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Case Study 12
Jackie Farrall
KNH 411
Professor Matuszak
November 13, 2012

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Melissa Gaines
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36 years old female; 5’3”
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Currently 92 lbs
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UBW is 112 lbs
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Patient Hx:
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Chief Complaint: “I have lost a tremendous amount of weight, and I have been having terrible diarrhea for awhile now. I don’t even have the energy to get off the couch”
GI issues on mothers side
Has been relying on chicken noodle soup, crackers and sprite for the past few days
Has a college degree and works as a secretary for a hospital administrator but just gave birth 3 months ago so on maternity leave

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Auto-immune condition which affects an individual for life once there is an onset
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Usually inherited (associated with the AGA/EMA antibody production)
Onset can occur at birth, after surgery, during pregnancy, after infection or any serious trauma
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Immune response to gluten, a wheat protein which causes damage to the intestinal villi
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Damaged villus will decrease the area of the intestines in which nutrients are absorbed into the bloodstream

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Abdominal bloating
Chronic diarrhea
Vomiting
Constipation
Foul smelling/fatty stool
Weight loss
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Anemia
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Fatigue
Arthritis
Skin rash
Osteoporosis
Infertility/miscarriage

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Weight loss
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Foul smelling/fatty stool
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Chronic diarrhea
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Anemia
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Fatigue

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36 year old female, thin, pale, experiencing fatigue, weakness and diarrhea
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BMI: 16.3
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UBW: 112 lbs
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Melissa is 82% of her UBW
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Actual body weight: 92 lbs
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Avoids eating due to nausea and diarrhea. Has resulted to weight loss

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Chemistry Melissa’s value
Albumin 2.9 g/dL
Total Protein 6-8 g/dL
Prealbumin 13 g/dL
AGA antibodies
EMA antibodies
HGB
HCT
Vitamin B12
Folate
Ferritin
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Normal values Reasons for
Abnormality
3.5-5 g/dL
5.5 g/dL
16-35 g/dL
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Weight loss, muscle wasting, inadequate protein intake
Abnormal autoimmune response to gluten
9.5 g/dL
34 g/dL
12-15 g/dL
37-47 g/dL
21.2 ng/dL 24.4-100 ng/dL
3 mm cubed 5-25 mm cubed
12 mg/mL 20-120 mg/mL
Low absorption of iron

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Requirements: 1185-1400 kcals per day
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Increased the kcal by 500 kcal/day because we want Melissa to gain weight
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Protein: 1.0 g/kg body weight/day (1.0 x 41.8 kg)=42 g/day
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Which would increase the protein by 63-73 gr/day
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Receiving:
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598 kilocalories
9 gr of protein and fat

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Involuntary weight loss (NC 3.2) related to inadequate energy intake and untreated Celiac disease as evidence by recent weight loss of 30 lbs and BMI of 16.3 kg/m squared.
Altered gastrointestinal function related to secondary malabsorption of nutrients, vitamins and minerals as evidence by reported consumption of gluten containing foods, small bowel biopsy indicating flat mucosa with villous atrophy and hyperplastic crypts, having diarrhea on and off for most of her adult life, and recent weight loss over one month.

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24-hour stool collection
100-g fat diet x 3 days
72- hour fecal fat
Sudan Black B fat stain
Blood tests
Collecting a sample of small intestine for testing
CBC, WBC, ESR, CRP, CMP tests
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MNT: Gluten-free diet
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Nothing containing wheat, rye or barley
Words such as stabilizer, starch, flavoring, emulsifier, hydrolyser, plant protein often mean wheat protein is involved
Corn, potato, rice, soybean, tapioca, arrowroot, carob, buckwheat, millet, amaranth and quinoa are allowed and good carbohydrate sources
Cross contamination
Alcohol
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Medication
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Steroids and immune suppressants
Vitamin supplements
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Treatment for this condition is non-surgical

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Education will be important part of recovery
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With a gluten-free diet regeneration of new epithelial cells in the gut will take place and within 2 years patients intestine will be healed
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If patient does not stay on gluten-free diet-
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Increase chances of developing cancer of the intestine
Osteoporosis
Untreated pregnant women have higher than normal rates of miscarriage and babies born with birth defects, especially neural tube defects, which arise from inadequate amounts of folic acid.

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American Association for Clinical Chemistry. (2009, May 16). Total protein and A/G ratio.
Retrieved November 9, 2012, from http://www.labtestsonline.org/understanding/analytes/tp/test.htm
American Dietetic Association. (2008). International dietetics and nutrition terminology
(IDNT) reference manual: Standardized language for the nutrition care process (2nd ed.)
Celiac Disease Foundation. (2011). Celiac disease symptoms. Retrieved November 9, 2012, from http://www.celiac.org/
Celiac Sprue Association. (2008). Symptoms of celiac disease. Retrieved November 7, 2012, from http://www.csaceliacs.org/celiac_symptoms.php
Nelms, M. N., Roth, S. L., & Lacey, K. (2009). Medical nutrition therapy: A case study approach
(2nd ed.). Belmont, CA: Wadsworth Cengage Learning.
USDA Center for Nutrition Policy and Promotion. (2010, September 28). MyPyramid tracker.
Retrieved November 9, 2012, from http://www.mypyramid.gov/
The University of Chicago Celiac Disease Center. (n.d.). The University of Chicago celiac
disease center. Retrieved November 8, 2012, from http://www.celiacdisease.net/