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Mickinzie Lopez

Assignment: Case Study #1

TR5320

Learning Objectives
1. To use the Nutrition Care Process (NCP) to assess, diagnose, intervene, and monitor/evaluate an adult patient
with an upper GI disorder.
2. To create a 1 day menu that supports the NCP and the clients need for food as medicine.
3. To document all stages of the NCP in ADIME chart note format.
Meet Agustn
Agustn is a 28 year old Hispanic male who is single and has no children. He lives alone and most of his close relatives
live in southern California. He comes to you today to get fresh advice about how to improve his diet to support his
health. He saw a nutritionist 3 years ago to help him the weight he gained when he quit smoking. He successfully
lost 25 pounds, mostly by making changes to reduce meat, soda, and junk food and working out 5 days per week.
Unfortunately, about 1 year ago he injured his back lifting weights and began managing the pain with ibuprofen pills.
Excessive use of the ibuprofen led to gastritis and diagnosis of a bleeding ulcer 6 months ago.
Laboratory data collected 2 weeks ago
Lab Test
Ferritin
Hgb
Hct
MCV
MCH
MCHC
Total cholesterol
Fasting blood glucose

Normal
12-300 ng/mL
14-18 g/dL
42-52%
80-99 fl
27-31 pg/cell
32-36 g/dL
<200 mg/dL
70-99 mg/dL

Result
60 ng/mL
14 g/dL
41%
82 fl
28 pg/cell
31 g/dL
205 mg/dL
85 mg/dL

Interpretation
WNL, low end
WNL

WNL
WNL

WNL

Note: see http://www.nlm.nih.gov/medlineplus/ency/article/003490.htm to interpret ferritin levels. Use your notes


to interpret iron tests. Use Appendix 30 to interpret other tests.
He reports his parents are reasonably healthy, but clarifies that his mother has pre-diabetes and his father has
hypertension. He says they dont exercise enough or eat well. His only sibling, a younger sister, struggles with her
weight. He is proud of his 25 pound weight loss and his ability to remain weight stable since then.
He describes his diet as flexitarian, eating meat about once per week. He reports no food allergies, intolerances, or
significant dislikes/preferences. For the purposes of the assignment, assume his 24 hour recall (below) is
representative of his usual, long-term intake. He continues to take a 10 mg iron pill twice daily as requested by his
doctor. However, since it causes him stomach pain when consumed on an empty stomach, he usually takes it with a
glass of milk in the morning and a bowl of ice cream in the evening. He consumes two beers while watching sports
on Sundays, but very infrequently otherwise. He cross-trains (weight lifting, running, cycling) about 60-75 minutes/d,
6 days/wk.
Agustn is a college-educated (MS degree) architect working in a busy office setting. He typically works long hours in
the office (60 hrs/wk), mostly sitting at his computer using design software. His job is particularly stressful since he
does not always get along well with his work supervisor. He is financially secure, owns his own home, and has the
ability to purchase needed foods and supplements.
Measurements you collect today: Blood pressure 118/67 mm Hg, height 180.3 cm, 80.9 kg. He is relaxed and
engaged during the visit, asking relevant questions and clarifying your suggestions to him.
Time
5:00 AM

Food
2% fat milk (taken with iron supplement)

Amount
1 cup

Mickinzie Lopez

Before workout
(Alone)
6:30 AM
Breakfast

7:15
(Driving to work)
1:00 PM
lunch
(at desk)

5:00 PM
Snack
(Alone, at desk)
8:00 PM
Dinner
(Alone, at table)
10:00 PM
Snack, at TV

Assignment: Case Study #1

Water

1 cup

Cottage Cheese, 1% fat, topped with:


Banana, fresh
Corn flakes, Erewhon brand
Orange juice
Water
Caffe latte w/whole milk, Starbucks

1.5 cups
1 medium
1 cup
6 fluid ounces
12 fluid ounces
16 fluid ounces

Home-made fajita
Tortilla, corn, 7, Mission brand
Cheese, Monterey jack, shredded
Red bell peppers, sauted
Yellow onions, sauted
Light sour cream
Guacamole, Trader Joes
Apple, fresh, large
Water
Barbeque flavored mini rice cakes, Quaker brand
Red grapefruit
Water
Vegetable fried rice, frozen, Trader Joes
Zucchini squash slices with skin, microwaved, drained
Topped with butter
2% fat milk
Vanilla Ice Cream, Breyers light
Water

