Lab Assignment & Case Study

CYSTIC FIBROSIS: MR. GOOD

03.13.2017 0900

Assessment
Patient Hx:
Client Hx: 32yo Caucasian male.
Lifestyle: he loves to work out, he trains horses, hes in Ag. Ed., extra-curricular, hiking, archery, grew
up playing baseball. States he took control of his health 8 years ago. Goes to MD every 3 months. Healthcare
team consists of MD, RD, social worker, respiratory therapist. He wants more help with meal plan and meal
prep.

Anthropometric measurements: Ht=55 (165.1cm), Wt=126.8lb (57.63Kg), UBW=123lb (55.9Kg),

%UBW= 103.08%, IBW=136lb (61.81Kg), %IBW=93.24%, Goal BW=140lb (63.63Kg), current BMI=21.14
(typically normal; healthy, low health risk) (CFF recommends males keep a BMI of 23, so he is lower than their
recommendation)

Medical Dx: CF diagnosed at 5 months old. In 2001, Dx c microbacterium (an infection that never goes away;
prognosis is <6months; went to Tyler, TX to see specialist; was on IV amikacin for a year straight; he lost some
hearing and had kidney issues; pancreatic issues at this point). In 2006, went to Yosemite for a horse backing
trip for 6-7 days, came back with stomach issues which required a fundoplication and feeding tube (NG and
then ND) didnt help.

Labs. Biochemical data. Medical tests and procedures.

Labs Today Normal If abnormal, what is cause?
Na (mEq/L) 143 135-145
K+ (mEq/L) 4.2 3.5-5.0
Cl- (mEq/L) 106 95-110
CO2 Total(mEq/L) 26 24-32
BUN (mg/dL) 16 8-22
Cr (mg/dL) 1.36 0.44-1.27 High; catabolism, excess protein intake, possibly
indicator or impaired kidney function or kidney
disease
E-GFR (mL/min/1.74 m ) 2
>60 >60 Could be in stage 2 CKD if <90
Vitamin A (Retinol) mg/L 0.31 0.30-1.20
Vitamin A (Retinyl Palmitate) <0.02 0.00-0.10
mg/L
Vitamin D, 25 Hydroxy (ng/mL) 14.4 20.0-50.0 Low; impaired absorption of fat-soluble vitamins
(pancreatic insufficiency)
Vitamin E (Alpha-Tocopherol) 6.2 5.5-18.0
mg/L
Vitamin E (Gamma- 1.2 0.0-6.0
Tocopherol) mg/L
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 Lab Assignment & Case Study
CYSTIC FIBROSIS: MR. GOOD
Hgb A1c (%) 5.5% 3.9-5.6%
Hgb A1c, Glucose est AVG 111
(mg/dL)
Immuno Globulin E (kU/L) 18.5 <25
C- Reactive Protein (mg/dL) 0.9 0-0.8 High; Acute non-specific response to tissue injury or
inflammation of chronic inflammation; correlations have been
demonstrated for postoperative recovery, infection diseases,
clinical evaluation of stress, trauma, infection, inflammation and
surgery
White Blood Cell count 7.0 4.5-11.0
(K/MM3)
Red Cell Count (M/MM3) 5.03 4.5-5.9
Hgb (g/dL) 14.3 14.-18.0
Hct (%) 43.5 40-52
MCV (UM3) 86.5 80-100
MCH (pg) 28.4 27-33
MCHC (%) 32.8 32-36
RDW (units) 13.8 0-14.7
MPV (UM3) 8.4 6.8-10.0
Platelet Count (K/MM3) 340 130-400
Neutrophils % AUTO 71.1
Lymphocytes % AUTO 19.4
Monocytes % AUTO 6.8
Eosinophils % AUTO 2.0
Basophils % AUTO 0.7%
Neutrophil ABS AUTO (K/MM3) 5.00 1.80-7.70
Lymphocytes ABS AUTO 1.3 1.0-4.8
(K/MM3)
Monocytes ABS AUTO 0.5 0.1-0.8
(K/MM3)
Eosinophil ABS AUTO (K/MM3) 0.1 0-0.5
Basophils ABS AUTO (K/MM3) 0.10 0-0.2
Carotene Serum Total (ug/dL) 12 60-200 Low; malabsorption of fat soluble vitamin (vitamin A)
due to pancreatic insufficiency
INR 0.92 0.87-1.18

Culture Cystic Fibrosis Resp:

Culture Cystic Fibrosis Resp Final
4+ Pesuedomonias Aeuginosa-nonmuc
4+ Pseudomonas Aeruginosa-mucoid
3+ Usual respiratory flora
1+ A. Xylosoxidans/Denitrifacans

In 2006, had a fundoplication.

