Professional Documents
Culture Documents
_____________________________________
To the
Dietary Department
_____________________________________
_____________________________________
By
Sosing, Marem C.
April 5, 2017
2
Table of Contents
Contents Page
I. General Information
A. Social History
B. Medical History
C. Diagnosis
D. Diet History
a. Usual Food Intake
E. Clinical and Biochemical Tests Results
II. Information About the Disease
Anatomy and Physiology of the Gallbladder
A. Definition of the Gallbladder Adenocarcinoma Stage IVA
Prevalence
Etiological Factors
Clinical manifestations
Pathophysiology
B. Definition of Lymph Node Metastasis
Prevalence
Etiological Factors
Clinical Manifestations
Pathophysiology
C. Definition of Liver Metastasis
Prevalence
Etiological Factors
Clinical Manifestations
Pathophysiology
D. Definition of Liver Metastasis
Prevalence
Etiological Factors
Clinical Manifestations
Pathophysiology
III. Medical management
IV. Nutritional Screening
V. Diet Order/Prescription
a. Computation of Desirable Body Weight (DBW)
b. Computation of Body Mass Index (BMI)
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I. General Information
A. Social History
Mrs. Adela Cabasa is a 90 years-old female from F. Rallos, Cebu City. She
was once a fish market vendor. She does not smoke or drink alcoholic
beverages. After her children got married, she now lives with a caretaker who
cooks her food and carrying out the day-to-day chores. She walks around the
home, do the shopping, pay the bills and goes to church prior to admission.
B. Medical History
The patient has a history of hypertension and she has osteoarthritis. Two
days prior to admission, the patient was noted to have a right upper quadrant
abdominal mass. It was non-tender on examination. She noticed that the lump is
growing. She did not feel any pain and remain on her usual diet. There was no
jaundice and fever. An ultrasound was done and was advised to be admitted.
C. Diagnosis
She was diagnosed with gallbladder cancer stage IV with lymph node and
liver metastasis and hypertensive cardiovascular disease.
The primary impression was Pancreatic Cancer. It was revised after the
multiple CT scan of the whole abdomen.
The result also showed an atherosclerosis of the abdominal aorta and iliac
arteries and mild spondylosis of the thoraco lumbar vertebra. The patient
underwent a percutaneous cholecystectomy and liver and gallbladder biopsy.
D. Diet History
The patient loves to eat home-cooked foods. They always avoid outside
foods and prepare foods at home. They rarely go to a fast food restaurant. She
does not prefer to eat fatty foods. But one of her favorite snack is Chicharon.
And because she is very near to market, she prepares fresh lean meat and fish
3
and vegetables. She is very meticulous to the freshness and chooses the best
ingredients. She wants her food to always taste good so, they add commercial
seasonings or flavor enhancers in every dishes.
In her age, she can still recognize the taste of the food. During the
hospitalization, she refuses to eat the food from the hospital since her diet
includes low salt. She also complains that the food is already cold.
The patient follows a no breakfast meal pattern. She eats between 10AM
to 11AM as her brunch meal, snacks between 2PM to 3PM and eats dinner as
early as 5PM. She is allergic to chicken and milk. She loves to eat fish and selects
those from large varieties. For every meal, there should be one vegetable dish.
She also eats sweet foods occasionally.
