MEDICAL CASE STUDY: COPD

EM I L Y B R A N T L E Y

DI ET ET I C I N T ER N

A N DR EW S UN I V E RS I T Y

INTRODUCTION

NM is a 62 year old white female who is 160.02 centimeters tall weighing 107.2

kilograms. She was admitted to Winter Park Memorial Hospital with shortness of breath,

respiratory abnormality, diarrhea and hypokalemia. I have chosen to conduct a case study on

this patient because of the multiple complications that she is facing such as Diabetes Mellitus,

Addison’s disease, Irritable Bowel Syndrome and IgA Deficiency. This case study began on

December 5, 2013 and ended two visits later on December 6, 2013. Although she has been

diagnosed with many health complications, the primary problem that NM has is Chronic

Obstructive pulmonary disease, or COPD. NM has other comorbidities that are comparable in

importance. Nevertheless, she is most often admitted to the hospital for exacerbation of COPD.

Therefore, COPD is the focus of this study.

SOCIAL HISTORY

NM is a Christian woman who lives at home with her husband and pet parakeet. She is

currently on Medicare. She is a retired RN. Her three children are all adults and live within the

region. NM is a former smoker but Medical records indicate that she does not smoke or drink

alcohol anymore.

NORMAL ANATOMY AND PHYSIOLOGY OF APPLICABLE BODY FUNCTIONS

COPD is characterized by slow, progressive obstruction of the airways. There are two

physical conditions that make up COPD. The first is known as Emphysema and it is characterized

by abnormal, permanent enlargement and destruction of the alveoli. The second is chronic

bronchitis where there is a progressive cough with inflammation of bronchi and other lung

changes. In both cases, the disease limits the airflow and frequently, both illnesses coexist as

part of this disorder.1&2

PAST MEDICAL HISTORY (INCLUDE PREVIOUS ADMISSIONS TO HOSPITAL)

Past medical history indicates that NM initially received the diagnosis of COPD in 1997.

According to the American Thoracic Society, comorbidities such as cardiac disease, diabetes

mellitus, hypertension, and psychological disorders are commonly reported in patients with

COPD, but with great variability in reported prevalence.

Along with the original diagnosis, NM also has also been diagnosed with Diabetes

Mellitus. The evidence for an interaction between diabetes and COPD is supported by studies

that demonstrate reduced lung function as a risk factor for the development of diabetes. In

fact, smoking has been established as a risk factor for both COPD and Diabetes Mellitus. 3

NM has been hospitalized six times within the past year for episodes of pneumonia.

When compared to other chronic diseases, COPD is more frequently associated with

pneumonia. Corticosteroids are standard of care for acute exacerbations of COPD, but their role

in the management of patients with COPD with pneumonia is less defined. 3

NM also suffers from Gastro-esophageal reflux disease (GERD). An increased prevalence

of GERD has been reported in patients with COPD. A recent study of 421 patients with severe

COPD using 24-hour esophageal pH monitoring showed that 62% had pathological GERD, and

notably 58% of the patients reported no symptoms of GERD.3

Besides COPD, Diabetes Mellitus and GERD as previously mentioned above, NM’s past

medical history also included other comorbidities. They are as follows:

Bronchial Asthma Adrenal Insufficiency Coronary Artery Disease Trachaeomalacia Addison’s disease Hypothyroidism

Bipolar Disorder Irritable Bowel syndrome Vascular stent placement Hyperlipidemia Hyperthyroidism Anemia

PRESENT MEDICAL STATUS AND TREATMENT

Theoretical Discussion of Disease Condition

COPD is the fourth leading cause of death in America. COPD is also more prevalent in

women.3&4 The primary risk factor in the development of COPD is smoking. Beyond the

cessation of smoking, it has been shown that the inflammatory stress continues to damage the

lung tissue. Other risk factors include air pollution, secondhand smoke, history of childhood

infections, and occupational exposure to certain industrial pollutants.

