Case Study 3- Upper GI

Patient Summary: Mr. Nelson; 48-yo male here for evaluation and treatment for increased indigestion History: Onset of Disease: Experiencing increased indigestion over last year. Previously it was only at night but now he experiences indigestion almost constantly. Takes Tums several times daily. He has gained almost 35 lbs since having knee surgery, has not been physically active, and has been eating and drinking more over the last year, which he attributes to stress. Medical Hx: Essential HTN- Dx 1 year ago Surgical Hx: s/p R knee arthroplasty 5 years ago Medications: Atenolol, Aspirin, Multivitamin, ibuprofen Tobacco use: None Alcohol: 1-2 beers 3-4 times/week Family Hx: Father; CAD Physical Exam: General appearance: Mildly obese 48-year-old white male in mild distress Neuro: Oriented x4 Extremities: No edema Skin: Warm, dry, Braden score= 20 Abdomen: No distention. BS present in all regions. Vitals Signs: Temp: 98.6 Pulse: 90 Resp. Rate: 16 BP: 119/75 Height: 59 Weight: 215 lb Medical Plan: Labs, Barium esophagram, Endoscopy with biopsy to r/o H. Pylori infection, begin omeprazole, reduce aspirin, D/C ibuprofen, Nutrition consult Usual Dietary Intake: Breakfast: Lunch: Afternoon snack: Dinner: HS Snack:

1.5-2 cups cheerios with cup skim milk, 32 oz orange juice 1.5 oz ham on whole wheat bagel, 1 apple, 1 cup chips, diet soda 2 cups chips, 1-2 16oz beers 9 oz fried meat, fried potato skin w/ butter & sour cream, 2 cups fresh fruit, iced tea 1 cup ice cream

Food allergies/intolerances/aversions: Fried foods make indigestion worse Previous nutrition education: None Laboratory Results: Na 144 Cl 102 Cr 0.7 Ca 9.1 K+ BUN Glucose Prealbumin 4.5 9 110 33

Answer the following Case Questions (type please) and complete NCP form 1.) What risk factors does the patient present with that might contribute to his diagnosis? The risk factors the patient presents with that might contribute to his diagnosis are his weight status (mildly obese with a BMI of 31.7), poor diet (high-fat, energy-dense, large meals), increased food and alcohol intake, high intake of caffeine/tea and soda, and overuse of NSAIDs. 2.) The physician biopsied for H. Pylori. What is this? H. Pylori is a gram negative bacteria, that is able to withstand the acidic environment of the stomach. This bacterium induces inflammation and the longer the patient is infected with it, the greater their risk of experiencing associated complications, such as damage to the epithelium and impairment of the mucus barrier. Its treatment involves 2-3 antibiotics and acid-suppressing medications. 3.) The MD has decreased the patients dose of daily aspirin and recommended discontinuing his ibuprofen. Why? How do aspirin and NSAIDs affect gastroesophageal disease? The patients daily dose of aspirin was decreased and the physician recommended that he discontinue the use of ibuprofen because overuse of NSAIDs (Non Steroidal Anti-Inflammatory Drugs) may compromise mucosal integrity and increase the patients chances of acquiring acute or chronic gastritis. 4.) The MD prescribed omeprazole. What class of medication is this? What is the basic mechanism of the drug? List 3 other medications used to treat GERD. Omeprazole is a proton-pump inhibitor used in treatment for GERD, gastric and duodenal ulceration and gastritis. The drug functions by inhibiting acid secretion. Its bioavailability is significantly decreased by the presence of food and should be taken on an empty stomach. Three alternative medications for the treatment of GERD include: 1. H2 blockers 2. Prokinetics 3. Antacids 5.) Using Mr. Nelsons usual dietary intake, outline necessary modifications you could use as a teaching tool. In order to lessen Mr. Nelsons symptoms, I would make the following modifications to his diet: Avoid eating at least 3-4 hours before laying down, sleeping Decrease total energy intake o Weight loss increase LES pressure In general, pay attention to serving sizes 1.5-2 cups cheerios: recommend high fiber cereal and decrease serving size 32 oz. orange juice: recommend cutting back to 1 cup or fresh orange slices

Chips, ice cream: recommend more nutrient dense snacks, such as nuts or greek yogurt which will also increase satiety Whole wheat bagel: recommend whole wheat bread slices or wrap to reduce calories Smaller, more frequent meals o Increase satiety o Promote weight loss Decrease overall fat intake, especially high-fat meals o Increase LES pressure o Promote gastric emptying and prevent acid production/secretion Fried meat: alternative cooking method, leaner cuts Fried potato skin: recommend roasted potatoes with herbs to decrease the need for condiments Increase protein intake, recommending leaner cuts of HBV proteins o Increase LES pressure 1.5 oz. ham: chicken 9 oz. fried meat: alternative cooking methods such as baking Avoid alcoholic beverages o Prevent gastric acid secretion o Prevent excess energy intake leading to weight gain Avoid caffeine-containing foods/beverages o Increase LES pressure o Recommend chamomile tea (other caffeine-free alternatives) instead of iced tea Monitor fiber intake o 14 g / 1,000 calories o Increase gastric motility