Blood Pressure
DAYS IN AM PM
DATE REMARKS
HOSPITAL 12 4 8 12 4 8
Admission Feb. 140 High
17, 70
2017
1 Feb. 110 100 100 90 100 100 Normal
18, 70 60 70 60 60 60
2017
2 Feb. 90 90 170 100 120 120 High
19, 70 70 80 70 70 60
2017
3 Feb. - 120 110 120 110 100 Normal
20, 70 80 70 60 60
2017
4 Feb. 120 110 110 110 130 90 High
21, 80 80 60 60 70 60
2017
5 Feb. 100 110 110 100 120 120 Normal
22, 70 70 80 60 60 60
2017
6 Feb. 100 110 100 120 110 110 Normal
23, 60 60 60 60 80 70
2017
7 Feb. 90 100 100 100 110 - Normal
24, 60 60 70 60 60
2017
8 Feb. 110 120 110 120 110 110 Normal
25, 80 80 60 60 60 70
2017
9 Feb. 100 100 120 110 120 100 Normal
26, 60 60 70 70 80 70
2017
10 Feb. 100 100 100 - 110 100 Normal
27, 80 80 70 60 60
2017
11 Feb. 120 110 110 120 100 100 Normal
28, 70 70 70 70 60 60
2017
12 March 100 120 110 110 100 100 Normal
5
1, 60 60 60 70 70 60
2017
13 March - - 120 - 120 120 Normal
2, 80 60 70
2017
14 March - 120 100 100 110 110 Normal
3, 80 60 60 80 70
2017
15 March 110 100 100 100 120 120 Normal
4, 80 70 80 80 80 80
2017
16 March 100 110 100 110 - - Normal
5, 60 70 60 70
2017
17 March - 110 100 100 110 90 Normal
6, 80 60 60 70 60
2017
18 March 110 120 - 120 Normal
7, 80 80 80
2017
Indications:
The ideal or normal blood pressure is less than 120 mmHg (systolic) and
120
less than 80 mmHg (diastolic). The blood pressure of the patient is mostly 80
which is already in its borderline. Between 120-139 (systolic) or between 80-89
140
(diastolic) will indicate prehypertension. means Stage 1 hypertension. The
70
higher pressure puts an extra strain on the patient’s heart and blood vessels.
Over time, this extra strain increases the risk of a heart attack or stroke. The
170
patient’s blood pressure reached to or stage 2 hypertension (Mayo Clinic,
80
n.d.).
6
LABORATORY NORMAL
DATE RESULTS UNIT REMARKS
EXAMINATIONS VALUES
Feb. CBC (COMPLETE BLOOD COUNT)
17, HEMOGLOBIN 10 g/dL 12.3 – 15.3 Low
2017 HEMATOCRIT 28.2 % 35.9 – 44.6 Low
MONOCYTES 14 % 0.00 – 8.00 High
RED BLOOD CELLS 3.02 /uL 4.50 – 5.10 Low
10^6
RDW 12.5 % 14.0 – 18.0 Low
PLATELET COUNT 177 /uL 140.0 – High
440.0 10^3
Feb. URINALYSIS ROUTINE
18, (CHEMICAL EXAMINATION)
2017 BLOOD LARGE Not normal
LEOKOCYTE LARGE Not Normal
URINALYSIS ROUTINE
(MICROSCOPIC EXAMINATION)
RED CELLS 134.8 /uL 0-11 High
PUS CELLS 135.6 /uL 0-11 High
BACTERIA 8.0 /uL 10-111 Low
URINALYSIS ROUTINE
(CONVENTIONAL)
RED CELLS 24.26 /hpf 0–2 High
PUS CELLS 24.41 /hpf 0–2 High
EPITHELIAL CELLS 9.63 /hpf 0–2 High
Results Indications
Low Hemoglobin The measures in these three areas are
Low Hematocrit lower than normal. The patient has
Low Red Blood Cell Count anemia. Anemia causes fatigue and
weakness. Anemia has many causes,
including low levels of certain vitamins
or iron, blood loss, or an underlying
condition.
bleeding
liver disorder
kidney disorder
malnutrition
malabsorption conditions, such
as celiac disease or
inflammatory bowel disease
9
Conditions causing
underproduction or loss of
albumins, like in nephrotic
syndrome, liver cirrhosis, etc
Source: www.healthline.com
10
The gallbladder is a small, hollow, pear-shaped pouch about 8cm long and
about 2.5cm wide. It lies underneath the right side of the liver, in the upper
abdomen. The gallbladder and bile ducts form the biliary tract. It is also called as
biliary tree or biliary system (Cancer Research UK, 2014).
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Bile is a greenish yellow, thick, sticky fluid that aids the digestion of lipids
in the small intestine. The composition of gallbladder bile is 97% water, 0.7%
bile salts, 0.2% bilirubin, 0.51% fats (cholesterol, fatty acids and lecithin), and
200 meq/l inorganic salts. Bile flows out of the liver through the right and left
hepatic ducts, which come together to form the common hepatic duct. This duct
then joins with a duct coming from the gallbladder, called the cystic duct, to
form the common bile duct. The pancreatic duct joins the common bile duct just
where it empties into the duodenum through the sphincter of Oddi. Between
meals, bile salts are stored in the gallbladder, and only a small amount of bile
flows into the intestine. When food that enters the duodenum, a hormone called
cholecystokinin is released, signaling the gallbladder to contract and secrete bile
into the small intestine through the common bile duct. As a result, bile flows into
the duodenum and mixes with food contents (Ruiz, n.d.).
