1. What is Helicobacter pylori and how does it relate to the duodenal ulcer? (2 points)

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2 ( Lab helps kill H.pylori. Furthermore, Bismuth subsalicylate works to help protect the tissues of the stomach and small intestine. No known drug-nutrient interactions. Metronidazole- is a class of antibiotic. The inclusion of an antibiotic in this scenario acts on H. pylori reducing the number of the bacteria present. Alcohol should be avoided when taking antibiotics. Side effects of this drug include GI distress, appetite and taste changes, dry mouth and irritation of the mouth. Tetracycline- is a class of antibiotic. The inclusion of an antibiotic in this scenario acts on H. pylori, reducing the number of bacteria present. Alcohol should be avoided when taking antibiotics. Omeprazole- is a proton pump inhibitor. Proton pump inhibitors help to reduce the amount of acid secretion occurring in the gut. This class of drugs has a drugnutrient interaction with calcium. Patients should limit high calcium foods. Side effects of omeprazole include GI distress. 4. Compare GA s current lab values with the normal values and describe how each relates to her diagnosis. (3 points) Total Protein Pt. Value 5.9 g/dl Albumin 3.2 g/dl Preablumin 22 mg/dl Hgb 10.5 g/dl Normal High/ Meaning Reference g/dL g/dl 15-36mg/dL g/dl Hct 34% 37-47% Inadequate protein intake or utilization. albumin may indicate malabsorption, malnutrition, ulcer, stress and ulcerative bowel disease. National institute of Medicine: Medline Plus Normal Normal 80 Indicates anemia, fluid 77 retention, malnutrition. Indicates anemia (hemolytic), malnutrition, dietary deficiency, idiopathic steatorrhea, 77

3 ) Ferritin 9 µg/l WBC 9000 mm µg/l 5,000-10,000 mm3 overhydration. Indicates adenoma (GI) 75 anemia. Normal Normal Write an appropriate PES statement for one of the patient s nutrition problems. (3 points) Inadequate oral intake NI-2.1 r/t epigastric pain by bleeding duodenal ulcer AEB reported unintended weight loss of 18lb from UBW. Case B Present illness: MT is a 56 yo M with a long history of alcoholism. He has recently been diagnosed with cirrhosis and portal hypertension. He reports poor appetite with limited po intake. He is 5 8 and weighs 170lbs. His UBW is 180lbs. CC: Fatigue, nausea and early satiety. Dx: Cirrhosis and portal hypertension Labs: Na: 120 meq/l K: 5 me/l Cl: 96 meq/l BUN: 24 mg/dl Glucose: 108 mg/dl CO2: 25 meq/l Cr: 0.7 mg/dl Albumin: 2.3 g/dl AST: 87 U/L ALT: 48 U/L 1. Compare MT s current lab values with the normal values and describe how each relates to his diagnosis. (3 points) Lab Pt. Normal Hig/ Meaning Reference Value Na 120 meq/l meq/l 80 Indicates adrenal insufficiency, cirrhosis, renal HTN and toxemia K High end If levels

4 * Cl 96 meq/l BUN 24 mg/dl Glucose 108 mg/dl CO2 25 meq/l Cr 0.7 mg/dl Albumin 2.3 g/dl AST 87 U/L ALT 48 U/L meq/l meq/l meq/l 10-20mg/dL 65-99mg/dL 20-29mEq/L mg/dl g/dl of normal increase this could lead to renal failure and renal HTN High High Within normal range Within normal range 8-48 U/L High 7-55 U/L Within normal limits Indicative of overhydration and renal failure Indicative of dehydration, cardiac failure, and renal insufficiency or failure. Indicative or malnutrition No indications No indications Indicates chronic inflammation, HTN, malnutrition and Cirrhosis. Indicates probability of liver disease No indications/ within norm Medline Plus 74 Pocket Reference 71 National Institute of medicine Mayo Clinic 2. Write the assessment portion of the ADIME note. Please include a brief discussion regarding your choice of equations and estimate nutritional needs. (6 points) ASSESSEMENT: Subjective: Pt. reports poor appetite with limited po intake. Pt c/o fatigue, nausea, and early satiety. Pt reports long history of alcoholism resulting in recent

