Lecturer: Abrar Alhebshi
Name: Jack Nelson
DOB: 22/7 (age 48)
Physician: J. Phelps, MD
ADMISSION DATABASE
BED #
3
DATE:
9/22
TIME:
TRIAGE STATUS (ER ONLY):
□ Red □ Yellow □ Green □ White
0900
Initial Vital Signs
TEMP:
RESP:
37 ℃
HT:
SAO2:
22 bpm
WT (kg):
B/P:
PULSE:
180 cm
97.5
LAST TETANUS
120/80
LAST ATE
90 bpm
LAST DRANK
1 year ago
11 PM
this AM
CHIEF COMPLAINT/HX OF PRESENT ILLNESS
PRIMARY PERSON TO CONTACT:
Name: Mary Nelson
Home #: 555-444-5689
Work #: 555-453-5689
ORIENTATION TO UNIT: □
Call light □Television/telephone
□ Bathroom □
Visiting □ Smoking □

Meals
□ Patient rights/responsibilities

“My wife insisted that I come see someo ne, The
yesterday
pain w a s sothat
bad I was afraid I was having a
PERSONAL ARTICLES: (Check if retained/describe)
□ Contacts □ R □ L
□ Dentures □ Upper □ Lower
□ Jewelry:
□ Other: eyeglasses

NKA (no known allergies)
VALUABLES ENVELOPE: no
□ Valuables instructions
“
heart
attack
ALLERGIES:
Meds, Food, IVP Dye, Seafood: Type of Reaction
INFORMATION OBTAINED FROM:
□ Previous record
□ Responsible party
□ Patient

□ Family

PREVIOUS HOSPITALIZATIONS/SURGERIES
S/p R knee
arthroplasty 5 years ago
Signature
Home Medications (including OTC)
Codes: A Sent home
Dose
Frequency
Medication
Aspirin
325 mg

□ Yes
Do you take all medications as prescribed?
PATIENT/FAMILY HISTORY
□
□
□
□
□
□
□

□
□
qd
□
□
□
□
□
□
□
□
□
Cold in past two weeks
Hay fever
Emphysema/lung problems
TB disease/positive TB skin test
Cancer
Stroke/past paralysis
Heart attack (Father)
Angina/chest pain
 Heart problems (Mother)
□ No
If yes, type:
Frequency:
Route:
Date last used:
/
/
this AM
C
C Not brought in
Patient Understanding of Drug
yes
If no, why?
High blood pressure
Arthritis
Claustrophobia
Circulation problems
Easy bleeding/bruising/anemia
Sickle cell disease
Liver disease/jaundice
Thyroid disease
Diabetes
RISK SCREENING
□ Yes
□ No
Have you had a blood transfusion?

□ Yes
□ No
Do you smoke? 
If yes, how many pack(s)? 1/day for 18 years
□ No
Does anyone in your household smoke? □ Yes 
□
Do you drink alcohol? □ Yes
No

If yes, how often?
How much?
When was your last drink?
□ No
Do you take any recreational drugs? □ Yes 
Jack Nelson
B Sent to pharmacy
Time of Last Dose
Code
□ Kidney/urinary problems
□ Gastric/abdominal pain/heartburn ( Patient)

□ Hearing problems
□ Glaucoma/eye problems
□ Back pain
□ Seizures
□ Other
FOR WOMEN Ages 12–52
Is there any chance you could be pregnant?
If yes, expected date (EDC):
Gravida/Para:
ALL WOMEN
Date of last Pap smear:
Do you perform regular breast self-exams?
ALL MEN
Do you perform regular testicular exams?
□ Yes
□ No
□ Yes
□ No
□ Yes

