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Comprehensive Medical Case Study of Maureen Donah: Dietary Management and Surgical Interventions

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This detailed case study covers the medical history, admission details, and treatment course of Maureen Donah, a 52-year-old female, during her hospitalization for multiple health issues, including left flank pain due to hydronephrosis and sigmoid diverticulitis with colovesical fistula. The account includes nutritional assessments, management of her type 2 diabetes, and surgical interventions. Documenting her progress through various stages of treatment, this case highlights the importance of interdisciplinary care in the management of complex medical conditions.

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Comprehensive Medical Case Study of Maureen Donah: Dietary Management and Surgical Interventions

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  1. L.M. 52 y.o. female Maureen Donah 2013 SodexoSouthcoast Dietetic Intern

  2. Past Medical History • COPD • Type 2 Diabetes • Hyperlipidemia • Obesity • Fibromyalgia • Hx of recent UTIs • Kidney Stones • Irritable Bowel Syndrome • Depression

  3. L.M. was admitted 1/8/13 • Caucasian • 5’0” 212# (stated) • BMI 41.4 • Social Hx: patient doesn’t drink alcohol and used to smoke in the past 140 99 16 186 4.3 27 1.1

  4. Emergency Room • In the ER L.M. presented with left-sided flank pain • CAT scan showed UPJ stone with hydronephrosis and diverticulitis • Hydronephrosis is the swelling of the kidney due to a back up of urine. http://www.nlm.nih.gov/medlineplus/ency/article/000506.htm

  5. Procedure 1/9/13 • Pre-op dx: ?colovesical fistula (due to air in the bladder) and left proximal ureteral stone • Cystoscopy • Fistulogram • Left retrograde pyelography • Left ureteral stent placement • Post-op dx: Left proximal ureteral stone and colovesical fistula confirmed

  6. The Plan • The pt was treated with IV antibiotics, IV fluids, and IV narcotics • 1/11/13 pt started clear liq diet and tolerated well and was adv to a DM diet • Pain was off and on and was better controlled with p.o. medications • 1/12/13 pt was d/c home

  7. The Plan • The pt was told to follow up with primary doctor within 5-7 days • Follow up with GI for colonoscopy after antibiotic is finished • Follow up with surgery in 2-3 weeks

  8. Re-admitted 1/25/13 • Left flank pain • Diarrhea and vomiting PTA 139 101 11 189 4.3 27 1.0 Started DM 1800cal dt 1/26/13-2/1/13 with fair to poor intake

  9. RD Assessment 2/4/13 • 5’0” 212# (Stated) BMI 41.4 • Adj. body wt: 128#/58kg • Kcals 1450-1750 (25-30 kcals/kg) • Protein 69-76g (1.2-1.3g/kg) • Fluid 1750mL (30mL/kg) • On full/clears since 2/1/13 with fair intake • Prep for surgery

  10. 2/5/13 Surgery • Dx: Sigmoid diverticulitis with colovesical fistula • Laparotomy with sigmoid colon resection and repair of colovesical fistula

  11. Nutrition after Fistula Repair • NPO 2/5-2/8 • Started clear liquid 2/9-2/10 • Not tolerating clears, episodes of vomiting • NPO 2/11-2/13

  12. 2/13/13 POD#8 • Anastomotic leakage • Confirmed by a barium enema • Procedure: Diverting loop ileostomy

  13. Nutrition after Ileostomy • Nutritional Needs (58kg) • Kcals 1450-1750 (25-30kcals/kg) • Protein 75-87g (1.3-1.5g/kg) • Fluid 1750mL (30mL/kg) • IVF D5 ½ NS + 20mEq KCl • Diet advance to clear liquids 2/13 • Diet advance 2/14 to diabetic diet for breakfast only • L.M. not tolerating, vomiting continues

  14. The Plan • Patient not tolerating liquids at all • In 2 weeks L.M. had 2 surgeries and was NPO for 7 days and received 7 days of liquid trays • With this minimal nutrition the plan was to start TPN - Central line 2/15/13 • Pt at refeeding risk! • Potassium 3.7 • Magnesium ? • Phosphorous ?

