Erin Baas
KNH 413
Case Study #3
Case Questions
1. What is depression?
a. Depression is a medical illness that causes a persistent feeling of sadness and loss of
interest. It affects how one feels, thinks, and behaves. It may cause a variety of
emotional and physical problems. It may be hard to do normal day-to-day activities,
and may make one feel as if life isn’t worth living.
(http://www.mayoclinic.com/health/depression/DS00175)
2. Dr. Byrd has decided to treat Ms. Geitl with Zoloft, a selective serotonin reuptake inhibitor
(SSRI). Are there any pertinent nutritional considerations when using this medication?
a. While taking Zoloft, Ms. Geitl needs to avoid drinking any alcohol. She also should
take Zoloft in combination with certain herbs, including St. John’s wort, unless
directed by a physician that it is okay to do so.
(http://www.appliedhealth.com/index.php?
option=com_content&view=article&id=400419&catid=89&Itemid=150)
3. How do serotonin reuptake inhibitors (SSRIs) work?
a. SSRIs ease depression by affecting neurotransmitters used to communicate between
brain cells. SSRIs block the reabsorption of the neurotransmitter serotonin in the brain.
This change in serotonin level seems to help brain cells send and receive chemical
messages boosting the mood of the individual.
(http://www.mayoclinic.com/health/ssris/MH00066)
4. During the diet history, you ask Ms. Geitl if she uses any OTC vitamins, minerals, or herbal
supplements. She tells you her mother suggested she try hypericum perforatum (St. John’s
wort) because in Germany it is prescribed to treat depression. Ms. Geitl did as her mother
suggested, as it is available without prescription in the United States. What is St. John’s wort?
a. St. John’s wort is an herb who’s flowers and leaves are used in making medicine. This
medicine is used most commonly to treat depression, anxiety, tiredness, loss of
appetite, and trouble sleeping.
(http://www.nlm.nih.gov/medlineplus/druginfo/natural/329.html)
5. How is St. John’s wort used in the United States?
a. Both the leaves and flowers of St. John’s wort are harvested, dried, and put into liquid
or pill form. The dried leaves can also be used as tea. The tablets in the U.S. have
varied amounts of active ingredient in the, so people she note how much they’re
getting in the tablets.
(http://my.clevelandclinic.org/disorders/depression/hic_st_johns_wort.aspx)
6. How does St. John’s wort work as an antidepressant?
a. Taking St. John’s wort improves mood and decreased anxiety and insomnia related to
depression. The chemical hyperforin in St. John’s wort plays a large role in depression.
It acts on chemical messengers in the nervous system that regulate mood.
(http://www.nlm.nih.gov/medlineplus/druginfo/natural/329.html)
7. Does St. John’s wort have any side effects?
a. It can cause some side effects such as trouble sleeping, vivid dreams, restlessness,
anxiety, irritability, stomach upset, fatigue, dry mouth, dizziness, headache, skin rash,
diarrhea, and tingling. It could be potentially unsafe when taken by mouth in large
doses. It might cause severe reactions to sun exposure.
(http://www.nlm.nih.gov/medlineplus/druginfo/natural/329.html)
8. How is St. John’s wort regulated in the United States?
a. The potency and purity of different extracts sold in the U.S. varies widely. The U.S.
Food and Drug Administration does not regulate herbs as tightly as it does prescription
and over-the-counter medicines and cannot guarantee strength of purity.
(www.cancer.org/treatment/treatmentsandsideeffects/
complementaryandalternativemedicine/herbsvitaminsandminerals/st-johns-wort)
9. How is St. John’s wort used in Europe?
a. In Europe, St. John’s wort is approved for the treatment of depression and anxiety, as
well as for burns and skin lesions. It is available by prescription only.
(www.cancer.org/treatment/treatmentsandsideeffects/
complementaryandalternativemedicine/herbsvitaminsandminerals/st-johns-wort)
10. Why do you think people are interested in alternative medicine and herbal treatments?
a. In the past 20 years in the U.S., public dissatisfaction with the cost of prescription
medications, combined with an interest in returning to natural or organic remedies, has
led to an increase in herbal medicine use. It is becoming more mainstream as
improvements in analysis and quality control along with advances in clinical research
show the value of herbal medicine in treating and preventing disease.
