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Multiple choice questions are two points each, ol.hers as noted. Partial credit is given, so do your best. Some questions have the notation CIRCLII ALL THAT APPLY. These may have more then one cowect response. Other multiple choice questions have only one correct response. Be sure to answer each question completely. Case Study #1: The patient is a 63 yo male with a medical history notable for gastroesophageal reflux, a partral gastrectomy (partial removal of the stomach) 5 years ago, chronic alcohol abuse, and depression. He also has hypertension (high blood pressure). Medications include lasix (a loop diuretic) cimetidine, Elavil, and Lisinopril. He iq 5l9ll ana weighs 201 pounds. He reports his weight has been stable for the past 2-3 years. You condu ct a Z4-hour recall and find nothing out of the ordinary, although he does have a limited intake of fruits and vegetables. He reports that he is not taking any dietary supplements at this time. His laboratory results from a blood draw includi mc ns UBC) are as fo lows:

Reference range 135-145 mEq/L 3.6-5 mEq/L l0l-111 mEq/L

Subiect values

29

Creatinine (Cr) Albumin Calcium Total cholesterol

21-31mEq/L 70-110 me/dl 5-20 meldl 0.6-1.2 ms/dl 3.5-5 s/dl 8.5-10.5 me/dl >150 me/dl

ALT

4-36UlL

H Lr'*,t', 203H i,,,,ri 611 H r, i:{r'-

Test

Na+

K+ c1-

HCOrGlucose

BIIN

6.i'

,

'-.1'"'J' . t' i

,

rr

t.:l

AST LDH Total bilirubin RBC Hsb Hct MCV MCH MCHC WBC

0-35

140

.

3.4L t

;

t07 101 T2

0.8 an J.t

9.1

t93 187

UlL

208-378rJtr. 0.1-1 me/dl

0.9 4.4

4.3-5.9 x 10u/mm' 14-17 eldl 39-49% 80-95 fL 27 -31 ps, 32-36 s.ldl 5-10 x 10'/mm'

15.1

43

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1. Calculate 1) his % IBW using the Hamwi ecluation and2) his BMI. Show your work and interoret the results. Be sure to include the appropriate units of measure for BMI (6 points). 't

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2. If you wanted to determine his frame size, which one of the following method(s) would be approp4ate? (CIRCLE ALL THAT APPLY) Elbow breadth Wristcircumference L"r'' c. Schilling test d. 3-Methylhistidine excretion

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3. Which one of the following lab results tells you about the size of the red blood cells (RBCs)?

a. b. c.

WBC RBC Hgb

&,

MCV

4. How would you classify his RBCs?

a. b. ffi ' d.

Microcytic Normocltic Macrocytic Paracytic

5. What nutrient deficiency or deficiencies do you suspect that could result in the observed RBC changes? (CIRCLE ALL THAT APPLY)

a. b. c.

Vitamin C Vitamin K Copper Folate

,#>

e. & g. h.

**BONUS

Iron Vitamin B12 Zinc Potassium

QUESTION** for 2 BONUS points!!

Based on the patient's information (other than lab results), what are contribute to the suspected deficiency/defi ciencies?

-+ A'.

TWO factors that could

"\: 'ii(! 7i;

6. Which follow up test or tests would help to confirm the suspected deficiency/deficiencies?

(CIRCLE ALL THAT APPLY) Serum iron

J

f

Serum homocysteine Total iron-binding capacity Serum ferritin Serum folate Serum methylmalonic acid Zinc protoporphlrin/heme ratio (ZPPH) Schilling test

7. Cimetidine, an H2-receptor antagonist, reduces gastric acid production. Which nutrient or nutrients are most likely to have impaired absorption as a result of using this drug? (CIRCLE

ALL

ll*\r k

APPLY) Calcium

'5s lL:l"u, e. f. g. h.

Vitamin C Vitamin E Chromium Vitamin D

8. Which of the following medications is the likely reason for the patient's hypokalemia (low blood potassium)? a. cimetidine

b. ,F) -d.

Lisinopril lasix

Elavil

9. The elevated alanine aminotransferase likely indicate damage to which organ?

a. b. fr.t !'n.