  15. Nutrition Support (TPN) 2/15 • Day 1 custom bag 1,000mL/day 50g AA, 100g dextrose, no lipids due to shortage • IVF (D5 ½ NS) kept at 100mL/hrwill decrease by day 2 per PA

  16. Day 2 TPN 2/16/13 • 2,000mL/day 80g AA, 175g dextrose, no lipids, 20 units insulin • IVF switched to Normal Saline • IVF decreased to a combined rate with TPN to 100mL/hr • Potassium 3.1 • Magnesium 1.7 • Phosphorous 1.9

  17. Day 3 TPN 2/17/13 • TPN at goal: 1,800mL/day 85g AA, 160g dextrose, 25 units insulin • IVF (NS) at combined rate of 100cc/hr • To provide 884 kcals/day • Only meeting 55% of calorie needs • Potassium 3.1 • Magnesium ? • Phosphorous1.6

  18. Day 4 TPN 2/18/13 • 1,800mL/day 85g AA, 160g dextrose, no lipids, 35 units insulin • Potassium 3.2 • Magnesium 2.3 • Phosphorous2.3 • Pt now not passing gas and has hypoactive bowel sounds

  19. 2/18/13 • Vomited • KUB showed multiple dilated small bowel loops, consistent with a small bowel obstruction. • Started NGT to LWS 1500cc output

  20. Day 5 TPN 2/19/13 • 1,800mL/day 85g AA, 160g dextrose, 50g lipids, 45 units insulin • To provide 1334kcals, meeting ~83% of calorie needs • NGT to LWS 2550cc output • Potassium 3.3 • Magnesium 2.3 • Phosphorous?

  21. Day 6 TPN 2/20/13 • 1,800mL/day 85g AA, 160g dextrose, no lipids, 55 units insulin • NGT to LWS output • Potassium 3.3 • Magnesium 2.2 • Phosphorous4.3 3000cc 3000c *Pt was weighed for the first time today! 5’0” 192.5# (Standing Scale) BMI 37.5 Down 19.5# since admission

  22. Gastric Secretions Production and composition of gastric secretions varies. Daily estimates ~1-3L ~1liter saliva and ~2 liters gastric secretions: ~3 liters total The electrolyte composition of each liter is estimated at 20-100mEq sodium, 50-160mEq chloride, and 5-15mEq potassium Johnson ML. Gastric Secretions: Physiology During Loss and Suggestions for Replacement. Support Line. 2012;34(6);13-18.

  23. Gastric Secretions * No blood gas labs taken

  24. Day 7 TPN 2/21/13 • 1,800mL/day 85g AA, 160g dextrose, 50g lipids, 60 units insulin • NGT to LWS 1500cc output • Started to pass flatus but still hypoactive bowel sounds • KUB still seeing multiple dilated loops

  25. Day 8 TPN 2/22/13 • 1,800mL/day 85g AA, 160g dextrose, no lipids, 60 units insulin • Started clear liquid diet • NGT clamped for 3hrs then LWS for 1hr • NGT to LWS 2250cc output • Pt was given MOM (30mL) q2h while awake

  26. TPN Continues • Pt continued on clear liquid diet and TPN, with fair PO intake • SBO resolving 2/25/13 per KUB • Diet advanced to full liquid on 2/27/13 with good intake • Lunch on 2/28/13 diet advanced to soft easy to chew and TPN d/c’d

  27. Cleared for Discharge • Pt was tolerating soft diet with fair intake and supplements. • Pt was discharged home with VNA on 3/2/13 • Pt was told to follow up with surgery for barium enema as an outpatient and eventually reverse her ileostomy

  28. Re-admitted on 3/6/13 • Abdominal pain and minimal output from ileostomy. • Low sodium of 122 on admission • Hyponatremia resolved after hydration • Electrolytes were stable and she was tolerating a full diet. • D/c’d home 3/12/13

  29. Re-admitted 3/20/12 • Fatigue, nausea, and abdominal pain • Found to have another low sodium on admission of 129 • Pt was hydrated and stable • D/c’d home on 3/22/13 • Still follow up with surgery regarding ileostomy

  30. Re-admitted 3/25/13 • Nausea, vomiting, and abdominal pain • Pt vomiting and unable to keep any food or fluids down • Pt was again found to be dehydrated • Sodium on admission 132 • Pt was given fluids and tolerated diet • D/c’d 3/31/13 to nursing home facility

  31. References • Johnson ML. Gastric Secretions: Physiology During Loss and Suggestions for Replacement. Support Line. 2012;34(6);13-18. • Medline Plus. Hydronephrosis. (2013). http://www.nlm.nih.gov/medlineplus/ency/article/000506.htm

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