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2
1 cup
1 cup
1 cup
0.5 cup
0.25 cup
1
16 fluid ounces
15
2
16 fluid ounces
3 cups
1 cup
1 Tbsp
1 cup
1 cup
16 ounces

Questions:
1. Analyze his current diet using Food Processor. Attach the required printout to this packet. [4 points]
a. Using the handout Calorie and Macronutrient Needs for Adults, calculate his estimated energy needs
and add that to the Energy/Criteria amount box. Add the DRI values (RDA, AMDR, AI) for macronutrients
and water in the Criteria amount boxes as well. Be sure to include units for your amounts. Then,
complete the His diet provides column by taking the data from your Food Processor report. Interpret
the data in the final column expressed either as a % of a recommended amount or , , WNL for
ranges. [7 points]
Component or
Nutrient

Criteria method

Criteria amount

His diet provides

Interpretation

Energy

Kcal/kg method

3,236 kcal

3,321 kcal

102.62%

Carbohydrate

RDA

130 g

407 g

313.07%

AMDR

45-65%

49%

WNL

Fat

AMDR

20-35%

35.81%

Protein

RDA

56 g

141 g

251.78%

Mickinzie Lopez

Assignment: Case Study #1

AMDR

10-35%

17%

WNL

AI

3.7 L/d

4.1 L/d

110.81%

Water

TR5320

b. Make a list below of at least SIX areas of his diet/lifestyle that you feel could be improved this could be
about a food, a nutrient, or any aspect of her diet/lifestyle (e.g. eating too close to bedtime, insufficient
physical activity). Rate how high of a priority you think each is on a scale of 1-10 (1=low, 10=high).
Consider the word priority as we have defined it in unit 1 in relation to prioritizing nutrition
problems/diagnoses. [6 points]
Area for improvement
Consumption of dairy with iron supplement
(impaired nutrient absorption).

Inadequate consumption of bioavailable iron.


Dietary imbalance.

Evidence that this is a problem


Hct 41% (normal: 42-52%), MCHC 31
g/dL (normal: 32-36 g/dL), despite
supplementation of 20 mg/d.
Hct 41% (normal: 42-52%), MCHC 31
g/dL (normal: 32-36 g/dL). Limits meat
consumption. Fe 60 ng/mL is on the low
end of normal (<70ng/mL).
Reported meat restriction.

Excessive fat intake.


Excessive calcium intake.
Reduce consumption of foods close to
bedtime.

Priority (1-10)
10

9
8

Dietary fat 35.81% of total kcal intake


(recommended: 20-35%).
Dietary calcium 2,705.83 mg > UL (2,500
mg)
Dinner at 8:00 PM and evening snack at
10:00 PM. Gastritis dx.

8
5
5

2. Consider your list of problems in #1b, their priority, and whether they are best listed as an individual nutrition
diagnosis or grouped into a more general nutrition diagnosis.
a. Write four possible PES statements in proper format below. Your first two PES statements in the chart
should be the two that you feel are the highest priority to be addressed at this initial visit. [6 points]

PROBLEM
nutrition diagnosis

Food-Medication
Interaction (IronCalcium NC-2.3)

related
to

related
to

ETIOLOGY
cause or contributing
factors

Consumption of dairy
products to ease GI
distress

as evidenced
by

as evidenced
by

SIGNS & SYMPTOMS


evidence from
assessment data
24-hour recall and
suboptimal Hct 41%
(normal: 42-52%) and
MCHC 31 g/dL (normal:
32-36 g/dL), despite
reported
supplementation of 20
mg/d.

Mickinzie Lopez

Assignment: Case Study #1

as evidenced
by

Suboptimal Hct 41%


(normal: 42-52%) and
MCHC 31 g/dL (normal:
32-36 g/dL), and
reported dietary intake
of non-heme iron (7.45
mg/d).

related
to

Food/nutrition related
knowledge deficit and
restricted meat intake

as evidenced
by

24-hour recall (no meat


consumption) and
reported avoidance of
meat.

related
to

Food/nutrition related
knowledge deficit

as evidenced
by

24-hour recall (35.81%


of total kcal from fat;
recommended: 2035%).

related
to

Suboptimal
consumption of
bioavailable iron food
sources and limited
attention/knowledge to
iron-rich foods

Undesirable food
choices (NB-1.7)

Less than optimal


intake of types of fat
(Saturated fats NI-5.6.2]

Inadequate mineral
intake (Iron NI-5.10.1]