Although normal lung function gradually declines with age, individuals who are smokers

have a more rapid decline—twice the rate of nonsmokers. Low body weight has also been

shown to be a risk factor for the development of COPD even after adjusting for other potential

risk factors including smoking and age.2 Malnourished patients with COPD experience worsened

respiratory muscle strength, decreased ventilator drive and response to hypoxia, and altered

immune function. 1, 5 & 6

Usual Treatment of Condition

An early and accurate diagnosis of COPD is the key to treatment. Quitting smoking is the

single most important thing that can be done to help treat COPD. 7 Once identified, the usual

treatment of COPD is composed of four main goals for effective management. They are to:

1. Assess and monitor the disease

2. Reduce risk factors

3. Maintain stable COPD and respiratory status

4. Manage any exacerbations

Once the disease progresses, rehabilitation programs along with oxygen therapy

are used as treatment. Additionally there are numerous medication prescriptions that

include bronchodilators, glucocorticosteroids, mucolytic agents, and antibiotics to treat

infections. In cases where COPD may be advanced, there is an option for surgical

intervention, such as a lung transplant.1

Patient’s Symptoms upon Admission Leading to Present Diagnosis

NM was admitted with shortness of breath, cough, diarrhea, hypokalemia and fever.

The patient revealed that one of the possible causes of her diarrhea may be the fact that she

had “been around a couple of people with Clostridium Difficile.” NM also showed symptoms of

hyperlipidemia and hypertension – High blood pressure is a complication of COPD. 6

Hyperglycemia is a side effect of steroid therapy for COPD. Steroids can increase the blood

sugar making diabetes harder to control.8

Laboratory Findings and Interpretation

The lab values for NM on December 5th were as follows:Lab Value Normal Range

Sodium 138 135 to 145 milliequivalents per liter (mEq/L)

Potassium 3.5 3.7 to 5.2 mEq/L

BUN 16 7 to 20 mg/dL

Creatinine 0.69 0.6 to 1.1 mg/dL for women

Blood Glucose 152 70 to 100 milligrams per deciliter (mg/dL)

Accuchecks 188, 130, 239, 282, 279, 233 70 to 100 milligrams per deciliter (mg/dL)

1

Medications

Below is a table that explains the uses and purpose of NM’s medications along with their

food/drug interactions and side effects.

Drug Name Dosage Uses Food/Drug interaction

Side Effects

Depakote ER (Valproic Acid)

1000 mg Valproic acid is in the anticonvulsant class of medications. Valproic acid is used to treat mania (episodes of frenzied, abnormally excited mood) in people with bipolar disorder. It works by increasing the amount of a certain natural substance in the brain.

Continue normal diet

Drowsiness, dizziness, headache, diarrhea, constipation, changes in appetite, weight changes, back pain, agitation, mood swings, abnormal thinking, uncontrollable shaking of a part of the body, loss of coordination, uncontrollable movements of the eyes, blurred or double vision, ringing in the ears, hair loss

Lexapro (Escitaloprem)

5 mg Escitalopram is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRI’s). It is used to treat depression and generalized anxiety disorder. It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance.

Continue normal diet

Dizziness, sweating, nausea, vomiting, tremor, drowsiness, fast or pounding heartbeat, seizures, confusion, forgetfulness, fast breathing, coma (loss of consciousness for a period of time)

Florinef (Fludrocortison Acitate)

0.1 mg Fludrocortisone is used to treat Addison's disease and syndromes where excessive amounts of sodium are lost in the urine. It is a corticosteroid, used to help control the amount of sodium and fluids in the body. It works by decreasing the amount

Doctors may instruct to follow a Low-Sodium, Low-Salt, Potassium-Rich, or High-Protein diet.

Upset stomach, stomach irritation, vomiting, headache, dizziness, insomnia, restlessness, depression, anxiety, acne, increased hair growth, easy bruising, irregular or absent menstrual periods

of sodium that is lost (excreted) in urine.

Fluticasone – salemeterol

2 puffs Fluticasone is in a class of medications called steroids. Salmeterol is in a class of medications called long-acting beta-agonists (LABAs).It works by relaxing and opening air passages in the lungs, making it easier to breathe. The combination of fluticasone and salmeterol is used to prevent wheezing, shortness of breath, coughing, and chest tightness caused by asthma and chronic obstructive pulmonary disease. It works by reducing swelling in the airways.

Talk to doctor about eating grapefruit or drinking grapefruit juice

runny nose, sneezing, sore throat, throat irritation, sinus pain, headache, nausea, vomiting, diarrhea, stomach pain, muscle and bone pain, dizziness, weakness, tiredness, sweating, tooth pain, red or dry eyes, shaking of a part of the body that cannot be controlled, sleep problems

Metronidazole Flagyl

500 mcg Metronidazole eliminates bacteria and other microorganisms that cause infections of the reproductive system, gastrointestinal tract, skin, vagina, and other areas of the body. Antibiotics will not work for viral colds, flu, or other viral infections.

