non celiac gluten senstivity
Instructions for Case Study
Dear Essay Tiger Writer;
Please read this case study for my Nutrition class. Please answer all questions following the case study thoroughly. Please answer the question IN THE DOCUMENT. PLEASE cite the reference for the answer after the answer. Please create an APA citation/reference page at the end of the case study. Please fill in the ADIME chart at the end of the case study – it is also a part of the case study so please complete it.
Here are a few sources you can MUST use to answer the questions:
• Textbook of pathophysiology, e.g. Kumar et al.: Robbins & Cotran: Pathologic basis of disease, or trustworthy online sources, e.g. Medscape.com.
• A useful starting point is medicalstudent.com, which leads you to further webpages
• For drugs:
o Pronksy et al.: Food Medication Interactions. (currently 18th edition)
o Medline Plus (.gov)(this is a starting point), http://www.fda.gov/Drugs/default.htm (sometimes helpful), rxlist.com, WebMD, epocrates (requires registration, free, worth the effort in my humble opinion)
• Nelms, Sucher, Lacey, Long Roth: Nutrition Therapy and Pathophysiology. 3rd ed., Cengage Learning 2014
ISBN-13:978-1-305-11196-7
• Nahikian-Nelms M, Long-Anderson S. Medical Nutrition Therapy: A Case Study Approach 4th ed. Belmont, CA: Wadsworth; 2013.
Other Resources:
Kumar V, Abbas AK, Aster JC: Robbins & Cotran Pathologic Basis of Disease. 9th ed. St. Louis, Missouri: Elsevier/Saunders; 2015. ISBN: 978-1-4557-2613-4
Note: This is the main source for information on the various diseases, exceeding the information provided in the Nelms text.
Nutrition Care Manual: http://www.nutritioncaremanual.org/member-pricing This is another resource you should know about. The department now has this resource available for you in the computer lab Remsen 308.
Mahan LK, Escott-Stump S, Raymond, JL. Krause’s Food and the Nutrition Care Process. 13th ed. St. Louis, Missouri: Elsevier/Saunders; 2012. ISBN: 978-1-4377-2233-8
American Dietetic Association / American Diabetes Association. Choose Your Food: Exchange Lists for Meal Planning. 2008. (Either Diabetes or Weight Management booklet). You could purchase from AND website, www.eatright.org. The same resource is available with less shipping costs elsewhere.
http://www.nhlbi.nih.gov/health/educational/lose_wt/eat/fd_exch.htm#1 also shows exchange lists, as do many other sites (.edu can be considered reliable for this purpose).
Pronsky ZN. Food Medication Interactions. 17th ed. Birchrunville. PA 2012. (optional; encouraged if on Dietetics Track)
ISBN: 0-9710896-4-7. Note: Choose your source – prices vary greatly!
Alternatively, consult Epocrates, or rxlist.com for information on food-drug interactions.
Stedman’s Medical Dictionary for Health Professionals. 7th ed. Baltimore, MD: Williams and Wilkins; 2011 (optional; if not purchased use online medical dictionary i.e. http://www.medterms.com/script/main/hp.asp)
Wallach: Handbook of Interpretation of diagnostic tests. Current ed., Lippincott. Or any similar handbook on (human) diagnostic tests.
Professional journals in nutrition and bio-medical disciplines (available in paper or online)
PubMed – http://www.ncbi.nlm.nih.gov/pubmed/
Full-text journals – High-Wire press – http://highwire.stanford.edu/
Phytochemical and Ethnobotanical Database http://www.ars-grin.gov/duke/
FDA on Dietary Supplements: http://www.fda.gov/Food/DietarySupplements/default.htm
Additional References from American Nutritional Society – www.nutrition.org
Rich website on the biology of aging and its relationship to diseases: American Federation for Aging Research http://www.afar.org/
Case study 1 FNES 366 Fall 2015 – Questions
Case sources will be provided in the solution sheet.
Patient CD has experienced intermittent diarrhea, bloating, and diffuse lower abdominal discomfort over the past 7 years, diagnosed with diarrhea-predominant irritable bowel syndrome 5 years ago. She presents with symptoms worsened over the past several months, dermatitis, and c/o fatigue though not limiting her ability to work. Ms. TG is 26 years old.
Pt. reports that RAST and PRIST, as well as hydrogen breath test have been performed in the past, with negative results.
PMHx: Osteopenia, no hospitalizations, no current medications; iron deficiency anemia refractory to oral iron supplementation; no GI bleeds, no rectal bleeding, gynecologic causes of anemia have been ruled out
FHx: Her father has a history of diabetes type 1, her mother has a history of atherosclerosis with narrowing of the carotid artery, migraine headaches, her siblings have no medical problems
Allergies: penicillin, unknown reaction
Medications: none, no herbal remedies, no supplements
Physical Examination
Vital signs:
Temp: 37.8C (100F),
Pulse: 78 BPM,
RR: 14 BPM,
BP: 118/66
Height: 5’6”, 122 lbs,,
Usual body weight: 122-126lbs.