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CYSTIC FIBROSIS: MR. GOOD
Need to monitor bone mineral density, potassium and magnesium levels due to medications effect on them
and risk associated with it. Want to monitor stool (either visibly or asking Pt.) due to many medication risk of
C/D and occult, melena and frank stool side effects of multiple meds. Want to monitor heart rhythms due to
arrhythmia side effects in multiple drugs. Need to monitor BP due to many contraindications of HTN for
multiple meds.

Medications/Supplementations/CAM:
Key: general; cautionary/monitor; Danger/Immediate attention

Medicati Contraindicati Purpose/ Side Dose Route Freque Nutrient Drug

on ons therapeuti effects ncy interactio interaction
c class n
Clofazimi Liver disease; Leprostati Abdominal 50mg PO 1x/d Taken None seen
ne stomach or c. pain and with with Pt
intestinal Antibiotic burning; orange med list
problems for D/N/V; juice
microbact dry, rough increases
erium or scaly risk of
infection skin; pink side
from to red to effects
brownish-
black
discolorati
on of skin
and eyes;
skin rash
and
itching;
change in
taste;
frank and
melena
stool;
jaundice/ic
terus;
mental
depression
amikacin Kidney disease Antibiotic; Kidney 500mg Inhalat 3x/wk Drink Azithromy
(renal For problems; /2ml ion; plenty of cin (an
dysfunction), bacterial may also Aeroso liquids aminoglyc
asthma, infection cause l oside)-
dehydration, nerve injecti further
hypocalcemia damage or on dehydrate
hearing s

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CYSTIC FIBROSIS: MR. GOOD
loss; skin
rash;
N/V/D
Azithrom Dehydration, Antibiotic. Diarrhea, 250mg PO 1x/d Amikacin
ycin jaundice or for loose (an
liver infection stool, aminoglyc
problems; fever, oside)-
kidney swelling, further
disease; colitis melena dehydrate
and frank s
stool,
body
aches or
pain;
Esomepr Hypokalemia, Proton Jaundice; 40mg PO 1x/d. Food None seen
azole, hypomagnese pump Bad, take at interferes on Pt. med
Nexium, mia, hypo- inhibitor. unusual or least with list
delayed serum Short- unpleasan one absorptio
release cobalamin, term t (after) hour n
capsule liver treatment taste; before
problems, for acid change in meal
osteoporosis reflux. taste;
GERD sleepiness;
acne, back
pain
Albuterol CVD, HTN, Bronchodi Shakiness 90mcg Inhalat 1-2 Different miralax
DM, lator and ion puffs as route (GI
arrhythmias, (relaxes trembling needed. vs resp.)
hypokalemia, airway in He does
renal muscles extremitie ~1x/d
dysfunction and s;
increases arrhythmi
air flow to a, cough,
lungs) difficulty
breathing
Fluticaso Severe allergy Steroid May help 250- Inhalat Prn (pro Different None
ne/ to milk inhibits growth of 50mcg ion; re route found on
salmeter proteins, inflammat microbe, Disk nata=as Pt. med
ol asthma and ion, keeps osteoporo inhaler needed) list
Advair COPD, HTN, bronchial sis,
CVD, DM, tubes melena,
hypokalemia, dilated SOB,
hepatic tachycardi
impairment a,
and wheezing

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CYSTIC FIBROSIS: MR. GOOD
dysfunction,
hyperadrenoc
orticism,
infections,
osteoporosis
Ipratropi Glaucoma; Bronchosp Upper 17 mcg inhalat 1x/d Different Acetamino
um urination asms; respiratory ion route phen;
problems; Actuation tract aspirin;
tachycardia; inhaler infection; miralax
renal UTI,
dysfunction; bronchitis,
liver disease exacerbati
on of
COPD,
sinusitis,
dyspepsia
Scandish Nutritiona PO 2packet
ake l s/d
suppleme
nt
AquADEK [multivita [PO] [2packe
s / ADEX min; ts/d]
[prescrib prevent
ed but low levels
hasnt of
taken vitamins
since and
cant minerals]
afford]
Singulair/ Asthma, Leukotrien Abdominal 10mg PO 1x/d at Aspirin,
monteluk allergy to e. Used to pain, SOB night acetomino
ast aspirin; liver prevent phen
disorder, PKU asthma
attacks.
Prevent
exercise-
induced
bronchosp
asm
RaNITIdi Kidney Histamine Headaches 150mg PO 2x/d nicotine None on
ne disease; liver -2 Pt. med
Zantak disease; blockers; list
porphyria; GI decreases
bleeding stomach
acid
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CYSTIC FIBROSIS: MR. GOOD
productio
n; used to
treat GI
ulcers
Creon 24 Kidney Combinati Headache; PO 3 with a Helps Acetamino
(pancrea disease; gout on of 3 N, D, meal, 2- digest phen;
tic lipase) (hyperuricemi pancreatic stomach 3 with a and ascorbic
a); DM enzyme cramps or snack, if therefore acid,
(lipase, pain, SOB, more absorb aspirin,
protease irritation high fat, macronut
and of mouth then rients
amylase); add an
used to extra
treat CF,
blocked
pancreatic
ducts and
inflammat
ion of
pancreas
Lubiprost Severe D; GI Increases D/N; 24mcg PO 2x/d c None on
one obstruction; secretion stomach water Pt. med
gallstones, of fluid pain, and list
Crohns into swelling of food
disease, intestine abdominal
diverticulitis, to ease area; full
polyps, Hx of constipati or bloating
hernia; liver on and IBS feeling;
disease melena;
dehydratio
n
Dornase Breakdow Transient 1mg/1 Inhale 2x/d Insulin
alfa n mucus skin rash, mL d
in lungs; voice
synthetic disorder,
protein laryngitis;
breaks up body
excess aches n
DNA in pains;
the chest pain;
pulmonar congestion
y ; cough;
secretions fever;
with CF dry/sore
Pts. throat;

