Case Study #1: Case 7 GERD

See the general instructions for all case studies posted to Canvas. Remember to cite your sources for all information and include all the group members' names. Read the case history (pp 75-81 in the Nelms book) and answer the following questions:

Disease and Pathophysiology

1. Describe the anatomic structures and normal physiology that are responsible for preventing acid reflux. (3 points)
2. List the common causes of GERD.
3. List 3 medications commonly prescribed to manage GERD. For each, list any significant nutritional implications these medications may have.
4. List the most common complications of GERD?

Nutrition Assessment

1. What risk factors does Mr. Gupta present with that might contribute to his diagnosis? Be sure to consider lifestyle, medical, and nutritional factors.

**Be sure to differentiate between risk factors that cause or have an association with GERD vs the actual symptoms of GERD. Symptoms are not risk factors.

1. Identify Mr. Gupta's symptoms that support a diagnosis of GERD.

1. Calculate calorie and protein requirements for Mr. Gupta. Briefly (1-2 sentences) explain why you chose those calculation methods/comparative standards. This must include a citation (you did not invent these calculation methods) and your rationale for why you chose it. Use Mr. Gupta's current weight.

1. Using Mr. Gupta's 24-hour recall and the table on the next page, estimate his caloric intake on this day.
   1. How does this compare to the kcal needs you estimated in question 7?
   2. What daily calorie intake goal would you recommend to address the nutrition problems you identified? Include an explanation of why you chose this daily calorie goal.

Nutrition Diagnosis

1. Think about the most pertinent nutrition problems. Using the standardized diagnostic terminology from the eNCPT, write two PES statements based on the problems you identified. (8 points - 1 point for using standard terms/format, 1 point for each part of the P/E/S).

Nutrition Intervention

1. Summarize the lifestyle interventions for GERD.
2. Summarize the nutritioninterventions for GERD.

1. Identify which of the interventions (from your answer to #10 and 11) you would recommend to Mr. Gupta. Be sure to consider his case history and current lifestyle. You should have at least one that is related to the etiology for each of your PES. Briefly describe how you would implement them. If education, what materials would you use? If counseling, what models or theories would you use?

1. Using Mr. Gupta's 24-hour recall, suggest five dietary modifications to help manage the symptoms of GERD. You should also consider Mr. Gupta's past medical history and cultural/personal preferences.
   1. Use the table on the next page and fill-in at least five specific food items or meal ideas. Include the rationale for these modifications - how will this improve his symptoms and help him meet his goals?
   2. Tips: Focus on changes that are realistic - that will fit in with his lifestyle and easy to do. You do not need to change ALL his foods (this would not be very realistic) so consider which diet changes will have the biggest effect. Remember to focus on GERD first as this is the case study topic and his primary concern.

Nutrition Monitoring & Evaluation

1. For each PES statement, establish a goal to evaluate on follow up.Make sure that your goal is a measurable outcome that is specific and relevant to your problem, and that it includes a timeframe. (8 points)

Time	Food Item	Estimated Calories	Modification	Rationale
Breakfast	2 scrambled eggs
	1 slice naan
	Hot tea with milk and sugar
Lunch	36 oz Diet Pepsi
	Leftover curry with spinach and chickpeas - 1 c
	Rice - 1 c
	Hot black tea
Afternoon Snack	2 c Chips
	1 Beer
Dinner	Lentil dal - 2 c
	Rice - 2 c
	2 slices naan
	Hot chai tea - 2c
Bedtime snack	2 c Ice cream mixed with 1 c skim milk for milkshake

