question archive Jack Nelson, 48 year-old male visits his MD for evaluation of increasing complaints of severe indigestion
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Jack Nelson, 48 year-old male visits his MD for evaluation of increasing complaints of severe indigestion. A barium esophagram shows a diagnosis of gastroesophageal reflux disease.
Onset of disease: Patient has been experiencing increased indigestion over the last year. Previously, it was only at night but now he experiences indigestion almost constantly. He has been taking Tums several times daily. Mr. Nelson has gained almost 35 pounds since his knee surgery, which he attributes to a decrease in his ability to run and not being able to find a consistent replacement for exercise. Patient states that he probably has been eating and drinking more over the past year, which he attributes to stress. He is worried about his family history of heart disease, which is why he takes an aspirin each day. He does not follow any diet restrictions.
PMHx: HTN Family Hx: CAD, father
Medications: Atenolol 50mg day; 325mg aspirin day; MVI; 500mg ibuprofen twice daily for the past month.
Tobacco: No Alcohol: Yes; 1-2 beers 3-4 times per week
Social Hx: married with 2 sons, retail manager of local department store, M-F, works consistently in evenings and on weekends
Education: BA
Ht: 5'9" CBW: 215 pounds BP: 119/75
Dx: Gastroesophageal reflux disease, HTN
Medical treatment plan: Endoscopy with biopsy to r/o H. pylori infection; begin omeprazole 30mg every am; decrease aspirin to 75mg day; D/C self-medication of ibuprofen daily. Nutrition consult.
Nutrition
Patient reports he has gained almost 35 pounds since his knee surgery one year ago. The only physical activity he participates in is playing with his children on the weekends. He is worried about his family history of heart disease, which is why he takes an aspirin each day. He is not really following any diet restrictions.
Usual dietary intake:
AM: 1-1/2 to 2 cups dry cereal (Cheerios, bran flakes), ½ t0 ¾ cup skim milk, 16 to 32 ounces of orange juice
Lunch: 1-1/2 ounce ham on whole wheat bagel, 1 apple or other fruit, 1 cup chips, diet soda
PM snack: handful of crackers, cookies or chips, 1 or 2 16 ounce beer
PM: 6 to 9 ounces of meat (usually grilled or baked), pasta, rice or potatoes (1 to 2 cups), fresh fruit, salad or other vegetable, bread, iced tea
Late PM: ice cream, popcorn or crackers. Drinks 5 to 6 12 ounce diet sodas per day as well as iced tea. States that his family's schedule has been increasingly busy, so they order pizza or stop for fast food 1 to 2 times per week instead of cooking.
24-hour Recall:
At Home: 2 cups of Cheerios, 1 cup of skim milk, 16 ounce orange juice
At work: 3 - 12 ounce cans of Diet Pepsi
Lunch: Fried chicken sandwich from McDonald's, small French fries, 32 ounce iced tea
Late PM: 2 cups potato chips, 1 beer
Dinner: 1 fried chicken breast from Kentucky Fried Chicken, 1-1/2 cup potato salad, ¼ cup green bean casserole, ½ cup fruit salad, 1 cup baked beans, iced tea
Bedtime: 2 cups ice cream mixed with 1 cup skim milk for a milkshake
Food allergies/intolerances/aversions: Fried foods seem to make the indigestion worse.
Previous nutrition therapy: No
Food purchase/preparation: Wife or eats out
Lab Values Normal Jack Nelson's
Albumin 3.5-5 4.9
Prealbumin 16-35 33
Cholesterol 120-199 220
HDL >45 20
LDL <130 165
Glucose 70-99 110
Question: provide assessment, diagnosis, intervention and evaluation
Assessment
Jack Nelson is obese with a BMI (body mass index) of 31.7. He is having a sedentary (inactive) lifestyle which owes to his gaining of weight. Moreover, his chemistry blood works for bad cholesterol (LDL) is increased while good cholesterol (HDL) is decreased which is a sign of poor diet and lack of exercise. Cholesterol must be controlled with medications combined with good diet and exercise. Glucose is also high which adds to risk of having heart diseases like his family history in his father's side.
His diet showed poor control in fatty food like fast food, junk food, ice cream and beverages like beer and milkshake. Fatty, oily and salty food are triggers for his diagnosed Gastroesophageal Disease that is also linked to his obesity. Increased belly fat can increase pressure in the abdomen resulting to reflux of stomach contents to the esophagus hence the name of the disease. Moreover, obese people also have increased risk for knee problems as their weight can overtime damage the joints on the knees and ankles.
Diagnosis
Gastro-Esophageal Reflux Disease Secondary to Obesity Secondary to Hypercholesterolemia (Increased Cholesterol in the blood)
Intervention
Weight loss is number one priority. Central obesity (fat in the abdomen) measured as the waist to hip ratio is a strong index for GERD (Gastro-Esophageal Reflux Disease). Exercise should be included in the daily activities. Control diet is number two intervention as these patients have to change their eating habits. Greens, low carbohydrates, high fiber and cutting salty and sweet food must be done to successfully lose weight.
The patient is already taking Aspirin (for decreasing blood clots) and Atenolol (decreasing blood pressure). However, blood chemistry showed also increased sugar levels. Medications for decreasing sugar levels can be given to these patients.
For his GERD, the patient was already started with Omeprazole. Continue Omeprazole for 10 to 14 days and avoid taking Tums as much as possible. Tums are only for quick relief. Avoid salty, spicy, oily food and switch to more greens and high fiber food. Coffee and milkshakes should be avoided. Avoid lying down after taking a meal as this can trigger reflux. One to two pillows incline when sleeping as to prevent and alleviate reflux.
Evaluation
The patient must come back after a month to see if his diet and exercise was done and if it made changes to his blood sugar and cholesterol. Results on weight changes might not be apparent so patient must be educated about managing his expectations. A personal trainer or a coach can be helpful in achieving his weight problems.
Patient like him must have yearly check-ups to see if they are taking their medications and check if medications must be upgraded or changed if deemed not helpful. Losing weight is difficult hence small decrease in weight should be encouraged and celebrated.