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Incidence:
R.B. is a 64 yo female last seen on 12/7/2017 in oncology. She states that she is scheduled for partial
thyroidectomy on 12/11/2017. She has had surgery previously this year. She reports chronic stress/ health
issues and concerns. She c/o undesired wt gain, hair loss, diarrhea, stress/ anxiety, and decrease in PA. Pt
wants to know what to eat to heal quickly and support immune functions, as well as what not to eat
following thyroidectomy. She read that she needs to watch the iodine in foods. She has d/c’d vit/min
supplements per pre-surgery orders. Pt was previously taking vit D and was told to take Vit C but did not.
Diagnosis:
Hyperlipidemia
Osteoarthritis
Atherosclerosis of Aorta
Emphysema
Multiple Pulmonary Nodules
Bilat Upper Dermatochalasis
Hx of Smoking
Cancer Survivorship
Hx of Thyroid Lobectomy
Follicular Carcinoma, Thyroid
Hx of Left Breast Cancer
Pathophysiology:
Symptoms could be r/t possible anemia, chronic stress, abnormal thyroid levels and menopause.
Medical Treatment:
Modifications in diet as mentioned in pathophysiology, incorporating whole foods, increase water
consumption and exercise. Limiting processed foods with high sugar, fat and sodium content.
2. Abstract:
R.B. is a 64 yo female with hx of breast cancer, chronic stress/ health issues. R.B. came into consult with
R.D. in oncology department d/t wt gain, hair loss, diarrhea, stress/ anxiety, and decrease in PA. R.B.
seeks advice in regards to foods to eat to help heal quickly and support immune function, following
anticipated thyroidectomy.
3. Nutrition Assessment:
Physical Examination:
Did not display any noticeable changes although mentioned concerned for undesired wt gain, hair loss,
stress/ anxiety.
Limited PA d/t low energy and surgery preparation. Anticipates on exercising after surgery, once fully
recovered.
Recently became sensitive to foods. Pt believes she is allergic to milk and is trying dairy-free products to
avoid diarrhea.
Likes fish, spinach and tomatoes.
Does not like bell peppers.
Foods that are not tolerated by body include milk and coffee.
There are no restrictions with medications in foods with the exception of Calcium.
Was told by PCP or RN that post-surgery, to only have dark grapes and berries. Was recommended by
RD to refer to anti-inflammatory list of foods provided for quicker healing.
Currently taking Vitamin D supplementation. Was recommended to take Vitamin C but did not start
taking it.
Currently seeking Turkey Tail supplementation to help eliminate possibility of cancer in the future.
Laboratory Data:
Assessment Lab Reference Range Status Date
WBC’S AUTO (x103/mm3) 5.9 4.8-11.8 WNL 12/02/2017
HGB (g/dL) 12.8 12-15 WNL 12/02/2017
HCT AUTO (%) 38.1 37-47 WNL 12/02/2017
3 3
PLT’S AUTO (x10 /mm ) 219 140-440 WNL 12/02/2017
VIT D, 25-OH (ng/dL) 38 20-100 WNL 12/02/2017
VIT D, 25-OH, D3 (pg/dL) 38 18-78 WNL 12/02/2017
VIT D, 25-OH, D2 (ng/dL) <4 >30 ↓ 12/02/2017
GLUC (mg/dL) 81 70-110 WNL 09/06/2016
GLUC (mg/dL) 81 70-110 WNL 02/24/2012
GLUC (mg/dL) 105 70-110 WNL 10/22/2013
GLUC FAST (mg/dL) 82 70-100 WNL 03/23/2015
GLUC FAST (mg/dL) 90 70-100 WNL 06/13/2013
GLUC FAST (mg/dL) 86 70-100 WNL 04/28/2010
HGBA1C (%) 5.3 4.0-6.0 WNL 04/29/2016
CHOL (mg/dL) 222 120-199 ↑ 11/29/2016
TRIG (mg/dL) 99 <150 mg/dL WNL 04/29/2016
HDL (mg/dL) 53 >50 WNL 11/29/2016
LDL CALC (mg/dL) 164 <100 ↑ 04/29/2016
LDL (mg/dL) 151 <100 ↑ 04/29/2016
CHOL/ HDL (mg/dL) 5.1 <5 04/29/2016
TRIG, NONFASTING (mg/dL) 136 35-135 WNL 11/29/2016
VIT B12 (pg/mL) 338 210-911 WNL 12/02/2017
CA (mg/dL) 10.1 9-11 WNL 12/02/2017
FOLATE (ng/mL) 11.4 2.8-40 WNL 12/02/2017
No results found for the following: IRON, IBC, FESAT, FERRITIN, ALB, PREALB
Medication usage:
Levothyroxine 50 mcg Oral Take 1 tablet PO 30 Limit food with goitrogens. CT
(Levothroid/ Tab min ā breakfast GI: N&V, diarrhea,
synthroid) epigastric distress
Diclofenac Na 1% Top Gel Apply to affected Caution with K CT
(Voltaren) Area BID PRN supplementation. GI:
PAIN Nausea, abdominal pain,
constipation, diarrhea,
flatulence, sore and ulcerated
mucosa
Pt could be experiencing side effects of Levothyroxine and could be experiencing possible reaction to
sudden discontinuation on all medications in preparation for surgery. The specific side effects that is
affecting R.B. is the diarrhea, unintentional wt gain and additional stress/ anxiety.