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 Lab Assignment & Case Study
CYSTIC FIBROSIS: MR. GOOD
Improve trouble
lung breathing
function
Albuterol CVD, HTN, Bronchodi Shakiness 2.5mg/ Inhale 3mL Different miralax
(0.083% DM, lator and 3mL d every route (GI
Neb) arrhythmias, (relaxes trembling 6h; he vs resp.)
hypokalemia, airway in does
renal muscles extremitie 3mL
dysfunction and s; every
increases arrhythmi 12h
air flow to a, cough,
lungs) difficulty
breathing
Polyethyl UC, IBS, Laxative; Dehydrati 17g/do prn for Albuterol
ene kidney increase on; se constip and
glycol disease, N/V water in cramps, powde ation ipratropiu
3350 or severe intestinal gas, more r m
miralax stomach pain; tract frequent
GI obstruction BM, N,
stomach
pain or
bloating
Centrum Anemia, liver Multivita PO 1x/d
complete problems or min
metabolism
problems
Probiotic friendly Stomach PO 2capsul
complex bacteria bloating or es/d
*Pt to discomfort
noticed maintain a
big healthy GI
differenc tract
e with
this*

Many drugs cause SOB (shortness of breath), which only exacerbates symptoms of CF; should monitor
respiratory function. Heart rhythm needs to be monitored due to miralax and albuterol/ipratropium interaction
causing irregular heart rhythm.

Nutrition Hx:
Previous RD recommendations: growing up they said he can eat whatever he wants, just need to get the
calories in. later in life, in Chico, they recommended cutting out greasy foods, eating a cleaner diet. Now he
eats like an athlete/body builder, states he feels and is doing better. Previous RD recommended 1g/Kg, which

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CYSTIC FIBROSIS: MR. GOOD
started affecting kidneys. Recommend ~90g protein (1.56g/Kg), try to stay as low as possible. 3500-4000Kcal,
minimum of 3000Kcal.

States he enjoys ribeye steak, teriyaki chicken, baked potato; if he can grill it, hell eat it.

He used to drink Boost and Ensure, but found better success with Scandishake.

24 hour recall:

Exchanges (kcals) Pro Cho Fat

(g) (g) (g)
BREAKFAST
c oatmeal w/ 1 tbsp. butter, c raisins, 1 starch 425 2 45 25
c pecans 1 fat
2 fruits
4 fats
1 packet Scandi shake w/ 8oz milk - 600 14 62 29
LUNCH
1 oz pork tenderloin 1 tsp oil 1LP 90 7 0 8
1 Fat
1/3 baked beans 1 Starch 115 9 15 0
1 VLP
1 c mixed grilled bell peppers 1 tsp. oil 1 NSV 70 2 5 5
1 fat
8 oz tea w/ 1 tbsp. sugar 1 starch 120 3 22.5 0
SNACK
6 chip ahoys cookie 3 starch 510 6 45 30
6 fats
6 oz whole milk WM 120 6 9 6
DINNER
1 serv chicken breast w/ 2 tbsp. teriyaki 1 MFP+ 2starch 272.5 14.5 30 7.5
c rice 1 starch 120 3 22.5 0
1 c bell peppers, broccoli, onions, carrots 2 NSV 50 4 10 0
LATE NIGHT SNACK
1 c raisin bran crunch 4 oz whole milk 2 starch 280 9 43.5 4
WM
Scandishake w/ 8 oz whole milk - 600 14 62 29

TOTAL 3372.5 93.5 371.5 143.5

Pt. lacking consumption of water. Very important being that multiple drugs cause dehydration which
exacerbates adverse effects. Macronutrients meet estimations below.

