EA is a 74 year old female with a history of GERD. Despite being treated with Ne
ID: 138648 • Letter: E
Question
EA is a 74 year old female with a history of GERD. Despite being treated with Nexium, she continues to complain of chronic indigestion, constipation, bloating and an annoying dry cough.Medical Diagnoses by MD: gastroesophageal reflux (GERD), hypertension, chronic urinary tract infections
Initial Assessment of EA:
B/P: 148/88 as noted on report from recent doctor exam
Height: 5’3”
Weight: 162 lbs
BMI: 28.7
History:
EA reports that she has been experiencing GI distress for about 5-6 years. Symptoms, as noted above, include heartburn, constipation, and bloating. She also complains of an annoying dry cough. Although she is on medication for hypertension, at her last doctor visit (3 weeks prior) high blood pressure was recorded as elevated. EA claims she suffers from white coat hypertension. In addition to EA’s GI symptoms, she is also suffering with emotional distress and reports severe chronic anxiety. She sleeps about 3 to 5 hours per night. When she wakes up, her mind starts racing and she cannot get back to sleep. EA feels her cognitive functions are declining as well. She worries because she has some difficulty balancing her checkbook, a task she has done her whole life, and her memory is not as good as it used to be.
In the past year, EA has had 4 urinary tract infections (UTIs). She was treated with antibiotic to clear these infections and is now on a prophylactic antibiotic. She would prefer a natural alternative to prevent recurrence, if possible.
Medication and Supplements:
Previous meds to treat UTI:
Cefpodoxime- 100 mg 2X’s daily
Cipro- 250 mg 2X’s daily
Current meds and supplements:
Nexium- 20 mg once daily
HIPREX (methenamine hippurate)- 1 gram twice daily
Ultima Flora- 30 billion daily
Vitamin C- 1000 mg twice daily
Vitamin E (alpha-tocopherol)- 400 IU
Dietary Intake:
A 24-hour recall revealed the following dietary intake:
Breakfast: cheerios with honey, milk, and strawberries, coffee with half and half and 1 tsp sugar
Lunch: turkey sandwich, apple, diet coke
Dinner: salmon, broccoli, brown rice, salad with “lite”vinaigrette, diet coke
Snacks: few pita chips in the late morning, cheese and crackers with a diet coke in the afternoon, 1 bowl ice cream after dinner
Laboratory Data:
Click below to view lab results that EA brought with her (ordered by her primary care MD):
CBC
Lipid, Thyroid, Liver, Chem Profile, Urinalysis
Questions 1. What is the chief complaint to be addressed with EA? Are there any additional issues that can be addressed nutritionally? It is not necessary to offer a nutritional plan, just identify areas that may benefit from nutritional support. You will be asked for dietary suggestions in part 2. What further information would you elicit (if any)? Keep in mind the four types of nutritional assessment- clinical, anthropometric, dietary, and biochemical. Explain your rationale for the assessments you suggest. 271-104-1386 TION SRC UR CO- 10428461 ATIENT NAME VA 220-0000 AcCOUNTNUMaKi 0430 Urine Culture. Rout Final report Result 1 Greater th Antinierobial 02 0,000 olony forming unitd per m Lbility S-SusceptibInteraediate-Reaistant **.. P-Positiva . Negative MICS re expreased in micrograma per l Antiblotic Ampieiiiin Cefarolin se-1 S4-1 Cefuroxine Cephalothin Ciprofloxacin ESBL Ertspenen Inipenen evotloxacin Nitrofurantoin Piperaci11in Tetracyelin Tobranyein Trinathoprin/Sulfa S0.12 Sc AA: 01 p Burlington 447 York Court,Burlington, sC 2721-3361 :27E 184-13854 ea 2700 Results are Flagged in Accordance with Age Dependent Reference Ranges Last Page of Report LCM Version: 03 26.0
Explanation / Answer
What is the chief complaint to be addressed with EA? Are there any additional issues that can be addressed nutritionally? It is not necessary to offer a nutritional plan, just identify areas that may benefit from nutritional support. You will be asked for dietary suggestions in part.