Thyroidectomy is a surgical operation that requires removal of all or part of the thyroid gland. This is the
second thyroidectomy that will be happening to this individual, suggesting a complete removal of the
thyroid. This is a general procedure in response to cancer as the thyroid stimulates hormone secretion.
The following errors during the surgical procedure can occur: bleeding, infection, airway obstruction
caused by bleeding, permanent hoarse or weak voice due to nerve damage. There can also be damage to
the four small glands located behind your thyroid (parathyroid glands), which can lead to
hypoparathyroidism, resulting in abnormally low calcium levels and an increased amount of phosphorus
in your blood.
PES Statement: Unintended wt gain r/t stressand anxiety and decrease in PA AEB change in UBW
before thyroidectomy.
Integrate all information above then write a nutrition diagnosis using reference 2; information
this process is also included in Krause. If hospital is not using Nutrition Care Process (NCP) you
must still include your PES statement in your case study.
Suggested to limit/ avoid processed foods that include added sugar, too much sugar, sweets, juice, salt/
sodium, trans fats “hydrogenated oils”, saturated fat such as red meat, dark meat poultry, regular fat
cheese, mayonnaise, creams, whole or 2% fat milk, coconut oil, palm kernel oil, cottonseed.
Limit red meat to twice a month and egg yolks 4 per week. Limit poultry to white meat skinless.
Egg whites, fatty fish, tofu and nonfat plain greek yogurt are good sources of protein.
Recommended to consider C0Q10; fish oil, flaxseed oil, turmeric with piperine, resveratrol, prebiotics,
probiotics, alpha lipoic acid, over the counter supplements.
Recommended to drink Green Tea.
Referred to Dr. Andrew Weil’s anti-inflammatory food pyramid as demonstrated above, refer to appendix
I.
Food safety reinforced post-surgery. No hard food or citrus until healed from thyroidectomy.
Encouraged increase in water. Encouraged exercise as tol. Reviewed and provided anti-inflammatory diet.
Provided list of anti-inflammatory foods and supplements. Recommended to do regular exercise cardio
and strengthening along with stress management exercises such as deep breathing, yoga, meditation,
massage, acupuncture, guided imagery. Kaiser Permanente has free classes pertaining to stress, mind and
body upon referral.
F/U will be addressed 4 weeks after surgery with 1:1 RD consult. Will address IRON, IBC, FESAT,
FERRITIN, ALB, PREALB labs as well and re-evaluate labs for Vit D, B12, Ca and Folate. At next
appointment address supplement usage, continued diet modifications, behavioral change and
incorporation of PA into daily routine as tol.
7. References
1. Pronsky, Z. M., Elbe, D., & Ayoob, K. (2015). Food medication interactions. Birchrunville
(Penn.): Food-Medication Interactions.
2. Width, M., & Reinhard, T. (2018). The essential pocket guide for clinical nutrition. Philadelphia:
Wolters Kluwer Health.
APPENDIX
I. Dr. Andrew Weil’s Food Pyramid
Dr. Andrew Weil’s Food Pyramid: I