Continue normal diet

Vomiting, diarrhea, upset stomach, loss of appetite, dry mouth; sharp, unpleasant metallic taste, dark or reddish-brown urine, furry tongue; mouth or tongue irritation, numbness or tingling of hands or feet

Insulin lispro (Humalog)

Medium scale

Insulin lispro is used to treat type 1 and type 2 diabetes. In patients with type 2 diabetes, insulin lispro may be used with another type of insulin or with oral medication(s) for diabetes. Insulin lispro is a short-acting, man-made version of human insulin. Insulin lispro works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into

Important to eat a consistent carbohydrate diet. Skipping or delaying meals or changing the amount or kind of food eaten, especially carbohydrates can cause problems

Redness, swelling, or itching in the place where insulin is injected. Changes in the feel of skin such as skin thickening or indentation in the skin, weight gain, constipation

other body tissues where it is used for energy.

with blood sugar control.

Misoprostal (Cytotec)

100 mcg Misoprostol is used to prevent ulcers in people who take certain arthritis or pain medicines, including aspirin, which can cause ulcers. It protects the stomach lining and decreases stomach acid secretion.

Talk to doctor about decreasing high acid foods.

Diarrhea, headache, stomach pain, upset stomach, gas, vomiting, constipation, indigestion

Monlelukast (Singulair)

10 mg Montelukast is in a class of medications called leukotriene receptor antagonists (LTRAs). It works by blocking the action of substances in the body that cause the symptoms of asthma and allergic rhinitis. Used to prevent wheezing, difficulty breathing, chest tightness, and coughing caused by asthma; prevent bronchospasm during exercise; relieve symptoms of seasonal, and perennial allergic rhinitis.

Continue normal diet

headache, dizziness, heartburn, stomach pain, tiredness

Pantoprazole (Protonix oral)

40 mg Pantoprazole is in a class of medications called proton-pump inhibitors. It works by decreasing the amount of acid made in the stomach. Pantoprazole is used to treat symptoms of (GERD), allow the esophagus to heal, and prevent further damage to the esophagus; Used to treat conditions where the stomach produces too much acid, such as Zollinger-Ellison syndrome.

Continue normal diet

headache, dizziness, nausea, vomiting, gas, joint pain

Potassium chloride

40 mEq Electrolyte mineral in tablet form used to treat deficiency.

Doctor may recommend foods high in potassium

Muscle cramps or spasms, abnormal heart rhythms, fatigue, constipation

foods such as bananas

RisperiDONE (RisperDAL)

0.5 mg Risperidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. It is used to treat the symptoms of schizophrenia, episodes of mania or mixed episodes in bipolar disorder. Risperidone is also used to treat behavior problems such as aggression, self-injury, and sudden mood changes in teenagers and children 5 to 16 years of age.

Continue normal diet

Drowsiness, dizziness, nausea, vomiting, diarrhea, constipation, heartburn, dry mouth, increased saliva, increased appetite, weight gain, stomach pain, anxiety, agitation, restlessness, dreaming more than usual, difficulty falling asleep or staying asleep, decreased sexual interest or ability, breast milk production, vision problems, muscle or joint pain, dry or discolored skin, difficulty urinating

Rosuvastatin (Crestor)

5 mg Rosuvastatin is in a class of medications called HMG-CoA reductase inhibitors (statins). It works by slowing the production of cholesterol in the body to decrease the amount of cholesterol that may build up on the walls of the arteries and block blood flow to the heart, brain, and other parts of the body. It is used together with diet, weight-loss, and exercise to reduce the risk of heart attack and stroke and to decrease the chance that heart surgery will be needed in people who have heart disease or who are at risk of developing heart disease.

Low cholesterol or low saturated foods diet.

Constipation, heartburn, dizziness, difficulty falling asleep or staying asleep, depression, joint pain, cough, memory loss or forgetfulness, confusion

NaCl 1 gm Combination of sodium and chloride in tablet form to assist with hydration and elecrolyte balance.

Caution with foods high in sodium, restrict use of table salt.

No side effects known.

Tolterodine 2 mg Tolterodine is in a class of Dry mouth, blurred vision, upset

(Detrol LA) medications called antimuscarinics. It is used to relieve urinary difficulties, including frequent urination and inability to control urination. It works by preventing bladder contraction.

stomach, headache, constipation, dry eyes, dizziness

Voriconazole 200 mg Voriconazole is in a class of antifungal medications called triazoles. It works by slowing the growth of the fungi that cause infection. It is used to treat serious fungal infections such as invasive aspergillosis and esophageal candidiasis.