(ALT) and aspartate aminotransferase (AST) most

Kidneys Pancreas

Liver Heart

Case Study #2:

An 43-year-old male post-surgical patient during routine nutrition screening is found to have the following lab results. There is no height available and his weight is 215 pounds. Sabiect values r41 4.r

c1-

Reference range 135-145 mEq/L 3.6-5 mEcL 101-111mEq/L

HCO:-

2l-31mEq/L

27

Glucose

70-110 me/dl 5-20 meldl 0.6-1.2 ms/dl 3.5-5 e/dl 8.5-10.5 me/dl >150 me/dl 0.1-1 me/dl 4.3-5.9 x 10o/mm' 14-17 s,ldl 39-49%

109

Test

Na+

K+

BIIN Creatinine (Cr) Albumin Calcium Total cholesterol Total bilirubin RBC Heb Hct

103

13

1.0

2.8L 7.9 L 211 0.7 4.4 16

45

,i,

80-95 fL 27-31os. 32-36 sldl 5-10 x 10'/mm'

MCV MCH MCHC WBC

91

29 34 8

10. You suspect his hypoalbuminemia is due to: a.

b.

(u) d.

Marasmus Kwashiorkor Acute phase response None of the above

I 1. Albumin plays a role in maintaining colloid osmotic pressure. Given this role, in a person with kwashiorkor, how does hypoalbuminemia manifest itself clinically (what is the result)? a. Dehydration .qL; Edema c. Hypertension (high blood pressure) d. No effect

tl

12. Suppose you decide to measure urinary creatinine as a somatic indicator of protein-energy malnutrition. Which of the following is/are TRUE of creatinine (CIRCLE ALL THAT APPLY). Its urinary excretion is affected by meat consumption It is a posttranslationally-modified amino acid 'c. It is a good indicator of visceral protein status It is a byproduct of creatine metabolism

dr

13. Which of the

following are typical criteria used

as part

of nutrition screening (CIRCLE ALL

THAT APPLYX

,.a .b. ,91' ,'d.l

a-

Laboratorv datalvalues Height and weight Diagnosis Medications

14. Nutrition screening, as in this patient, is the entry point to the Nutrition Care Process QIICP). What is the first step in the NCP? a. Nutrition Diagnosis rrT'. Nutrition Assessment c. Nutrition Monitoring and Evaluation d. Nutrition Intervention

15. When the is known as:

Nutrition Care Process is applied in practice, the overall care and service provided

a.

dpplied Medical Nutrition

b.

Medical Nutrition Treatment Medical Nutrition Therapy Applied Medical Dietetics

@ d.

-3

Nutrition Intervention include (CIRCLE ALL THAT APPLY): Nutrition screening Nutrition education Clinical Food and/or nutrient delivery

16. The classes of

a. ff' c. 6:d) t{-s'

Case Study #3: An 89 yo female is admitted to the hospital with progressively worsening cg4l5!gn, lethargy, and hypotension (low blood pressure). There is no height available and the patient is unable to stand in her current state. Her skin is dry with p:ggllg5gor and she has had very low urine output over the past24 hours. She has had type 2 diabetes for many years and it is &LtlX:ve-l-1.

gg#gs,e-.d. Her admission weight is 113 pounds. Usual weight reported by her daughter is 132 pounds. Her laboratory results (including partial data from CBC and urinalysis) are as follows: Test Na+ K+

clHCOrGlucose

Btli.{ Creatinine (Cr)

Albumin Osmolality Total cholesterol Total bilirubin RBC Heb Hct

MCV MCH MCHC WBC Urine specific sravitv Ur ne nrtnte Ur ne leukoct4e esterase

Reference range 135-145 mEqlL 3.6-5 mBqlL 101-111 mEq/L

Subiect vulues L52[I { .i:'

21-31mEq/L 70-110 me/dl 5-20 msldl 0.6-1.2 me/dl 3.5-5 e/dl

29 175

280-320 mOsm/kg >150 me/dl 0.1-1 ms/dl 3.5-5.9 x 1Oo/mm' 12-15 s.ldl 33-43% 80-95 fL

