Date:May27,2015Time:1:30p.m.

ADIMENote
Assessment:
KMisa36yofemaleadmittedtohospitalwithstomachpainandseverediarrhea.Abowelbiopsyindicates
flatmucosaandvillusatrophyandhyperplasticcryptsinflammatoryinfiltrateinlaminapropia.Thepatient
hastestedpositiveforTTG,EMAantibodies.Thepatientadmittingdiagnosisisceliacdiseasewith
secondarymalabsorptionandanemia.Patientstatesthatsheishungryallofthetimeandwhenshedoes
eat(especiallylargeamounts)shealmostimmediatelyhasdiarrhea,butdoesnothaveanynauseaor
vomiting.KMalsostatesthatwhensheeatsfriedfoodsorbeef,herdiarrheaseemsworse.Patientmostly
eatsnoodlesoups,somechicken,crackersandsprite.PatientisnottakinganymedicationandisonaNPO
dietorderwhileinthehospital.
Ht.53;Wt.92#;UBW(1monthago)112#;BMI16.3(currentwt.);IBW115#;%UBW82%
Labs:Albumin2.9g/dl(low),Prealbumin14mg/dl(low);Hgb10.5g/dl(low);Hct35%(low);Ferritin
12g/dl(low)
EER:15601820kcalsperday(basedonaverageof3035kcal/kg/dayofidealwt.);EPR:6065g
protein(basedonaverageof1.2/kgofidealwt.)
Diagnosis:
Inadequateenergyintakerelatedtoassumptionthatsomefoodscanmakediarrheaworseasevidencedby
limitedfoodchoiceofnoodlesoups,chicken,crackersandspriteandaBMIof16.3.
AlteredGIfunctionrelatedtorecentdiagnosisofceliacdiseaseasevidencedbypositiveTTGandEMA
antibodies.
Unintendedweightlossrelatedtodiarrheaandmalabsorptionasevidencedby18%weightlossin1month.
Intervention:
1.Recommendglutenfreedietwithtemporarylowfatanddairyfreemealstohelpwithdiarrhea.
2.Increasekcalconsumptionto1600adaytoslowlyreachUBW.
3.Increaseproteinto60gbyconsumingavarietyofproteininsteadofeatingonlychicken.
4.Provideinformationofglutenfreedietandrecommendpatienttoattendaceliacdiseaseworkshop.
5.Recommendpatienttotakeironsupplementstohelpwithanemia.
6.Encouragepatienttoconsumeenriched/wholegrainslikebuckwheatflourandbrownrice.
7.Educatepatientontheimportanceofreadingnutritionlabels.
Monitoring/Evaluation:
1.Reassessdietandweightstatuswithin1month.
2.Patientwillkeepafooddiarytomonitorintakeofcarbohydrateandprotein.
3.Evaluatepatientsunderstandingofnutritionalneedsanddieteducation.
4.Willmonitornutritionrelatedlabs:Hgb,Hctandferritinin1month
5.Continuetocounselandeducatepatientregardingglutenfreediets.
6.Patientwilleliminateallglutencontainingproductswithin3months.
7.PatientslabdatawillbeWNLwithin3months.
8.Patientisabletotellwhichfoodsareglutenfreeandreadnutritionlabels.
Signature:
StephanieWong,NutritionStudent