read this case study below and answer all the questions thoroughly. Please also fill out the ADIME chart at the end. This is a case study based in nutrition. Please create a references citation sheet at the end of the case study. Please answer the questions inside the document. Here are some references you can use to answer the questions but use your own references as well:
1. Nelms, Sucher, Lacey, Long Roth: Nutrition Therapy and Pathophysiology. 3rd ed., Cengage Learning 2014
ISBN-13:978-1-305-11196-7

http://www.coursesmart.com/IR/1845467/9781305111967?__hdv=6.8

Note: This textbook will be used in FNES 366 as well.

2. Nahikian-Nelms M, Long-Anderson S. Medical Nutrition Therapy: A Case Study Approach 4th ed. Belmont, CA: Wadsworth; 2013.
ISBN: 978-1-133-59315-7 Note: Electronic versions of the individual case studies from the text can be purchased at www.cengagebrain.com for $3.99 each

3. Gylis BA, Wedding ME: Medical Terminology Systems (with Termplus 3.0): A Body Systems Approad (with medicallanguagelab.com), 7th Edition
ISBN: 978-0-8036-3575-3
Brown JE, Isaacs J et al: Nutrition through the Life Cycle. 5th ed. Wadsworth 2014
ISBN-10: 1133600492, ISBN-13: 9781133600497 (recommended, especially when with community focus)
4. Nutrition Care Manual: http://www.nutritioncaremanual.org/member-pricing This is another resource you should know about. The department is trying to provide access to this resource as well.

5. Mahan LK, Escott-Stump S, Raymond, JL. Krause’s Food and the Nutrition Care Process. 13th ed. St. Louis, Missouri: Elsevier/Saunders; 2012. ISBN: 978-1-4377-2233-8

6. American Dietetic Association / American Diabetes Association. Choose Your Food: Exchange Lists for Meal Planning. 2008. (Either Diabetes or Weight Management booklet). You could purchase from AND website, www.eatright.org. The same resource is available with less shipping costs elsewhere.
http://www.nhlbi.nih.gov/health/educational/lose_wt/eat/fd_exch.htm#1 also shows exchange lists, as do many other sites (.edu can be considered reliable for this purpose).

7. Pronsky ZN. Food Medication Interactions. 17th ed. Birchrunville. PA 2012. (optional; encouraged if on Dietetics Track)
ISBN: 0-9710896-4-7. Note: Choose your source – prices vary greatly!
Alternatively, consult epocrates, or rxlist.com for information on food-drug interactions.

8. Stedman’s Medical Dictionary for Health Professionals. 7th ed. Baltimore, MD: Williams and Wilkins; 2011 (optional; if not purchased use online medical dictionary i.e. http://www.medterms.com/script/main/hp.asp)

9. Wallach: Handbook of Interpretation of diagnostic tests. Current ed., Lippincott. Or any similar handbook on (human) diagnostic tests.

The following 4 books are resources for more in-depth studying:
? Edelstein S and Sharlin J: Life Cycle Nutrition: An Evidence Based Approach. Jones and Bartlett 2009. ISBN 13: 978-0-7673-3810-5 (assigned chapters are included in the required textbook)
? Samour P Q, King K: Pediatric Nutrition, 4th ed., Jones and Bartlett, 2012. ISBN-13: 978-0-7637-8450-8 (assigned chapters are included in the required textbook)
? Chernoff R. et al.: Geriatric Nutrition: The Health Professional’s Handbook. Jones and Bartlett, 3rd ed., 2006. ISBN-13: 978-0-7637-3181-6 (assigned chapters are included in the required textbook)
? McArdle WD, Katch FI, Katch VL: Sports and Exercise Nutrition, Wolters Kluwer, 4th ed., 2013. ISBN-13 978-1-4511-1806-3

Case study Anemia in Pregnancy
Note: This case study is based on cases in the Nelms books in combination with a review of current literature to generate an original case study. Cases of iron deficiency anemia and folate deficiency anemia occur more frequently, thus their treatment challenges are included here.

Patient summary: A.B.C. is a 21 year-old white female, 5 months pregnant, admitted through the ER after falling and possible syncope to rule out premature labor. Her CBC warranted a complete hematologic work-up.

Pt Summary: 21yo wf, gravida 1, para 0, presented 23rd week of gestation, after a fall with vaginal spotting and abdominal pain. Admitted to r/o premature labor secondary to the fall. Patient c/o fatigue.

History: ABC is a 21 year-old pregnant woman, gravida 1, para 0, who presented to the ER in her 23rd week of gestation. She has experienced vaginal spotting and some abdominal pain. She reports being very tired and sometimes being unusually short of breath.
Medical history: not contributory
Surgical history: none
medications at home: prenatal vitamins – pt reports not using the prescription
Tobacco use: none
alcohol use: about 1 glass of wine per month, socially
family history: Mother: pernicious anemia, colon cancer; Father: HTN, CAD s/p MI

Demographics:
Married, lives with husband, 2 years of college, full-time position as office clerk; ethnicity: Caucasian, no religious affiliation

Admitting Hx/PE
CC: “I was shopping at the mall when I passed out and fell while looking at some clothes. After I got back home I noticed a small amount of bleeding when I went to the bathroom. Over the next hour, I had some abdominal pain. I called my doctor and the office said I should come here to be checked out.”
General appearance: 21-year-old pregnant female, pale, in no acute distress.

