncommon.Clinical features of osteomyelitis include an elevated white blood cell count due to the infection. Signs and symptoms include ulcers, pain, fever, chills, and warmth and redness over the area of infection. NS had all of these signs and symptoms described.NS entered the hospital because of the pain she was experiencing in her right foot. Her physician decided to fight the wound with vancomycin. Once they started this antibiotic, NS’s renal labs began to elevate. Staff did not know if that was due to the uncontrolled diabetes or vancomycin. Then they had to treat the renal failure, foot wound, and diabetes.Specific tests were performed to try to figure out the best plan of action for treating NS, since staff was unsure of what exactly was causing what. First, a MRI was performed that revealed osteomyelitis within the proximal phalanx of the great toe. There was evidence of significant septic arthritis. They also performed a kidney biopsy on the ninth day after being admitted to the hospital. The needle biopsy showed that she had severe acute tubular necrosis, focal interstitial nephritis, and severe diabetic glomerulopathy. This all evidenced that there had been long, extensive damage done to the kidneys by diabetes. Below is a history of the patient’s labs that were found significant to this case study.3/233/223/213/193/173/143/11Glu105113-124129172202CRP-----5.7-BUN3236.037.031.049.036.019.0Alb2.92.82.82.82.7--Creat3.614.024.213.846.065.62.05P4.95.75.75.2---Na139139139137137134135These lab values indicate that blood glucose started to come within normal limits once the patient was receiving proper medications and interventions for her diabetes. The most interesting thing to note is that on day five, after being admitted to the hospital, NS’s BUN and creatinine levels significantly elevated. This is what alerted physicians to end vancomycin treatment and perform a kidney biopsy. NS’s prognosis is that she will make a full recovery. Her diagnosis does raise some nutritional concerns. Due to her diabetes and renal failure, she was put on a special diet, restricting sodium, potassium, and carbohydrates. She also has an increased need for protein to assist in wound healing. Those are some of the treatment that she received. She also was given Lantus and Humalog for her diabetes. In addition to combat her diabetes, a nutritional education was done and she is expected to receive care with outpatient services once she is discharged from the hospital. To treat her renal disease she was on the special diet and given Nephro-vite, which is a standard medication given to everyone in renal failure to help their kidneys function. Lastly, to treat the osteomyelitis she was given an array of antibiotic treatment such as, vancomycin (up until day 3), Zosyn, Clindamycin, Penicillin, and DAPTomycin. NS also had her right, great toe amputated.Nutrition AssessmentNS has a history of noncompliance with diabetic protocol such as following a consistent carb diet and taking her medications. It is reported that NS stated that this was due to the fact that she does not have insurance, and thus cannot afford insulin. This was evidenced by her elevated blood glucose and an A1C from a year ago was 13. NS was admitted to the hospital at a height of 63 inches and a weight of 103.5 kg. During her stay her weight trended upward to 117.9 kg at the highest, but dropped back down to 110.3 kg once discharged. This weight gain may be due to fluid fluctuations related to her kidney failure. Her BMI was 42.4 and her ideal body weight 52.1 kg, so NS was 208% of her ideal body weight.When pt entered the hospital most labs were within normal limits, with an exception of her glucose levels, which were 392. Renal lab values elevated on day 5 to a BUN of 36 and a creatinine of 5.51. These values continued to elevate. This is when physicians noticed distressed kidney function and started to investigate a little more into her antibiotic regiment.The only clinical signs that NS exhibited was that she had swelling, pain, and discoloration in her right great toe.The patient has a history of smoking and uses Percocet for chronic pain when not in the hospital. NS is also adopted and does not know her family’s medical history. She was diagnosed with type 2 diabetes in 2003, thirteen years ago. Her accidents in Hawaii a year ago, that caused damage to her feet, is when problems with her feet began.All the above mentioned information was taken into account and her nutritional needs were calculated. It was decided she needed an intake of 1875-2075 kcals, which is 18-20 kcal.kg. This was decided based on the fact that she is classified as morbidly obese, and was based on her actual body weight. Protein needs were determined to be 78-91 g/day. Because of need for wound healing she needed 1.5-1.75 g/kg, based off of her ideal body weight. Fluid was