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L.M. 52 y.o . female. Maureen Donah 2013 Sodexo Southcoast Dietetic Intern. Past Medical History. COPD Type 2 Diabetes Hyperlipidemia Obesity Fibromyalgia Hx of recent UTIs Kidney Stones Irritable Bowel Syndrome Depression. L.M. was admitted 1/8/13. Caucasian

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l m 52 y o female

L.M. 52 y.o. female

Maureen Donah 2013 SodexoSouthcoast Dietetic Intern

past medical history
Past Medical History
  • COPD
  • Type 2 Diabetes
  • Hyperlipidemia
  • Obesity
  • Fibromyalgia
  • Hx of recent UTIs
  • Kidney Stones
  • Irritable Bowel Syndrome
  • Depression
l m was admitted 1 8 13
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

emergency room
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

procedure 1 9 13
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
the plan
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
the plan1
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
re admitted 1 25 13
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

rd assessment 2 4 13
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
2 5 13 surgery
2/5/13 Surgery
  • Dx: Sigmoid diverticulitis with colovesical fistula
  • Laparotomy with sigmoid colon resection and repair of colovesical fistula
nutrition after fistula repair
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
2 13 13 pod 8
2/13/13 POD#8
  • Anastomotic leakage
  • Confirmed by a barium enema
  • Procedure: Diverting loop ileostomy
nutrition after ileostomy
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
the plan2
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 ?
nutrition support tpn 2 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
day 2 tpn 2 16 13
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
day 3 tpn 2 17 13
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
day 4 tpn 2 18 13
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
2 18 13
2/18/13
  • Vomited
  • KUB showed multiple dilated small bowel loops, consistent with a small bowel obstruction.
  • Started NGT to LWS 1500cc output
day 5 tpn 2 19 13
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?
day 6 tpn 2 20 13
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

gastric secretions
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.

gastric secretions1
Gastric Secretions

* No blood gas labs taken

day 7 tpn 2 21 13
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
day 8 tpn 2 22 13
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
tpn continues
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
cleared for discharge
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
re admitted on 3 6 13
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
re admitted 3 20 12
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
re admitted 3 25 13
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
references
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