FINAL INTERNSHIP PRESENTATION

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 PRESENTED BY
Saira Jabeen
Roll no. 18060 (Evening)
BS (Hons.) Human Nutrition and Dietetics

PRESENTED TO
Madam Hamna Saleem

Department of Nutritional Sciences

Government College University, Faisalabad 2
 INTRODUCTION

As per curriculum of BS (Hons.) Human Nutrition and Dietetics it is mandatory to do an

internship for at least 2 months in last semester. I opted for clinical nutrition internship
program at Fatima Memorial Hospital, Lahore.

This presentation gives an introduction of the hospital. The planner of internship is also
wrapped-up that gives the idea of what I learned during this entire period. Finally a
clinical case study of celiac disease patient is explained with the brief explanation of
disease, its etiology, clinical manifestations, diagnosis, and its Medical Nutrition Therapy.
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 INTERNSHIP SITE

NUR International in collaboration with Fatima Memorial Hospital

 Location
Shadman, Lahore
 Established in 1977
 Specializes in the field of maternal and child health care
 Vision
“Quality health care and research-based education for all leading to integrated socio-
economic community development”
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Divisions
• Surgical Division
• Medical Division

Services
• Clinical Services
• Emergency Medical Service
• Diagnostic Services
• Critical Care Units
• Out Patient Department (OPD) FATIMA MEMORIAL HOSPITAL, LAHORE
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 Department of Clinical Nutrition
Offers nutrition services to a wide range of patients suffering from
various ailments such as:
• Diabetes Mellitus
• Weight Management
• Eating Disorders
• Cardiovascular Diseases
• Gastrointestinal Disorders
• Liver Diseases
• Renal Disorders
• Pancreatic Disorders
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 Department of Clinical Nutrition (continued…)

• Pulmonary Diseases
• Cancer
• Bone Disorders
• Pediatric Disorders
• Metabolic Stress and Chronic Illness
• Gynecological Disorders

Also provides nutrition services to pregnant and critically ill patients

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OTHER SERVICES OF NUTRITION DEPARTMENT
• Private Sector
Clinical Services • Government Sector

• BSc. Nutrition and Dietetics at NIU

Academic Services • Internship programs
• Inpatient Food Service
Food Services • Cafeteria of FMH
• Event Management
• NUR Food Camps
Social Services • Seminars
• School of Nutrition
Other Collaborations • Health and Nutrition Lounge
• Nutrition Club 8
 OVER-VIEW OF INTERNSHIP PLAN

 Orientation Day

 Lecture on Basic Nutrition Calculations

 Nutritional Assessment Forms and SGA form

 Lecture on Exchange List and How to Make a Basic Eating Plan

 Lectures on Medical Nutrition Therapies for Weight Management, Diabetes, CVD,

Hypertension, Liver Diseases, Renal Diseases, Upper and Lower GI Disorders, Gynae
and Pediatrics complications
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 OVER-VIEW OF INTERNSHIP PLAN (Continued…)
 Patient Assessment
 Presentation of Clinical Case Studies

 Formulate Survey Reports on the following:

i. List of Nutrients available at nutrient stores (GNC, Herbimed)
ii. List of organic and fortified food items
iii. List of nutrients for GIT
iv. Pediatrics formula milk and supplements list
v. Formula milk and supplements list for pregnant and lactating women
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 CELIAC DISEASE

CELIAC DISEASE = GLUTEN-SENSITIVE ENTEROPATHY

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 WHAT IS CELIAC DISEASE?

 An auto-immune condition affecting small intestine

 Occurs in genetically susceptible individuals

 Intolerance to wheat gluten and similar proteins found in rye, barley and to lesser

extent in oats

 Gluten contains gliadin → ingestion of gluten → exposure to gliadin →inflammatory

response → damages intestinal mucosa

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 ETIOLOGY

CD, or gluten-sensitive enteropathy, is characterized by a combination of four factors:

i. Genetic susceptibility

ii. Exposure to gluten

iii. An environmental “trigger”

iv. An autoimmune response

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(Sams and Hawks, 2014)
 PATHOPHYSIOLOGY

 Inflammatory Response

T-lymphocytes → cytokines → inflammatory response → damages tissues

 Innate immune response

Activates cytotoxic T-cells → damages enterocytes

 Both responses damage the villi → height is reduced, flattened in appearance

 Damaged enterocytes → reduced absorptive surface area, loss of digestive enzymes

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(Setty M et al., 2008;12(5):289–98) (Green PHR and Cellier C. 2007;357:1731–43)

 CLINICAL FEATURES

Infants Children Adults

Malabsorption
Diarrhea Delayed growth Tiredness
Malabsorption Malnutrition Weight loss
Failure to thrive Abdominal distention Folate deficiency anemia
Pubertal delay Iron deficiency anemia
Oral ulceration
Dyspepsia
Bloating

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(Davidson’s Principles and Practice of Medicine, Vol 2; 23 Edition)
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 DIAGNOSIS