□ No
Lecturer: Abrar Alhebshi
Client name: Jack Nelson, DOB: 7/22, Age: 48, Sex: Male, Education: Bachelor dgree
Occupation: Retail manager of local department store
Hours of work: M–F, works consistently in evenings and on weekends as well
Household members: Wife age 42, 2 sons ages 10 and 16 all in good health
Ethnic background: Caucasian,
Referring physician: Patricia Phelps, MD (family practice)
Patient history:
Mr. Nelson has been experiencing increased dysphagia, heartburn, regurgitation, coughing with meals over
last month, previously only at night but now almost constantly.
Physical exam:
General appearance: Obese 48-year-old white male in mild distress
Heart: Regular rate and rhythm, heart sounds normal
HEENT: Noncontributory
Neurologic: Oriented x 4
Extremities: No edema; normal strength & sensations
Skin: Warm, dry
Chest/lungs: Clear
Abdomen: No distention. BS normal
Nutrition Hx:
General: Patient relates that he has gained almost 16 kg since his knee surgery. He attributes this to a decrease
in ability to run and has not found a consistent replacement for exercise. Patient states that he plays with his
children on the weekends but that is the most exercise that he receives. 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.
Relates that his schedule has been increasingly busy so that he order pizza or stop for fast food 1–2 times
per week instead of cooking. He states that he loves fatty food, soft drinks, lemon juice and fatty snacks
such as chips, French fries, cookies and popcorn. However, pt. states that he has been experiencing
difficulty eating & swallowing such snacks over the last month.
Food allergies/intolerances/aversions: spicy & citrus foods seem to make the pain worse
Previous nutrition therapy? no
Food purchase/preparation: Wife or eats out
Vitamin intake: none
Dx: pt. Dx 3 days ago with GERD & mild dysphagia (level 3), pH monitoring and barium esophagram
support diagnosis of gastroesophageal reflux disease with negative biopsy for H. pylori. Endoscopy indicates
no ulcerations or lesions in the esophagus but mild esophageal dysphagia present with adequate chewing
ability.
Tx plan:
24-hour pH monitoring, decrease aspirin to 75 mg daily, Consult to dietitian.
Lecturer: Abrar Alhebshi
NAME: Jack Nelson
AGE: 48
PHYSICIAN: P. Phelps, MD
DOB: 7/22
SEX: M
****************************************CHEMISTRY*****************************************
DAY:
DATE:
TIME:
LOCATION:
Admit
9/22
NORMAL
Albumin
Total protein
Prealbumin
Transferrin
Sodium
Potassium
Chloride
PO4
Magnesium
Osmolality
Total CO2
Glucose
BUN
Creatinine
Uric acid
Calcium
Bilirubin
Ammonia (NH3 )
ALT
AST
Alk phos
CPK
LDH
CHOL
HDL-C
VLDL
LDL
LDL/HDL ratio
Apo A
Apo B
TG
T4
T3
HbA1C
3.5–5
6–8
16–35
250–380 (women)
215–365 (men)
136–145
3.5–5.5
95–105
2.3–4.7
1.8–3
285–295
23–30
70–110
8–18
0.6–1.2
2.8–8.8 (women)
4.0–9.0 (men)
9–11
0.3
9–33
4–36
0–35
30–120
30–135 (women)
55–170 (men)
208–378
120–199
55 (women)
45 (men)
7–32
130
3.22 (women)
3.55 (men)
101–199 (women)
94–178 (men)
60–126 (women)
63–133 (men)
35–135 (women)
40–160 (men)
4–12
75–98
3.9–5.2
UNITS
4.9
7.2
33
350
g/dL
g/dL
mg/dL
mg/dL
144
4.5
102
3.8
2.0
278
28
110
9
0.7
mEq/L
mEq/L
mEq/L
mg/dL
mg/dL
mmol/kg/H2 O
mEq/L
mg/dL
mg/dL
mg/dL
mg/dL
9.1
0.8
30
22
156
100
300
220 H
45
130
mg/dL
mg/dL
mol/L
U/L
U/L
U/L
U/L
U/L
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
178 H
mg/dL
mcg/dL
mcg/dL
%
Lecturer: Abrar Alhebshi
NAME: Jack Nelson
AGE: 48
PHYSICIAN: P. Phelps, MD
DOB: 7/22
SEX: M
****************************************HEMATOLOGY**************************************
DAY:
DATE:
TIME:
LOCATION:
Admit
9/22
NORMAL
WBC
RBC
HGB
HCT
MCV
RETIC
MCH
MCHC
RDW
Plt Ct
Diff TYPE
ESR
% GRANS
% LYM
SEGS
BANDS
LYMPHS
MONOS
EOS
Ferritin
ZPP
Vitamin B12
Folate
Total T cells
T-helper cells
T-suppressor cells
PT
4.8–11.8
4.2–5.4 (women)
4.5–6.2 (men)
12–15 (women)
14–17 (men)
37–47 (women)
40–54 (men)
80–96
0.8–2.8
26–32
31.5–36
11.6–16.5
140–440
0–25 (women)
0–15 (men)
34.6–79.2
19.6–52.7
50–62
3–6
24–44
4–8
0.5–4
20–120 (women)
20–300 (men)
30–80
24.4–100
5–25
812–2,318