General: well-developed young woman
Skin: rash in extensor surfaces of elbows and knees, no bruises
Heart: RRR without murmurs or gallops
HEENT:
Eyes: PERRLA, normal fundi
Ears: noncontributory
Nose: noncontributory
Throat: pharynx clear
Chest: CTA
Breasts: no masses
Rectal: no evidence of perianal disease
Neurologic: oriented x 4
Extremities: no edema, pulses full, no bruits, normal strength, sensation and DT
Abdomen: some distention, hyperactive bowel sounds.
Assessment: R/o Celiac disease vs. NCGS vs. Inflammatory bowel disease vs. infections
Plan:
CBC/Chem 24
ASCA
EMA IgA and IgG
Anti-tTG IgA and IgG
AGA DGP IgA and IgG
HLA DQ2
EGDS (esophagogastroduodenoscopy)
Results:
ASCA: negative
EMA IgA and IgG: negative
Anti-tTG IgA and IgG: negative
AGA DGP IgA and IgG: negative
HLA DQ2: positive
EGDS (esophagogastroduodenoscopy): no macroscopic alterations found, histology of the duodenum shows a picture compatible with Marsh-Oberhuber class 1 (>40 intraepithelial lymphocytes per 100 enterocytes but no villous atrophy).
EMA of biopsy supernatants: results doubtful, anti-tTG results of culture supernatants from biopsies were positive
Nursing Assessment
(relevant information only)
Abdominal appearance: rounded
Bowel function: continent
Stool color, consistency: light brown, soft to liquid
Urine: clear, yellow
Skin color: pale
Skin turgor: good
Lab results
Reference range Measured (current date)
Chemistry
Sodium (mEq/L) 136-145 136
Potassium (mEq/L) 3.5-5.5 3.7
Chloride (mEq/L) 95-105 101
Carbon dioxide (mEq/L) 23-30 26
BUN (mg/dL) 7-20 7.0
Creatinine serum (mg/dL) 0.5-1.2 0.9
Glucose (mg/dL) 70-110 82
Phosphate, inorganic (mg/dL) 2.3-4.7 2.9
Magnesium (mg/dL) 1.8-3 1.8
Calcium (mg/dL) 8.5-10.5 7.5
Bilirubin, direct (mg/dL) <0.3 0.3
Protein, total (g/dL) 6-8 5.5
Albumin (d/dL) 3.6-4.5 3.2
Prealbumin (mg/dL) 16-35 13
Ammonia (µmol/L) 9-33 11
Alkaline phosphatase (U/L) 50-130 48
ALT (U/L) 10-40 81
AST (U/L) 10-40 49
C-reactive protein (mg/dL) <1.0 1.4
Cholesterol (mg/dL) 120-199 149
HDL-C (mg/dL) >55 F, >45 M 38
LDL (mg/dL) <130 111
LDL/HDL ratio <3.22 F, <3.55 M 2.92
Triglycerides (mg/dL) 35-135 F, 40-160 M 85
T-transglutaminase IgA AB Neg Neg
Tissue transglutaminase IgG Neg Neg
Total serum IgA WNL
ASCA Neg Neg
Coagulation
PT (s) 12.4-14.4 15
Hematology
WBC (x 103/mm3) 4.8-10.8 5.0
RBC (x106/mm3) 4.2-5.4 F, 4.5-6.2 M 3.85
Hemoglobin (Hgb, g/dL) 12-16 F, 14-17 M 8.6
Hematocrit (Hct, %) 37-47 F, 40-54 M 26.4
Mean cell volume (µm3) 82-94 68.2
Mean cell Hgb (pg) 26-32 30
Mean cell Hgb content (g/dL) 31.5-36 33
Platelet count (x 103/mm3) 150-350 422
Iron (mcg/dL) 56
Transferrin (mg/dL) 250-380 F, 215-365 M 185
Ferritin (mg/mL) 20-120 F, 20-300 M 5
ZPP (µmol/mol) 30-80 85
Cobalamine (ng/dL) 24.4-100 30
Folate (ng/dL) 5-25 6
Zinc, serum (µg/mL) 0.6-1.2 0.5
25-hydroxy-vitamin D (ng/mL) 30-100 22.7
Free retinol (µg/dL) 20-80 17.2
Ascorbic acid (mg/dL) 0.2-2.0 <0.1
Selenium (ng/mL) 70-150 123
Nutrition:
Patient reports to have eaten normally for at least seven years. She lost 6 pounds over the past 4 weeks.