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b. Defend your choice of why these two diagnoses should be addressed today. Be sure your defense
explains why the top two choices are highest priority AND why the other two are not. [4 points]
ALs poor Hct and MCHC lab values and iron-poor diet recall indicate the presence of iron deficiency, further
evidenced by his MDs prescription of iron supplementation. Supplementation is the quickest way to improve his
medical condition and is considered an essential component of his medical care at the moment. His consumption of
the iron supplement with calcium-rich meals inhibits the absorption of the iron and is preventing his recovery. Failure
to address food-drug interactions will lead to anemia, and a severe decrease in ALs health. Nutritional intervention is
relevent and appropriate, and within the scope of practice for an R.D.
ALs inadequate mineral intake, relating to his choices of non-heme iron-containing foods is important and
immediate, as it directly relates to his iron deficiency status. A discussion regarding the value of heme iron in regards
to absorption and maintenance of good iron status is needed and within the scope of practice for nutrition
professionals. Because AL is flexitarian, he may be open to increasing his weekly intake of heme food sources,
especially if he understands the health benefits associated with lean meat consumption. AL can also benefit from
education regarding appropriate sources and required quantities of non-heme iron, should he refuse to increase his
meat intake. The goal of educating him on this topic is to eliminate his need for supplemental iron, once he has
recovered from deficiency. I hope that in the future he will obtain adequate iron from his diet. Let food be thy
medicine.
AL explains that his method of losing weight 3 years ago was accomplished, in part, by his reduction of meat
consumption. He has since then maintained a restricted meat diet, for no other apparent reason than either out of
fear of gaining his weight back, or as a means of improving his healthboth of which are unsupported by nutritional
education. Because this is an initial intake, I did not choose to tackle this directly just yet, as the book notes to use
this diagnosis with caution. He may become distrustful of my advice if he does fear weight gain, and may not return. I
opted to gently offer information about the benefits of consuming heme iron under the diagnosis of inadequate
mineral intake (above) in hopes that he may begin to consider the possibility of increasing his meat intake. If he

Mickinzie Lopez

Assignment: Case Study #1

TR5320

refuses to include more meat, further counseling may be required, in which case this diagnosis will become more
relevant in future sessions.
ALs excessive fat intake exceeds the AMDR for fat consumption. His elevated cholesterol levels indicate a need
for action, but since they are considered borderline high, they are prioritized second to his iron deficiency. Because
he is at an increased risk for CVD due to family hx of hypertenstion and weight gain, this is a problem I would like to
address in the near future. Nutritional intervention can positively impact his cholesterol levels and is within the scope
of practice for an R.D. We have the chance to remedy the situation before medical intervention and Rx use is
required.
3. Type up a chart note for this initial visit on using the provided template and follow all charting guidelines
discussed in class/lecture. [15 points]
4. Using the BCNH form for patient goals, translate your two professional goals into 2 patient goals that are
accessible and behavior-oriented. [4 points]
5. Write a 1 day whole-foods, therapeutic menu for this client that will address his nutrition diagnoses and medical
condition(s). The menu should include at least 3 meals and one snack. List all foods and beverages included in
the days meal plan here. [4 points]
Pre-workout Snack (5:00 AM)

1 slice whole grain bread, toasted

1 TB chunky peanut butter

6 oz orange juice

8 oz water
Breakfast (6:30 AM)

1.5 cup 1% cottage cheese

1 medium banana, sliced

1 cup corn flakes, Erewhon brand

1 large orange

12 oz water
Morning Snack (7:15 AM)

Coffee latte w/ 2% milk, Starbucks

1 oz walnuts
Lunch (1 PM)

Home-made fajita:
o 2 tortillas, corn 7
o .5 cup low fat Monterey cheese, shredded
o 1 cup bell peppers, sauteed
o 1 cup yellow onions, sauteed
o 2 oz light sour cream
o .25 cup guacamole
o 4 oz flank steak, lean, brld

1 large apple

16 oz water
Afternoon Snack (5:00 PM)

15 mini rice cakes, BBQ, Quaker

1 red grapefruits

16 oz water
Dinner (8:00 PM)

Mickinzie Lopez

Assignment: Case Study #1

TR5320

3 cups vegetable fried rice, frozen


1 cup zucchini squash slices w/skin, drnd

.5 Tb butter

.5 cup spinach, ckd

8 oz water
Evening Snack (10:00 PM)

1 cup peach sorbet, fat free (taken w/iron supplement)

