Karina​ ​Almanza,​ ​CSUN​ ​Dietetic​ ​Intern​ ​2017

David.​ ​X.​ ​Alvarez,​ ​Director​ ​and​ ​Elaine​ ​Stuart,​ ​Assistant​ ​Director

R.D.,​ ​Nicole​ ​Del​ ​Guercio

Community​ ​Outpatient​ ​Case​ ​Study:​ ​Thyroidectomy

1.​ ​Description​ ​of​ ​primary​ ​disease​ ​and​ ​nutrition​ ​treatment​:

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​:

Past​ ​medical​ ​history​:

GeneDx​ ​High​ ​Moderate​ ​Risk​ ​23​ ​Gene​ ​Panel-​ ​Negative
No​ ​known​ ​family​ ​hx​ ​of​ ​cancer
Hx​ ​of​ ​Thyroid​ ​Lobectomy-​ ​Right​ ​thyroid​ ​lobectomy​ ​8/23/2017​ ​for​ ​Bethesda​ ​3​ ​nodule
Follicular​ ​Carcinoma,​ ​Thyroid-​ ​Added​ ​automatically​ ​from​ ​request​ ​for​ ​surgery
Hx​ ​of​ ​Left​ ​Breast​ ​Cancer
Diagnosed​ ​9/22/2016
Breast,​ ​Lumpectomy,​ ​Left:
Tumor​ ​Type:​ ​Adenoid​ ​Cystic​ ​Carcinoma
Tumor​ ​Size:​ ​1.3​ ​cm
Carcinoma​ ​was​ ​present​ ​at​ ​the​ ​inferior​ ​anterior​ ​margin

Family​ ​and​ ​Social​ ​history​:

No​ ​family​ ​hx​ ​of​ ​cancer​ ​or​ ​hyperthyroidism.
Pt​ ​information​ ​including​ ​name,​ ​family​ ​contact,​ ​medical​ ​record​ ​number​ ​were​ ​collected​ ​but​ ​for​ ​the​ ​purposes
of​ ​this​ ​Case​ ​Study​ ​were​ ​not​ ​included.

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.

Wt​ ​Readings​ ​from​ ​Last​ ​3​ ​Encounters:

12/07/17 165#​ ​(74.8​ ​kg)
12/06/17 165#​ ​2​ ​oz​ ​(74.9​ ​kg)
10/19/17 162#​ ​11.2​ ​oz​ ​(73.8​ ​kg)

BMI:​ ​28.32​ ​kg/m​2

12/07/17 Ht:​ ​5’4”​ ​(1.626​ ​m)
12/07/17 Wt:​ ​165​ ​#​ ​(74.8​ ​kg)

4.​ ​Oral,​ ​enteral​ ​or​ ​parenteral​ ​intake​:

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.

Feeding​ ​or​ ​Eating​ ​skills/limitations​:

None​ ​known​ ​about​ ​at​ ​this​ ​time.

Laboratory​ ​Data:
Assessment Lab Reference​ ​Range Status Date
WBC’S​ ​AUTO (x10​3​/mm​3​) 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​:

Medication/ Dosage Significance Complications Currently

Supplement Taking​ ​or
Not​ ​Taking

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

Curcumax+Turme 380​ ​mg Anti-inflammatory N/A NT

ric​ ​oil

Sunflower​ ​lecithin N/A N/A N/A NT

vitamin

Baking​ ​Soda ¼​ ​spoon Anti-inflammatory N/A NT

with​ ​H2O

Mushroom 2-3x/D Anti-inflammatory N/A NT

Powder/​ ​Cramer

Coriolus 2-3x/D Anti-inflammatory N/A NT

Vitamin​ ​D 4-5,000 Prevent​ ​deficiency N/A CT

mg/D

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.

Medical​ ​procedures​ ​or​ ​surgical​ ​procedures​:

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.

4.​ ​Nutrition​ ​Diagnosis​:

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.

5.​ ​Nutrition​ ​Intervention​:

Previously​ ​recommended​ ​to​ ​have​ ​an​ ​80%​ ​vegan​ ​diet​ ​and​ ​the​ ​following​ ​suggestions​ ​were​ ​made​ ​by​ ​PCP:
1. Organic​ ​above​ ​ground​ ​vegetables​ ​(no​ ​roots)
2. Melatonin​ ​(in​ ​spray​ ​on​ ​the​ ​tongue,​ ​02​ ​mL​ ​x2​ ​and​ ​add​ ​gradually)
3. Free​ ​range​ ​chicken
4. Non-dairy​ ​cheese
5. Substitute​ ​Almond​ ​Milk,​ ​Unsweetened
6. Organic​ ​Coffee
7. Fruit,​ ​more​ ​dark​ ​berries,​ ​small​ ​amount
8. Cut​ ​sugar​ ​or​ ​not​ ​at​ ​all
9. Take​ ​Vitamins: Curcumax+Turmeric​ ​oil 380​ ​mg
Sunflower​ ​lecithin​ ​vitamin
Baking​ ​Soda ¼​ ​spoon​ ​in​ ​H2O
Mushroom​ ​Powder 2-3x/D​ ​w/​ ​H2O
Coriolus 2-3x/D
Vit​ ​D 4-5,000/D

Suggested​ ​by​ ​RD​ ​to​ ​eat​ ​whole​ ​food,​ ​plant-based​ ​diet.

Eat​ ​a​ ​variety​ ​of​ ​colored​ ​fruit​ ​and​ ​vegetables:​ ​purple,​ ​orange,​ ​red,​ ​green,​ ​yellow,​ ​and​ ​white.
Eat​ ​good​ ​fats​ ​such​ ​as​ ​olive​ ​oil,​ ​canola​ ​oil,​ ​avocado,​ ​nuts-unsalted,​ ​natural​ ​style​ ​peanut​ ​butter.
Eat​ ​whole​ ​grains​ ​such​ ​as​ ​quinoa,​ ​couscous,​ ​wild​ ​rice.​ ​Eat​ ​lentils,​ ​legumes,​ ​edamame​ ​beans,​ ​kidney​ ​beans,
black​ ​beans.
Try​ ​garbanzo​ ​bean​ ​pasta​ ​and​ ​black​ ​bean​ ​pasta​ ​from​ ​Whole​ ​Foods.
Try​ ​almond​ ​cheese​ ​from​ ​Sprouts,​ ​Trader​ ​Joe’s​ ​and​ ​preferably​ ​Whole​ ​Foods.
Encourage​ ​consumption​ ​of​ ​garlic,​ ​ginger,​ ​curry,​ ​water​ ​soluble​ ​cinnamon​ ​and​ ​parsley.

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.

MNT​ ​Goal​ ​Statement​:

Pt​ ​will​ ​incorporate​ ​more​ ​whole​ ​foods​ ​and​ ​colorful​ ​vegetables​ ​into​ ​diet​ ​to​ ​promote​ ​antioxidant​ ​and
antiinflammatory​ ​support​ ​before​ ​and​ ​after​ ​thyroidectomy​ ​procedure.​ ​Will​ ​address​ ​mineral​ ​and​ ​vitamin
supplementation​ ​at​ ​a​ ​later​ ​time.

6.​ ​Nutrition​ ​Monitoring​ ​and​ ​Evaluation​:

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