___________________________________________

Diabetes and Multiple Myeloma

Case Study
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Reviewed and analyzed by:

Lea Palmer

Introduction

PT was admitted after having been seen at an alternate hospital for

uncontrollable pain. The patient had an extensive medical and surgical history that had

1
previously affected nutritional status including a long history of type 1 diabetes mellitus

(DM). The alternate hospital had seen evidence of multiple myeloma and transferred the

patient to IMC for official diagnosis and care management.

The following case study addresses the medical disease state of the patient, as

well as the assessment, diagnosing, and treatment plan determined and executed by

the medical care team at IMC.

Patient Profile and Social History

PT was a 70-year-old, Hispanic Latino female who had a Catholic religious

affiliation. The patient was married and was highly supported by a husband. The patient

was retired and living at home. Although previously high functioning, the patient had

begun to decline in health, requiring extra assistance from the husband. Over the few

months prior to admission (PTA), the patient had become too weak to walk, and there

was a decline in abilities to perform basic daily activities such as cooking, toileting, and

ambulating up and down the stairs. The patient had a strong family support system and

frequently mentioned granddaughters and children visiting.

Medical History

PT had an extensive medical and surgical history. The patient had been

diagnosed with type 1 DM during childhood, approximately 60 years PTA. For the first

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20 years, the patient had controlled DM with oral medications, and had then transitioned

to insulin for management.

In addition to the diabetes, the patient had an extensive list of medical conditions

over the years that impacted the current nutritional state and medical diagnosis. Most

nutritionally relevant was the history of obesity, hypertension (HTN), microalbuminuria,

peripheral neuropathy (from prolonged DM), and GERD. The diagnoses factoring into

current multiple myeloma diagnosis included monoclonal gammopathy of undetermined

significance (PTUS), retinopathy, infections including sinusitis (sinus infection), otitis

(ear infection), bronchitis (lung inflammation), and arthritis, and bone complications

including osteopenia, degeneration of lumbar intervertebral disc, carpal tunnel and back

pain.

Additionally, the patient had experienced mild intermittent asthma, obstructive sleep

apnea syndrome, major depressive disorder, ganglia infarction leading to

cerebrovascular accident (CVA), and radicular syndrome of the lower limbs.

The patient had been through a variety of surgical procedures including a carpal

tunnel release, multiple cataract removals, cholecystectomy, uterine ablation, and spinal

surgery.

Literature Review

Multiple Myeloma

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 PT was diagnosed with multiple myeloma during admission at IMC. Multiple

myeloma (also known as Kahlers disease), is a cancer that forms in plasma cells

resulting in alterations that form tumors in bones throughout the body 1. The exact cause

of multiple myeloma is unknown, but research indicates there are potential risk factors

including genetic mutations, prevalence of monoclonal gammopathy of undetermined

significance (PTUS), exposure to various chemicals, older age (96% of cases were

older than 45, and 63% of cases were older than 65), race (prevalence is higher among
2
black population), and gender (males are more susceptible).

If a novel microbe enters the body of a healthy individual, B cells in the bone marrow

will mature into plasma cells. Those plasma cells then initiate an immune response and

produce antibodies, or immunoglobins, to fight off the foreign object 3. With multiple

myeloma, the plasma cells are abnormal (also called myeloma cells) and malignant. As

they continue to reproduce and grow out of control, they form tumors (neoplasms) in

bones and soft tissues. Plasma cell neoplasms types can include PTUS, plasmacytoma

(tumors form in one specific area), or multiple myeloma (tumors form in multiple sites).

Additionally, myeloma cells produce antibodies called monoclonal proteins (M proteins),

which are essentially useless to the body. The build-up of these M proteins can thicken
1
the blood and cause clots or even damage to the kidneys.

Approximately 1 in every 143 individuals in the United States develops multiple

myeloma over their lifetime. It was estimated that in 2016 there would be a total of

30,330 new cases of multiple myeloma diagnosed with 17,900 of those cases being

men, and 12,430 of those cases being women. Additionally, it was estimated that

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12,650 of diagnosed patients would die during the year with 6,430 of those deaths being

men, and 6,220 being women. 4

Symptoms of multiple myeloma vary from case to case and are occasionally

unnoticeable (smoldering multiple myeloma, SMM). The potential symptoms or

manifestations include bone pain, pathologic fractures, spinal cord compression,

thrombocytopenia, hyperviscosity (typically serum is 4 times the viscosity of normal

serum), carpal tunnel, meningitis, anemia, nausea and vomiting, constipation, loss of
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appetite, confusion, fatigue, recurring infections, weight loss, and excessive thirst.

When these signs and symptoms do arise, medical care teams will first do a full review

of medical history and physical exams. This is then followed by routine testing including

complete blood counts (CBC), basic metabolic panels 5, and some form of

immunoelectrophoresis or immunofixation test to identify the presence of myeloma

proteins 6 (M proteins) in the blood or urine 5. M proteins can be present before multiple

myeloma fully develops, but the presence of M proteins is both a risk factor and

indicator of multiple myeloma. After M proteins have been identified, a bone marrow

biopsy is performed followed by imaging. The International Myeloma Working Group

recommends that imaging include a whole body computed tomography (CT) scan or

magnetic resonance imaging (MRI) to aid in diagnosis 5.

The diagnostic parameters of multiple myeloma have previously been characterized

by using the CRAB acronym: Calcium (hypercalcemia due to breakdown of bone),

Renal (suboptimal kidney function from M protein build up), Anemia (disrupted

hematopoiesis), and Bone (presence of bone lesions) 7. The criteria were updated in

2015 and multiple myeloma is now defined as clonal bone marrow plasma cells >10%

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or biopsy-proven bony or extramedullary plasmacytoma and any one or more of the

CRAB features and a myeloma-defining event. Myeloma defining events are

biomarkers of malignancy, simply stated. Biomarkers can include greater than 60% of

plasma cells appearing abnormal during a bone marrow exam, or it can include more

than one focal lesion greater than 5 millimeters in size observed during a MRI.

After diagnosed, interventions are put in place to reduce the spread of multiple

myeloma and help an individual return to a normal functional state, as there has not yet

been a complete cure developed for this cancer. Common treatment includes targeted

therapy (medication therapy that prevent myeloma cells from breaking down proteins,

which in turn kills the myeloma cells), biological therapy (using drugs to enhance the

immune system), chemotherapy (medication therapy that kills fast growing cells

including myeloma cells), corticosteroids administration (medications that regulate

inflammation and myeloma cell reproduction), stem cell transplantation (replacing

diseased bone marrow with healthy bone marrow), and radiation therapy (concentrated

doses of radiation that damage myeloma cells in a specific area).