calculated based off of actual body weight as well, being 1875-2075 ml/day and 18-20 ml/kg.Nutrition DiagnosisTwo nutritional diagnoses were given to NS. The first: Increased nutrient needs related to physiological causes increasing nutrient needs due to disease/condition as evidences by need for wound healing. The second was: Altered nutrition-related laboratory values related to kidney dysfunction as evidenced by diabetes mellitus poorly controlled prior to admittance and acute renal failure.Nutrition Intervention Nutrition interventions were planned and based off of the two nutritional diagnoses given to NS. The first is to address the problem of increased nutrient needs r/t to physiological causes increasing nutrient needs due to disease/condition as evidences by need for wound healing. The intervention is food and/ or nutrient delivery. The long term goal was that her wounds would heal. Short term goals, while here in the hospital were that the patient received all necessary nutrients by eating > 75% of meals, that she received a high protein supplement (specifically the product Juven), and multivitamins.Altered nutrition-related laboratory values related to kidney dysfunction as evidenced by diabetes mellitus poorly controlled prior to admission and acute renal failure is the next diagnosis that interventions were created for. Two intervention were used; food and nutrient delivery and nutrition education. Long term goals for NS were that her renal and blood glucose lab values would come into normal limits and short term goals to achieve this would that she would be on a renal and consistent carbohydrate diet. Pt was also given a diabetic instruction. NS expressed that she was noncompliant before admittance to the hospital partly due to the fact that she did not have insurance to pay for insulin and partly to the fact that she was “lazy”. During the education session with the dietitian she was taught 75g/meal (5 servings of carbs per meal), to have a goal range of blood glucose of 70-130 premeal, she voiced knowing how to use glucometer, insulin therapy was taught to be 70/30 and Humalog. She also voiced ability to draw and inject insulin. At the end of the education she was given instruction on symptoms, prevention, and treatment of hypoglycemia and hyperglycemia.Nutrition Monitoring and EvaluationTo monitor that all these changes took place her goals were noted in the charts. Goals were to have oral intake meet 75% of needs, that her wound would heal, glycemic control, and that renal lab values would come into normal limits and stabilize. All interventions were completed in the hospital. NS ate very well while in the hospital. Pt was on a consistent carb and renal diet until the last day in the hospital. Her nutrition seemed to support wound healing. Blood glucose was under control while in the hospital. Hopefully the patient will stay compliant while after discharge. NS was discharged on March 23, 2016. She left with the diagnoses of osteomyelitis and cellulitis, acute renal failure, mild hypoxemia, nausea and vomiting, hyponatremia, hyperphosphatemia, hyperkalemia, diplopia, uncontrolled diabetes mellitus type 2, and tobacco abuse. She was ordered insulin and test strips for her diabetes and oxygen for at home to use for a month for pulmonary edema.Appropriateness of CareI believe the care that could be provided from inpatient services was effective because of how the staff tried to address each of the patient’s many complications. Most of her conditions improved as well during her stay, complications that did arise, did not seem to be at the fault of the hospital staff.Billing and CodingBilling and coding is not normally done by the dietitian. Inpatient does not bill individually unless it is for formula. Everything is all included with their room charge, which if a flat rate. If NS chooses to use outpatient services these are some of the following codes that would be used. 7813009 (Initial Assessment – 15 mins), 7813058 (reassessment – 15 mins)And ICD-10 Code: E11.2 Diabetes Type 2 with Kidney complication (not used in inpatient setting). Outpatient uses CPT codes, billing in increments of 15 minutes. They do not charge based on diagnosis. They use a blanket charge.ConclusionThis paper discussed the medical case of NS, observed at LDS Hospital. Osteomyelitis with secondary diabetes and renal failure is the case that was discussed in detail including the patient’s profile and the illness. Also, medical nutrition therapy for this specific patient and their situation was reviewed and evaluated on how well it was received and functioned in healing NS. ReferencesThe Mayo Clinic. Osteomyelitis. . Accessed March 21, 2016.Image 1.. Accessed March 22, 2012. The Academy of Nutrition and Dietetics. ICD-10 codes.. Accessed March 23,2016 ................
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