Leo Ontiveros - 415A-03

ADIME #2

A: 36 y/o female with stomach pain and severe diarrhea. A bowel biopsy indicates: flat mucosa and villi
atrophy and hyperplastic crypts-inflammatory infiltrate in lamina propria. Pt. tested positive TTG, EMA
antibodies. Pt. diagnosed with celiac disease with secondary malabsorption and anemia. Pt. states that she
is hungry all of the time. Pt. also states that when when she does eat, she almost immediately has
diarrhea, worsens when she eats fried foods or beef. Pt. reports no nausea or vomiting. Pt. also reports she
mostly eats noodle soups, some chicken, crackers and sprite.
Dx: Celiac disease with secondary malabsorption and anemia
Ht: 53 Wt: 92#
UBW: 112# UBW%: 82% (18% wt. loss in 1 month = Severe) IBW: 115# IBW%: 80%
BMI: 16 (Underweight)
Labs: Alb 2.9g/dL (L), PAB 14mg/dL (L), Hgb 10.5g/dL (L), Hct 35% (L), Ferritin 12 (L)
Estimated Energy Requirements: 1500 kcals/day (Based on MIfflin St-Jeor using actual wt. + 500kcals
for weight gain)
Estimated Protein Requirements: 63 grams/day (Based on actual wt. x 1.5)
Diet Order: NPO
D: Unintended weight loss R/T secondary malabsorption and diarrhea after eating AEB severe weight
loss (18% wt. loss in 1 month), a BMI of 16, and patient reported hunger.
Food and nutrition-related knowledge deficit R/T no prior education on a diet to manage celiac disease
AEB patient reported consumption of foods containing gluten, diarrhea after eating and damaged villi.
Altered GI function R/T celiac disease with secondary malabsorption and anemia AEB diarrhea after
eating, HGB 10.5g/dL, Hct 35%, and Ferritin 12.
I: 1.Modify diet to a low-residue, lactose-free, and gluten-free diet. As villi are regenerated and
absorptive capability returns, lactose can be slowly added back to the diet. To stabilize weight (back to
UBW - 112lbs) diet should provide 1500 kcals per day along with 63 grams of protein per day, 237 grams
of carbohydrates per day and 33 grams of fat per day.
2. Provide patient with nutrition education on the gluten-free diet (avoid wheat, oats, rye, and barley).
Education will also include handouts for advanced topics related to label reading for targeted ingredients,
foods that might be cross-contaminated with gluten and specialty products that provide alternatives for
wheat, rye, and barley. Teach patient that deep-fat fryers, pans, and grills may contain gluten residue.
3. Provide patient with a multivitamin with iron and modify diet to ensure 18mg of Iron per day. Possible
food sources includes meats, canned clams, beans, peas and seeds. Educate the patient on how to increase
bioavailability of iron (pair with vitamin C foods such as broccoli, brussel sprouts, collards and avoid
consumption with calcium sources).
M/E: 1. Monitor patient's weight and update BMI during follow up visit in 2 weeks.
2. Patient will record food intake in a food journal and share during follow up visit in 2 weeks to assess
gluten-free food knowledge.
3. Monitor HGB, Hct, and Ferritin lab values for increases to normal levels during follow up visit in 2
weeks.