16 oz water

6. Analyze your proposed menu using Food Processor. Attach the required printout to this packet. [4 points]
7. Briefly (1 paragraph) summarize the therapeutic aspects of your proposed menu what were the important
changes you made and why? Then, briefly (1 paragraph) describe at least three foods you added to the menu for
specific therapeutic purposes (e.g. for nutrient density, healing, etc.) and explain those choices. [4 points]
In an effort to improve his absorption of the iron supplement, I recommended that AL abstain from
consuming dairy within 1.5-2 hours of his medication. Since he experiences GI distress with the supplement, I
recommended non-dairy sources of food, and offered suggestions for foods that may increase his absorption of
the pill, such as citrus. I also chose to substitute ingredients in his diet for additional sources of both heme and
non-heme iron throughout his day in hopes of improving his iron intake. I chose to focus solely on increasing his
mineral intake and absorption, so I did not change other aspects of his diet that may be considered unhealthy
for him. For example, I allowed him to keep his evening dessert before bed, but changed the composition of the
meal to prevent inhibition of the iron supplement. I want him to focus on making a few small changes to his diet
that will restore his iron status. Also, because AL is Hispanic, there is a possibility that quesadillas may be part of
his regular diet, depending on how relevant his culture is on his food choices. Rather than eliminating a key
cultural menu item, teaching him how to improve the meal for his benefit may lead to increased compliance,
effectiveness, and client satisfaction.
As mentioned above, I substituted his pre-workout and evening snacks for non-dairy containing choices to
prevent inhibition of the iron supplement absorption. The orange juice, toast and peanut butter contain an
appropriate mix of carbohydrates and proteins that are suitable for an easily-digestible pre-workout snack.
Additionally, the citrus from the orange juice increases absorption of the iron supplement. To ensure an easy
transition from his nightly ice cream habit, I suggested a non-dairy alternative such as fat-free sorbet. He can still
enjoy the quality of the dessert, while minimizing the detrimental effects of dairy with iron absorption.
Furthermore, fat-free sorbet will not contribute to his secondary problem of high fat intake, which will be
discussed in a later visit. I also substituted .5 cup of cheese in his quesadilla for lean flank steak, in hopes of
increasing his heme iron intake. As a Hispanic, AL may consume quesadillas frequently, so substituting
ingredients in his usual foods may prove to be most effective in the long run.
8. Briefly (1 paragraph) describe one natural medicine remedy that may complement the medical management
provided by the health care team. Using this website: naturaldatabase.therapeuticresearch.com/ briefly
summarize: 1) the main therapeutic ingredient(s), 2) the remedys effectiveness, and 3) safety considerations. [2
points]
According to the natural database, English walnut fruit is frequently recommended for hypertension,
lowering cholesterol, gastritis, ulcers, anemia, and more. Research shows that the walnut may possibly be
beneficial for the treatment of CHD and high cholesterol, but there is currently insufficient evidence for its
effective treatment of any other disease. Walnuts are considered safe when consumed in usual amounts as
food. Individuals at risk include people with a nut allergy. Weight gain is also a concern if walnuts are

Mickinzie Lopez

Assignment: Case Study #1

TR5320

consumed in excessive quantity. Walnuts may be particularly beneficial to AL for his range of medical
conditions and history, and as such, I have included an ounce of walnuts in his morning snack routine.