589–1,505
325–997
11–16
UNITS
5.6
5.2
103/mm3
106/mm3
14.0
g/dL
40
%
85
m3
%
pg
g/dL
%
103/mm3
28
32
mm/hr
%
%
%
%
%
%
%
mg/mL
mol/mol
ng/dL
g/dL
mm3
mm3
mm3
sec
Lecturer: Abrar Alhebshi
Case Questions:
Understanding the Disease and Pathophysiology
Q: In the etiology of gastroesophageal reflux disease, what factors affect LES pressure?
Factors that potentially affect LES pressure include the hormones gastrin, estrogen, and progesterone; the
presence of abdominal fat or obesity, hiatal hernia; the presence of scleroderma, smoking, or some medications
including NSAID; and nutritional factors. Foods high in fat, chocolate, spearmint, peppermint, alcohol, and
caffeine have been noted to decrease LES pressure.
Q: What risk factors (habits) do the patient present with that might contribute to his diagnosis?
(Be sure to consider lifestyle, medical, and nutritional factors).
Weight gain, high-fat diet, lack of physical activity, smoking, and the use of nonsteroidal anti-inflammatory drugs
(aspirin) on a daily basis.
NCP steps
1. Nutrition assessment (5 categories):
Age, gender, smoker/or not, Dx, c/o (s/s)
(medical Hx, surgeries), family Hx, medications
a. Client History:
48 years old male, smoker, Dx with GERD 3 days ago, c/o (S/S) dysphagia level3,
heartburn, regurgitation, coughing over last month, PMH of gastric pain, R knee
Appetite, food intake, food quality, food supply, wt
change,
physical and
activity,
nutritional
supplements
arthroplasty 5 years ago, family Hx of heart
attack
heart
problems.
On
Aspirin qd
b. Food/Nutrition- Related History:
Good appetite, high calories intake especially from fatty or fast food, no meal
preparations, sedentary or light active lifestyle, weight gain in the last 5 years. recently,
pt. has mild difficulty swallowing
c. Anthropometric Measurements:
Q. Assess this patient’s available anthropometric data. Does his BMI contribute to his diagnosis?
BMI = 30, Mr. Nelson has Grade I obesity. Obesity has been correlated with GERD and is thought to increase
intra-abdominal pressure.
IBW= (Ht (cm) -150 )\2.5 x 2.7 + 48.2= 80.6 kg
ABW= 0.25x(actual wt-Ideal wt)+Ideal wt = 84.8 ~ 85 kg
 Calculation of energy and nutrient requirements:
Q. Calculate energy, macronutrient and fluid requirements for Mr. Nelson. Identify the
formula/calculation method you used.
Lecturer: Abrar Alhebshi
Mifflin= (10XWt) + (6.25XHt) – (5 X Age) + 5
REE: (10X 84.8) + (6.25X180) – (5X48) + 5 =1738 kcal
PA (1.3): 2259.4 kcal
TEF10% of PA: 225.94 kcal
TEE :2484.9 kcal =2500 kcal
All macronutrients % should be converted to grams: CHO →50-60% , Fat→ 25 -35% , Protein→15%
1- Protein ( 15% ): 375 kcal = 93.75 g/day
2- Fat (25%): 625 kcal \9= 69.4
g/day
3- CHO(remaining calories): TEE- (kcal from protein + kcal from fat) = 1500 kcal/day (÷4)= 375
g/day
or percentage of CHO (60%)=
Fluids: 1 ml / 1kcal = 2500 kcal = 2500 ml
d. Biochemical Data, Medical Tests, and Procedures
Q. Are there any other abnormal labs that should be addressed to improve Mr. Nelson’s health?
(please write the Reason for Abnormality)
Abnormal Lab
Indications (Reason for Abnormality/ Nutritional Implication)
Lipid profile (↑ Chol. & Obesity BMI >30, dyslipidaemia, high saturated fat intake, he is at
TG)
high risk for heart disease
e. Nutrition-Focused Physical Findings:
Obese male in mild distress
******************************************************************************************
2. Nutrition Diagnosis: Problem.....related to....Etiology......as evidenced by....S/S
Q. Identify this patient nutrition problems and complete the PES statement (at least one statement).
Intake domain:
 Excessive energy intake related to frequent consumption of fast foods (e.g. fried meals and
popcorn) as evidenced by typical daily high calories intake compared to recommended intake of
2500 kcal and a BMI of 30, lab findings of chol and TG, wt gain
 Excessive fat intake and excessive saturated fat intake........
Recently:
 Inadequate oral intake related to difficulty swallowing as evidence by coughing with meals,
regurgitation & patient diet history
Clinical domain

