Case Study- AV_ Brain Teaser- Segment 4; ROF-3

 

Read the entire case study below, this case study is very complicated but a very real life potential future client. This is a sample of understanding when its time to refer out, not to "jump" into interventions right away, until you are convinced that you have all your facts lined up. Once you have read this case, you should read the ROF (AV - ROF on next page) and see how this case was handled. You do  not need to do anything with this case or ROF, this is just an example. You will be provided a different comprehensive case (DD - case) to write up an ROF.

 

Case Study- AV

AV is a 67 year old female. She had breast cancer 10 years ago and the chemotherapy and radiation damaged her liver. She is supposed to have a liver transplant but is not very high on the list of transplants because of her age and the fact that her liver seems to “hold up” as her doctors are saying. AV is severely jaundiced on appearance; she is also suffering from severe edema in her ankles. She is suffering from severe fatigue, RA, migraines, osteopenia, GERD, hypothyroid. By looking at her you can see eczema, hirsutism, soft brittle nails, skin tags, and acanthosis nigricans. She is desperate for some help, she realizes you might not be able to assist her, but nobody seems to care about her health, she feels it is almost like she is being pushed aside due to her age. She has grand kids and wants to see if she can maybe get healthier and extend her life a little. She is very depressed and teary eyed when she is providing you with this information.

 

Initial Assessment:

B/P:  145/85

Height:  5.4”

Weight:  235 lb

BMI:  36

Fat%: 56%

 

History:

As explained above all of her health issues started with the chemotherapy and radiation. Before this she was a healthy 140 lbs female, she played sports and was an active teacher. She had suffered from cysts for many years until the diagnosis of cancer. She has had multiple yeast infections over her lifetime. She was told she might be “non-celiac gluten sensitive so she has incorporated a gluten free lifestyle. She feels full very quickly. She suffers from depression and is on medication

Medication and Supplements:

Lotensin (ACE inhibitor)- 40 mg once daily

Prevacid (proton pump inhibitor)- 30 mg once daily        

Metformin- 500 mg twice daily

Effexor (SSRI)- 150 mg daily

Furosemide (loop diuretic)- 40 mg twice daily

 

Laboratory Data:

Vitamin D 25 OH – 15.2 (L) (32 – 100 ng/mL)

Potassium – 5.7 (H) (3.5-5.0 mEq/L)

Sodium – 128 (L) (136-145 mEq/L)

Bun/Creatinine Ratio – 23 (H) (10-20)

Co2 – 19 (L) (23-30 mEq/L)

Albumin – 2.9 (L) (3.5-5 g/dL)

Total Bilirubin – 5.3 (H) (0.3-1.0 mg/dL)

ALP – 162 (H) (30-120 U/L)

ALT – 222 (H) (4-36 U/L)

AST –112 (H) (0-35 U/L)

RBC – 2.50 x 10¹²/L (L) (4.2-5.4 x 10¹²/L)

Platelets – 80,000 x 10⁹/L (L) (150,000-400,000 x 10⁹/L)

RDW – 21.1 (H) 11-14.5%

MCH – 40.5 (H) 27-31 pg

MCV – 122 (H) 80-95 fL

HCT – 30% (L) (37-47%)

Hgb – 10.4 g/dL(L) (12-16 g/dL)

LDL – 158 (H) (<130 mg/dL)

Triglycerides – 235 (H) (40-160 mg/dL)

TSH – 12 mU/L (H) (2-10 mU/L)

Thyroid peroxidase antibody (TPO-Ab) – 103 (H) (<35 IU/mL)

Fasting glucose – 117 (H) (70-110 mg/dL)

Dietary Intake:

Breakfast: Gluten free cereal and banana or scrambled eggs or gluten free pancakes – tea black

Snack: yogurt (low fat Greek) - water

Lunch: Salad with cottage cheese or soup (canned) with fruit or PB sandwich on gluten free bread – water

Snack: Fruit – water

Dinner: 4 ounces of beef/chicken/turkey, steamed broccoli or asparagus, small herb salad – tea black and water