Bile has two important functions: It assists in the digestion and absorption
of fats, and it is responsible for the elimination of certain waste products from
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the body, particularly hemoglobin from destroyed red blood cells and excess
cholesterol. Specifically, bile is responsible for the following actions:
Bile salts make cholesterol, fats, and fat-soluble vitamins more soluble
(more dissolved), which aids in their absorption.
Bile salts stimulate the secretion of water by the large intestine to help
move the contents along.
Bilirubin (the main pigment in bile) is excreted in bile as a waste product
of destroyed red blood cells, giving stool a green-brown color.
Drugs and other waste products are excreted in bile and later eliminated
from the body.
Various proteins that play important roles in bile's absorptive function are
secreted in bile (Ruiz, n.d.).
Bile salts are reabsorbed by the last portion of the small intestine,
extracted by the liver, and resecreted into bile. This recirculation of bile salts is
known as the enterohepatic circulation. All the bile salts in the body circulate
about 10 to 12 times a day. During each pass, small amounts of bile salts reach
the large intestine, where some are reabsorbed and the rest are excreted in the
stool (Ruiz, n.d.).
The gallbladder is not an essential part of the body. The body can still
digest food without it. It is often removed by a surgical procedure known as a
cholecystectomy in cases of gallbladder disease or gallstones. (Cancer Research
UK, 2014).
innermost layer and spreads through the outer layers as it grows (Mayo Clinic,
2014).
The patient has a Gallbladder Cancer stage IVA. The cancer has already
spread to a main blood vessel of the liver or to 2 or more nearby organs or areas
other than the liver. Cancer has spread to nearby lymph nodes (Burke, 2015).
(initiation stage). The cell will attempt to eliminate the carcinogen from the DNA
by cutting out the damaged portion thus allowing the cell to function as before.
The ability of the cell to reproduce new normal cells of its own kind depends on
the undamaged DNA. However, if the cell reproduces and divides into two cells
before the DNA is repaired, then the altered DNA structure is passed on to the
new daughter cells. It is this altered DNA passed on from cell generation that is
thought to be responsible for the growth of cancer cells (stage of promotion).
Transformed cell may remain dormant from a period of time until activated by
promoting agents. Diets are believed to be inhibitors or enhancers of
carcinogenesis. The formation or progression of the neoplasm from the initiated
cells characterized the promotion stage of carcinogenesis (Ruiz, Claudio &
Castro, 2004, pp. 12-2).
Prevalence
Statistics showed that around 189.1 persons per 100,000 Filipinos today
will eventually have cancer and one of every five Filipinos who live to age 74 will
get cancer (Ruiz, Claudio & Castro, 2004, pp. 12-1).
Etiological Factors
a. Modifiable Factors
Gallstones and inflammation – Gallstones (cholelithiasis) and
inflammation of the gallbladder (cholecystitis) are the most
common risk factors for gallbladder cancer. Gallstones are hard
lumps, like little rocks, that form in the gallbladder. They are mostly
15
Clinical manifestations
Bloating
A lump in the abdomen
Fever
Jaundice, anorexia, and weight loss often indicate more advanced disease
(American Society of Clinical Oncology (ASCO), 2015).
S Sudden unexplained weight loss (Ruiz, Claudio & Castro, 2004, pp.
12-3).
Pathophysiology
studies revealed that 10-7% or an average of 35% of all cancer deaths may be
linked to diet. Unhealthy eating habits that comprise mainly of red meats, high
fat foods (especially saturated fats), and salt- cured foods are associated with
increased cancer risk. Susceptibility to cancer escalates when this diet is poor in
protective foods such as fruits and vegetables that are high in phytochemicals,
antioxidant nutrients, and dietary fiber (Ruiz, Claudio & Castro, 2004, pp. 12-1).