5 + diagnosis of cirrhosis and portal HTN. Pt is currently ten pounds below UBW and has not tried to lose weight. Objective: 56 yo Male Dx: Cirrhosis and portal HTN Ht: 5 8 CBW: 110lbs or 77 kg UBW: 180lbs or 81kg; %UBW=94.4% IBW: 154lbs or 69kg; %IBW= 110.4% Labs:! Na: 120mEq/L ()! Cl: 96mEq/L ()! BUN: 24mg/dL (High)! Glucose: 108mg/dL (High)! Albumin: 2.3g/dL ()! AST: 87 U/L (High) 3. List the interventions you would recommend for this patient. (5 points) Advise pt. to stop consuming alcohol kcal/kg body weight per day with a protein intake of 1.5-2g/kg/d, moderately high in carbohydrate (6-8g/kg body weight); reduced sugar intake, moderate fat intake (less than 30% kcals) in small frequent meals. Vitamin and mineral supplementation of water-soluble vitamins 24 hour diet recall and continuing food journal to gain more insight into diet habits. Adequate rest and fluid intake. If small frequent meals combined with needs recommendations are not tolerated eternal tube feed with a renal formula may be necessary until lab values stabilize. 4. Which parameters would you monitor to assess the efficacy of your interventions? (2 points) Tolerance of feedings Amount of nutrients consumed based on diet history Weight changes Lab values trending more towards normal ranges Evaluation of the patients overall sense of well-being Monitory for signs of hyperglycemia.

6 , Case C Present illness: JB is a 21 yo F currently attending UC Davis. She is a swimmer for the UC Davis swim team and trains excessively throughout the year. She is 5 5 and weighs 52kg. Her UBW is 130lbs. CC: I have lost 15 pounds in the past 1-2 months. My stomach hurts a lot, especially after eating. I have been having terrible diarrhea. I don t have the energy I used to. I can t keep up with my swim team training or my school work. Patient Hx: Onset of disease: JB is a previously healthy female with no known medical history. Denies family history of gastrointestinal disease but reports that her mother and grandmother have funny stomachs and have had diarrhea on and off for most of their adult lives. Over the past six weeks however, JB reports that she has developed abdominal pain, bloating and loose frequent stools. She reports that she feels very tired lately and is having trouble keeping up with her swimming training. She reports that during this time she has been losing weight, approximately 15 pounds over the past 1-2 months. She also reports that she has stopped menstruating. Physical Examination: General appearance: thing, very pale appearing female who c/o fatigue, abdominal pain and diarrhea. Abdomen: slightly distended, bowl sounds present Intestinal Biopsy results indicate flat mucosa with villus atrophy. Laboratory values: Albumin: 3.0 g/dl Preablumin: 14mg/dL Sodium: 137 meq/l Potassium: 3.6 meq/l Chloride: 100meq/L Phosphorous: 3.6 mg/dl Magnesium: 1.8mg/dL Glucose: 75mg/dL BUN: 10mg/dL Creatinine: 0.7mg/dL Calcium: 7.9mg/dL Iron: 15mcg/L Vitamin D 25 OH: 25nmol/L AGA antibodies: + EMA antibodies: + RBC: 4.9 million cells/ml Hct: 32% Hgb: 9.0 g/dl MCV: 65.3 mcg3 MCHC: 26.4 g/dl