Many complications tend to arise from multiple myeloma, and are often treated in

addition to the cancer treatment. Complications such as bone pain can be treated with

pain management therapy, radiation therapy, and even surgery. Kidney complications

can include severe kidney damage which may require dialysis. Infections can be treated

with medications and prevented with vaccines, and bone loss or anemia complications
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can be treated with medications.

PTUS

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 Monoclonal gammopathy of undetermined significance (PTUS) is a disorder that

occurs when monoclonal antibodies (mAB) are produced by noncancerous plasma

cells. PT had a history of PTUS prior to diagnosis of multiple myeloma.

Individuals are at a higher risk for PTUS as they age, if they are obese, if they

have a history of autoimmune disease, when inflammation is present, or if they have

been exposed to radiation or pesticides. 9 PTUS is often asymptomatic and often has a

slow progression rate10. It is estimated that PTUS progresses about 1% each year 9 and

most individuals will live out the rest of their lives asymptomatic 10 without any form of

treatment. Occasionally, PTUS can exhibit symptoms of neuropathy due to M proteins

binding with nerves and causing numbness. PTUS can increase the risk of bone loss

and fractures and approximately 25% of PTUS cases progress to either multiple

myeloma or another type of B cell cancer10.

When M proteins are found in routine blood or urine tests, PTUS is suspected.

Further testing is done to diagnose using the criteria of less than 30 gram(g) per liter (L)

of M protein, less than 10% bone marrow plasma cell percentage, and absence of signs

relating to multiple myeloma (using the CRAB diagnosing guidelines). 9 Currently

treatment is not routinely done for patients diagnosed with PTUS, as it is benign.

Diagnosed patients do, however, routinely have check-ups twice a year to monitor any

progression that may have occurred. The monitoring can help physicians catch multiple

myeloma progression in the early stages allowing symptoms to be managed or

prevented early on.10

Chemotherapy

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 Multiple myeloma is not fully curable, but symptoms can be managed and

progression can be delayed with current treatments. PT had been diagnosed with

multiple myeloma during the hospital stay and was working with an oncology care team

to determine course of action. One treatment that was agreed upon was chemotherapy.

In the body, cells are constantly growing and dividing to reproduce. They start out

initially in an inactive resting phase called the G0 phase. They begin to grow and create

proteins in the G1 phase. In the S phase, those cells use the proteins made to create 2

copies of the DNA followed by another G phase (G2) of growth and protein

development. In the last phase, cells divide into two daughter cells in a process called

mitosis during the M phase. Along the DNA, there are various checkpoints that control

the rate of division. To remain healthy, the body reproduces cells at the same rate as

cell atrophy. During cancer, many of the control points are either broken or altered and

do not control the rate of division, making it so that cells divide and grow uncontrollably.

Chemotherapy works by medications attaching to various locations along the DNA or

the cell itself to prevent replication in the different phases. For example, some

medications attach to the DNA during the S phase so that when the DNA tries to
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replicate, the process is blocked and division is prevented.

There has been a great deal of progress made in the medications involved with

chemotherapy. The progress of chemotherapy for multiple myeloma started in the

1960s, when a medication called mephalen-prednisone (MP) was introduced and the

rate of response to treatment increased. There was, however, no change in long term

survival rate. In the 1980s, a high dose of chemo and stem cell rescue called

autologous stem cell transplant (ASCT) was introduced and many trials indicated an

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improvement in survival rates, but some trials indicated the MP and ASCT had the same

effects on prognosis. In 1999, a medication called thalidomide was introduced and both

the response rate and survival rates improved, especially when added to MP. In 2003,

both bortezomib and tandem ASCT were produced and seemed to improve survival

rates with just a single treatment. Lastly, in 2005 Lenalidomide was introduced as an

additive with dexamethasone, and survival rates increased when compared to

dexamethasone alone in phase III of the cancer.14 When patients are diagnosed with

multiple myeloma, they work with an oncologist to determine what course of action they

will take. With such a rapid progression in research for multiple myeloma, patients now

have more options than ever before.

Nutrition during cancer treatment

Nutrition is most impactful in multiple myeloma during actual treatment.

Chemotherapy can have several side effects including infections from a weakened

immune system, anorexia, nausea and vomiting, dry mouth, sore throat, diarrhea,

constipation, and weight loss or wasting. 12 These side effects can significantly impact

the nutritional status of an individual. Any patient going through cancer treatment should

learn to manage these symptoms to prevent further complications such as malnutrition,

which would worsen the prognosis of the medical condition. Following are

recommendations for managing common side effects of chemotherapy to prevent

malnutrition:

Weakened immune system: Many medications suppress the immune system (by

causing neutropenia) making an individual more susceptible to infection and illnesses.

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To manage this side effect, patients should strictly follow food safety guidelines to

prevent unnecessary exposure to bacteria. The United Stated Food and Drug

Administration (FDA) developed a manual specifically for cancer patients, to provide a

resource on proper food purchasing, handling, and consumption. In the manual, it

discusses the main points of keeping all surface areas clean, avoiding cross

contamination, cooking foods to a safe temperature, and chilling foods quickly to

prevent extended time spent in a dangerous temperature zone 15.

Anorexia: Patients will often lose their appetite during treatment, putting them at

an even higher nutritional risk. To manage anorexia, a dietitian should educate and

encourage the patient to consume small frequent meals throughout the day, drink high

calorie and protein supplements, instigate a power packing diet, eat more when they are

feeling well, consume softer and cooler foods, and ask their doctor for appetite

stimulants 12.

Changes in taste and smell: Patients who experience a change in taste and smell

are encouraged to avoid the most triggering smells to avoid nausea. This might include

eating cold foods since hot foods have a stronger aroma. For changes in taste, pts can

add sugar or salt to salty and sweet foods respectively to reduce the potency of flavor.

Using plastic utensils are also recommended, as many patients already have a metallic

taste in their mouth, so placing a metal utensil in their mouth might be unbearable 12.

Xerostoma: Xerostoma (or dry mouth) is common during chemotherapy because

often, salivary gland cells are damaged and cannot produce enough saliva to keep the

mouth moist. This can make it difficult to chew, swallow, and even speak. To manage

these symptoms, pts should brush their teeth after every meal, rinse with water

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frequently, use a humidifier throughout the night, stay hydrated, avoid caffeinated

beverages, and only consume moist foods.16

Nausea and Vomiting: When a patient is nauseated it is important to pay

attention to what foods are most irritating to them. Many find symptom relief by

consuming foods that are not sweet, fatty, spicy, or have strong odors. They can also

manage symptoms by eating small frequent meals, drinking liquids between meals, and

asking a doctor for anti-nausea medication 12

Diarrhea and Cramping: Diarrhea and cramping might present itself if

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chemotherapy damages intestinal lining cells. It is recommended that patients affected

by these symptoms stay hydrated and replace lost fluid, consume less dairy products,
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consume foods higher in electrolytes, and avoid caffeinated drinks.

