Case Study 1 Questions



Case PresentationML is a 75 year old widow who was brought to her primary care physician’s office by the local Older Americans Transportation Service. She had missed her two prior scheduled office visits because of the recent death of her husband and a subsequent fall, which resulted in an intertrochanteric fracture of her right hip. On presentation, ML appeared withdrawn and much more frail than on previous visits. She answered in a monotone with terse, nonspontaneous speech, and she lacked expression. When asked about how she has been coping after the loss of her husband, she became tearful. She admitted that in addition to the loss of companionship, the loss of his pension has caused tremendous financial hardship.Past Medical HistoryML tripped on the steps in her house 2 months ago and fractured her hip. She underwent an open reduction/internal fixation surgery to repair the fracture, and the operation went well. She had no serious operative complications, but she lost approximately 250cc blood during the procedure (1 unit = 500cc). ML underwent inpatient rehabilitation for 10 days after discharge from the surgical service and then returned home, where she lives alone. She ambulates slowing with a cane and can climb stairs only with difficulty. During her inpatient rehabilitation stay, she was diagnosed with depression and she was started on an antidepressant. She has no major chronic diseases except for osteoporosis, discovered at the time of her hip fractures 2 months ago. ML had an appendectomy at age 46 and bilateral cataract surgeries 10 years ago. She has no previous history of pneumonia, tuberculosis, hepatitis, or urinary tract infection.MedicationsML currently taking fluoxetine (Prozac), 20mg daily, for depression and an iron supplement for anemia three times per day. She also self-medicates with over the counter preparations of ibuprofen (200-400mg three times a day) and frequently uses over the counter laxatives and glycerin suppositories for her constipation, which she attributes to her iron tablets. She does not take a multiple vitamin, calcium or vitamin D. She has no known food allergies.Social HistoryML lives alone in the four-bedroom, two-story home she has occupied since she married 55 years ago. Her son and daughter both live out of state. Although they call her every few weeks, they have not visited since her husband’s death. ML also explains that she used to attend church and visit the local senior center regularly with her husband but has not been to either lately. ML explains that she has no energy to “get up and go” anymore and she falls asleep in front of the television. She also reports being constipated and that her food does not have much taste. She avoids alcohol and tobacco and drinks one cup of coffee and two cups of tea daily.Review of SystemsGeneral: Weakness, fatigue, weight loss, and depression.Mouth: Food lacks taste (hypoguesia); dry, “thick-feeling” tongue; sores in corners of mouth.Gastrointestinal (GI): Poor appetite, constipation.Extremities: Hip pain when climbing stairs, some tenderness at old incision site, and chronic low back painPhysical ExaminationVital SignsTemperature: 97.0 deg FHeart rate: 88 BPMRespiration: 18 BPMBlood pressure: 130/80 mm HgHeight: 5’6”Current weight: 110 lbUsual weight: 140lbGeneral: Thin, elderly woman who is appropriately conversant but withdrawn. She is well groomed, but her clothes are loose fitting, suggesting weight loss.Skin: Warm to touch, patches of dryness and flaking to elbows and lower extremitiesHead, ears, eyes, nose, throat (HEENT): Temporal muscle wasting, no enlargement of thyroidMouth: Ill-fitting dentures, sore beneath bottom plate, cracks/fissures at corners of mouth (angular cheilitis)Cardiac: Regular rate at 88 BPMAbdomen: Well-healed appendectomy site scar, no enlargement of liver or spleen, diffusely diminished bowel soundsExtremities: Well-healed hip surgery incision with slight surrounding erythema, no sores on feet, trace pretibial edema to both lower extremitiesRectal: Hard stool in vault, stool test for occult blood negativeNeurologic: Alert, good memory, no evidence of sensory lossGait: Slightly wide-based with decreased arm swing, antalgic and tentative but with safe, appropriate use of