7 - Transferrin: 2.0 g/l Nutrition Hx: JB states that she has felt very hungry lately but reports that when she eats large amounts of food she has abdominal pain and diarrhea almost immediately. She notes that fried and fatty foods and dairy products, particularly milk and ice cream, tend to make the diarrhea worse. As a result she has been avoiding these foods and not eating very much because she is afraid of having diarrhea at school. 24hour recall: Brk: 2 slices whole wheat toast with 1 tsp butter, 8oz hot tea with 2 tsp sugar. Lunch: Turkey sandwich (2 slices whole wheat bread, 4 slices turkey lunch meat, 1 leaf lettuce, no cheese, no mayo or mustard),! cup applesauce, 8-10 plain baked potato chips, 12 oz. lemon lime soda. Snack: 1 cup dry cereal ( cheerios or wheat Chex), 1 banana, sips of lemon lime soda Food allergies: none noted Social: JB lives in an off campus apartment with 2 female roommates. She prepares her own food but shares kitchenware and dishes with her roommates. Dx: Celiac disease with secondary malabsorption and anemia. Case Questions: 1. What are AGA and EMA antibodies? Briefly explain the connection between the positive results of these tests and celiac disease. (2 points) In Celiac Disease, alpha gliadin (from gluten) damages the small intestine causing an inflammatory response. This inflammatory response signals the production of anti-tissue transglutaminase (anti-ttg), antiendomysal IgA (EMA) and antigliandin (AGA) antibodies. The inflammatory response and action of the antibodies causes damage to the villi of the small intestine, which can lead to absorptive damage. The primary diagnosis for Celiac Disease used to be a biopsy of the small intestine mucosa. Now tests are preformed that screen for the presence of antibodies to gluten including anti-ttg, EMA and AGA. The test for Anti-tTG is the most common, but EMA is considered to have over 90% sensitivity. The presence of AGA is also accounted for in screening, but not as important as Anti-tTG and EMA. (Nutrition and Pathophysiology 2 nd edition Nelms, Sucher, Lacey, Roth p. 402) 2. How do the other lab results (specifically vitamin D and anemia related blood tests) relate to the diagnosis of celiac disease? What other nutrition related labs might you want to check? (2 points) Vitamin D lab results are specifically related to Celiac Disease because patients with Celiac disease have trouble absorbing nutrients including Vitamin D. Vitamin D is a fat soluble vitamin, thus patients should be observed for adequate fat intake and signs of steatorrhea. Vitamin D deficiency can eventually lead to

8 . bone loss especially in combination with Ca deficiency. Thus, calcium levels should also be monitored. Iron deficiency anemia is also present in patients with Celiac Disease. This deficiency anemia does not respond to iron therapy due to the malabsorptive nature of the damaged intestinal mucosa and villi. Other labs to keep an eye on would include: fat, fat soluble vitamins, B12s, and calcium. 3. Patients with celiac disease are often lactose intolerant prior to dx and remain temporarily lactose intolerant following adherence to a gluten free diet, though this often resolves over time. Explain why this occurs. (2 points) Nutrition therapy for Celiac Disease typically involves the adherence to both a gluten free and lactose free diet. The lactose restriction can often be temporary. The lactose intolerance seen in patients with Celiac Disease prior to diagnosis and immediately following is related to the damage of the villi in the small intestine as well as the damage to enzyme secretion. Because of this damage, the body is unable to breakdown lactose due to the lack of lactase enzymes. This can cause additional gastrointestinal discomfort on top of the symptoms exhibited by Celiac Disease alone. The level of damage to the intestinal mucosa affects the degree of malabsorption and the time frame in which an individual may be lactose intolerant. The lactose intolerance is directly related to the lactase deficiency. By adhering to the gluten free portion of the diet therapy, the villi are able to regenerate and enzyme secretion is increased to closer to normal allowing for the eventual inclusion of lactose for most individuals. 4. Write a complete ADIME note including all necessary components. Please include your calculations on a separate sheet of paper. (15 points) ASSESSMENT: Subjective: 21 yo F pt. c/o abdominal pain and gastric distress reporting I have lost 15 lbs in the past 1-2 months, my stomach hurts a lot especially after eating. I ve been having terrible diarrhea. I don t have the energy I used to. I can t keep up with my swim team or my school work. Pt. was previously healthy, reports no known medical history and denies family history despite pt. report of mother and grandmother having funny stomachs with on/off diarrhea for most of their adult lives. Pt. c/o abdominal pain, bloating, loose frequent stools, fatigue, unintended wt. loss and absence of menses. Pt. appears thin, very pale, with slight abdominal distention. Pt. s symptoms are consistent with diagnosis of Celiac disease with secondary malabsorption and anemia. Objective: (include calculated values/make sure to put calculations at end of doc) Age: 21 yo Sex: Female Ht: 5 5 CBW: 52kg or 114.6lbs UBW: 130lbs or 59kg; %UBW= 88.2% IBW: 125lbs or 57kg; %IBW=91.7% Wt. loss: 15lbs over past 1-2 months (unintended)

