a case study: astrocytoma
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DESCRIPTIONCase study presented during the dietetic internship at Reid Hospital
- 1. ASTROCYTOMAJune 9, 2010 Victoria Parry, Dietetic Intern
2. AstrocytomaAstrocytomas normallydevelop inthecerebrumbut canoriginate inother partsof the brainand spinalcord. 3. AstrocytesStar-shaped glial cells located in the brain and spinal cord (CNS)Function: Regulate external chemical environment of neurons; blood flowin brain 4. Stages of Astrocytoma Stage 1: Pilocytic Astrocytoma Stage 2: Diffuse Astrocytoma Stage 3: Anaplastic Astrocytoma Stage 4: Glioblastoma Multiforme (GBM) Gliosarcoma Giant Cell Glioblastoma (1) 5. Examples of AstrocytomasLow-grade Astrocytoma Giant Cell Astrocytoma (2) 6. Cause of Astrocytoma Currently unknown Cell phones Prophylactic Radiationfor Acute LymphaticLeukemia Genetics Family history ofastrocytoma Molecular Mutation (3) 7. PrevalenceGender Age Male predominance Affects all ages 10% less than 20 years 1.18:1 Low-grade 60% 20-45 years 1.87:1 Anaplastic (Grade 30% 45 years or olderIII)Race Mortality and Morbidity Affects all races Grade 1:10 years Grade 2:More than 5 years Grade 3:2-5 years Grade 4:Less than 1 year(3) 8. Symptoms Altered development orgrowth (in children) Double Vision Drowsiness Eyesight Problems Headache Lethargy Mental Status Change Obtuseness Personality Changes Seizures Vomiting (1,4 9. Diagnosis and TreatmentTesting:Treatment Options: Neurological Exam Surgery Vision Resection of tumor Hearing Balance Radiation Coordination Chemotherapy Computed Tomography TemozolomideScan (CT) Magnetic ResonanceImaging (MRI) Angiogram Biopsy (1, 2, 3, 5) 10. Case Study Patient Information Admit Diagnosis: AspirationPneumonia, Dehydration, Sepsis Sex: Female Age: 36 Years Old Weight: 157# Height: 50 BMI: 31 Ideal Body Weight: 90-110# Percent Ideal Body Weight: 157% Adjusted Body Weight: 114# Home Diet Regimen: G-Tube with Jevity Bolus 5 CansDaily 11. Past Medical History Astrocytoma 1987: Cerebral AstrocytomaSurgery 1992: Repeat Brain Surgery Pituitary Insufficiency Post radiation treatment Seizure Disorder Post brain surgery Hypothyroidism Pneumonia Gastrostomy Tube Placement 2006 12. Social History Resides with mother and other family Bed bound last 3-4 years Home Health Care Aide Three times daily Nonverbal 13. Relevant Medications Os-Cal: Calcium supplement. Alsoused as antacid, phosphate binder,antidiarrheal Prilosec: Proton Pump Inhibitor. Usedto decrease gastric acid secretion andincrease gastric pH Lactinex: Lactobacillus probiotic.Used to aid with GI regulation andantidiarrheal Zofran: Antiemetic. Used to decreasevomiting Flagyl: Antibiotic used to treat C. diff. (6)Can cause nausea, diarrhea, anorexia, 14. Laboratory ValuesDateHgb HctMCV Na+ K+Gluc.BUNCreat. Ca+ 12-18 37-47 82-101135-155 3.5-5.570-1208-26 .6-1.3 8.7-10.24/18 16.449.281.8 1414.4 86120.99.14/19 220.127.116.11 1353.4 97100.98.54/20 12.335.980.9 1403.8 845 0.68.24/21 N/A N/A N/A1452.9 731 0.68.04/22 11.433.079.5 N/AN/A N/A N/A N/AN/A4/23 N/A N/A N/A1452.9 902 0.68.04/24 12.637.079.8 1413.4 102 6 0.67.74/25 12.337.081.6 1433.4 868 0.57.94/26 12.637.982.3 N/AN/A N/A N/A