Estimation of Nutrient Needs:

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 Lab Assignment & Case Study
CYSTIC FIBROSIS: MR. GOOD
As per CFF recommendation, calories should be 1.5 to 2 times the typical recommendation of a healthy person
without CF.

Kcal. MSJ: 4400Kcal (A.F. of 2.0 and multiplied by 1.5 as per CFF recommendation)

35Kcal/Kg: 2020Kcal * 1.5(as per CFF recommendation = 3030Kcal

*2.0 = 4040 Kcal

Range of calorie intake= 3030-4400Kcal and adjust as need; he does want to gain weight so with the high-
energy demand, he needs even more Kcal to gain that wanted weight.

Protein. CFF recommends 1.5g/Kg 1.5g*57.63Kg= ~86.5g protein (346Kcal) (~11.5-7.8% total Kcal [3030-
4400Kcal])

Fat. CFF recommends 40% total Kcal from fat .40*3030Kcal=1212Kcal from fat/9g= ~135g from fat

.40*4400Kcal=1760Kcal from fat/9g= ~196g from fat

Fat range 135-196g

Carbohydrate. 50% total Kcal from carbs .5*3030Kcal=1515Kcal from carb/4g= ~379g from carb

.5*4400Kcal=2200Kcal from carb/4g=550g from carb

Carb range 379-550g

Fluid. 1mL/Kcal= 3030-4400mL/day

Increase nutrient needs of Vit. A, D, E, K and B complexes, as well as sodium, chloride, iron, zinc and calcium

Nutrition-Focused Physical Findings:

Detailed physical not performed, only observed from a distance. Pt. looked lean and healthy. No evidence of
labored breathing, SOB or difficulty breathing when speaking in front of class.

Motivation:

Highly motivated. Wants to stay active and do what he loves. He has been trying hard to control his intake,
been harder living back with parents.

His goal is to spend a day preparing variety of meals for at least 4 days

Diagnosis ( 1 PES statement)

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CYSTIC FIBROSIS: MR. GOOD
1. Increased energy expenditure r/t voluntary physical activity and increased nutrient
needs due to work for breathing aeb Pt. Dx of CF, less than optimal BMI, very physically
active, and some medications side effect of SOB which further increases caloric need
2. Inadequate fluid intake r/t increased exercise, in hot sun and losing water via sweat aeb
being an Ag. Major he is outside for long hours, he is physically active, no water
consumption in 24-hour recall, and multiple medications that cause dehydration and
dehydration exacerbates the adverse effects

Intervention (Nutr Rx, Plan of Care w/ strategies)

1. Increase energy intake to counteract the excess expenditure due to CF increasing need
as well as being physically active. Pt. states that he has been eating too many meals out
and would like to prepare more food at home. Large scale recipes (from USDA) have
been given to him with breakdown of nutriture; he can make a variety of meals for the
week so they are ready to eat when he wants to (saves time on meal prep for each
individual meal). Each recipe could be made on one day (i.e. Sunday) and then portion,
packaged and stored (either in refrigerator or freezer, depending on when that meal will
be eaten [if not going to eat within 3 days then put in freezer])
2. Increase fluid consumption, since outdoors in sun for most of day, increased need due
to medications and lack of intake; preferably water, but since need to increase Kcal, can
drink whole milk and fruit juices for more Kcal and nutrients with needed fluid.

Monitor/Evaluate

Follow up in two weeks.

1. Indicator Current level of Criteria for success F/U
(based on indicator
PES
statements)
1. less than optimal 21.14 CFF recommends 23. Success Meet again in two weeks.
BMI if BMI increases by .5 See if BMI increased
further

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CYSTIC FIBROSIS: MR. GOOD
2. physically activity Very active Do not decrease activity, Assess weight, gaining?
level rather increase intake; if losing, then increase
success if remain very active intake further, if cannot
eat more, then decrease
some activity

3. increased caloric Currently at Increase Kcal by 500; Assess weight, gaining? If

need 3373Kcal with 24- therefor will be at 3873Kcal so, maintain Kcal/day. if
hr recall staying same or losing,
increase Kcal by another
500 and assess BW in
another two weeks. How
does Pt feel with intake?

2. Indicator (based Current level of indicator Criteria for success F/U

on PES
statements)
1. increase fluid intake No water, just 26oz Drink at least another How Pt. feel with
(~780mL) of milk cup, so at 32oz (~960mL) intake? Can he
consumed milk, or drinking at least tolerate more fluid?
a cup of water to He should get to
complement 26oz milk ~3000mL at least

Agustin Garcia wannabe RD

03.13.2017 0900

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