caneLaboratory DataAlbumin: 2.5 g/dL (normal 3.5-5.8g/dL)Hemoglobin: 11.0 g/dL (normal 11.8-15.5 g/dL)Hematocrit 33.0% (normal 36-46%)ML’s 24 hour dietary recall:At her physician’s request, ML provided the following 24 hour recall, stating that this represent her usual daily intake:Breakfast (home)1 Jelly donut1 slice white toast2 tbsp Jelly1 cup coffeeLunch (home)2 butter cookies1 cup chicken and rice soup6 saltine crackers2 cups teaDinner (home)1 slice white bread2 tbsp jelly2 tbsp peanut putter2 butter cookiesTotal kcals: 1270Protein: 25 gm/day (8% of kcals)Fat: 42 gm (30% of kcals)Carbohydrate: 201 gm (63% of kcals)Calcium 153mgIron 6 mgCase Study 1 QuestionsName: Jule O’Dea Section: 0041.Calculations: a.BEE (using Mifflin St Jeor): 1,020 kcalsb.Total energy needs for repletion (weight gain): 1520 kcalsc.Protein needs: 60gd.Fluid needs: 1,250- 1500 mL e.Ideal body weight: 130 lbsf.Percent ideal body weight: 85%g.Percent usual body weight: 79%h.BMI: 17.72.What medical, environmental, and social factors could lead to nutritional problems in this patient? The medical factors negatively affecting ML include her hip fracture, surgery, and blood loss, which all created extra stress on her body. Osteoporosis also requires additional nutrients. ML’s depression may cause decreased motivation to eat, which is exasperated by her antidepressant, fluoxetine, which is known to cause anorexia. Social and environmental factors also could lead to nutritional problems. Her decreased mobility impacts her ability to prepare food and shop for food. ML is also experiencing financial trouble which could prevent her from accessing the food she needs. Another factor effecting ML’s nutrition is her complete isolation. This may further reduce her desire to eat, and also reduces accountability to follow nutritional and health instruction. 3.What do ML’s BMI and percent weight change indicate about her nutritional status?ML’s underweight BMI and 21% recent weight loss indicate high nutritional risk due to moderate malnourishment. 4.What nutrition-related issues do her lab values indicate?ML’s albumin levels are lower than normal, which further supports the conclusion that she has protein-energy malnutrition. It is also important to keep in mind that her current albumin levels are most likely even lower than 2.5g/dL. Her decreased hemoglobin and hematocrit indicates possible nutrition-related anemia, and also might be attributed to blood loss during surgery. 5.What general conclusions can you draw regarding the adequacy of her current diet?Overall, ML should try eating about 300 more calories/day to begin. She currently has inadequate protein, fiber, and micronutrient intake. 6.How can ML’s diet be improved to meet her increased requirements, achieve weight gain, and relieve her constipation? (suggest alternatives to foods she is currently consuming)Improving ML’s diet needs to focus on keeping food preparation limited and simple. For breakfast, I would recommend substituting whole wheat bread with butter and jelly for the white bread toast, drinking a glass of OJ instead of or in addition to her coffee, and fruit yogurt instead of a jelly doughnut. For lunch, I would see if she would be willing to substitute a cup of tea for a bottle of ensure and replace her chicken and rice soup with chicken vegetable soup. For dinner, I would recommend substituting the peanut butter and jelly sandwich for a tuna sandwich with cheese. 7.What specific recommendations would you offer to improve ML’s nutritional status?Specific recommendations that I would offer to improve ML’s nutritional status include suggesting more soft foods such as applesauce and yogurt that would be easy to eat. I would encourage her to reach out to a friend from church or the community center that would be willing to take her to these places with them. Because of her limited appetite and difficulty chewing, I would recommend a multivitamin that contains calcium and vitamin D to help manage her osteoporosis, as well as zinc to possibly help her sense of smell and relieve some of her disgeusia. I would also refer her to a meals on wheels program and senior services that may help her receive more social interaction. ................
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