Talk to doctor about eating grapefruit and drinking grapefruit juice while taking this medicine

Blurred or abnormal vision, difficulty seeing colors, sensitivity to bright light, diarrhea, vomiting, headache, dizziness, dry mouth, flushing

9

Observable Physical and Psychological Changes in Patient

Upon observation, Nm physically looked well nourished. She did not appear to have

difficulty breathing until after she spoke for a long period of time. She did have a severe cough

that she tried to conceal. NM was a very agreeable patient for both psychological interviews. In

spite of her COPD diagnosis and all of the multiple medical comorbidities that NM faced, she

still presented a positive attitude and spoke openly about her faith.

Treatment

NM received a chest x ray that revealed consolidation in the left lung and midline lung

level. Once this was identified, she was admitted to the hospital from the Emergency room for

treatment. She was started on IV steroids, IV antibiotics, flagyl and nebulizers around the clock

to see how she progressed.

MEDICAL NUTRITION THERAPY

Nutrition History

NM stated that beginning in March 2012, she began intentionally losing weight by

following a PCP prescribed commercial diet known as Optifast. Optifast offers shakes, protein

bars and soups. With this regimen, NM has lost 70 pounds since March 2012. At home, NM

usually sticks to her Optifast food items for breakfast, lunch and snacks between meals. For

dinner, however, she shares a meal with her husband. He is a professional chef who is control

of purchasing groceries and prepares dinner most nights.

Analysis of Previous Diet

Below is an example of a typical day for NM with her Optifast products incorporated

multiple times during the day.

Time Meal Food Item Calories (kcal)

Carbohydrates (grams)

Protein (grams)

Fat (grams)

8:00 AM Breakfast 1 cup Oatmeal 160 31 5 3

Optifast 800 Ready to Drink Shake 160 20 14 3

3 tsp Margarine 108 0 0 123 packets Splenda 10 3 0 0

11:00 AM

Mid-morning snack 1 large apple 110 29 1 0

Optifast 800 Bar 170 21 14 51:30 PM Lunch Optifast 800 Ready to

Drink Shake 160 20 14 3

Optifast 800 Soup 170 20 14 48 Wheat Thins 60 10 1 2¾ cup Raw Carrots 25 5 1 01 Tbs Ranch dressing 71 1 0 8

4:30 PM

Mid-afternoon snack

Optifast 800 Bar170 21 14 5

7:00 PM Dinner 1 cup Spaghetti 220 43 8 1

2 Tbs Alfredo Sauce 125 1 3 0¾ cup Yellow Squash 25 5 1 0¾ cup Green Beans 25 5 1 0

9:30 PM HS Snack ½ cup Grapes 104 27 1 0

3 oz Cheddar 147 2 21 6Totals for the Day 2020 264 113 52

1& 11

Current prescribed diet

NM was on steroid therapy to treat her COPD. Because of the steroid therapy, NM was

admitted with consistently high blood glucose levels. For this reason, doctor’s orders were

given for an Average Diabetic Diet for the duration of her stay at Winter Park Memorial

Hospital. An Average Diabetic Diet allows the patient to select up to 60-75 grams of

carbohydrates for each meal. NM’s diet order remained the same for her entire stay.

Objectives of dietary treatment

The objective of the Average Diabetic diet is to maintain NM’s blood sugars within

normal limits or as close as possible to normal levels. This may have proved an arduous task

given the steroid therapy that NM was undergoing to treat her COPD. Finger-stick blood sugar

levels referred to as “Accuchecks” ranged inconsistently from 130 to 289 as seen on the lab

values table above.

Patient’s Physical and Psychological Response to Diet

NM stated that at home, she followed an eating pattern similar to that of the Average

Diabetic Diet but with the addition of snacks in between meals. She denied facing vomiting or

constipation while on this diet. She did admit to experiencing diarrhea and nausea upon

admission to the hospital. As previously mentioned, NM believed she was exposed to

Clostridium Difficile, to which she attributes to the cause of having diarrhea.

List nutrition-related problems with supporting evidence

COPD: Increased energy expenditure related to increased energy requirements during

COPD exacerbation as evidenced by estimated resting energy expenditure greater than

predicted needs.

Evaluation of Present Nutritional Status

According to the diet analysis table above, NM was meeting her increased caloric needs for

COPD. Additionally, her diarrhea subsided by day two of hospitalization. Per lab values as

those noted above in the table, there did not appear to be any indication of dehydration.

Kcal/Protein Guidelines

Nutritional needs are often increased in COPD due to the increased work of breathing.