GERD is related with an arrangement of common (esophageal) indications, including acid reflux, spewing forth, and dysphagia. Notwithstanding these average manifestations, anomalous reflux can cause atypical (extraesophageal) indications, for example, hacking, chest torment, and wheezing. Gastroesophageal reflux sickness (GERD) is a perpetual condition in which retrograde stream of stomach substance into the throat makes disturbance the epithelial coating. Reflux scenes are basically caused by improper, transient unwinding of the inferior eso sphincter (LES). Hazard factors incorporate smoking, liquor utilization, stress, corpulence, and anatomical variations from the norm of the esophagogastric intersection (e.g., hiatal hernia). The central protest is retrosternal consuming agony (indigestion), yet an assortment of different indications, for example, dysphagia and a sentiment of expanded weight, are likewise normal. Suspected GERD should as of now get observational treatment, however advance analytic advances, for example, an upper endoscopy or potentially 24-hour pH test, might be demonstrated to affirm the analysis. Administration includes way of life changes, drugs, and potentially medical procedure. PPIs are the treatment of decision, albeit different specialists –, for example, histamine H2-receptor opponents (H2RAs) – may likewise be useful. Notwithstanding soothing side effects, treating esophagitis is particularly vital, as ceaseless mucosal harm can prompt a premalignant condition known as Barrett's throat, additionally advancing to adenocarcinoma of the throat.
Boss grumbling: retrosternal consuming torment (indigestion) that declines while resting (e.g., during the evening) and in the wake of eating
Weight sensation in the chest
Burping, disgorging
Dysphagia
Ceaseless non-beneficial hack and nighttime hack
Queasiness and heaving
Halitosis
Triggers:
Twisting down, prostrate position
Propensities: smoking and additionally liquor utilization
Mental elements: particularly push
Way of life adjustments
Dietary
Little bits; abstain from eating (< 3 hours) before sleep time
Dodge nourishments with high fat substance
Physical
Standardize body weight
Raise the leader of the bed for patients with evening time side effects.
Dodge poisons: nicotine, liquor, espresso, and certain medications (e.g., calcium channel blockers, diazepam)
Therapeutic treatment
Treatment of decision: Standard-dosage of PPI for no less than about two months (once every day treatment)
No reaction: advance analytic assessment
Halfway reaction: increment the measurement (to twice every day treatment) or change to an alternate PPI
Great reaction: cease PPI following two months
Upkeep treatment: if indications repeat after suspension of PPIs and on account of inconveniences (see "Complexities" underneath)
Following two months of beginning treatment, lessen PPI to most reduced powerful dosage or change to H2RAs (just in patients without entanglements!)
What further information would you elicit (if any)? Keep in mind the four types of nutritional assessment- clinical, anthropometric, dietary, and biochemical. Explain your rationale for the assessments you suggest.
Administration and reconnaissance
Medicinal treatment with PPIs
On the off chance that no dysplasia: rehash endoscopy each 3– 5 years
On the off chance that inconclusive for dysplasia: rehash endoscopy with biopsies following 3– 6 months of improved PPI treatment
On the off chance that poor quality dysplasia
Endoscopic treatment of mucosal inconsistencies
On the further hand: reconnaissance at regular intervals with biopsies each 1 cm
On the off chance that high-review dysplasia: endoscopic treatment of mucosal abnormalities
Diagnostics
Barium esophagram (best introductory test): narrowing of the throat at the gastroesophageal intersection
Endoscopy with biopsies: to discount threat and eosinophilic esophagitis
Treatment
First-line treatment: widening with bougie dilator/swell dilator + proton direct inhibitors in patients with reflux
In unmanageable cases (different repeats): steroid infusion before enlargement, endoscopic electrosurgical entry point
Repeat happens in the larger part of patients; regularly numerous treatment endeavors important
Desire of gastric substance prompts:
Desire pneumonia
Endless bronchitis
Asthma (worsening)
Laryngitis and raspiness
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