case management 56 y.o. female, a smoker with a PMH of hypercholesterolemia, and osteoporosis

T.C is a 56 y.o. female, a smoker with a PMH of hypercholesterolemia, and osteoporosis. Her initial presentation to the emergency department was for abdominal and low back pain, jaundice, and heartburn. Further examination and abdominal magnetic resonance imaging (MRI) revealed a 2 cm mass in the head of the pancreas with distal bile duct obstruction. Ten days later a Whipple procedure (pancreaticoduodenectomy) was performed. Post -op complications included pleural effusions, perihepatic abscess, DVT, obstructive jaundice. Chemotherapy was initiated 3 months later after her original presentation with gemcitabine HCL. Over the next 8 months she continued to receive gemcitabine along with a course of fluorouracil and radiation therapy. During month 11 she suffered a T12 and L2 compression fracture.
At time of fracture she was found to have a vitamin D level of < 19 mcg/ml -deficiency.
Height – 62″
Weight hx:
Baseline/ at time of diagnosis- 150#
3 months after dx- 135#
4 months after dx 126 #
10 months 125#
Social history: T.C is married with no children. She currently smokes ½ pack of cigarettes per day. Drinks alcohol socially.
Family hx: unremarkable for cancer
Food/nutrition related history:
The client complained of weakness, pain, belching, gas, severe cramping associated with meals. Her bowel movements were erratic and fluctuated between constipation and diarrhea. She complains of dry mouth and taste changes.
Medications: oxycodone, teriparatide, prevacid, pacrelipase lipase units 36000 per tablet, vitamin D3 2000 IU daily
Nutrition Focused Physical Exam: jaundice, moderate temporal and clavicle wasting, petechiae
1.      Calculate her % UBW at months 3, 4, 10.
2.      Explain what a Whipple procedure is and describe post-operative nutrition related complications. What are the main medical nutrition therapy interventions for patients who have this procedure?
3.      Describe signs and symptoms of pancreatic enzyme insufficiency. Identify signs from T.C.’s history that may have indicated insufficiency earlier. Which of T.C.’s medications’ provides pancreatic enzymes to T.C.? T.C. was not taking this medication with meals as is directed, explain why this is necessary.
4.      Identify symptoms in pt’s nutrition history that could have been caused by her chemotherapy and radiation therapy, discuss one nutrition intervention to help manage each symptom identified.
5.      Why is it important to monitor her Vitamin D level? Explain the factors in her case that may contribute to vitamin D deficiency. Why is it important to have a normal vitamin D level?
6.      Name two other micronutrient (vitamin/mineral) deficiencies you should be concerned about in T.C. Why?
7.      What are T.C.’s other risk factors for osteoporosis other than the vitamin D deficiency? Name 2.

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