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