Git-ctn-case-3 Edited By Raffy.docx

IDENTIFYING DATA: JM, 28 years old, Male, Married, Bank teller, Filipino, Roman catholic, Born in Manila on May 20, 1989, residing at Batasan hills Quezon City. Admitted first time in FEU-NRMF on September 10, 2016. CHIEF COMPLAINT: Heartburn HISTORY OF PRESENT ILLNESS: The present illness started 1 week prior to admission when the patient felt indigestion which was present 30 minutes to 1 hour after meals and with reclining. This was accompanied by epigastric tenderness 5/10 on the pain scale. No medications taken and consult made. 3 days prior to admission, patient still felt indigestion and epigastric tenderness but increased in severity, with a grade of 7/10 on the pain scale present after meals and waking him most nights. This was accompanied by regurgitation of acidic fluid and heartburn. No medications taken and consult made. Few hours prior to admission, patient presented with similar symptoms of indigestion, epigastric tenderness, heartburn. Regurgitation of acidic fluid that is blood streaked was noted and this prompted the patient to seek consult in FEU NRMF Medical Center where he was subsequently admitted. PAST HEALTH HISTORY: - Had Chickenpox and Measles during childhood - History of Surgery for ACL tear FAMILY HISTORY: - Mother, 55, diagnosed Hypertensive - Father, 58, apparently well - Wife, 27, apparently well PERSONAL AND SOCIAL HISTORY: Patient is married for 2 years. Regular exercise such as jogging for 30 minutes every morning, playing basketball once a week. The patient is a 4 pack year smoker. He is an occasional alcoholic beverage drinker, once a month, consuming 2 bottles of san Miguel pale pilsen. Fond of eating fried, salty and spicy food, and rice. He takes Multivitamins everyday. He drinks 3 cups of coffee everyday and sleeps 6 hours a day from 11 pm to 5 am, interrupted sometimes by abdominal discomfort. Lives in a 2-story house that is well ventilated. Drinks potable water. The household observes segregation of refuse/litter with disposal and collection twice a week. No history of illicit drug use and sexually transmitted infections. BP: 120/80 mmHg HR: 90 bpm RR: 20 cpm Temp: 37.0 C Weight: 60kgs Height: 5’6 or 167 cm PHYSICAL EXAMINATION and LABORATORY FINDINGS: NORMAL

DIAGNOSIS: ESOPHAGITIS SECONDARY TO GASTROESOPHAGEAL REFLUX DISEASE COMPUTATIONS

A. Ideal Body Weight 60 kg + 2.3 kg (for each inch over 5 feet) 60 kg + (2.3 kg x 6) IBW=73.8 kg

B. Energy for BMR Harris – Benedict Equation BMR = 66 + (13.7 x weight in kg) + (5 x ht. in cm) – (6.8 x age in years) =66+ (13.7 x 60 kg) + (5 x 167 cm) – (6.8 x 28 y/o) =66 + (822) + (835) – (190) =1533 or 1530 kcal

C. % Ideal Body Weight ABW / IBW x 100 % 60 kg / 74kg x 100 % % IBW =81 %

D. Total Caloric Requirement TCR = BMR x Activity Factor x Injury Factor *Activity Factor = 1.6 *Injury Factor = 1.4 BMR = 1530 kcal TCR = 1530 kcal x 1.6 x 1.4 = 3427 or 3430 kcal

Distribution of CHO, CHON and Fats PROTEIN REQUIREMENT Protein requirement = 1.5 g/kg x 60kg = 90g = 90g x 4 = 360 kcal for proteins Energy from Non-protein = TER- Kcal from protein = 3430 kcal - 360kcal =3070 kcal CHO (70%) = 3070 x 0.70 = 2149 kcal = 2149 /4 = 537.25 grams or 540 grams Fats (30%) = 3070 x 0.30 = 921 kcal = 921/9 = 102.33 grams or 105 grams Diet RX: Kcal 3430 CHO 540g (63%) CHON 90g (10%) 540 90 FOOD Veg A Veg B Fruits Milk Sugar 540g-236g= 314/23= 13 exchange Rice 90-38= 52/8= 6 exchange meat Meat, MF 105 -82 = 23/5= 4 exchange fat Fats Total