Weight loss and muscle wasting: Wt loss is very common among chemotherapy

patients. RDs will give a power packing diet education to encourage a patient to

increase calorie and protein consumption. Supplements are often required if the patient

cannot consume enough nutrition to compensate for the catabolic activity happening

during treatment. 12

Symptom management is crucial during chemotherapy, since patients are at a

high risk for malnutrition. A registered dietitian is a great resource during treatment, and

should be utilized in both in-patient settings and out-patient settings.

Diabetes with multiple myeloma

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 In addition to multiple myeloma, PT had a chronic history of diabetes (DM). It is

estimated that 8-18% of cancer patients have DM. Although DM is not likely a cause of

multiple myeloma, both conditions have similar complications and can worsen the other

condition, especially during cancer treatment. Complications that both multiple myeloma
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and diabetes have in common include neuropathy, nephropathy, and retinopathy.

Neuropathy is when one or more peripheral nerves are dysfunctional. It is

estimated that approximately 50% of diabetic patients will develop some degree of

neuropathy within the first 25 years of diagnosis. When an individual is diabetic, they

develop hyperglycemia, and hyperinsulemia due to dysfunction in glucose

management. When this occurs, various metabolic pathways (such as the polyol and

myo inositol metabolism pathways) are disrupted, leading to increased oxidative stress,
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consequential nerve malfunction and ultimately nerve damage. In multiple myeloma,

neuropathy becomes a risk during treatment. It is estimated that out of all patients with

neuropathy and multiple myeloma, only 15% had the neuropathy prior to diagnosis of

cancer. There has been some research indicating that strict diabetic management can

help reduce diabetic neuropathy by 60%, in ad the chances of developing neuropathy

during treatment. 18

A second common complication of diabetes and multiple myeloma is retinopathy.

Retinopathy covers a variety of diseases in the retina that cause impaired or lost vision.

Diabetic retinopathy occurs because of the hyperglycemia. Normally the polyol pathway

metabolizes excess glucose into fructose through a series of pathways. When that

pathway is hyperactive for long periods of time in response to high amounts of glucose,

there is a buildup of glycating agents and sorbitol which increases oxidative activity and

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breaks down retinol cells. Additionally, the over-exertion of aldose reductase (AR),

which is the enzyme that reduces glucose into sorbitol, can also destroy cells. The

combination leads to functional cell breakdown and impaired vision. 20

In multiple myeloma, retinopathy is often of the first signs for diagnosis. All

patients with multiple myeloma have regular routine visits with an ophthalmologist to
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prevent further complications with vision. Retinopathy in multiple myeloma is typically

related to the increase in blood viscosity from overproduction of plasma cells. 21 There

are dozens of ocular manifestations that could arise that would be potential signs of a

multiple myeloma diagnosis. Those manifestations include, but are not limited to

proptosis (eyeball protrusion), diplopia (double vision), eyelid ecchymosis (discoloration

from bleeding under the skin), xanthomatosis (nodules along skin), scleritis

(inflammation of scleral tissue), episcleritis (inflammation of the episcleral tissues),

hyperviscosity retinopathy (increased blood viscosity), and retinal vasculitis

(inflammation of vascular branches in the retinal artery). These ocular manifestations

often will complicate diabetic retinopathy, putting the individual at a higher risk for vision

impairment or blindness. When retinopathy is present, it is likely that other

complications such as nephropathy will occur. 18

Both multiple myeloma and DM have a common complication of nephropathy.

Nephropathy is defined as kidney insufficiency or damage. Nephropathy affects

approximately 40% of diabetic patients22, about 20% of new multiple myeloma

diagnoses have pre-existing nephropathy due to diabetes, and about half of multiple
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myeloma diagnosed patients will develop some degree of nephropathy. Nephropathy

can lead to kidney failure and is a high-risk factor for early mortality. Risk factors can

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include hyperglycemia, increased blood pressure, genetic predispositions, smoking

habits 22, light chain deposition disease (a disease where infection-fighting

immunoglobulins, called light chains, which are typically filtered by the kidneys, begin to

damage organs starting with the kidneys), and chemotherapy 18. Medications that are

common with multiple myeloma chemotherapy such as Bortezomib and thalidomide are

not cleared by the kidneys, which leads to build up and kidney damage. If an individual

has diabetes with possible nephropathy at diagnosis, an oncologist might recommend

using alternative chemotherapy medications such as Lenalomide to prevent further

kidney damage. Creatinine levels must be monitored closely during the use of

Lenalomide, but this medication does clear from the kidneys and is a preferred
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alternative when nephropathy is a high risk. strict glucose and blood pressure control

can be helpful for DM management and may improve prognosis for multiple myeloma. 22

Treatment and Progress

PT had developed severe shoulder pain in April of 2016, which resulted in a trip

to a local Instacare. X-rays were taken and films were unremarkable, so the MD

suggested pain relievers and physical therapy. In September of the same year, the

patient was still in severe pain and a primary physician performed an MRI which

displayed a mass expanding to the humeral head consistent with malignancy. On

October 7th, a CT guided biopsy of that mass was taken. The results showed

plasmactyenia with monoclonal pappo light expression and the patient was then

transferred to IMC for diagnosis confirmation and management.

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 The patient was admitted with multiple symptoms that were managed during the

stay. Those symptoms included the shoulder pain, left groin pain (with a pain scale of 8

out of 10), left weakness and difficulty walking for the previous 3 months (likely related

to a previous cerebrovascular accident (CVA)), insomnia, anxiety, edema in legs,

fatigue, anorexia, and some dyspnea.

During admission, the patient was put on multiple medications for symptom

management, and was taken to the MRI lab to do further testing to confirm diagnosis of

multiple myeloma. Once officially diagnosed, an oncology specialist team was put

together to determine an appropriate treatment plan and discussed the options with the

patient. The RD was consulted to discuss the anorexia, wt loss, and nutrition during

cancer treatment. Upon discharge, the goal was to have the symptoms fully managed,

and an established course of action for the cancer treatment.

Nutrition Assessment

Anthropometrics

Upon admission, PT weighed 93.4 kilograms (kg) and was 162.6 centimeters (cm)

tall. BMI was 35.33 kg/meters2 indicating class II obesity. A weight adjusted for obesity

of 64.2 kg was used to determine estimated needs for the patient. PT reported having a

usual body weight (UBW) of 98 kg. The charted weight history indicated a 6% weight

loss over the previous 3 months, which did not quite meet the 7.5% standard to be

considered significant. The weight loss was likely related to the cancer and possible

bone deterioration.