Ebooks - Cengag X My Home X Ebooks - Cengag X Ebooks - Cengag X Gastroesophagealx Gastroesophageal X Instructions for A X @ is statpearls relia x C a ebooks.cenreader.com/#!/reader/6378115d-77f0-4329-9283-4357c79674bf/page/0547686d3dd0aa97d77392aldcd1ec54 eTextbook: Medical Nutrition Therapy: A Case Study Approach TT Quick Tour Print Search Annotations Accessibility Book Usual dietary intake: AM : 11/2-2 c hot cereal; 1/2-3/4 c skim milk on cereal; sometimes egg and naan 16-32 oz orange juice Hot tea with milk and sugar Lunch: Fast food burger with fries, Diet Coke (or leftovers from previous evening) Snack when he comes home: Handful of crackers, cookies, or chips, 1 12-oz beer PM: Typically eats traditional Indian foods at home for evening meal: 3-4 oz of meat (chicken primarily) or tofu (grilled or cooked on top of stove) cooked with rice and vegetables; chapattis; hot chai or black tea; Relates that his family's schedule has been increasingly busy, so they sometimes (1-2 times per week) order pizza or stop for fast food instead of cooking. Late PM : Ice cream, popcorn, or crackers. Drinks 3-4 12-oz diet sodas daily as well as hot tea. 24-hr recall: (at home PTA): 2 scrambled eggs, naan; hot black tea At work: 3 12-oz Diet Pepsis Lunch: Leftover curry with spinach, chickpeas, rice-2 c Hot black tea Late afternoon: 2 c chips, 1 beer Dinner: Lentil dal-2 c over approx. 2 c rice 2 slices naan 2 c hot chai tea Bedtime: 2 c ice cream mixed with 1 c skim milk for milkshake Food allergies/intolerances/aversions: Fried foods seem to make the indigestion worse NEXT PAGE PREVIOUS PAGE Case Questions Case 7. Gastroesophageal Reflux Disease MacBook Air 2 25 FB esc O - 00 7 11 @ N P T Y U O Q W E R tab -. . . G H J K A S D F caps lock V Z C B N M XEbooks - Cengag X My Home x Ebooks - Cengag X Ebooks - Cengag X Gastroesophageal x Gastroesophageal Instruction - C a ebooks.cenreader.com/#!/reader/6378115d-7710-4329-9283-4357c79674bf/page/0547686d3dd0aa97d77392a1dcd1ec54 eTextbook: Medical Nutrition Therapy: A Case Study Approach ? Q Quick Tour Print Search MD PROGRESS NOTE: Review of Systems Constitutional: Negative Skin: Negative Cardiovascular: No carotid bruits Respiratory: Negative Gastrointestinal: Heme + stool Neurological: Negative Psychiatric: Negative Physical Exam General appearance: Mildly obese 48-year-old Indian male in mild distress Heart: Noncontributory HEENT: Noncontributory Genitalia: WNL PREVIOUS PAGE Case 7. Gastroesophageal Reflux Disease MacBook Air DO F7 Fic esc O W # 2 P Y U O Q W E R T tab G H K S D F A caps lockx My Home x Ebooks - Cengag X Ebooks - Cengag X Gastroesophagealroesophageax Instructions for A X @ is statpearls relia X + ebooks.cenreader.com/#!/reader/6378115d-77f0-4329-9283-4357c79674bf/page/0547686d3dd0aa97d77392a1dcd1ec54 eTextbook: Medical Nutrition Therapy: A Case Study Approach (? TT Quick Tour Print Search Annotations Accessibility Bookmark Ref. Range Chemistry 11/1 0700 Sodium (mEq/L) 136-145 144 Potassium (mEq/L) 3.5-5. 4.5 Chloride (mEq/L) 98- 107 102 Carbon dioxide (CO2, mEq/L) 23-29 25 Bicarbonate (mEq/L 23-28 24 BUN (mg/dL) 6-20 8 Creatinine serum (mg/dL) 0.6-1.1 F 0.9 0.9-1.3 M Uric acid (mg/dL) 2.8-8.8 F 5.1 4.0-9.0 M Est GFR, non-Afr Amer >60 117 (mL/min/1.73 m?) Glucose (mg/dL) 70-99 91 Phosphate, inorganic (mg/dL) 2.2-4.6 3.8 Magnesium (mg/dL) 1.5-2.4 1.9 Calcium (mg/dL) 8.6-10.2 8.9 Bilirubin total (mg/dL) $1.2 0.9 Bilirubin, direct (mg/dL) Gastroesophagealroesophageax Instructions for A x @ is statpearls relia x & ebooks.cenreader.com/#!