N/AN/A 15. Laboratory Values Date Alb Alk PhosSGOT PO4RBCWBCCl-3.4-5.050-1367-47 2.5-4.94.2-5.4 4-10.5 96-1074/18N/A N/AN/AN/A 6.01 16.2 1004/192.4 33943 3.2 5.21 18.4 1024/20N/A N/AN/AN/A 4.44 12.4 1074/21N/A N/AN/AN/A N/AN/A1084/222.2 23263 N/A 4.16 7.7N/A4/232.5 25758 N/A N/AN/A1074/242.3 18932 N/A 4.63 16.7 1064/252.2 18718 N/A 4.53 14.7 1094/26N/A N/AN/AN/A 4.60 13.4 N/A 16. Dietary Trigger Dietary Consult for Tube FeedingRecommendation Moderately Depleted Albumin Level of 2.4 andPre-albumin Level of 11.6 17. PES Statements (NC-1.1) Swallowing difficulty related todysphagia and past medical history asevidenced by patient needing GastrostomyTube for main nutrition and hydration support. (NI-5.1) Increased protein needs related toincreased demand for protein as evidenced bymoderately depleted albumin level of 2.4 andpre-albumin level of 11.6. (7) 18. Interventions Await restart of tube feedings Recommend necessary adjustments to tubefeeding rate and fluids Monitor tolerance of tube feeding 19. Energy, Protein, and FluidNeeds* Estimated Energy Needs: 1266 (BEE) x 1.2 x 1.1= 1,671 kcals Estimated Protein Needs: 1.2-1.3g/kg= 62-68g Estimated Fluid Needs: 35mL/kg= 1,820mL*All needs based on Adjusted Body Weight of 114# 20. Tube FeedingRecommendationsInitial MD OrderRD Recommended Order* Jevity 1.5 at 30cc/hr Jevity 1.5 at 50cc/hr Provides: Provides: 1,800 kcals 1,080kcals 77g protein 26g fiber 46g protein 912cc free water 16g fiber 100% RDIs vitamins andminerals 547cc free water IV Fluid KVO IV Fluid 100cc/hr Water Flushes 200cc QID *RD recommendation based on Adjusted Body Weight of 114# 21. Tests and Procedures Chest X-Ray Kidney, Ureters, Bladder X-ray (KUB) Abdominal Ultrasound Conversion G-Tube to G-J Tube Abdominal CT Scan with Contrast 22. Diet Orders Tube Feeding via G-Tube Jevity1.5 at 30cc/hr Held due to projectile vomit Gatorade via G-Tube 30cc/hr Held for testing Tube Feeding via G-J Tube Jevity 1.5 at 40cc/hr 23. Discharge Notes April 26, 2010 Approximate 15# Weight Gain Positive Fluid Balance Discharge to home Continue with Home Health Care Medical follow ups in two-three weeks Resume Jevity bolus of 5 cans daily 24. Questions? 25. Works Cited 1. Astrocytoma. Astrocytoma. 2007. Available at: http://www.astrocytoma.org/. Accessed June 1, 2010. 2. Glioma. Mayo Clinic. April 2010. Available at: http://www.mayoclinic.org/glioma/. Accessed June 1,2010. 3. Kennedy B, Bruce JN. Astrocytoma. eMedicine Oncology. January 23, 2009. Available at:http://emedicine.medscape.com/article/283453-overview. Accessed June 2, 2010. 4. Brain tumor-primary-adults. Medline Plus Medical Encyclopedia. May 7, 2010. Available at:http://www.nlm.nih.gov/medlineplus/ency/article/007222.htm. Accessed June 5, 2010 5. Adult brain tumor treatment. National Cancer Institute. October 13, 2009. Available at:http://www.cancer.gov/cancertopics/pdq/treatment/adultbrain/HealthProfessional/page7. AccessedJune 4, 2010. 6. Pronsky ZM. Food Medication Interactions. 15th Ed. Birchrunville, PA: Food-Medication Interactions;2008. 7. American Dietetic Association. International Dietetics & Nutrition Terminology Reference Manual. 2ndEd. Chicago, IL: American Dietetic Association; 2009.