Graphic shows typical appearance for gallbladder carcinoma with hepatic invasion .
Lymph nodes are small, bean-shaped organs which produce and store
blood cells that help fight disease and infection. Also known as lymph glands,
lymph nodes remove cell waste and fluids from lymph (lymphatic fluid), and
store lymphocytes (white blood cells). Lymph nodes are part of the lymphatic
19
system and are located throughout the body, including the neck, armpits,
abdomen and groin.
The patient has been diagnosed with lymph node metastasis after the
biopsy. (Canadian Cancer Society, n.d.). There are lymph glands around the
gallbladder. The lymph nodes are often the first place that cancer cells spread to
when they break away from a tumour. (Chhabra, n.d.).
20
Prevalence
Etiological Factors
a. Modifiable Factors
Cancer (Primary) - Pain or swelling in the area of the lymph
nodes is a common symptom of cancer that starts in the lymphatic
system, such as non-Hodgkin lymphoma and Hodgkin lymphoma.
Cancer that starts in another part of the body and spreads to the
lymph nodes is called a metastasis. Even when cancer spreads to
the lymph nodes, it is still named after the area of the body where
it started.
Clinical Manifestations
Pathophysiology
When cancer cells break away from a tumor, they can travel to other
areas of the body through either the bloodstream or the lymph system. Cancer
cells can travel through the bloodstream to reach distant organs. If they travel
through the lymph system, the cancer cells may end up in lymph nodes. Either
22
way, most of the escaped cancer cells die or are killed before they can start
growing somewhere else. But one or two might settle in a new area, begin to
grow, and form new tumors. This spread of cancer to a new part of the body is
called metastasis. In order for cancer cells to spread to new parts of the body,
they have to go through several changes. They first have to become able to
break away from the original tumor and then attach to the outside wall of a
lymph vessel or blood vessel. Then they must move through the vessel wall to
flow with the blood or lymph to a new organ or lymph node. When cancer grows
inside lymph nodes, it usually affects the lymph nodes near the tumor itself. The
CT scan results showed that the lymph node metastasis is very near to the
primary site of the cancer. These are the nodes that have been doing most of
the work to filter out or kill the cancer cells (American Cancer Society, 2015).
Source: http://www.ladycarehealth.com/symptoms-of-cancer-in-the-lymph-nodes/
cancer originates in the liver and most commonly affects individuals who have
risk factors such as hepatitis or cirrhosis. Most of the time, cancer in the liver is
secondary, or metastatic. The cancer cells found in a metastatic liver tumor are
not liver cells. They are the cells from the part of the body where the primary
cancer began. Other names for this condition include liver metastases or stage IV
or advanced cancer. There may be no symptoms in the early stages of liver
metastasis. In later stages, cancer can cause the liver to swell or obstruct the
normal flow of blood and bile (Rice n.d.).
We also found out that the most common malignancies associated with
the development of ascites include cancers of the colon/rectum, ovary, breast,
lung, pancreas, liver, and lymphoma. Approximately 50% of patients with
malignant ascites are related to liver metastases (Kristler, 2015).
Prevalence
The three most deadly cancers in Philippines during 2013 were "tracheal,
bronchus and lung cancer", liver cancer, and colon and rectum cancer
respectively. Though this was the trend in Philippines overall, different
demographic groups are affected differently and is likely much different between
men and women at different ages in life (Global Health Data Exchange, n.d.).
Etiological Factors
Clinical manifestations
loss of appetite
weight loss
dark-colored urine
abdominal swelling or bloating
jaundice, a yellowing of the skin or the whites of the eyes
pain in the right shoulder
pain in the upper right abdomen
nausea
vomiting
confusion
sweats and fever
enlarged liver
Pathophysiology
The risk that cancer will spread, or metastasize, to the liver depends on
the location of the original cancer. The patient’s gallbladder cancer is most likely
to spread to the liver. Liver metastases are foreign tissue growing within the
liver. They either grow expansively (as a mass) or infiltratively (spreading
through surrounding tissues). Physically, they grow and compress the
surrounding liver tissue. A connective tissue rim is usually formed around the
metastasis, and surrounding tissue is wasted away. Large metastases may even
compress branches of the portal vein. Because they grow so quickly, liver
metastases, like primary tumours, may outgrow their blood supply, resulting in
death of the center of the lesion (Nawaz & Mcdonald, 2013).
