Patient CD has experienced intermittent diarrhea

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: 37.8?C (100?F), Pulse: 78 BPM, RR: 14 BPM, BP: 118/66 Height: 56, 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 (‘mol/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 (‘m3) 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 (‘mol/mol) 30-80 85 Cobalamine (ng/dL) 24.4-100 30 Folate (ng/dL) 5-25 6 Zinc, serum (‘g/mL) 0.6-1.2 0.5 25-hydroxy-vitamin D (ng/mL) 30-100 22.7 Free retinol (‘g/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: Pronksy et al.: Food Medication Interactions. (currently 18th edition) 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: What are the typical symptoms of a patient with celiac disease or gluten-sensitive enteropathy? Explain the acronyms in the initial assessment: RRR (heart): PERRLA: Oriented x 4: Explain the following tests: What do they measure and how does this relate to Celiac Disease or to non-celiac gluten-sensitivity (NCGS)? EMA tTG ASCA AGA DGP IgA and IgG HLA DQ2 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. What micronutrients do you expect to be linked to the patients celiac disease? The diagnosis made is Celiac Disease. Provide guidelines for MNT for this disease. Be sure to indicate the source. The differential diagnosis included non-celiac gluten sensitivity. What is the appropriate MNT for this disease? Be sure to indicate the source. Which cereal grains contain gluten? (find a source different from the lecture slides) Which foods are safe to eat on a gluten-free diet? (find a source different from the lecture slides) How would you modify this patients diet (24-hour recall) to provide for relief of symptoms? How does a patient identify foods, beverages, dietary and herbal supplements, and medications that contain gluten? Evaluate Ms. CDs % UBW and BMI. Calculate Ms. CDs energy requirements. Be sure to include the formula you use to determine this, including the name of the formula. Estimate protein requirements for Ms. CD. Be sure to include the source for your estimate. Identify any significant and/or abnormal laboratory measurements from the CBC and chemistry labs. Select two nutrition problems and complete the PES statement for each. Use the appropriate NCP terminology. 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. For each of the PES statements you have written, establish an ideal goal based on Ms. CDs signs and symptoms, and an appropriate intervention, based on the etiology. Use the appropriate NCP terminology. What parameters will you monitor and evaluate? Use the appropriate terminology from the NCP. 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