 Biopsy of the small intestine → gold standard for diagnosis of CD

 Serologic tests → identify presence of antibodies

 Higher incidence of immunoglobulin A (IgA) deficiency

If serological findings are normal → measure IgA level

 Video capsule endoscopy → images the entire intestinal mucosa → show inflammation

related to CD
(Bouchard et al, 2014) 16
 COMPLICATIONS

 Systemic autoimmune disorders  Down, Turner, William

including Type1 diabetes
mellitus
 Thyroid disease
 Systemic lupus erythematous
 Primary biliary cirrhosis
 Rheumatoid arthritis
syndromes
 IgA deficiency
 Persons with CD higher risk for
lymphoma and osteoporosis
 Complications of nutrient
deficiencies and malnutrition
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 MEDICAL NUTRITION THERAPY

 Lactose-free, gluten-free diet

 Vitamin and mineral supplementation as needed (calcium, vitamin D, vitamin K, iron,

folate, B12, A & E)

 Delete gluten sources from diet (wheat, rye, barley, malt)

 Restriction of oats is controversial

 Recent nutrition practice guidelines for celiac disease indicate that up to 50 grams of

oats per day is safe 18

(American Dietetic Association. Evidence-based Nutrition Practice Guideline on Celiac Disease published January 2009)
 CASE STUDY

Name of Patient Gender Age Weight BMI Stature

Ahmad Ali Male 14 years 39 kg 16.5 154 cm

24 Hours Dietary RecallPATIENT INFORMATION

Bread and Vegetables Fruits Meat Milk products Total calories
Anthropometric
cereals Measurements
1 cup Rice 2 servings Potato 1 Apple 1 cup Chicken 2 cups Milk 800 Calories
1 Banana Broth
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GI Function
Appetite Nausea Anorexia Vomiting Constipation
Good Absent Absent Absent Absent

Clinical Signs and Symptoms

Muscle Gums Nails Tongue Hair Skin Teeth Eyes
Wasting
Weakness Normal Normal Normal Normal Dry Cavities Normal

Dietary Pattern
Feeding Number of Start of Type of Food Allergy Sleep Cycle Physical
Practice Feeds/day Weaning Food Weaning Food (If any) Activity
Breastfed 6-7 times/day 6th month Cerelac, Rice Gluten 9-10 hours Lethargic
Intolerance
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Recommendations
Calories Required 1400-1600 Calories

CHO Protein Fats

55% 17% 28%

Mechanism of Diet Regular

Type of Diet ↔Kcal, ↔CHO ↑Pro, ↔Fat, Gluten-Free Diet

Feeding Route Oral

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 DIET PLAN

Timing Food Items Serving size Calories

Pre-Breakfast Strawberries 1 ¼ cup 60

Breakfast Gluten-Free bread 2 slices 160

Boiled Egg 1 whole 75
Tomato ½ cup 12.5
Milk (reduced fat) 1 cup 120
Margarine ½ T. 45

Mid-morning Snack Boiled corn ½ cup 80

Apple 1 cup 60

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 Timing Food Items Serving size Calories

Lunch Gluten Free Pasta Cooked 1/3 cup 80

Chicken 1 oz. 75
Boiled Carrots 1 cup 50
Capsicum ½ cup 12.5
Evening Snack 4’’ across Gluten free pancake 1 80
Banana Smoothie
Banana 1 small(4oz.) 60
Milk(reduced fat) 1 cup 120
Peanut butter 1 tsp. 45
Dinner Brown Rice(cooked) 1 cup 240
Fish 1 oz. 75
Spinach(cooked) 1 cup 25
Olive oil ½ tsp. 45
Bedtime Snack Milk(reduced fat) 1 cup 120

Total Calories 1665 kcal

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 CONCLUSION

This as a brief presentation about my internship at FMH, Lahore. It showed me the difference
between learning in theory and in practice. This internship has been an excellent and
rewarding experience for me.

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 REFERENCES

1. American Dietetic Association. Evidence-based Nutrition Practice Guideline on Celiac Disease published January 2009 at
http://www.adaevidencelibrary .com/ and copyrighted by the American Dietetic Association

2. Sams A, Hawks J: Celiac disease as a model for the evolution of multifactorial disease in humans, Hum Biol 86:19, 2014

3. Bouchard S, Ibrahim M, Van Gossum A: Video capsule endoscopy: perspectives of a revolutionary technique, World J
Gastroenterol 20:17330, 2014

4. Green PHR and Cellier C. Celiac Disease. N Engl J Med. 2007;357:1731–43

5. Setty M, Hormaza L, Guandalini S.Celiac disease:risk assessment,diagnosis, and monitoring.Mol Diagn Th er. 2008;12(5):289–98

6. Davidson’s Principles and Practice of Medicine, Vol 2; 23 rd Edition

7. Nutrition Therapy and Pathophysiology 2 nd Edition 25

8. Krause’s Food and Nutrition Therapy 14 th Edition