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Central V ermont medical Center

Central V ermont medical Center. Clinical Case Study Presented by: Tegan Bissell, KSC Dietetic Intern 2012-13. Objectives. Discuss the role of alcoholism in the deterioration of essential organs Understand the physiology of the Pancreas

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Central V ermont medical Center

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  1. Central Vermont medical Center Clinical Case Study Presented by: Tegan Bissell, KSC Dietetic Intern 2012-13

  2. Objectives • Discuss the role of alcoholism in the deterioration of essential organs • Understand the physiology of the Pancreas • Determine the differences between Acute and Chronic Pancreatitis • Determine the clinical manifestations of malnutrition • Meet the case study patient and follow his plan of care and treatment

  3. Central Vermont Medical Center • Montpelier's Heaton Hospital and Barre City Hospital merged in 1963 to form the Central Vermont Medical Center. • 30 distinctive departments employing 1,400 full and part-time employees. • Licensed for 122 inpatient beds

  4. Role of Dietitians Responsible for: • Performing nutrition screening • Assessments • Developing and implementing nutrition care plans • Providing nutrition education to patients, patients’ families, CVMC Medical staff, employees, and outside groups and agencies as required. • Participating on interdisciplinary healthcare teams, departmental and interdepartmental work teams.

  5. Meet Mr. H • 56 year old Male admitted to IP on 7/11/13 with depression, suicidal and EtOH detox

  6. Alcohol Metabolism pubs.niaaa.nih.gov

  7. PMH • Alcohol dependency with alcoholic liver disease • Seizure disorder • HTN • HPLD • Chronic Hepatitis B • GERD • Alcohol induced Pancreatitis • Bipolar disorder • Depression • Anxiety • DJD • Hypothyroidism

  8. The Pancreas

  9. Anatomy of the Pancreas • Glandular tissue and system of ducts • Pancreatic duct merges with the bile duct to form Ampulla of Vater • Leads to duodenum

  10. Pancreatitis Inflammation of the pancreas • Characterized by edema, cellular exudate, and fat necrosis.

  11. Alcohol’s contribution • EtOH is responsible for 30% of AP cases in the US. • AP is common in men aged 35-45 years old from alcohol abuse or gallstones. • Oxidative stress • Increased pressure within ducts • Auto-digestion

  12. Acute Pancreatitis – (AP) • Hyper-metabolic and Catabolic State • Signs of malnutrition: Reduced serum albumin, transferrin, lymphocytes, and serum calcium • Symptoms: • Abdominal pain • Nausea/Vomiting • Abdominal distention • Steatorrhea • Hypotension • Oliguria • Dyspnea • Shock • Coma

  13. Chronic Pancreatitis – (CP) • Evolves slowly over time • Continual attacks of pain radiating into the back • Nausea, vomiting, diarrhea • Increased energy needs • Weight loss • Impaired immune function

  14. Medical Nutrition Therapy

  15. Medications • Antibiotics • Bile salts or fat-soluble vitamins • Diuretics • H2-receptor antagonists • Insulin • Octreotide • Opiates and other pain killers • Pancreatic enzymes • Vitamins and antioxidants

  16. Day 3: 7/13/13 Nutrition consult was received for pt with need for increased Mg and K in diet, as levels are affected by EtOH detox.

  17. Social Hx • Pt is homeless and had been wandering between VT and Maine. • Unable to access shelters while intoxicated and continues to drink. • Has a tent and has been living in the woods at times. • Has been on a current binge for about 2 months. Family hx: • Alcoholic father died at age 43 from suicide, stepfather who hung himself and alcoholic paternal uncles. • Mother’s history unknown.