Vital Signs: Temp: 98.6, Pulse: 88, RR: 19, BP: 118/72, height: 5’5”, weight: 128#, prepregnancy weight: 118#

HEENT: Head: WNL
Eyes: Sclera pale, PERRLA, fundi without lesions
ears: clear
nose: clear
throat: pharynx clear without postnasal drainage
genitalia: normal
neurologic: alert and oriented x4
extremities: no edema, DTR 2+ and symmetrical throughout
skin: pale, warm and dry
chest/lungs: cta and percussion
peripheral vascular: diminished pulses bilaterally
abdomen: bowel sounds x4

Nursing Assessment (2 days ago)
Abdominal appearance (concave, flat, rounded, obese, distended) Rounded with pregnancy
Palpation of abdomen (soft, rigid, firm, masses, tense) Soft
Bowel sounds (P=present, AB=absent, hypo, hyper)
RUQ P
LUQ P
RLQ P
LLQ P
Stool color None
Stool consistency
Tubes/ostomies N/A
Genitourinary
Urinary continence Yes
Urine source Clean catch
Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, blue, tea) Clear, yellow
Integumentary
Skin color Pale
Skin temperature (DI=diaphoretic, W=warm, dry, CL-cool, CLM=clammy, CD+=cold, M=moist, H=hot) W
Skin turgor (good, fair, poor, TENT=tenting) Good
Skin condition (intact, EC-ecchymosis, A=abrasions, P=petechiae, R=rash, W=weeping, S-sloughing, D=dryness, EX=excoriated, T=tears, SE=subcutaneous emphysema, B=blisters, V=vesicles, N=necrosis) Intact
Mucous membranes (intact, EC=ecchymosis, A=abrasions, P=petechiae, R=rash, W=weeping, S-sloughing, D=dryness, EX=excoriated, T=tears, SE=subcutaneous emphysema, B=blisters, V=vesicles, N=necrosis) Intact
Other components of Braden score: special bed, sensory pressure, moisture, activity, friction/shear (>18=no risk, 15-16=low risk, 13-14=moderate risk, ? 12=high risk) 21

Admissions orders:
Laboratory: CBC, RPR, Chem 27, shite count with differential, folate, B12, homocysteine, anti-parietal cell antibodies, anti-intrinsic factor antibodies, MMA
Repeat CBC, Amylase, Lipase in 12 hrs
Repeat Chem 7 every 6hrs
Radiology: abdominal U/S: Pregnancy >1st
Vital Signs: every 4 hrs;
monitor fetal heart tones and contractions
I&O recorded every 8hrs
Diet: NPO
Activity: bed rest
IVF: LR @ 100ml/hr

Nutrition:
Meal type: NPO
Fluid requirement 2000-2400m/d
History: Patient states appetite is good right now. She suffered some morning sickness during her first trimester but is better now. States that she follows a vegan diet and does not take her prenatal vitamins because they make her stomach hurt. States that she does go the prenatal care to her OB/GYN
Usual dietary intake:
Breakfast: 2 slices whole wheat bread, 1 Tbs. margarine, 1 serving scrambled tofu (200g), 2 wedges cantaloupe
Snack: 4pz soy yogurt, 1 Tbs. flax seed, ½ cup rolled oats
Lunch: black bean and potato salad, ½ grapefruit
Snack: trail mix (1.5oz)
Dinner: 1 cup quinoa with grilled vegetables, 1 cup fruit salad

MD progress note: (1 day ago)
Subjective: ABC previous 24 hrs reviewed
Vitals: temp 98.5, pulse: 82, RR 20, BP: 120/82
Urine output: 4344ml (67.3ml/kg)

Physical exam
General: 23 week gestation – no contractions; no further vaginal spotting
HEENT: WNL
Neck: WNL
Heart: WNL
Lungs: CTA
abdomen: WNL

Dx: Megaloblastic macrocytic anemia, 23 week gestation with normal ultrasound. Fetal heart sounds WNL

Plan: CD IVF. Begin 100µg cyanocobalamin po daily for 1 week, then 50µg/d for 6 weeks. Continue prenatal vitamins daily.
Nutrition consult
Discharge to home.

