James D. is referred to your outpatient clinic following a recent admit for comp

Question

James D. is referred to your outpatient clinic following a recent admit for complications related to his DM type 2. James is a 38 YOWM, 5’9” 210# with a L BKA. He has had multiple admissions to the hospital due to PVD, peripheral neuropathy and dehydration. His most recent admission was for treatment of a non-healing ankle wound that began as a blister and has progressed into a stage 3-pressure ulcer. His foot is cyanotic and the admission was for the purpose of debridement. The physician is quite concerned due to the advanced level of complications in such a young patient. She has referred the patient to your clinic for aggressive outpatient intervention and education.

Lab values:

Albumin: 2.2 mg/dl

Prealbumin 8.9 mg/dl

BUN 52 mg/dl

Creatinine 3.1 mg/dl

Anion gap 12

H/H 10.8/32

Fasting Blood glucose: 210 mg/dl

K+ 4.2 mg/dl

Na + 136

Osmolality 289 mMol/dl

24 hour recall:

2 scrambled eggs

3 slices bacon

2 slices toast with butter

2 tsp jelly

8 ounces orange juice

1 cup whole milk

Large cheeseburger (Mcdonald’s or Burger King)

Large fries

2-3 pkgs ketchup

apple pie

24 ounce coke

4 slices deep dish pepperoni pizza

3-12 ounce beers

6 oreo cookies

Complete an assessment. This includes anthropometric, dietary and biochemical parameters. Include estimates of Kcal, protein and fluid needs. Assess the needs compared to the intakes. Is his diet adequate?

Explanation / Answer

Anthropometric measurements are referred to comparative measurements of human body in terms of height, weight, length is used in infants and toddlers as they are not able to stand well and ratios of height to weight. These are used as tools to assess the growth and development in children. Individual measurements are usually compared to reference standards on a growth chart to understand their health status of the children.

Whereas in adults the measurements includes height, weight, body mass index (BMI), waist-to-hip ratio, and percentage of body fat. These measures are then compared to reference standards to assess weight status and the risk for various diseases an dappropriate interventions can be taken with these findings.

Height can be measured in all participants, except wheelchair bound individuals, persons who have difficulty standing steady or straight, patients with amputationof lower limbs and participants with hairstyle or head dress (e.g. turban) that prevents proper use of the height measuring equipment. Shoes or footwears are removed before measuring height.

Weight is measured by a weighing machine and heavy jackets or outer garments and footwears shall be removed before the assessent.

Waist circumference and hip circumference shall be analysed and the ratio of two will give brief insight to the presence of fat deposition around the this region.

Body Mass Index is a simple calculation which uses a person’s height and weight. BMI is calculated as kg/m2 where kg is a person’s weight in kilograms and m2 is their height in metres squared. A BMI of 25.0 or more is overweight, while the healthy range is 18.5 to 24.9. BMI applies to most adults 18-65 years.

Biochemical Parameters are very significant to assess the status of malnutrition and nutrient deficiency in the human body. Some of the important parametres for evaluatuion are albumin, pre albumin, albumin to globulin ratio, electrolytes like sodium, potassium, bicarbonate and liver parameters like AST,ALT, LDH and the list goes on.

in this patient there are clear deviations in the biochemical lvels with abnormal ranges. The reference range for albumin testing is 3.5 to 5.5 g/dL or 35-55 g/liter and bumin composes 50%-60% of blood plasma proteins. On the other hand, Normal serum prealbumin concentrations range from 16 to 40 mg/dLand values of <16 mg/dL are associated with malnutrition.The half-life of prealbumin (two to three days) is much shorter than that of albumin, making it a more favorable marker of acute change in nutritional status.

Hence, the patien has a very low albumin and pre albumin levels which indicates severe protein loss and deficience in the client which needs to be replaced because proteins are the building blocks of our body. Proteins are necessary to boost immunity which is also in deteriorating in this patient.

Blood urea nitrogen (BUN) and creatinine level are the indicators to understand the normal kidney function. Urea is also a metabolic byproduct which can build up if kidney function is impaired. Normal In general, around 7 to 20 mg/dL (2.5 to 7.1 mmol/L) is considered normal. Most men with normal kidney function have approximately 0.6 to 1.2 milligrams/deciliters (mg/dL) of creatinine. Most women with normal kidney function have between 0.5 to 1.1 mg/dL of creatinine.

However, James have increased levels of BUN & creatinine levels ,this indicates the kidneys are not working efficiently and there is stagnation of urea and creatinine. thus, very high protein diet is not recommended for him. He has multiple issues within the body and a very well planned diet is needed for him.

The patients 24 hours recall indicates a diet which is very unplanned and unhealthy in nature. Juices are needs to be avoided because juice can be extracted from more number of fruits which will again increase the insulin demand. He had consumed food which is high in caloric value suc as cheese, beverages, beers, butter. This type of food can increase the fat consumption which is not good for digestion as well for better metabolism.

The diet is not adequately well balanced with nutrients, minerals and fibre. Water intake is seemingly very low for him. High intake of Junk foods can interrupt the metabolism. Whole milk is high in fat content and hard to digest. With such associated illness, such diet can be more harmful.

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