FATS 105g (27%) 105

EXCHANGE 2 4 12 4 10

CHO 6 (3) 12 (3) 120 (10) 48 (12) 50 (5) 236

CHON 2 (1) 4 (1) 32 (8) -

FATS 40 (10) -

ENERGY 16 64 480 680 200

13

299 (23)

26(2) 38

-

1300

6

-

48 (8)

42(7) 82

570

4 55

535

86

20 (5) 102

180 3490

FOOD

No. of exchange

Veg A Veg B Fruits Milk Sugar Rice Meat, MF Fats TOTAL

2 4 12 4 10 13 6

Breakfast

1 3 1 2 3 2

4 55

13

AM Snack

2 1 2 2 2 8

Lunch 1 2 3 2 3 2 13

PM Snack

Dinner

Late Evening Snack

1 1 3

1 2 2 2

2 1

2 2

2 9

9

3

24 hour meal plan FOOD Veg B

EXCHANGE 1

Fruits

3

Milk

1

Sugar

2

Rice

3

Meat, MF

2

Total

12

FOOD Fruits

EXCHANGE 2

Milk

1

Sugar

2

BREAKFAST MENU CHO ½ cup 3 Baked kalabasa 3 medium 30 slice 10 x 6 x 2 cm, ripe papaya 1 cup whole 12 milk 2 pcs. yema 10 5 1 ¼ cm 6 pcs 7 x 69 4cm pan de sal 2 slices of luncheon meat 9 x 5 x 1 124 AM SNACK MENU CHO 2 medium 20 slice 11 x 6 ripe mango ½ cup of 12 Yoghurt 2 pcs. 2 x2 10

CHON 1

FAT

8

10

6 16

14

31

24

CHON

FAT

8

10

Rice

2

Fats

2

cm caramel 2 slices 3x2x2 cm Chocolate cake ½ medium 12 x7 cm avocado red

46

4

10

Total

88

12

20

LUNCH FOOD

EXCHANGE MENU ( Paksiw naTilapya)

Veg A

1

Veg B

CHO CHON FAT

2

½ cup cooked 45 g Ampalaya bunga mixed with paksiw na tilapya 1 cup cooked sibuyas mixed in paksiw

6

Fruits

3

3 slices of Melon 23 x6 cm

30

Sugar

2

1 tbsps Ube halaya

10

Rice

3

1 ½ cup of cooked rice

69

Meat, Mf 2 Free foods Total 13

2

6

2 pcs of Maalat (salted duck’s egg) ½ cup Vinegar

16

14

24

14

CHON

FAT

16

20

115 PM SNACK

FOOD Fruits Milk Sugar Rice Fats Total

FOOD Veg A Veg B FRUITS

EXHANGE 1 2 2 2 2 9

MENU 2 segments-8cm Langka ( jack fruit) 2 cups of whole milk ½ pc 8x5 cm Pulburon 1 pc 11 x8 cm Ensaymada 10 pcs of Pili nut

DINNER EXCHANGE MENU 1 ½ cooked Malunggay mixed in sinabawang isda 1 ½ cup cooked sibuyas 3 21 medium 4 x 2 cm Lansones

CHO 10 24 10 46 90

4 20

10 30

CHO CHON FATS

3 30

1

Rice Meat, MF Free foods TOTAL

FOOD Sugar Rice Total

2 2

1 cup of cooked rice 2 slices of Fish Karpa 16 x 7 x 2cm Lemon added in sinabawang isda

9

EXCHANGES 2 1 3

46

79 LATE EVENING SNACK MENU 4pcs round chocolate candy with milk 1 pc cinnamon rolls 9 x6 cm

CHO 10 23 33

4 16

14

21

14

CHON 2 2

FATS