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Biochemical

PT had various abnormal labs that correlated with the current medical state.

Many labs reflected the diabetes, multiple myeloma, and the kidney and bone damage

resulting from the multiple myeloma.

Lab Purpose Reference Actual Analysis 23

Glu Glucose 60-115 153-246 Levels are likely high due to the
availability and (H) diabetes exacerbated by physical
absorption in the stress.
body
A1C 3-month percent < 5.7 9.2 Levels were high related to diabetes.
average of
glycated red
blood cells
Hgb Measurement of 12.1-15.6 11.3-11.7 Low levels of Hgb are potentially
the protein in red (L) related to the multiple myeloma,
blood cells that which can result in anemia.
transports iron.
BUN Measurement of 8-21 16-33 (H) Elevated levels of BUN are likely
urea that was not related to the patients history of
filtered through diabetes, as well as the catabolism
the kidneys and occurring with multiple myeloma,
is now in the and possible dehydration.
blood serum
Creat Measurement to .42-0.90 .9-1.49 (H) The elevated levels of creatinine are
help determine related to the kidney damage that
kidney function occurs during multiple myeloma, as
status. well as possible nephropathy of
diabetes.
Ca Measurement of 8.8-10.7 8.4-11.1 Hypercalcemia is likely related to the
Ca circulating in (trending multiple myeloma with bone
the blood high) breakdown.

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GFR Measurement of >90 54 44 Multiple myeloma often is associated
kidney function (trending with suboptimal kidney function and
by measuring lower) is likely the cause of the lower GFR.
creatinine
clearance

PT presented with elevated A1C levels and glucose serum levels related to a

prolonged diabetes diagnosis. The patient was managing glucose levels with oral

medications and insulin, but had not had any significant diet changes. In the previous

test, the PT had an A1C of 12.6, but since onset of multiple myeloma, glucose levels

had stabilized, resulting in an A1C of 9.2 and a reduced need for diabetic medication

dosage.

PT had various indicators of nephropathy, including elevated levels of BUN and

creatinine. The kidneys function as filters for waste in the blood including urea and

creatinine. When kidney function is insufficient, there will be a build-up of these waste

products in the blood which is indicated by serum blood tests. The other kidney function

test is the measure of the glomular filtration rate (GFR). This test measures the

creatinine clearance, and the higher the number, the better the functioning status of the

kidney is. PT had both the diabetes and multiple myeloma increasing risk of

nephropathy together, indicated by the lab values.

Other abnormal lab values including the calcium (Ca) and the hemoglobin (hgb)

levels were both likely relevant to the multiple myeloma. As plasma cells duplicated

rapidly, and form tumors throughout various bones, excess calcium is broken down from

the bone and begin to circulate in the blood. With this new diagnosis of multiple

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myeloma, the body had just begun to increase that bone breakdown, evidenced by the

lab values.

Medications

Prior to admission, PT was taking multiple medications including insulin to control

DM. After admission, additional medications were administered to manage diabetes,

anxiety, hypertension, and pain. Following is an explanation of each medication

received by PT during stay along with possible diet related side effects:

Medication Use Diet-related side effects

Norco24 Pain reliever Dizziness, stomach pains, loss of appetite,

N/V, sore throat
Lower Fruit-like breath odor, increased hunger,
Simvastatin25 cholesterol increased thirst, increased urination, muscle
cramps, N/V, abdominal pain, unexplained wt
loss, diarrhea, difficulty swallowing, loss of
appetite
Ativan 26 Anxiety control Abdominal pain, difficulty swallowing, dry
mouth, loss of appetite, N/V
Paxil 27 Antidepressant Dry mouth, loss of appetite, pale skin
Carvedilol 28 Beta blocker to Chest pain, wt gain, dry mouth, fruit-like
treat heart breath odor
failure and
hypertension
Novolog 29 Fast acting Excessive hunger, dryness of mouth
insulin for
glucose control
Lantus23 Glucose Excessive hunger, headache, increased thirst
control difficulty swallowing, dry mouth

The medications received all had some nutrient interactions that were important

to assess and educate the patient on prior to discharge. The most significant

interactions included alcohol and grapefruit juice. Alcohol had the potential to decrease

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effects of the medications (like insulin) or amplify the effect of other hormone related

medications, such as Ativan, to the point of impairing mental status.

Clinical Evaluation

The patient was found to have minimal signs of malnutrition during a physical

assessment. The major physical finding was hair loss. There are various support forums

for diabetic pts on the correlation between diabetes or diabetic medications and hair

loss, but no research has been done to prove this is a true cause. Some research that

has been done, however, is on the impact inadequate nutrient intake including iron, and

some vitamins has on hair growth 30. PT might have been in the beginning stages of

malnutrition causing hair loss, so intake would be an important component to look at,

especially with plans to start chemotherapy and be put at an even higher nutritional risk.

Dietary

While in the hospital, PT was placed on a consistent carbohydrate diet. This was

appropriate for glucose control. Prior to admission, the patient had an extensive history

of diabetes, primarily controlled by medications and not many dietary changes. A

consistent carbohydrate diet limits the number of grams of carbohydrates an individual

can have at each meal, preventing any significant spikes of serum glucose. For PT, a

mild restriction was placed at 4-6 servings or 60-90 g carbohydrates/meal.

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Summary of Assessment

The plan of treatment for PT was arranged to improve the nutritional quality of life

(FH 8.1) by controlling glucose levels in the body, and suppressing pain preventing a

suppressed appetite. Additionally, weight trends were monitored (AD 1.1.4) closely

since the patient had lost 6% body weight over the 3 months PTA. With appropriate

assessment, the patient would be able to establish a better nutritional state and have a

better prognosis with chemotherapy in the future.

Nutritional Diagnosis

As evidenced by significant weight loss over the previous 3 months PTA, it was

assumed there was chronic insufficient nutrient consumption. The patient had admitted

to having a poor appetite, and this was likely a contributor to the decreased intake, but it

could have also potentially been related to the increased catabolic state of multiple

myeloma. In addition to the inadequate oral intake, PT was found to have with altered

lab values. In uncontrolled diabetes, glucose levels and A1C levels are typically

elevated. The patient had been controlling diabetes with medications, but had not

initiated full diet modifications and still had elevated levels of both glucose and A1C.

PES statements were written as followed:

Inadequate oral intake related to increased catabolic state (multiple myeloma)

increasing nutrient needs as evidenced by PO <50% PTA, 6% wt loss x 3

months.

Altered nutrition related lab values related to diabetes as evidenced by glucose of

246, and A1C of 9.2.