Obesity class 1 related to excessive energy intake and physical inactivity as evidenced by BMI
of 30, abnormal lipid profile.
Recently:
 Swallowing difficulty or dysphagia related to GERD as evidence by (S/S) coughing with meals,
regurgitation & difficulty eating hard snacks over the last month
 Altered GI function.......
Lecturer: Abrar Alhebshi
Behavioural–environmental domain
 Food and nutrition-related knowledge deficit as evidenced by undesirable food choices
 Undesirable food choices related to knowledge deficit and busy schedule prompting frequent
fast food consumption as evidenced by fried foods, cookies, and eating fast food 1–2 times per
week
 Physical inactivity related to inability to find consistent replacement to previous physical activity
of running following knee arthroplasty as evidenced by patient stating that he has little to no
exercise, pt high BMI , obese
*************************************************************************************
3. Nutrition Intervention (4 categories):
a. Food/ Nutrition Delivery, (Provide this patient with 1 day menu plan using exchange list)
Q. For each of the PES statements that you have written, establish an ideal goal and an
appropriate intervention.
Goal:
reach a more desirable BMI between 25 and 30 (or IBW), Modify meals and snacks to reduce GERD & dysphagia
symptoms
Intervention: (how much cal, type of diet , how many grams )
Provide 2500 kcal/day dysphagia advanced diet contains ....g proteins,....g CHO,.....g fat
b. Nutrition Education & c. Counseling, (you have to explain in your own words)
Q: Are there specific foods that may contribute to GERD? Summarize the current
recommendations for nutrition therapy in this disease.
Q: What food items should be allowed/avoided regarding Mr. Nelson swallowing ability? Give him an
example of one meal menu.
Q. What nutrition education should this patient receive prior to discharge?
There has been very limited research that addresses how foods may contribute to GERD. The treatment goals
include restricting foods that lower LES pressure. To reduce gastric acidity, black and red pepper, coffee (both
caffeinated and decaffeinated), and alcohol are avoided, because all have been identified as stimulants for
gastric acid production. Likewise, meals of larger quantity tend to produce more acid, delay gastric emptying,
and increase the risk of reflux. Thus, smaller, more frequent meals may be indicated. Foods that lower LES
pressure should also be restricted. These include chocolate, mint, and foods with a high fat content.
Furthermore, any food the client identifies as irritating should be avoided. If the patient is obese, weight
reduction should be a component of the plan for nutrition therapy.
Regarding his dysphagia status, patient should avoid very hard, sticky, or crunchy items such as..... & foods
allowed are most regular foods and tender, moist meats
Q. Do any lifestyle issues need to be addressed with this patient? Explain.
Q. What other components of lifestyle modification would you address in order to help in treating
his disorder?
Lecturer: Abrar Alhebshi
Discussion about home meal preparation and reduce fatty food intake and smoking. Discussion of the role of
smoking in GERD should be addressed. Referrals to assist with smoking cessation can be made within the health
care team.
The client should remain upright during and immediately after meals. Client should avoid eating or drinking
anything for up to 3 hours prior to retiring in the evening. Client may also benefit from smaller meals prior to
bedtime. The head of the client’s bed may also be elevated at night to assist with nighttime reflux
******************************************************************************
4. Nutrition Monitoring and Evaluation:
Q. What tools are necessary to follow up this patient? Food records, weekly measurements
of weight, nutrient intake reports, resolution of vomiting episodes, swallowing progression.