Reference range 2 days ago
Chemistry
Sodium (mEq/L) 136-145 142
Potassium (mEq/L) 3.5-5.5 3.8
Chloride (mEq/L) 95-105 104
Carbon dioxide (CO2, mEq/L) 23-30 26
BUN (mg/dL) 8-18 8
Creatinine serum (mg/dL) 0.6-1.2 0.7
BUN/Crea ratio 10.0-20.0 11.4
Uric acid (mg/dL) 2.8-8.8 F
4.0-9.0 M 3.2
Glucose (mg/dL) 70-110 105
Phosphate, inorganic (mg/dL) 2.3-4.7 3.1
Magnesium (mg/dL) 1.8-3 2.2
Calcium (mg/dL) 9-11 10.2
Osmolality (mmol/kg/H2O) 285-295 292
Bilirubin, total (mg/dL) ?1.5 0.4
Bilirubin, direct (mg/dL) <0.3 0.1
Protein, total (g/dL) 6-8 6.2
Albumin (g/dL) 3.5-5 3.9
Prealbumin (mg/dL) 16-35 33
Ammonia (NH3, µmol/L) 9-33 10
Alkaline phosphatase (U/L) 30-120 45
ALT (U/L) 4-36 8
AST (U/L) 0-35 2
CPK (U/L) 30-135 F
55-170 M 31
Lactate dehydrogenase (U/L) 208-378 210
Lipase (U/L) 0-110 5
Amylase (U/L) 25-125 26
CRP (mg/dL) <1 0.004
Cholesterol (mg/dL) 120-199 145
HDL-C (md/dL) >55 F, >45 M 62
VLDL (mg/dL) 7-32 13
LDL (mg/dL) <130 70
LDL/HDL ratio <3.22 F
<3.55 M 1.12
Triglycerides (mg/dL) 35-135 F
40-160 M 75
FT4 (ng/dL) 0.54-1.18 (2nd trimester) 0.94
T4 (µg/dL) 6.09-12.23 12.00
T3 (ng/dL) 87-178 178
HbA1C (%) 3.9-5.2 4.9
Coagulation (Coag)
PT (sec) 12.4-14.4 13.2
PTT (sec) 24-34 27
Hematology
WBC (x 103/mm3) 4.8-11.8 9.2
RBC (x 106/mm3) 4.2-5.4 F
4.5-6.2 M 4.2
Hemoglobin (Hgb, g/dL) 12-15 F
14-17 M 10.5
Hematocrit (Hct, %) 37-47 F
40-54 M 30
Mean cell volume (µm3) 80-96 106
Mean cell Hgb (pg) 26-32 34
Mean cell Hgb content (g/dL) 31.5-36 38
RBC distribution (%) 11.6-16.5 17.8
Platelet count (x 103/mm3) 140-440 145
Transferrin (mg/dL) 250-380 F
215-365 M 270
Ferritin (mg/mL) 20-120 F
20-300 M 20
Iron (µg/dL) 65-165 F
75-175 M 66
Total iron binding capacity (µg/dL) 240-450 442
Iron saturation (%) 15-50% F
10-50% M 15
ZPP (µmol/mol) 30-80 32
Vitamin B12 (ng/dL) 24.4-100 11
Folate (ng/dL) 5-25 14
MMA (mmol/L) 0.08-0.56 0.75
Hcy (µg/dL) 66-160 F
80-210M 168
Anti-parietal cell antibodies Neg Neg
Anti-intrinsic factor antibodies Neg Neg
Hematology, Manual Diff
Neutrophil (%) 50-70 55
Lymphocyte (%) 15-45 20
Monocyte (%) 3-10 5
Eosinophil (%) 0-6 3
Basophil (%) 0-2 0
Blasts (%) 3-10 8
Segs (%) 0-60 58
Bands (%) 0-10 8
Case study questions

1. Evaluate the patient’s admitting history and physical. Are there any signs or symptoms that support the diagnosis of anemia?

2. What laboratory values or other tests support the diagnosis of megaloblastic macrocytic anemia? List all abnormal values and explain the likely cause for each abnormal value.

3. What hematological values normally change in pregnancy?

4. Define the following types of anemia: megaloblastic anemia, pernicious anemia, normocytic anemia, microcytic anemia. Include nutrients the deficiency of which can cause or be caused (distinguish) by these anemias.

5. Vitamin B12 and folate deficiencies are often difficult to distinguish from one another. Describe the interdependence of these two nutrients and how the deficiency of one may be related to the deficiency of the other.

6. List the most common causes of folate and B12 deficienies.

7. Explain why the following tests were included in the medical diagnostic work-up:
a. anti-intrinsic factor antibodies

b. anti-parietal cell antibodies

c. methylmalonic acid

d. homocysteine

8. Discuss the specific nutritional requirements during pregnancy. Be sure to address all macro- and micronutrients that are altered during pregnancy.

9. Assess Mrs. ABC’s height and weight. Calculate her BMI and % usual body weight

10. Check Mrs. ABC’s prepregnancy weight. Plot her weight gain on the maternal weight gain curve (indicate your source). Is her weight gain adequate? How does her weight gain compare to the current recommendations?

11. Determine Mrs. ABCs energy and protein requirements. Explain the rationale for the method you used to calculate these requirements.

12. Using her 24-hr recall, compare her dietary intake with her requirements for energy, protein, folate, B12 and iron. Indicate the method you used for calculation.

13. Write a PES statement for each nutrition problem.

14. Mrs. ABC says she does not take her prenatal vitamin. What nutrient does this supplement provide?

15. List factors that you would monitor to assess her pregnancy, nutritional and B12 status.