  18. Diet/Wt Hx • Drinks about 24 beers per day • No special diet • Ht: 5’ 11” Wt: 130# or 59 kg BMI: 17.6 • Sept 2011: 145# • Oct 2011: 175# • June 2013: 137# • 5% wt loss in 1 mo. • Clinical indicators of muscle wasting

  19. Malnutrition ADA/ASPEN Clinical characteristics that the RD can obtain and document to support a diagnosis of malnutrition • Energy intake • Interpretation of weight loss • Physical findings • Body Fat • Muscle Mass • Fluid Accumulation • Reduced grip strength

  20. SOAP Notes • Subjective: • No specific complaints, feels he’s eating well. Discussed high potassium foods and pt likes potatoes.

  21. Objective: • Dx: Depression, EtOH detox • 7# loss noted in last month per Meditech • Calories needed: 25-35 cal/kg 1470-1770 cal/day • Protein needed: 1-1.2g/kg 59-71 g/day • Alternate Equation: Mifflin x 1.2 • Diet: Low Fat, Low Cholesterol Intake: 90% meals • Rx: Folic Acid, Thiamine, KCL, Pantoprozole, Mg, Multivitamins

  22. Assessment: • Unintentional wt loss 2’ mental health issues affecting self care, appetite, and access to calories as evidenced by wt changes, underwt status, and H&P. • Plan: • Provide 1-2 high K foods each meal per pt preferences, Mg not readily repleted by diet – Rec supplement as needed • Not appropriate for diet ed at this time. • RD to follow

  23. Day 5: 7/15/13 • Pt transferred to DSCU this AM with Chest Pain • Put on telemetry monitoring, cardiac enzymes • Nutrition follow up: • S: “I ate all my meals when on IP. I love fish, chicken, potatoes..” • O: Diet NPO this AM, advance to NAS, Low Fat Low Chol • A: Tolerating PO diet with excellent intake, expecting transfer back to IP today. • P: Continue current diet • To follow when admitted back to IP

  24. Day 6: 7/16/13 • New admission back to IP, requires new RD Assessment • Wt: 135# • New PES: Underweight related to poor PO intake prior to admission and EtOH intake as evidenced by BMI, Alb levels, and cachectic appearance. • Current Plan: • Added NAS to current diet order of Low Fat, Low Chol • Nighttime nourishment of PB&J • Calorie count start x3 days

  25. Day 9: 7/19/13 • Nutrition Follow Up: Pt presenting with signs of refeeding syndrome as evidenced by Phos and Mg labs.

  26. Correcting Refeeding Syndrome • Put on QID phos and IV mg • Wt: 141# • Results of Calorie count: 7/17- 2000cal 7/18- 2300cal 7/19- 2537cal • 8% wt gain in 8 days

  27. Day 11: 7/21/13 • Pt positive for pneumonia and emphysema changes. • Vomiting episode this AM • Tired and depressed.

  28. Day 14: 7/24/13 • Improved lung sounds, pneumonia resolving. • Intake has been 100% at all meals. • Pt states the food here is great! • Wt: 142#

  29. Day 16: 7/26/13 • Unable to interview pt • Intake 100%

  30. Day 20: 7/30/13 • Discharge Plans • Electrolytes within normal limits • To go to an assisted living facility in VT • Wt gain 10# over 2 weeks, BMI now 18.99 • Discussed plan to maintain wt and pt confident with strategies to prevent wt loss in the future. • Scheduled for mental health follow up within the next week.

  31. Questions? Thank you!! Tegan Bissell, KSC Dietetic Intern, 2012-2013

  32. References • —Escott-Stump, S. Nutrition and diagnosis-related care. 7th ed. Lippincott Williams & Wilkin; 2012. • Whitcomb DC. Clinical practice. Acute Pancreatitis. N Engl J Med 2006; 354:2142 • Mahan, K. Krause’s Food and Nutrition Therapy. 12th edition. Saunders Elsevier; 2008. • Steer ML, Waxman 1, Freedman S. Chronic Pancreatitis. • N Engl J Med 1995; 332: 1482. • Anand P, Park JH, Wu BU. Modern management of acute pancreatitis. Gastroenterol Clin North America. 2012; 41:1-8. • Gropper, S. Advanced Nutrition and Human Metabolism. 5th ed. Wadsworth, Cengage Learning; 2009.

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