327 H

27-31oe 32-36 s.ldl 5-10 x 10'/mm' 1.010-1 .025 melml

28

Negative Negative

Positive Positive

17. What do you suspect is happening

3.8 111

H

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0.8 4.3 193

0.6 5.6

t6 42 81

33 9

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diagnosis? (4 points) -,t llr,"t

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with this patient and which factors are clues in the

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Her serum sodium level of 34nlEOlL, if converted to mmol/L, is equivalent to a serum potassium of 39 mmo-l/L. 3I ur',"''iL t : r "'-ri":' i L 19. What might the positive urin-e nitrite and leuko.g*,e-_9jlg_rgse tests indicate for this patient? a. Kidney disease

rs.

I

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b. c. ,. 'd.. .,.-- '

Diabetes

Liver disease Urinary tract infection

20. Explain how you

will

measure/estimate height to conduqlL-a nutrition assessment for this

patieniwho .glq!gef.op1plbp{,gf-*atd.

risiat leasf;l@alternatives.

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(2 points):

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22. To monitor her visceral protein status once the enteral tube feeding is started, you want to measure a serum protein with a short half life.(2-3 days) and that is not affected by iron or vitamin A deficiency. What do you measure? transthyretin (TTHY)/prealbumin b. albumin c. transferrin d. retinol-binding protein

ffi

23. When she does begin consuming food, you want to assess how she is doing by determining her food intake over a 3-day period. What do you do? a. Conduct a24-hour recall b. Ask her to keep a food diary c. Conduct a food frequency d; Conduct a nutrient intake analysis or "calorie count"

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Case Stu Ellen i

male who is seeing you for help to improve her weight and health. S@is 5'5" s, and is relatively sedentary. Her BMI is 30.2 kglm2. She has high blooT-"' ntly began taking medications to treat both her blood pressure and her high cholesterol. She has a hectic lifestyle and tends to frequent fast food restaurant drive-thrus for lunch and high end steak houses for dinner meetings with colleagues and clients. According to her dietary intake data, her energy consumption is -15% above her estimated requirements. You decide to take some additional anthropometric measurements as part of her initial assessment. 24. Ellen's waist circumference is 40 inches. How do you interpret this? increased risk of obesity-related disease low risk no risk c. d. unable to interpret without hip circumference

25.In your dream world, you have access to any body composition measurement techniques you choose. Any of the following can be used as measures of body composition EXCEPT: 6> Body mass index (BMI) b. Dual energy x-ray absorptiometry (DXA) c. Bioelectrical impedance analysis (BIA) d. Air displacement plethysmography 26. After much deliberation, you choose to use dual-energy x-ray absorptiometry (DXA)

as

your

meaSurementtool.Whichofthefollowingbestdescribestheprincipleofthis@ Lean tissue conducts an electrical current better than fat tissue Uses low-level radiation to measure tissue density and thickness The volume of the body (the size or amount of space it takes up) can be used to determine percent of lean and fat tissue when combined with information on height, weight, gender, etc. Uses imaging to view "slices" of the body in order to see and calculate percentage offatvs. leantissue.

a.

@

c.

d.

27.TfF) V-/

Youalsoconsidermeasuringtricepsskinfoldthickness. Thismeasureata sipde / point in time is a useful measure of body composition.

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28. Calculate Ellen's REE using the Mifflin-St. Jeor equation (1990) (4 points, show your work): '.' ii,:l ? Nf\ * ,1 *i i. t" 'i.':' t . !,:yr t{ t ".' REE : (10 x weight in kg) + (6.25 x height in cm) - (5 * age in years) + 5 (men) -161 (women) fr t 13 t,, "i. irf x f.t-r{:. ii.,!'!r'tl*

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29. What do you need to do with the results from the previous question in order to estimate her energy expenditure (TEE) for one day (2 points).

TOTAL

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If you wanted to actually MEASURE her energy expenditure, what is the method measuring and what is the principle behind it? Just a brief description (4 points) 30.