There are six steps in the metastasis process. Not all cancers follow this
process, but most do.
Local invasion: Cancer cells move from the primary site into nearby
normal tissue.
Circulation: Cancer cells migrate through the lymphatic system and the
bloodstream to other parts of the body.
Arrest and extravasation: Cancer cells stop moving when they reach a
distant location. They then move through the capillary (small blood vessel)
walls and invade nearby tissue.
Proliferation: Cancer cells grow at the distant location and create small
tumors called micrometastases.
Source: http://library.med.utah.edu/WebPath/LIVEHTML/LIVER002.html
NORMAL LIVER
Source: https://radiopaedia.org/articles/hepatic-metastases-1
Liver Metastasis
affects the heart muscle causing it to enlarge. High blood pressure can also
cause stroke and heart problem due to the increased amount of oxygen that is
needed by the heart. It also contributes to blood vessel walls thickening, which
can worsen atherosclerosis, increasing the risks of stroke and heart attacks.
When left untreated hypertensive cardiovascular problem can cause angina,
heart attack, stroke, heart failure, arrhythmias and sudden death (Forte and
Forte, 2017).
Prevalence
In the Philippines, about 30 percent of all the deaths are caused by heart
and vascular disease and one in every four Filipino adults (25.7 percent) has
hypertension, according to Philippine Society of Hypertension.
Etiological Factors
a. Modifiable Factors
Overweight or obese- The more the patient gain weigh the more
blood is needed to supply of oxygen and nutrients to your tissues.
As the volume of blood circulated through the blood vessels
increases, so does the pressure on the artery walls.
heart must work with each contraction and the stronger the force
on the arteries. Lack of physical activity also increases the risk of
being overweight.
Too much salt (sodium) in the diet- Too much sodium in the
diet can cause the body to retain fluid, which increases blood
pressure.
Clinical Manifestations
Fatigue or confusion
Vision problems
Chest pain
Difficulty breathing
Irregular heartbeat
Blood in the urine
Pounding in your chest, neck, or ears
Severe headache (Beckerman, 2016).
Pathophysiology
build-up in the arteries. When those blockages occur in the arteries that supply
blood to the heart muscle, the end result is called coronary artery disease
(Klodas, 2016).
She was monitored accordingly and medications were adjusted and some
are added as prescribed. She also had undergone chemotherapy.
Source: www.drugs.com
35
The patient did not lose weight within the last two (2) months. There is
no change in her dietary intake. No complains of nausea, vomiting or diarrhea.
The patient is recovering from the surgery which causes her unable to stand.
There are no signs of muscle wasting. The patient has a small amount of ascites
as seen in her laboratory results.
To compute TLC,
WBC = 9.5
% lymphocytes = 27
The total score of 3 indicates that the patient is high risk of malnutrition.
The overall nutritional status of the patient is "severe malnutrition."
Low salt, 4g NaCl, low fat, <200 mg cholesterol/day, <7 % Saturated Fat
Height: 4’9’’
NDAP Method
Female
5 ft. = 106
±4
𝐷𝐵𝑊 = 106 – 8
98 𝑙𝑏𝑠
=
2.2
𝑫𝑩𝑾 = 𝟒𝟒. 𝟓𝟓 𝒌𝒈.
37
D. Meal/Diet Plan
E. Sample Menu
Sample Menu
BREAKFAST
Fresh fruit or dessert Apple, 1 piece
Meat, Egg or substitute Baked fish, 1 piece
Rice, cereal or bread, Rice, ½ cup
Hot beverage Coffee, 1 cup
Lunch
Soup From Utan Bisaya
Meat, fish, poultry, or substitute Fried Fish, 1
Vegetable Utan Bisaya, 1 cup
Rice or substitute Brown Rice, 1 cup
Fruit or dessert Banana, 1 piece
Supper
Soup Soup from Pork
Nilaga, 1 cup
Meat, fish, poultry, or substitute Pork Nilaga,
1 matchbox size
Vegetable Chopsuey, ½ cup
Rice or substitute Brown rice, ½ cup
Fruit or dessert Grapes, 10 pieces
Snacks
AM -
PM Sweet Potato,
½ cup
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The AHA/ASA recommends a diet that is low in sodium, is high in potassium, and
promotes the consumption of fruits, vegetables, and low-fat dairy products for
reducing BP and lowering the risk of stroke. Other recommendations include
increasing physical activity (30 minutes or more of moderate intensity activity on
a daily basis) and losing weight (for overweight and obese persons).