9 / Labs: Lab Pt. Value Normal High/Lo w Meaning Albumin 3.0g/dL g/dl Malabsorptio n due to damage to microvilli Prealbumi 14mg/dL 15- Malabsorptio n 36mg/dL n due to damage to Sodium 137mg/d L mg/dL Calcium 7.9mg/dL mg/dl Iron 15mcg/L mcg/L Vitamin D 25 OH AGA antibodies EMA antibodies 25nmol/L nmol/ L end of norm. microvilli Malabsorptio n due to damage to microvilli Malabsorptio n due to damage to microvilli Most likely anemia due to chronic disease and dx of Celiac Disease. Malabsorptio n due to damage to microvilli + - Present Present due to Celiac Disease and inflammation of intestinal mucosa + - Present Present due to Celiac Disease and inflammation of intestinal mucosa Hct 32% 37-47% Most likely anemia due to chronic Reference for Nut Assessment p Nutrition Therapy and Pathophysiolog y p. 403 Nutrition Therapy and Pathophysiolog y p. 403 Assessment

10 '0 disease and dx of Celiac Disease. Hgb 9.0g/dL 12-16g/dL Most likely anemia due to chronic disease and dx of Celiac MCV 65.3 mcg mcg3 Disease. Most likely anemia due to chronic disease and dx of Celiac Disease. MCHC 26.4 g/dl 32-36g/dL Most likely anemia due to chronic disease and dx of Celiac Disease. Transferrin 2.0 g/l g/L Related to secondary malabsorptive anemia Nutrient needs: Estimated Kcal needs (w/ IF and AF and UBW) 3,700kcal/day IF= 1.3 celiac disease and symptoms AF=2.0 swim team practice p.77 Assessment p Estimated pro needs: 59-71g/day Estimated fluid needs: 3,700ml (1ml/kcal) Current kcal intake (per 24 hour recall): 1,200kcal (from 24hour recall and USDA FoodTracker) DIAGNOSIS: PES statement #1: Inadequate oral intake (NI 2.1) r/t abdominal discomfort and pain after eating AEB reported unintended wt. loss of 15lbs in the past 1-2 months and dietary 24hour recall information. PES statement #2: Altered gastrointestinal (GI) function (NC 1.4) r/t changes in digestion/absorption due to damage from Celiac Disease AEB nutrient deficiencies and anemia.

11 '' INTERVENTION: Goals: To replete deficiencies by healing the intestinal mucosa and villi through a gluten-free and lactose-free diet with adequate kcal needs for activity and injury factors present. Recommendations: 1. Adhere to a gluten-free, lactose-free diet. Nutrition education and meal planning materials will be provided by the dietician. 2. Increase kcals to meet estimated needs through small frequent meals to manage weight loss and return to UBW. 3. Avoid foods that contain gluten (wheat, rye, barley, malt and oats). 4. Avoid lactose for a minimum of 2 weeks and reintroduce once tissue of intestinal mucosa and villi have regenerated. Reintroduce in forms of cheese or yogurt as tolerated. 5. Maintain adequate fluid needs 6. Manage symptoms of diarrhea with a low residue diet for first 2 weeks or until symptoms improve. 7. Take a multi-vitamin once per day to manage deficiencies MONITOR AND EVALUATION: Monitor/Evaluate (Documentation of progress towards goal, Factors that are facilitating/preventing progress, changes in clients level of understanding/behavior, Future plans of care) Keep a diet record to monitor adequate intake of kcals/fluid Keep record of occurrence of diarrhea symptoms and abdominal discomfort Note general overall sense of well-being to track symptoms of fatigue Follow up Return in 2 weeks to have laboratory values reassessed to monitor anemia and secondary malabsorptive deficiencies Check in with clients understanding of gluten-free diets Assess client s tolerance of lactose products once they are reintroduced into the diet. Signature: Blythe Young Credentials: Clinical Nutrition BS UC Davis Time: 5:00pm Date: 1/26/2013