Usual recent dietary intake:
24-hour Food Recall
Patient states that this is a typical eating pattern during the week:
Breakfast
Bagel (1 plain, 3.5”), cream cheese (2 Tbs), orange juice (6 oz.), banana (1 medium)
Morning snack
Licorice (black, 4 pieces), pretzels, honey wheat (1 oz)
Lunch
Deli turkey breast (6 thin slices, 3oz), whole wheat bread, light (2 slices), low fat mayonnaise (1 Tbs), baby carrots (8), apple (1 medium), oatmeal cookie with raisins (2), bottled water (16 oz)
Afternoon snack
Latte with skim milk (12 oz)
Dinner
Salmon, baked (3 oz), angel hair pasta (2oz dry), marinara sauce, canned, no meat (1/4 cup), green salad (1.5 cup), croutons, plain (2 Tbs), light vinaigrette (2 Tbs.), steamed broccoli (1/2 cup), biscotti, almond, drom bakery (1 pc.), tea, herbal, no sweetener (8 oz.)
Current diet order: clear liquids, nutrition consult
Helpful sources other than your textbook:
• Textbook of pathophysiology, e.g. Kumar et al.: Robbins &Cotran: Pathologic basis of disease, or trustworthy online sources, e.g. Medscape.com.
• A useful starting point is medicalstudent.com, which leads you to further webpages
• For drugs:
o Pronksy et al.: Food Medication Interactions. (currently 18th edition)
o Medline Plus (.gov)(this is a starting point), http://www.fda.gov/Drugs/default.htm (sometimes helpful), rxlist.com, WebMD, epocrates (requires registration, free, worth the effort in my humble opinion)
Questions:
1. What are the typical symptoms of a patient with celiac disease or gluten-sensitive enteropathy?
2. Explain the acronyms in the initial assessment:
a. RRR (heart):
b. PERRLA:
c. Oriented x 4:
3. Explain the following tests: What do they measure and how does this relate to Celiac Disease or to non-celiac gluten-sensitivity (NCGS)?
a. EMA
b. tTG
c. ASCA
d. AGA DGP IgA and IgG
e. HLA DQ2
4. Another test set performed is done using supernatants of a tissue biopsy. Explain what this test set consists of and, briefly, how and why it is done.
5. What micronutrients do you expect to be linked to the patient’s celiac disease?
6. The diagnosis made is Celiac Disease. Provide guidelines for MNT for this disease. Be sure to indicate the source.
7. The differential diagnosis included non-celiac gluten sensitivity. What is the appropriate MNT for this disease? Be sure to indicate the source.
8. Which cereal grains contain gluten? (find a source different from the lecture slides)
9. Which foods are safe to eat on a gluten-free diet? (find a source different from the lecture slides)
10. How would you modify this patient’s diet (24-hour recall) to provide for relief of symptoms?
11. How does a patient identify foods, beverages, dietary and herbal supplements, and medications that contain gluten?
12. Evaluate Ms. CD’s % UBW and BMI.
13. Calculate Ms. CD’s energy requirements. Be sure to include the formula you use to determine this, including the name of the formula.
14. Estimate protein requirements for Ms. CD. Be sure to include the source for your estimate.
15. Identify any significant and/or abnormal laboratory measurements from the CBC and chemistry labs.
16. Select two nutrition problems and complete the PES statement for each. Use the appropriate NCP terminology.
17. You find in the chart that the patient has not consumed anything other than clear liquids for 5 days, due to several test procedures. What diet would you recommend? Provide reasons for your choice.
18. For each of the PES statements you have written, establish an ideal goal based on Ms. CD’s signs and symptoms, and an appropriate intervention, based on the etiology. Use the appropriate NCP terminology.
19. What parameters will you monitor and evaluate? Use the appropriate terminology from the NCP.
20. Complete the ADIME sheet. (scroll down)
A – Assessment
S – Subjective
Chief Complaint:
UBW:
Weight change: gain / loss
Appetite:
Chewing / swallowing problem / sore mouth
Nausea / vomiting / diarrhea / constipation
Food intolerance / allergies:
Diet prior to admit: Nutritional supplement:
Vitamins / herbs:
Food preparation:
Factors affecting food intake:
Social / cultural / religious / financial
Other:
O – Objective
Current Diet Order:
Medical Diagnosis:
Pertinent Medical History:
Nutrition Focused Physical Signs &Symptoms:
Age:
Gender: Male
Female Ht: Wt: Admit
Current DBW: BMI:
% UBW:
% wt: % DBW: Other:
Nutritionally Relevant Laboratory Data:
Drug Nutrient Interaction:
Estimated Energy Need:
______________ kcal / day
Based on:
Estimated Protein Need:
_______________ g/day
Based on: Estimated Fluid Need:
_____________ ml / day
Based on:
Nutrition Diagnosis (D)
A – Assessment (A)
State no more than 2 priority Nutrition Diagnosis statements in PES Format. Use Nutrition Diagnosis Terminology sheet
ND Term (Problem) related to (Etiology) as evidenced by (Signs and Symptoms) :
1.
2.
Nutrition Intervention (I)
P – Plan
List Nutrition Interventions. Use Nutrition Intervention Terminology sheet. (The intervention(s) must address the problems (diagnoses).
Goal(s):
Plan for Monitoring and Evaluation (M E)
List indicators for monitoring and evaluation. Use Nutrition Assessment and Monitoring & Evaluation sheets. (Upon follow-up, the plan for monitoring would indicate if interventions are addressing the problems).