/reader/6378115d-77f0-4329-9283-4357c79674bf/page/0547686d3dd0aa97d77392a1dcd1ec54 eTextbook: Medical Nutrition Therapy: A Case Study Approach Q TT Quick Tour Print Search Annotations Accessibility Bookmark Neurologic: Oriented x 4 Extremities: No edema; normal strength, sensations, and DTR Skin: Warm, dry Chest/lungs: Lungs clear to auscultation and percussion Peripheral vascular: Pulses full-no bruits Abdomen: No distention. BS present in all regions. Liver percusses approx 8 cm at the midclavicular line, one fingerbreadth below the right costal margin. Epigastric tenderness without rebound or guarding. VITAL SIGNS: Temp: 98.6 Pulse: 90 Resp rate: 16 BP: 119/75 Height: 5'9" Weight: 215 lbs ASSESSMENT AND PLAN: DX: Gastroesophageal reflux disease, HTN NEXT PAGE > Case Questions PREVIOUS PAGE Case 7. Gastroesophageal Reflux Disease MacBook Air 80 E3 esc O e W # O T Y U R Q W E tab - . . . K G D F H J A S aps lock N M B Z X C V optionCengag X My Home X Ebooks - Cengag X Ebooks - Cengag X Gastroesophagealroesophageax Instructions for A X @ is statpearls relia x ebooks.cenreader.com/#!/reader/6378115d-77f0-4329-9283-4357c79674bf/page/0547686d3dd0aa97d77392a1dcd1ec54 eTextbook: Medical Nutrition Therapy: A Case Study Approach TT Quick Tour Print Search Annotations Accessibility Bookmark Alkaline phosphatase (U/L) 30-120 83 ALT (U/L) 4-36 11 AST ( U / L ) 0-35 9 CPK (U/L) 30-135 F 71 55-170 M Lactate dehydrogenase (U/L) 208-378 210 Cholesterol (mg/dL) 59 F. >50 M 52 VLDL (mg/dL) 7-32 35 11 LDL (mg/dL) 60 117 (mL/min/1,73 m?) Glucose (mg/dL) 70-99 91 Phosphate, inorganic (mg/dL) 2.2-4.6 3.8 NEXT PAGE PREVIOUS PAGE Case Questions Case 7. Gastroesophageal Reflux Disease "MacBook Air esc 00 * O 1 de Y U O P E R Q W T tab K . . . . G H J A S D aps lock N M Z X C V B command option option commandX My Home X Ebooks - Cengag X Ebooks - Cengag X Gastroesophagealx GastroesophagealX Instructions for A X @ is statpearls relia x ebooks.cenreader.com/#!/reader/6378115d-77f0-4329-9283-4357c79674bf/page/0547686d3dd0aa97d77392a1dcd1ec54 eTextbook: Medical Nutrition Therapy: A Case Study Approach O TT Quick Tour Print Search Annotations Accessibility Book Hematology, Manual Diff Neutrophil (%) 40-70 55 Lymphocyte (%) 22-44 28 Monocyte (%) 0- 7 6 Eosinophil (%) 0-5 0 Basophil (%) 0-2 0 Blasts (%) 3- 10 W C Urinalysis Collection method Clean catch Color Pale yellow Appearance Clear Specific gravity 1.001-1.035 .006 P.H 5-7 6.1 Protein (mg/dL) Neg Neg Glucose (mg/dL) Neg Neg Ketones Neg Neg Blood Neg Neg Bilirubin Neg Neg Nitrites Neg Neg Urobilinogen (EU/dL) C @ ebooks.cenreader.com/#!