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 Moderate chronic malnutrition related to multiple myeloma as evidenced by PO

intake <75% estimated needs x 3 months, and mild edema.

Intervention

Medical

Upon admission, the multiple myeloma diagnosis was unknown so medical treatment

involved various tests for diagnosing as well as pain management with medications.

Symptom management was the primary focus of the visit. After diagnosing multiple

myeloma, an oncologist team discussed treatment options for the cancer, but that

further treatment would be done as an outpatient.

Nutritional

Nutrition was a significant priority in symptom management for the patient during the

noted hospital stay. The patient had experienced weight loss and suppressed appetite,

so the dietitian intern discussed the importance of proper nutrition and the nutritional

implications of weight loss. Additionally, glucose control through diet was discussed, and

an education was given on nutrition during cancer treatment as preparation for the next

steps of medical care.

PTA, the patient had a decline in PO related to a lack of energy and was eating

between 0 and 50% of what was considered normal. The patient noted that the husband

would cook, but there was such a poor energy level, eating was not appealing. PO

continued to be insufficient on the first day of admission, but after medications were give

to address symptoms, PT gained enough energy to start eating again.

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Monitoring/Evaluation

PT had multiple nutrition related health risks including weight loss, diabetes, and

future cancer treatment side effects, that required monitoring and evaluation.

For weight loss, weight was taken daily, and the RD closely monitored trends so

that if weight was declining, it could be addressed immediately. As the patient was

beginning to have an improved appetite, it was presumed that the weight would

increase with PO intake, but if PO were to decrease and/or weight loss continued, the

RD was to increase diabetic Boost supplementation to three times a day (TID).

For diabetes, the RD was to monitor serum glucose trends whenever labs were

drawn and continue to encourage appropriate diet management. Monitoring PO will also

help with diabetes control as the RD would be able to monitor the frequency and type of

food to note any potential risks for serum glucose spikes.

Lastly, for future cancer treatment, the intern did an initial education on the

nutrition related side effects that would possibly occur during chemotherapy, but for

monitoring and evaluation, the RD was to follow-up and address any question or

concerns that might have arisen since the education. Additionally, the RD was to

discuss options for outpatient counseling during treatment with the patient, and provide

any resources needed to set up of that counseling.

Conclusion

In conclusion, PT was diagnosed with multiple myeloma and both medical and

nutrition care plans were designed to reduce the side effects of the diagnosis,

22
(specifically pain), and manage a previous diagnosis of diabetes. An oncology care

team was put together to begin treatment planning for cancer, and the standard medical

team was available for support. Due to the incurable nature of multiple myeloma,

prognosis was suboptimal, but the patient had agreed to chemotherapy, which if

successful, would prolong life, as well as increase quality of life by minimizing negative

side effects. Appropriate educations were given to PT, and follow-ups were planned to

provide any further education or support needed.

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Appendix

Images

24
 Nutrition Care Process
A systematic problem-solving methodto critically think and make decisions to
address nutrition related problems and provide safe and effective quality nutrition care.

1. Patient Information:

Initials PT Medical Dx For Multiple Myeloma

This Admit w/ uncontrollable
pain
Age 70
Gender Female
Ethnicity/Religion Hispanic, Latino Physician
Occupation Non Insurance AARP
Coverage Medicare/Self Pay
Allergies/Intolerances Gabapentin Care Giver (If Husband- d/c with
Needed) home health or
skilled nursing
facility

2. Medical History:

Identify
Family / Social Mother- died from ESRD
Hx Father- died from carbon monoxide poisoning
Most aunts, cousins, grandparents, uncles, etc have DM.
Social:
Retired, never smoked, drinks on occasions
Past Medical / Medical:
Surgical Hx PTUS, DM, GERD, sinitus, otitis, bronchitis, severe calf
spasm, mild intermittent asthma, obstructive sleep apnea
syndrome, obesity, HTN, ganglia infarction, CVA, radicular
syndrome of lower limbs, degeneration of lumbar
intervertebral disc, arthritis, MDD, back pain,
microalbuminuria, peripheral neuropathy, proteinuria
syndrome, hirsutism, stress incontinence, osteopenia,
shoulder pain.
Surgical:
carpal tunnel release, cataract removal, cholecystectomy,
uterine ablation, L spine surgery (10/2015)
Symptoms Left shoulder pain x 4 months
Related to Left groin pain (pain scale 8/10)
Current Left weakness /difficulty walking x 3 mos (r/t CVA)
Diagnosis
Insomnia/anxiety

25
 Swollen Legs x 3 weeks
Fatigue
Anorexia
Some dyspnea

Summary of Important Shoulder pain in April Went to Instacare: films

Events While in Hospital
were unremarkableStarted PATIENT
(9/28/16)MRI showing mass expanding to humeral
head w/ cortical breakthrough consistent w/
malignancy (10/7) CT guided biopsy of mass:
Shows plasmacytenia w/ monoclonal pappo light
chain expression transferred to IMC for
management
Admit: 10/19
10/19:
For leg swelling- Vascular lab completed a
complete real time venous duplex exam w/
pulsed wave directional poppler and spectral
analysis: No evidence of deep/superficial
venous thrombosis in L or R extremities
MRI of pelvis and hips findings r/t
plasmacytoma:
o Innumerable enhancing lesions
scattered throughout visualized lower
lumbar, spine, pelvis, and proximal
femurs
o Slightly heterogeneous bone marrow
o Degenerative changes of visualized
lower lumbar spine
o Mild tendinopathy of L proximal
hamstring tendons

Procedures Done While in MRI- 10/19

Hospital (Include Dates) or
Procedures that are
Planned

26
3. Anthropometrics:

Current Weight: 93.4 kg Current Height: 162.6 cm_ UBW: 98 kg

IBW: 52.6 kg % IBW: 178%_ BMI: 35.33

Amputations: None Adjustment for spinal cord injury: N/A

Weight History:

Date/Time Weight Date/Time Weight

8/24/2015 15:16 99.97 kg
10/23/2015 16:32 99.16 kg
11/10/2015 12:09 100.24
04/18/2016 11:30 98.88 kg
05/05/2016 13:36 98.79 kg
07/21/2016 16:29 96 kg
8/1/2016 11:51 98.88 kg
8/25/2016 15:10 96.20 kg
10/19/2016 93.40 kg
16:49

Interpret weight history and give possible explanations for variation in the weights
recorded. Include in your explanation recent weight loss prior to admission and state
whether the weight loss was intentional or unintentional:
The patient has had a fairly stable wt over the past year up until the past 3 months
where there was a 6% unintentional wt loss. The wt loss is likely r/t the myeloma and
declined appetite.