Mickinzie Lopez

Assignment: Case Study #1

TR5320

Mickinzie Lopez

Assignment: Case Study #1

TR5320

BASTYR CENTER FOR NATURAL HEALTH


Nutrition Team Care
CLIENT INITIALS: AL

DATE OF CONSULT: 2/5/14

ASSESSMENT
Client History:
28 y/o Hispanic male Dx of gastritis and bleeding ulcer 6 mo. ago, due to chronic NSAID use (from sports injury).
Client wants to improve his diet to support his health. Single, no children, and no family members nearby. Highstress job. Owns home.
Food and Nutrition-Related History:
Self-reported flexitarian; eats meat 1x/wk. Weight gain 3 years ago. 10 mg iron 2x/day, per recommendation of
MD. Pill causes him stomach pain, so he takes it with milk or ice cream (dairy). 2 beers on Sundays only. Exercises 6075 min/d, 6d/wk (Very Active). Otherwise sedentary desk job (60 hrs/wk, ~12hrs/d). Frequently eats alone at home,
at desk, and in car. Able to purchase food/supplements as needed. Shops at Trader Joes (eats healthy, convenient
meals; packaged dinners). Diet analysis: Iron is 93.17% of recommended intake (non-heme sources). B1 is 69.36% of
recommended intake. B3 is 36.19% of recommended intake.
Anthropometric Measures:
Height: 180.3 cm. Weight: 80.9 kg. BMI is normal (24.89; normal: 18.5-24.9). Weight is normal (IBW 78.18 kg +/- 10%;
80.9 is WNL). Stable weight management.
Biochemical Data, Medical Tests, and Procedures:
Hct (41%; normal: 42-52%); MCHC (31 g/dL; normal: 32-36 g/dL); Total cholesterol (205 mg/dL; normal: <200
mg/dL). Ferritin is on the low range of normal (60 ng/ML; normal: >70 ng/mL). Lost 25 lbs with help of nutritionist.
Nutrition-Focused Physical Exam Findings:
AL appears relaxed and engaged.

Diagnosis
PES #1:
Food-Medication Interaction (Iron-Calcium) [NC-2.3] related to limited knowledge of dairy interaction with iron
supplement consumption as evidenced by food record and suboptimal Hct 41% (normal: 42-52%) and MCHC 31 g/dL
(normal: 32-36 g/dL), despite reported supplementation of 20 mg/d.

Mickinzie Lopez

Assignment: Case Study #1

TR5320

PES #2:
Inadequate mineral intake (Iron) [NI-5.10.1] related to suboptimal consumption of bioavailable iron food sources and
limited attention/knowledge to iron-rich foods as evidenced by suboptimal Hct 41% (normal: 42-52%) and MCHC 31
g/dL (normal: 32-36 g/dL), and reported dietary intake of non-heme iron (7.45 mg/d).

Intervention
Nutrition Prescription: General diet; total iron from diet and supplements between 8-45 mg/day (between RDA and
UL), avoiding iron consumption with calcium-rich meals.
Intervention #1: Nutrition EducationContentPriority Modification (E-1.2)
Discuss calciums role in the inhibition of iron intake and its relationship to iron status and anemia. Discuss ideas
about ways to reduce nausea by substituting non-calcium-rich foods for his current choices. Educate client about
foods that may increase iron absorption. Suggest orange juice as an appropriate substitute for milk. Vitamin C will
increase absorption of iron.
Intervention #2: Nutrition EducationContentNutrition Relationship to Health and Disease (E-1.4)
Discuss importance of bioavailable iron sources/omnivore diet in relationship to iron intake and anemia. Identify
what he already knows about meats role in health, and educate him in areas where information is lacking. Offer
resources to help him understand the role of meat in relation to nutritional health. Disucss ways to adjust his diet to
increase dietary meat intake.

Monitoring/Evaluation
Professional Goal #1:
At the end of todays session, patient will be able to successfully answer questions about calciums inhibitory effects
on iron absorption and will be able to identify appropriate food choices to substitute in place of his current choices.
Professional Goal #2:
At the end of todays session, patient can clearly explain the bioavailability differences between heme and non-heme
iron sources in relation to his recovery from iron deficiency. Patient can identify 3 sources each of heme and nonheme iron-rich foods.
Follow up in 2 weeks. Follow up activities: Will assess clients success/failure in implementing dietary changes. Were
the substitutions for dairy as effective in relieving nausea, or has his nausea increased? Will assess clients intake of
meat and evaluate reaction to doing so. How does the client feel?

Clinician Signature (electronic): Mickinzie Lopez

Date: 2/6/14

Mickinzie Lopez

Assignment: Case Study #1

TR5320

BASTYR CENTER FOR NATURAL HEALTH


Nutrition Team Care
NUTRITION CONSULTATION

Name: Augustine Lopez

Date of Birth: September 25, 1986

Clinician: Mickinzie Lopez


Date: 2/6/14
Nutritional Recommendations:
Starting 2/6/14, patient agrees to avoid consumption of dairy products within 2 hours of
iron supplement to ensure adequate absorption. Client will take iron supplement with citrus
foods to increase absorption.

Starting 2/6/14, patient agrees to:

review pamphlet/website about increasing dietary sources of heme iron


consume 2-4 servings of iron (red meat, fortified cereal, etc.) from food and
supplements daily
complete a 3-day food log prior to 2-week follow-up appointment

Next Appointment:

2/20/14

Clinic Phone: (206) 834-4100

Mickinzie Lopez

Assignment: Case Study #1

TR5320