12 '( Calculations: Case B: IBW: men= 106lbs for first 5 then 6lbs per inch after first 5 ( for Nutritional 32) Ht: lbs + 6lbs (8inches)= 154lb or 64kg IBW %IBW= CBW/IBW x 100 ( for Nutritional 34) CBW=170lbs; IBW=154lbs %IBW= 170lbs/154lbs x 100 = 110.4%IBW %UBW= CBW/UBW x 100 ( for Nutritional 34) UBW= 180lbs; CBW=170lbs %UBW= 170lbs/180lbs x100 = 94.4%UBW Case C: IBW: women= 100lbs for first 5 then 5lbs per inch after first 5 ( for Nutritional 32) Ht: lbs + 5lbs (5inches)= 125lb or 57kg IBW %IBW= CBW/IBW x 100 ( for Nutritional 34) CBW=114.6lbs; IBW=125lbs %IBW= 114.6lbs/125lbs x 100 = 91.7% IBW %UBW= CBW/UBW x 100 ( for Nutritional 34) UBW= 130lbs; CBW=114.6lbs %UBW= 114.6lbs/130lbs x100 = 88.2%UBW Estimated Kcal needs (w/ IF and AF) Harris Benedict Equation ( for Nutritional 5) Used UBW, AF 2.0 (due to swimming) and IF 1.3 (severity of trauma from symptoms) Women: BEE= (9.56xwt.kg)+(1.85xht in cm)-(4.68xage in yrs) BEE= (9.56x 59kg (UBW))+(1.85x165.1cm)-(4.68x21yrs)x AF x IF BEE= x AF(2.0)x IF(1.3) BEE= 3, or ~3,700kcal Estimated pro needs (mild depletion 1-1.2g/kg based on UBW) 1.0g x 59kg= 59kg 1.2g x 59kg= 71kg Estimated pro needs = 59-71g/day Estimated fluid needs 1ml/kcal 1ml x 3,700kcals= 3,700ml needed Current kcal intake (per 24 hour recall) ~1,200 kcals based on 24 hour recall put into Food Tracker (see nutrient report attached)

13 ') Nutrients Report from 24hr recall Case C: Your plan is based on a default 2000 Calorie allowance. Nutrients Target Average Eaten Status Total Calories 2000 Calories 1210 Calories Under Protein (g)*** 46 g 53 g OK Protein (% Calories)*** 10-35% Calories 18% Calories OK Carbohydrate (g)*** 130 g 214 g OK Carbohydrate (% Calories)*** 45-65% Calories 71% Calories Over Dietary Fiber 25 g 16 g Under Total Fat 20-35% Calories 14% Calories Under Saturated Fat < 10% Calories 4% Calories OK Monounsaturated Fat Polyunsaturated Fat No Daily Target or Limit No Daily Target or Limit 5% Calories No Daily Target or Limit 3% Calories No Daily Target or Limit Linoleic Acid (g)*** 12 g 3 g Under Linoleic Acid (% Calories)*** 5-10% Calories 3% Calories Under!-Linolenic Acid (g)*** 1.1 g 0.2 g Under!-Linolenic Acid (% Calories)*** % Calories Omega 3 - EPA Omega 3 - DHA No Daily Target or Limit No Daily Target or Limit 0.2% Calories Under 7 mg No Daily Target or Limit 48 mg No Daily Target or Limit Cholesterol < 300 mg 96 mg OK Minerals Target Average Eaten Status Calcium 1000 mg 335 mg Under Potassium 4700 mg 1559 mg Under Sodium** < 2300 mg 1265 mg OK Copper 900 "g 825 "g Under Iron 18 mg 15 mg Under Magnesium 310 mg 215 mg Under

14 '* Phosphorus 700 mg 685 mg Under Selenium 55 "g 98 "g OK Zinc 8 mg 11 mg OK Vitamins Target Average Eaten Status Vitamin A 700 "g RAE 323 "g RAE Under Vitamin B6 1.3 mg 1.8 mg OK Vitamin B "g 2.3 "g Under Vitamin C 75 mg 21 mg Under Vitamin D 15 "g 1 "g Under Vitamin E 15 mg AT 2 mg AT Under Vitamin K 90 "g 27 "g Under Folate 400 "g DFE 601 "g DFE OK Thiamin 1.1 mg 1.2 mg OK Riboflavin 1.1 mg 1.1 mg OK Niacin 14 mg 19 mg OK Choline 425 mg 154 mg Under Information about dietary supplements. ** If you are African American, hypertensive, diabetic, or have chronic kidney disease, reduce your sodium to 1500 mg a day. In addition, people who are age 51 and older need to reduce sodium to 1500 mg a day. All others need to reduce sodium to less than 2300 mg a day. *** Nutrients that appear twice (protein, carbohydrate, linoleic acid, and!-linolenic acid) have two separate recommendations: 1) Amount eaten (in grams) to your minimum recommended intake. 2) Percent of Calories eaten from that nutrient to the recommended range. You may see different messages in the status column for these 2 different recommendations.