Name



Your Name and/or Name of Partner (if working with one):

_________________________Whitney Weymiller___________________

_____________________Lauren Whitman_______________________

University of Minnesota - Department of Food Science & Nutrition

FScN 4665 - Medical Nutrition Therapy II – Spring 2014

Case 2

100 Points

Adapted from Morrison, G., Stover, J. Case 1 Chronic Renal Failure: Advancing to Dialysis, in Integrative Systems and Disease, Chapter 11, Part III. pp. 350-359.

Due Date: April 16, 2014

Please be sure to do the following:

• Show all calculations, and explain your rationale. Calculations do not have to be typed.

• Answer all questions directly on this form. Type all answers (except calculations). Submit in hard copy in class on the due date. You will be deducted one point per day after the due date until the hard copy is turned in.

• You may work ALONE or with ONE other person. Do not share your work with other individuals beyond your group. If you work with a partner, you should hand in only ONE case with your name and your partner’s name clearly listed at the top of the first page.

Some resources needed for solving the Case:

1. Krause’s Food and the Nutrition Care Process, 13th edition. Chapter 36: Medical Nutrition Therapy for Renal Disorders.

2. Lecture notes and supplemental readings posted under the class topic “Renal Disorders” in the Moodle site, particular the Chronic Kidney Disease notes and materials at the end of the note set.

3. I have created two Excel files that will help you calculate AB’s current intake, and your recommended diet plan for AB. These are posted with the case on Moodle, and are labeled as follows:

a. “Case 2 Worksheet for Analysis of AB’s Current Intake” - contains formulas that will help you evaluate AB’s current diet using National Renal Diet Food Lists

b. “Case 2 Worksheet for Renal Diet Calculations” – contains formulas that will help you devise your renal diet plan for AB.

4. The following note sets are from MNT-1. These are posted in the Moodle under “Reference Materials and Resources for Cases” ( “Selected FSCN 4665 MNT I Course Materials for your Reference”:

a. Nutrition Assessment I-History and Physical Examination

b. Nutrition Assessment II- Anthropometry

c. Nutrition Assessment III-Biochemical/Laboratory

d. Module I: Nutrition Care Process, Nutrition Diagnosis and Medical Record Documentation

e. Module II: Energy, Protein, and Fluid Requirements in the Clinical Setting

5. Academy of Nutrition and Dietetics: Evidence Analysis Library Nutrition Guidelines on Chronic Kidney Disease. Link to EAL website is posted in Moodle

6. White JV, Guenter P, Jensen GL, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). JPEN 2012;36(3):275-283.

7. KDOQI Guidelines: Nutrition in Chronic Renal Failure (PDF Download from National Kidney Foundation site).

8. Brown, Compher, et al. ASPEN Clinical Guidelines: Nutrition Support in Adult Acute and Chronic Renal Failure. JPEN July 2010; 34(4):366-377.

9. IDNT Manual

Part I.

AB, a 22-year-old Caucasian college student, presented to the emergency room with headaches and shortness of breath (SOB). He was admitted to the hospital for evaluation when he was found to have a blood pressure of 200/120 mm Hg and mild congestive heart failure (CHF). AB reports that over the past year, his weight has increased approximately 10 lb., although his diet has remained unchanged. He attributed this weight gain to decreased exercise and a busy class schedule.

Past Medical History

AB has had no recent viral illness, sore throat, or upper respiratory infection. He has never had rheumatologic symptoms and has no family history of renal disease. He had a history of multiple streptococcal infections of the throat as a child, some of which were treated with antibiotics and some that went undiagnosed. He is currently not taking any medications, vitamins, minerals, or herbal supplements, and has no known drug or food allergies.

Social History

AB’s roommate at the dorms is a fellow student in good health. AB denies alcohol, tobacco, or oral drug use.

AB’s 24-Hour Diet History

Breakfast

Coffee, 8 oz, brewed strong

Whole milk,½ cup, heated, and mixed with coffee

Fried egg, 1

2 slices whole wheat toast with 2 Tbsp Butter

Orange juice, 8 oz

Lunch

Cheese burger (3 oz burger, white bun, 1 oz cheddar cheese)

Potato chips (2 oz)

1 medium banana

Coke, 12 oz

Snack

Pretzels, 1.5 oz

Coke, 12 oz Coke

Dinner

1 cup cream of mushroom soup made with milk

Baked potato,1 medium with 2 Tbsp Butter and 1/8 tsp season salt

Steamed broccoli, 1 cup

Small salad made with iceberg lettuce, 1 cup total with 2 Tbsp Wishbone Italian dressing

Snickers bar, 2 oz

Coke, 16 oz

Snack

Dry roasted salted peanuts, 1 oz

Coke, 12 oz

Review of Systems

General: Fatigue, weakness, SOB

GI: Anorexia

Physical Examination

Vital signs:

Temperature: 97° F

Heart rate: 96 beats per minute (BPM)

Respiration: 24 BPM

BP: 200/120 mm Hg

General: well-developed man

Lungs: decreased breath sounds with faint crackles at the right base

Cardiac: regular rate and rhythm, systolic murmur at the apex, S3 gallop

Abdomen: Soft, nontender, no hepatomegaly

Extremities: 3+ peripheral edema on both legs, ring tight on finger

Skin: Warm to touch

Neurologic: Intact, mild asterixis

AB is 5'9" tall. His current weight is 77.3 kg.; Usual body weight (UBW): 70.5 kg. (6 mo. ago). Standard body weight by NHANES tables: 78 kg

The following lab work was done:

Urinalysis: Protein 1+, 3+ heme

|Lab Test |Result |Normal Range |

|Na+ |135 mEq/L |136 – 145 mEq/L |

|Cl- |111 mEq/L |95 – 107 mEq/L |

|K+ |5.8 mEq/L |3.5 – 5.0 mEq/L |

|BUN |108 mg/dL |8 - 25 mg/dL |

|Cr |14.0 mg/dL |0.8 - 1.2 mg/dL (men) |

|Phosphorus |10.2 mg/dL |2.6 - 4.5 mg/dL |

|Calcium |7.5 mg/dL |8.5 - 10.8 mg/dL |

|Albumin |3.2 g/dL |3.5 - 5.0 g/dL |

|MCV |70 fL |80-100 fL |

|Hct |24.3% | 42 - 52% (men) |

|Hgb |8.3 g/dL |14 - 18 g/dL (men) |

|CO2 |15 mEq/L |24-32 mEq/L |

|Transferrin saturation |18% |>20% (CRF) |

|Ferritin |142 ng/mL |>100 ng/mL (CRF) |

|WBC |8.7 x 109/L |4.5-11.0 x 109/L |

Urinalysis

Urinalysis reveals blood and protein, indicating renal glomerular damage. RBC casts are highly suggestive of glomerulonephritis, and broad waxy casts suggest dilated renal tubules associated with chronic glomerulonephritis (CGN).

24-Hour Urine Collection

This procedure reveals the quantity of protein and creatinine excreted over 24 hours. If the amount of urinary creatinine can be measured in a 24-hour urine specimen, a creatinine clearance can be calculated.

Protein Excretion

2.2 g per 24 hours, normal value ................
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