Optimal nutritional status plays an important role in maintaining the integrity of the respiratory

system and in allowing maximal participation in daily living.1 Caloric requirements for COPD

should be individually determined based on patient age, weight and gender, the extent of

protein energy malnutrition loss of lean body mass, current medications and other acute or

chronic medical conditions.

The Mifflin St. Jeor equation can be used to estimate the REE. In patients with COPD,

this calculation may underestimate the caloric requirements because of the caloric increase

from metabolically active tissue in COPD. To compensate for this underestimation, a stress

activity factor may be added according to the degree of stress. Furthermore, in most cases the

total calorie intake of the COPD patient is more important than the source from calories. For

maintenance 1.33 x REE or 25/35 calories per kilogram is appropriate for the needs of the COPD

patient. Protein is recommended at 1.0-1.5 grams per kilogram of body weight for

maintenance.1

Below is a chart of how NM’s needs were clinically calculated during her hospital

admission on December 5th through the 6th.

Kcal calculations Protein calculations for adjusted body weight Fluid requirements

1926-2408 66-79 1500 ml per physician

Need for Alternative Feeding Methods and the Patient’s Nutrition Education Process

Since NM was in fact meeting the additional needs required for COPD, I do not believe

that there was any need for alternative feedings such as tube feeding. Moreover, in explaining

the prescribed diabetic diet to NM, no type of barrier to learning was identified.

PROGNOSIS

NM expressed her motivation to continue to follow a diet similar to that of the Average

Diabetic Diet upon her return home as long as her increased COPD needs were met. She was

aware of the effects of steroid therapy on her blood sugar levels. In fact, NM clearly verbalized

her understanding on the use of steroids, their effects on increasing blood sugar levels and the

importance of meal planning especially around carbohydrates. This was more of a motivating

factor for her to continue monitoring her diet on discharge.

SUMMARY

From this study, I learned how very serious COPD is. It was once explained to me some

time ago that COPD was like a gradual suffocating in a pillow. Seeing NM experiencing

shortness of breath during the interviews or when speaking to me during the interviews made

me realize that even the slightest amount of energy requires oxygen. Imagine not being able to

breathe to conduct the simplest activities of daily living! In addition to other medical issues as

NM had, it made me realize how important nutrition energy is needed for healing.

BIBLIOGRAPHY

1. Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food, Nutrition and Diet Therapy, 13th Edition, Philadelphia, Pa: Elsevier; 2012

2. Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy and Pathophysiology, 2nd Edition. Cengage Learning, Inc: 2010.

3. Chatila WM, Thomashow BM, Make BJ. Comorbidities in Chronic Obstructive Pulmonary Disease. Journal of the American Thoracic Society. 2008 May 1; 5(4): 549-555

4. Centers for Disease Control. Chronic Obstructive Pulmonary Disease (COPD) Data and Statistics. Available at: http://www.cdc.gov/copd/data.htm. Accessed December 29, 2013.

5. American Society for Parenteral and Enteral Nutrition. Disease-Related Malnutrition and Enteral Nutrition Therapy. Available at: http://www.nutritioncare.org/index.aspx?id=5696. Accessed January 5, 2014.

6. Mayo Clinic. Disease and Conditions: COPD. Available at: http://www.mayoclinic.org/diseases-conditions/seo/basics/symptoms/con-20032017. Accessed January 8, 2014.

7. National Institutes of Health: National Heart Lung and Blood Institute. How Is COPD Treated? Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/copd/treatment.html. Accessed January 8, 2014.

8. British Lung Foundation. Steroids. Available at: http://www.blf.org.uk/Page/Steroids. Accessed December 29, 2013.

9. MedlinePlus: A service of the U.S. National Library of Medicine From the National Institutes of HealthNational Institutes of Health. Drugs and Supplements. Available at: http://www.nlm.nih.gov/medlineplus/druginfo/drug_Ca.html

10. U.S. National Library of Medicine. Drug Information from the National Library of Medicine. Available at: https://www.nlm.nih.gov/learn-about-drugs.html. Accessed January 8, 2014.

11. Optifast. Product Information. Available at: http://www.optifast.com/Pages/index.aspx. Accessed Januery 7, 2014.

Images1. http://sciencelife.uchospitals.edu/2013/05/07/qa-dr-christopher-wigfield-on-the-future-of-lung-

transplantation/2. http://www.nlm.nih.gov/medlineplus/ency/imagepages/19376.htm 3. http://www.cdc.gov/copd/data.htm 4. http://www.optifast.com/Pages/index.aspx