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31. Read the following diagnostic statements and cirel-e all that are appropriately formatted selected (1-3), label correctly the -,'i just components of a nutrition diagnosis (do NOT use the letters - use the whole terms) (5 pts):

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evidenced

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:i t.t ii i t ; I 1i.,,r"._ -1 { Excess energy intakefelated toirequentfastfood dininglas evidenced bypalir:ic intake ! 15% above istimatel

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Cardiovascular disease f'elated toffrequentfost'food diningfas evidenced ny,,hign cholesterol and a presciiptionlo/"ct itesteiol-ll*errng *ihiration. LL.i f,'',: ..' !. t {i,

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32.Her physician has prescribed Lipitor, a statin drug, for Ellen. Which ONE food should Ellen not consume while taking this statin drug due to risk of drug toxicity (2 points)?

,,':3, , Wtrat is the effect of consuming this food on Lipitor metabolism? It decreases the amount of cytochrome P450 enzymes (specifically CYP3A4 in the small

/D

b.

c. d. e.

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three

Hyperrension (high blood pressure)fretatect bt'besiry

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nutrition diagnoses for this patient. On those

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decreases the amount of CYP3A4 in the small intestine and thereby decreases the serum concentration of Lipitor. It increases the amount of CYP3A4 in the small intestine and thereby increases the serum

concentration of Lipitor. It increases the amount of CYP3A4 in the small intestine and thereby decreqses the serum concentration of Lipitor. None of the above.

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Case Studv #5: Teenie is a 78-year-old woman with hypertension (high blood pressure) for which she is taking spironolactone, a potassium-sparing diuretic. She also takes \qrc!!l-A11plg4lne oxidase inhibitor, orally for her depression, and warfarin. She is 5'1" ana weifs iiO Due to her hypertension, she recently began purchasing some reduced sodium foods containing KCI (potassium chloride) as a salt substitute. Her lab data are as follows:

p*"?i

Test

Na+

K+

clHCOcGlucose BLIN Creatinine (Cr) Albumin Total cholesterol Total bilirubin RBC Hsb Hct WBC INR

Reference range 135-145 mEq/L 3.6-5 mEq/L 101-111 mEq/L

Teenie's vulues 136 5.3 H i;4 {r -.,, , ,,

21-31mBqlL

29 125 H

70-110 me/dl 5-20 mgldl 0.6-1.2 me/dl 3.5-5 e/dl >150 me/dl 0.1-1 me/dl 3.5-5.9 x 10"/mm 12-15 eldl 33-43% 5-10 x 1O'/mm' 0.85-1.00 (ratio)

r {r ;,

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111

l5 0.8

2.8L t73 0.6 5.6 t3 37 9

1.5

H

34. Why does she need to limit pressor amines, such as tyramine, in her diet (what would be the effect and why?) and what are two examples of foods she should avoid? (4 points) Tu.lL,t"il'e.1t},!4''|,.i|||7,lrlrrTrli;ilir'':i.,.{!tl.,,.,.'...l, tt

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35. Components in cruciferous vegetables such as broccoli can influence rates of phase

detoxification of drugs. What is happening during phase I detoxification? a. Drugs bind to receptors to exeft pharmacodynamic effects

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Conjugation enzymes in the liver add side groups to drugs and toxins to make them water soluble so they can be excreted in urine None of the above

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Taking her medications with alcohol could result in drug toxicity.

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37. Teenie's albumin is 2.8 g/dl. Hypoalbuminemia can have what effect on drug metabolism? Increased pharmacodynamic effect leading to potential drug toxicity b. Increased rate of biotransformation leading to low levels of the drug and lack of effect of

S1

the drug

c. Increased absorption d.

ofthe drug

No effect

38. The warfarin interferes with the normal actions of which vitamin?

a. b.

Vitamin D Folate

c. Vitamin C @VitaminK e. None of the above 39. What is the appropriate dietary management for a patient taking warfarin? What is the effect if they consume too much or too little of the specific nutrient involved? (4 points) {.rririr.r wa"rlttuiq {*s. ffi{cerc{. (t+i,,"r.n,n, *r*ieir*.*ue.{ea:,of} wr"u\ fu

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**BONUS** 2 more points just for fun: The first day of the fall season (and the approach of cooler weather!) is coming on Tuesday, Seplember

ra

a. b.

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ZZ@nleeins each year on: The summer solstice The winter solstice rne equinox The vernal equinox

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