4. Estimated Energy Needs (1):

ASPEN guidelines: 22-25 kcal/kg adjusted wt: 22-25 kcal (64.2 kg)= 1412-1605 1400-
1600 kcal

Estimated Energy Needs (2):

Mifflin St Jeor: 10 (ABW)+ 6.25 (ht)-5 (age)-161
1439 kcal x 1.0-1.2 Activity factor
1439-1728 1440-1730 kcal/day

My calculated recommendations for this patient at IMC (facility) were formulated

using the following standard estimates of (ASPEN) 22-25 kcal/kg adj. wt energy
needs, (ASPEN)1.2-1.5 g/kg adj. wt protein needs, and _(ASPEN) 25-30 ml/kg ABW_
fluid needs.

27
Justification for my calculated recommendations:
For this particular equation, both the Mifflin St Jeor using ABW and the ASPEN
guidelines using adjusted wt come equate the needs similarly. This helps determine an
appropriate recommendation, and as IMC RDs typically use the ASPEN guidelines, my
final kcal estimations were based off of the ASPEN. The protein needs were also
calculated using ASPEN guidelines for cancer- moderately stressed pts. Protein
turnover increases with disease progression so as the cancer progresses, the protein
needs will increase.

Kcal/day: 1400-1600 Grams of protein/day: 80-95

Fluid needs/day: 2335-2800

Nitrogen needs/day: 90 g protein / 6.25= 14.4 g N

NPC:N ratio: 79.17

Total calorie- calories from protein: 1500-360= 1140 kcal
G nitrogen= 14.4 g
Non-protein calories/ g nitrogen= 1140 kcal/14.4 g= 79.17

5. Biochemical:

Laboratory Information
Date Date Date Date Date Date
Test 5/30 7/25 9/27 10/07 10/19 10/20 Normal
Gluc* 186 221 169 - 153 246 60-115 High
Pt/dl
Alb 7.4 - - 3.0 L 2.9 L - 3.4-5.3 Trending
g/dL low
Hct 41.7 - - 34.9 - 35.3 36- WNL
46%
Hgb 13.9 - - 11.3 - 11.7 12-16 Low
g/dL
MCV 90.8 - - 94.8 - 92.7 78-102 WNL
RDW 13.4 - - 13.5 - 13.4 11.3- WNL
15.6%
BUN 16 32 31 - - 33 8-21 Trending
Pt/dL high
Crea .90 1.08 1.27 H - - 1.49 .42-.90 Trending
H Pt/dL high
Na 139 143 144 - - 136 137- Low-
146 Normal
mmol/L
K 3.8 4.2 4.4 - - 4.1 3.4-4.7 WNL
mmol/L

28
 Ca 8.4 8.9 8.8 - - 11.1 8.8- Normal-
10.7 high
GFR - 51 44 - - - >90 Low

Provide evidence-based interpretation for nutrition-related values:

Lab Purpose Reference Actual Analysis Pronsky

Glu Glucose 60-115 153-246 Levels are potentially high due to
availability and (H) prolonged physical activity, and
absorption in the possibly from the antihypertensive
body medications
A1C 3-month percent < 5.7 9.2 Levels were high related to diabetes.
average of
glycated red
blood cells
Hgb Measurement of 12.1-15.6 11.3-11.7 Low levels of Hgb are potentially
the protein in red (L) relates to the multiple myeloma, and
blood cells that possible anemia.
transports iron.
BUN Measurement of 8-21 16-33 (H) Elevated levels of BUN are likely
urea that was not related to the patients history of
filtered through diabetes, as well as the catabolism
the kidneys and occurring with multiple myeloma,
is now in the and possible dehydration.
blood serum
Creat Measurement to .42-0.90 .9-1.49 (H) The elevated levels of creatinine are
help determine related to the kidney damage that
kidney function occurs during multiple myeloma, as
status. well as possible symptoms of
diabetes.
Ca Measurement of 8.8-10.7 8.4-11.1 Hypercalcemia is likely related to the
Ca circulating in (trending multiple myeloma with bone
the blood high) breakdown.
GFR Measurement of >90 54 44 Multiple myeloma often is associated

29
 kidney function (trending with suboptimal kidney function and
by measuring lower) is likely the cause of the lower GFR.
creatinine
clearance

If diabetic, summarize blood glucose readings:

History:
Test 5/30 7/25 9/27 10/07 10/19 10/20 Normal
Gluc* 186 221 169 - 153 246 60-115 High
Pt/dl

Admit/Homecare:
Date/Time Blood glucose
level
10/19 14:20 153
10/20 12:30 246

At home, per
patient:
Mornings 120-180

Personal lows: 60-99

Personal highs: In the 500s

Home readings:
The patient checks glucose levels about 5x/day after waking up, at each meal,
and before bed. The patient stated that usual levels are between 120 and 180
and when levels read under 100, the patient experiences cold sweating. To
manage those symptoms, the patient drinks a class of orange juice to pull up
levels, but that often results in diarrhea.

Interpret glycemic control and give possible explanations for variation in blood
glucose levels. Include in your explanation interventions taken to normalize blood
glucose levels:
Glucose Management:
The patient has been diagnosed with diabetes for about 60 years. For 20 years,
glucose levels were controlled with pills and after that, insulin was initiated. The

30
 patient has been prescribed to take about 160 units in the morning and 160 unit
in the evening, and has recently been able to lower it down to 140 units in the
morning and 80 in the evening. Over the past 3 mos., glucose levels have
stabilized and the A1C level dropped. This might be r/t the cancer, as nothing
else had changed in the pts glucose management.

6. Medications:

Medication Use Diet-related side Drug-nutrient interactions

(include dose) effects
NorcoNorco drug.com Pain reliever Dizziness, Alcohol- potentiate
stomach pains, CNS leading to
loss of appetite, impaired judgement,
N/V, sore throat hypotension,
respiratory
depression, coma, or
death
Grapefruit juice-
increases plasma
concentrations of
hydrocodone fatal
respiratory
depression
SimvastatinSimvastati Lower Fruit-like breath Grapefruit juice-
drug.com
cholesterol odor, increased increase blood levels
hunger, increased of simvastatin liver
thirst, increased damage, skeletal
urination, muscle muscle breakdown.
cramps, N/V,
abdominal pain,
unexplained wt
loss, diarrhea,
difficulty
swallowing, loss of
appetite
AtivanAtivan Anxiety control Abdominal pain,
difficulty Alcohol- can increase
swallowing, dry nervous system side
mouth, loss of effects
appetite, N/V
PaxilPaxil drugs.com Antidepressant Dry mouth, loss of Alcohol- can increase
appetite, pale skin effects such as
dizziness,
drowsiness, and
difficulty