/reader/6378115d-77f0-4329-9283-4357c79674bf/page/0547686d3dd0aa97d77392aldcd1ec54 Textbook: Medical Nutrition Therapy: A Case Study Approach Q TT Quick Tour Print Search Annotations Accessibility Alcohol use: Yes; 1-2 beers 1-2 times/week Family history: What? CAD. Who? Father. DEMOGRAPHICS: Marital status: Married-lives with wife and 2 sons Spouse name: Saanvi Number of children: 2 (ages 8 and 12) Years education: BA Language: English and Hindi Occupation: Retail manager of local department store Hours of work: M-F, works consistently in evenings and on weekends as well Ethnicity: Indian Religious affiliation: Hinduism MD PROGRESS NOTE: NEXT PREVIOUS PAGE Case Questi Case 7. Gastroesophageal Reflux Disease MacBook Air T V esc 11 O A W # O P T Q W E R tab D F G H C K A S caps lock M 7 X C BEbooks - Cengag X My Home x Ebooks - Cengag X Ebooks - Cengag X Gastroesophagealroesophagez x Instructions for A X @ is statpearls relia x + C a ebooks.cenreader.com/#!/reader/6378115d-77f0-4329-9283-4357c79674bf/page/0547686d3dd0aa97d77392a1dcd1ec54 eTextbook: Medical Nutrition Therapy: A Case Study Approach ASSESSMENT AND PLAN: Quick Tour TT Print Search Annotations Accessibility Bookmark DX: Gastroesophageal reflux disease, HTN MEDICAL TX PLAN: Hematology, Chem 24, Ambulatory 48-hour pH monitoring with Bravo TM pH Monitoring System, Barium esophagram-request radiologist to attempt to demonstrate reflux using abdominal pressure and positional changes; Endoscopy with biopsy to r/o H. pylori infection; Begin omeprazole 30 mg every am; Decrease aspirin to 75 mg daily; D/C self-medication of ibuprofen daily; Nutrition consult J Li, MD.. NUTRITION: History: Patient relates he has gained almost 30 lbs since his knee surgery. He attributes this to a decrease in his ability to run, and he has not found a consistent replacement for this form of exercise. He plays with his children on weekends, but that is the extent of his physical activity. He states he probably has been eating and drinking more over the last year, which he attributes to stress with his busy lifestyle and long work hours. He is worried about his family history of heart disease, which is why he takes an aspirin each day. He has not really followed any diet restrictions for health concerns. He eats a combination of traditional Indiarf foods along with more American-style food choices. He has lived in the United States since his high school years so he does not follow any strict dietary practices related to his religious background of Hinduism. Usual dietary intake: AM : 1/2-2 c hot cereal; V/2-/4 c skim milk on cereal; sometimes egg and naan 6-32 oz orange juice NEXT PAGE PREVIOUS PAGE Case Questions Case 7. Gastroesophageal Reflux Disease MacBook Air F12 esc 11 7 O 1 delete Y U O A W E R tab S " . . . J ret H K S D F G A caps lock V A IN M Z X C V shift command optionMy Home X Ebooks - Cengag X Ebooks - Cengag X Gastroesophagea Gastroesophagea Instructions for A X G is stat enreader.com/#!/reader/6378115d-7710-4329-9283-4357c79674bf/page/0547686d3dd0aa97d77392a1dcd1ec54 eTextbook: Medical Nutrition Therapy: A Case Study Approach ? Quick Tour Print Search Annotations Acc Blasts (7%) 3-10 Urinalysis Collection method Clean catch Color Pale yellow Appearance Clear Specific gravity 1.001-1.035 1.006 PH 5 -7 6.1 Protein (mg/dL) Neg Neg Glucose (mg/dL Neg Neg Ketones Neg Neg Blood Neg Neg Bilirubin Neg Neg Nitrites Neg Neg Urobilinogen (EU/dL) PREVIOUS PAGE Electronic Medical Record (EMR) Ur Unit Three. Nutrition Therapy for Upper Gastrointestinal Disorders MacBook Air BO FB esc * 11 1 O delete A tA W# P T Y U O Q W E R ab s . . . F G H J K S D A s lock N M C V B Z X command option nd