CVS: distinct heart sounds, (-) murmur, regular rate and rhythm
VII. Prognosis
How well the patients do depend on the location of the original cancer
and how much it has spread to the liver or anywhere else. In rare cases, surgery
to remove the liver tumors leads to a cure. This is usually only possible when
there are a limited number of tumors in the liver.
In most cases, cancer that has spread to the liver cannot be cured. People
whose cancer has spread to the liver often die of their disease. However,
treatments may help shrink tumors, improve life expectancy, and relieve
symptoms.
It is important to educate patients about the nature of their disease and the
risks associated with untreated hypertension. In addition, dietary modifications
and the importance of regular exercise, taking medications regularly, weight loss,
and avoiding medications and foods that can potentially elevate blood pressure
should be emphasized.
Problems in bowel
Nausea in chemo
Maintain or adopt a healthy lifestyle. If your blood pressure goal isn't reached
in about a month, talk to your doctor about taking one or more medications.
Hemoglobin - transports oxygen from our lungs to the cells in our body.
The hemoglobin molecule contains iron, an essential mineral found in our
diet.
About the Gallbaldder. (2014, June 4). Cancer Research UK. Retrieved March
17, 2017, from http://www.cancerresearchuk.org/about-
cancer/type/gallbladder-cancer/about/about-the-gallbladder
Gallbladder and Biliary Tract Cancer in Philippines. (n.d.). Global Health Data
Exchange. Retrieved March 29, 2017, from http://global-disease-
burden.healthgrove.com/l/35906/Gallbladder-and-Biliary-Tract-Cancer-in-
Philippines#Overview&s=3D2kvJ
43
Gallbladder Cancer. (2014). Mayo Clinic. Retrieved March 17, 2017, from
http://www.mayoclinic.org/diseases-conditions/gallbladder-
cancer/basics/definition/con-20023909
High blood Pressure (hypertension). (n.d.) Mayo Clinic. Retrieved March 28,
2017, from http://www.mayoclinic.org/diseases-conditions/high-blood-
pressure/basics/risk-factors/con-20019580
Lapeña, C.G. (2012). 30% of PHL deaths due to heart, vascular disease;
25.7% of Pinoys hypertensive. GMA Network. Retrieved March 28, 2017, from
http://www.gmanetwork.com/news/story/269935/lifestyle/healthandwellness/
30-of-phl-deaths-due-to-heart-vascular-disease-25-7-of-pinoys-hypertensive
Liver Cancer. (n.d.). Department of Health. Retrieved March 29, 2017, from
http://www.doh.gov.ph/node/362
Liver Metastasis. (n.d.). Canadian Cancer Society. Retrieved March 17, 2017,
from http://www.cancer.ca/en/cancer-information/cancer-type/metastatic-
cancer/liver-metastases/?region=on
Lymph Node and cancer. (2015). American Cancer Society. Retrieved March
17, 2015, from https://www.cancer.org/cancer/cancer-basics/lymph-nodes-
and-cancer.html
44
Riaz, K. & Ali, Y.S. (2014). Hypertensive Heart Disease. Medscape. Retrieved
March 28, 2017, from http://emedicine.medscape.com/article/162449-
overview
Rice, S.C. (n.d.). Liver Metastasis. Healthline. Retrieved March 17, 2017, from
http://www.healthline.com/health/liver-metastases
Ruiz, A. (n.d.). Gallbladder and Biliary Tract. Merck Manual. Retrieved March
17, 2017, from http://www.merckmanuals.com/home/digestive-
disorders/biology-of-the-digestive-system/gallbladder-and-biliary-tract
Ruiz, A.J., Claudio, V.S. & Castro, E.E. (2004). Medical Nutrition Therapy for
Filipinos. Manila, Philippines: Merriam & Webster Bookstore, Inc.