(http://www.umm.edu/altmed/articles/herbal-medicine-000351.htm)
11. Because Ms. Geitl is ambulatory, you are able to measure her height and weight. She is 5’11”
tall and weights 160 pounds. You also determine that she is of medium frame. Because Ms.
Geitl is from German, she is used to reporting her weight in kilograms and her height in
centimeters. Convert her height and weight to metric numbers.
a. Height = 71 inches x 2.54 = 180.34 cm
Weight = 160/2.2 = 72.7 kg
BMI = 22.4 kg/m^2
12. Is Ms. Geitl’s recent weight loss anything to be worried about?
a. Yes, weight loss is a symptom of depression. Since she has been diagnosed with
depression, this weight loss can only become worse if she is not treated properly. It
may cause her to become even more malnourished than she already seems to be.
13. Because Ms. Geitl is alert and cooperative, you ask her to complete a patient-generated
subjective global assessment (PG-SGA) of nutritional status. How would you score her? (See
appendix I)
Sections
Score
Box 1
1
Box 2
1
Box 3
1
Box 4
3
Weight loss section (Table 1)
0
Disease section (Table 2)
0
Metabolic section (Table 3)
0
Physical section (Table 4)
0
Total
6
SGA Rating
Select one:
A=Well nourished
B=Moderately (or suspected of being malnourished)
C=severely malnourished
14. Using Appendix I, how would you triage nutritional intervention?
a. Ms. Geitl requires intervention by dietitian, in conjunction with nurse or physicians as
indicated by symptoms survey.
15. What methods are available to estimate Ms. Geitl’s energy needs?
a. There are a number of methods available to estimate Ms. Geitl’s energy needs. They
include WHO, Harris Benedict, estimated energy requirements, total energy
expenditure, and the Mifflin St. Jeor.
16. Calculate Ms. Geitl’s basal energy needs using one of the methods you listed in question 15.
a. Mifflin St. Jeor = (10 x w) + (6.25 x h) - (5 x a) - 161
= (10 x 72.7) + (6.25 x 180) - (5 x 20) - 161
= 1,591 kcal/day
17. What is Ms. Geitl’s estimated energy expenditure?
a. Harris Benedict = (9.56 x w) + (1.85 x h) - (4.68 x a) + 655
= (9.56 x 72.7) + (1.85 x 180) - (4.68 x 20) + 655
= 1589 x 1.1 (PAL)
= 1,748 kcal/day
18. Evaluate her diet history and her 24-hour recall. Is she meeting her energy needs?
a. No, Ms. Geitl is not meeting her energy needs. Her 24 hour recall shows that she is not
choosing many high calorie foods, nor is she eating much food throughout the day.
19. What would you advise?
a. Mrs. Geitl definitely needs to increase her energy intake. This could be done by eating
smaller, more frequent meals that are nutrient dense. She is also really lacking in her protein
intake. Eating more protein will be an important factor helping to give Ms. Geitl more energy.
Once she starts having more energy, she will be more likely to want to be active, which in turn
will decrease her depression symptoms. While taking Zoloft, it will be important for Ms. Geitl to
know how to eat properly with this medication so as to speed up her recovery so she doesn’t
need to be on the medication for too long.
20. List each factor from your nutritional assessment and then determine an expected outcome
from each.
Assessment Factor
Expected Outcome
Increase energy intake
small/frequent/nutrient dense meals
Increase protein intake
small protein rich foods
Physical activity
increase with time, find an activity she enjoys
21. What is your immediate concern regarding this patient’s use of St. John’s wort?
a. Taking St. John’s wort can negatively interfere with other antidepressant medications.
St. John’s wort can also decrease the effectiveness of birth control pills. These are both
factors for Ms. Geitl to take into consideration before using St. John’s wort.
(http://www.nlm.nih.gov/medlineplus/druginfo/natural/329.html)
22. Review the initial nutrition note written for this patient. Is this progress note appropriate? Is
is complete? Any errors? Any omissions?
a. I think this is an appropriate progress note, however I think it could still be more
descriptive. I think evaluation needs to be taken into account, meaning how will Ms.
Geitl be evaluated to make sure she is increasing her kcal and protein intake. I also
think nutrient needs are somewhat high for Ms. Geitl. Her height may be effecting this
in calculation. I think trying to make her take in 2600 kcals a day right away will only
make things worse. I think it would be a better idea to steadily increase her daily intake
overtime.