31
 concentrating
Carvedilol carvedilol
Beta blocker to Chest pain, wt Alcohol- lower blood
drugs.com
treat heart gain, dry mouth, pressure too low
failure and fruit-like breath MVI- consumed less
hypertension odor than 2 hours apart
can decrease the
effects of carvedilol.
NovologNovolog Fast acting Excessive hunger, Alcohol- disrupts
drugs.com
insulin for dryness of mouth regulation of glucose
glucose control levels
Lantus Glucose Excessive hunger, Alcohol- disrupts
control headache, regulation of glucose
increased thirst levels
difficulty
swallowing, dry
mouth

Self-prescribed None
medications and
nutrition
supplements

7. Clinical Evaluation:

Circle observed signs of nutrient deficiency:

Hair: Loss Mouth: Stomatitis

Thin, sparse Cheilosis
Nails: Spoon shape Glossitis
Transverse ridging Gingivitis
Skin: Dry, scaling Teeth: Missing
Jaundice Poorly fit dentures
Dermatosis Muscles: Edema
Petechiae Muscle wasting
DQ ulcer: Stage _____ Eyes: Icteric

Identify observed signs of nutrient deficiencies and list possible nutrition-related

causes:
Some hair loss- potentially r/t declined health from cancer, wt loss, possible start of
malnutrition.

Describe any physical handicaps that affect intake. Determine patients ability to
perform activities of daily living: the patient has been unable to stand/walk for long

32
periods d/t lack of energy and strength. The patient is unable to cook, and has a difficult
time using the bathroom since her bathroom toilet is low seating. To compensate for
these handicaps, the patients husband cooks the meals, and purchased a toilet seat
riser so the patient would not have to struggle.

8. Dietary:

Date & time Diet order PO % Assess tolerance Is diet adequate to

to diet meet patients
needs?
10/19 14:25 Consistent 75- The patient initially Yes
Carb 100% had a poor appetite
medium but after
(60-90) medications were
initiated the patient
was able to
consume 75-100%
of meals with good
tolerance.

Identify and evaluate any chewing/swallowing problems. Include in your

explanation interventions taken to modify diet:
The patient denied any chewing or swallowing difficulties. The patient understood that
there might be side effects that affect chewing or swallowing during chemotherapy and
was prepared to address concerns as symptoms arise.

Obtain a diet history when needed for diet instructions or to discern patients
nutritional status when appropriate:
Meal & time Food & preparation Amount
method
Peanut butter and Jelly 2 slices bread, 2 Tb PB,
Breakfast sandwich 2 TB jelly
Coffee 8 oz
Sweet n low 2 pkt.
Arizona Tea

Bagel 1 full
Lunch Cream Cheese 3 Tb
Arizona Tea 1 can

33
Dinner BBQ chicken 1 breast
Rice 1 cup

Evaluate diet history by using dietary software. Interpret findings:

PT's Nutrients Report

Your personal Calorie goal is 1500. Your plan amounts are based on meeting
your nutrient needs.

Nutrients Target Average Eaten Status

Total Calories 1500 Calories 1238 Calories Under
Protein (g)*** 90 g 58 g Under
Protein (% Calories)*** 10 - 35% Calories19% Calories OK
Carbohydrate (g)*** 130 g 161 g OK
Carbohydrate (% Calories)*** 45 - 65% Calories52% Calories OK
Dietary Fiber 21 g 7g Under
Total Sugars No Daily Target 32 g No Daily Target
or Limit or Limit
Added Sugars < 37 g 26 g OK
Total Fat 20 - 35% Calories30% Calories OK
Saturated Fat < 10% Calories 11% Calories Over
Polyunsaturated Fat No Daily Target 6% Calories No Daily Target
or Limit or Limit
Monounsaturated Fat No Daily Target 11% Calories No Daily Target
or Limit or Limit
Linoleic Acid (g)*** 11 g 7g Under
Linoleic Acid (% Calories)*** 5 - 10% Calories 5% Calories OK
-Linolenic Acid (% 0.6 - 1.2% 0.3% Calories Under
Calories)*** Calories
-Linolenic Acid (g)*** 1.1 g 0.4 g Under
Omega 3 - EPA No Daily Target 10 Pt No Daily Target

34
 or Limit or Limit
Omega 3 - DHA No Daily Target 23 Pt No Daily Target
or Limit or Limit
Cholesterol < 300 Pt 143 Pt OK
Minerals Target Average Eaten Status
Calcium 1200 Pt 352 Pt Under
Potassium 4700 Pt 1380 Pt Under
Sodium** 2300 Pt 1606 Pt OK
Copper 900 g 663 g Under
Iron 8 Pt 14 Pt OK
Magnesium 320 Pt 177 Pt Under
Phosphorus 700 Pt 592 Pt Under
Selenium 55 g 78 g OK
Zinc 8 Pt 6 Pt Under
Vitamins Target Average Eaten Status
Vitamin A 700 g RAE 188 g RAE Under
Vitamin B6 1.5 Pt 0.9 Pt Under
Vitamin B12 2.4 g 0.5 g Under
Vitamin C 75 Pt 2 Pt Under
Vitamin D 15 g 0 g Under
Vitamin E 15 Pt AT 3 Pt AT Under
Vitamin K 90 g 5 g Under
Folate 400 g DFE 608 g DFE OK
Thiamin 1.1 Pt 1.4 Pt OK
Riboflavin 1.1 Pt 1.1 Pt OK
Niacin 14 Pt 24 Pt OK
Choline 425 Pt 142 Pt Under

If the patient accurately indicated a usual 24-hour diet recall, the patient is not receiving
adequate nutrition. The patient is consuming > 75% estimated calorie requirements
(83%), but is only consuming 64% of protein needs. Protein will be essential through
cancer treatment and should be increased in the diet. The recall also indicated
suboptimal intake of most Vitamins and Minerals. Consuming more fruits and
vegetables will help increase these values, and taking a daily MVI would be beneficial.

35
Determine if food security influences diet. List possible interventions available to
improve food procurement:
The patient was not concerned about any food security difficulties. There is concern,
however, for when the patient begins paying for chemotherapy. The cost of the
treatment might put the patient at a higher risk for food insecurity and additional
resources will need to be utilized. Some potential sources for improved food
procurement could include:
Supplemental nutrition education assistance (if qualified)
Cancer Care financial aid: http://www.cancercare.org/financial
Medication financial assistance: http://www.needymeds.org

9. Education:

List all nutrition education given to the patient. Determine if there are any social,
emotional, or physical factors that affect adherence to the education. Assess
patients understanding, compliance, and receptivity:
The patient received:
a nutrition during cancer treatment education
a power packing diet education
The patient felt overwhelmed by the recent cancer diagnosis, and was interested in
learning about nutrition during treatment. When talking about family and history, the
patient would occasionally become emotional and appear distressed. A good social
support for cancer patients would be appropriate for this patient to help with the feeling
comfortable and confident in the treatment.

10. Coordination of Nutrition Care:

Determine if any referrals need to be made to other programs or services and

explain why:
Outpatient RD: to monitor wt trends, and diet through treatment
Psychologist: to allow the patient to express concerns and deal with the
emotional distress
Occupational therapist: to help improve ADL functioning
Community cancer support programs: to establish a good support system
throughout treatment.

11. Nutrition Screening:

Currently patient is assessed at Moderate nutrition risk based on the nutritional

standards at IMC.

36
Justification for degree of nutrition risk assessed: The patient is at an increased
moderate nutritional risk d/t new cancer diagnosis. The patient will continue to be at
moderate risk as chemotherapy is initiated and progresses.

Nutrition Assessment(s) and Follow-Up Note(s) based on IMC format:

Admit diagnosis: Multiple Myeloma

Admit date: 10/19/2016
Language: English, Spanish
Religion: Catholic
Wt (kg/lb): 93.4 kg/ 219 lbs Ht: 162.6 cm/ 64 in
BMI: 35.33 IBW: 54.5 kg % IBW: 171%

Current Medical Problems:

Diabetes
Multiple myeloma
Edema
Anorexia
Past medical history:
Diabetes, PTUS, GERD, Sinitus, otitis, bronchitis, mild intermittent asthma,
obstructive sleep apnea syndrome, obesity, HTN, ganglia infarction, CVA,
arthritis, MDD, back pain, microalbuminuria, peripheral neuropathy, proteinuria
syndrome, osteopenia, shoulder pain.
Past Surgical history:
Carpal tunnel release, cataract removal, cholecystectomy, uterine ablation, left
spinal surgery

Estimated Needs:
Kcals: 1440 (Mifflin with ABW)
Protein: 110-140 g (1.2-1.4 ABW)
Fluid: Per MD

Additional Data:
I met with pt at bedside today. Pt admitted having an improved appetite since yesterday
evening, but had previously had a poor appetite due to a lack of energy. The pt was
controlling Glu at home with insulin. She stated that she was checking blood sugars
between 3 and 5 times a day with usual readings falling between 120 and 180. The
patient had been able to cut insulin dosage in half a few months prior and her blood
sugar stabilized really well at that time likely due to cancer. The pt described a typical
24-hour recall and it was noted a high number of carbs, and little to no fruits and
vegetables. Pt stated that she has an extensive family history of diabetes. She will be
starting chemotherapy for multiple myeloma management today. UBW: 98 kg

Evaluation of Data:

37
The pt was at a moderate nutritional risk due to multiple myeloma diagnosis and
diabetes. Wt hx indicated a 6% loss x 3 months. Abnormal labs correlate with current
medical condition: elevated Glu, BUN, Creat, Ca, and low Alb, H/H, GFR. 2+ edema
noted. Noted sparse hair. Currently on a consistent diet, which is appropriate for current
medical condition. PO had been <50% estimated needs over past few weeks but had
improved to 75-100% over past day. No chewing/swallowing difficulties to note.
Discussed nutrition through cancer treatment with patient and provided handout. RD to
monitor wt trends, PO, and tolerance for further recommendations.

Goals:
Increase PO to meet 75-100% estimated needs
Maintain LBM
Lab values WNL

Interventions:
Consistent carb diet
Nutrition through cancer treatment education
Diabetic community support resources
Diabetic Boost BID

Nutrition Recommendations:
Encourage PO
Manage lab values
Initiate MVI
Initiate a 3-day calorie count

ADIME Note:

38
A PT was a 70 y.o. f. dx with multiple myeloma, DM, edema, anorexia. Current wt
93.4 kg was 171% IBW (54.5 kg). Ht 162.6 cm. BMI 35.33 (class 2 obesity). Wt
hx indicated a 6% loss x 3 months. Wt stable x several years prior to recent
loss. Abnormal labs indicative of DM, kidney damage, multiple myeloma,
malnutrition: elevated Glu, BUN, Creat, Ca, low Alb, H/H, GFR. Insulin used to
control DM at home. Recent change in medical state (related to multiple
myeloma) caused a shift in hormones allowing glu to stabilize with lower levels
of insulin. Physical assessment revealed 2+ edema, and sparse/thinning hair.
No wounds to assess. Recent decline in ability to perform ADL x 3 months.
Currently on a carb controlled diet for DM (appropriate). PO poor PTA (<50%
estimated needs). Appetite improved upon assessment related to appetite
stimulants. 24-hour recall indicated a poor intake of fruits/vegetables, high
amounts of carbs. Pt was retired, married, and living at home. A strong social
support was available, and good compliance to recommendations is expected.

Oral Intake: FH- 1.2

Glucose/endocrine profile- BD 1.5
Wt change- AD 1.1.4
D Inadequate oral intake (NI 2.1) related to increased catabolic state
(multiple myeloma) increasing nutrient needs as evidenced by PO <50%
PTA, 6% wt loss x 3 months.
Altered nutrition related lab values (NC 2.2) related to diabetes as
evidenced by glucose of 246, and A1C of 9.2.
Moderate chronic malnutrition (NI 5.2) related to multiple myeloma as
evidenced by PO intake <75% estimated needs x 3 months, 6% wt loss
x 3 months, and mild edema.

I Medical Food Supplements/ commercial beverage (ND 3.1.1): Diabetic

Boost BID
Nutrition education: Nutrition relationship to health/disease (E 1.4):
Nutrition during cancer treatment.
Referral to community programs: organizations, magazines,
accessories, travel assistance, medication assistance programs,
continued learning websites, social networking (RC 1.4): Education
resources for diabetes handout.
Modified type of diet (ND 1.2): Consistent Carb diet
M/E RD to monitor wt trends (AD 1.1.4).
If wt continues to decline, will consider increasing supplementation to
TID, discuss a power packing diet
If wt stabilizes, continue current treatment
If wt increases too quickly, lower supplementation to once a day
RD to monitor endocrine profile (BD 1.5)
If glucose/A1C levels increase discuss carb counting with patient and
discuss options with the MD for increasing medication or insulin dosage
If glucose levels decrease, continue current treatment

39
 RD to monitor oral intake:
If PO declines, will consider increasing supplementation to TID, discuss
power packing diets, symptom management, and discuss medications
with MD for stimulating appetite.
If PO improves, continue current treatment
RD to follow up in 3 days to analyze a carb count if initiated, and monitor PO
RD to follow up in 5-7 days to reassess current nutritional status.

1.

2.

3.

40
41
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