Major case study


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  • -surgical removal of uterus-Surgcal removal of gallbladder-A hernia is the protrusion of an organ through the wall of the cavity that normally contains it from within
  • #1 Ruling it out as a cause of recurrent UTIsFistulas may develop if an infected diverticulum reaches an adjoining organ and forms a connection between themThis most frequently occurs between the large intestine and the bladder, and it can lead to an infection of the neighboring kidneys. Fistulas can occur less commonly between the large intestine and either the skin or the vagina.
  • -ranitidine=zantac= inhibits stomach acid production-Pravachol=pravastatin=lowering cholesterol-Neurontin-to treat nerve pain-escitalopram=to treat depression
  • Who they are, Place and time60-100 = normal resting heart rate for adults ranges from 60-100Lab results are listed in Appendix CLow sodium= kidneys are not working properlyLow potasium= it could be side effect of medication, and also because of vomiting, diarrheaHigh Phos= usually caused by kidney problemsPrealbumin= using the trend it could be indicator of poor intakeA/G ratio= albumin to globulin ration it is indicator of liver function since most enzymes are produced in liver
  • Posterior-Anterior and lateral D5W vs D5NS=isotonic vs hypertonicD5.NS =hypertonic= moves fluid out of the cells and into the circulationZosyn=antibiotic
  • 2.4 L x 50 g dextrose x 3.4kcal/g =408kcal
  • Means 60 percent of total about of blood in the left ventricle is pushed out with each heart beat
  • -dilaudidPeripheral parenteral nutrition
  • IBW= 209% it is>160% IBW 15-20ml/kg
  • Inadequate fiber intake related to poor food choices as evidenced byInadequate fluid intakeInappropriate intake of types of carbohydratesAs recommended the goal was to slowly begin low-fiber nutrition therapy until inflammation and bleeding are no longer a risk.High fiber diet meaning 6-10 g beyond the standard recommendations of 20-35 g per dayEmphasize the sources of insoluble fiber or fiber supplements if dietary intake is not sufficient.Ensure adequate fluid intake as fiber amount increase
  • Pt will identify and reduce intake of specific foods that result in pain, diarrhea, constipationThe pt will identify the food choices that are higher in fiberThe pt will identify sources of probiotic
  • 2.4 liters x 50gm dextrose/liter x 3.4 calories/gm dextrose= 408 caloriesOveral 1500 ml of PPN =670 Kcal
  • Presence of sac like pouches involving the mucosal layer of the colon. Substantial rise in colonic diverticula with in the past few decades. It affects approximately 5% to 10% of the population by age 50.Long-term changes in dietary intake during human evolution may have contributed to the onset of this disease process( the fairly rapid changes that occurred over the last 200 years in industrialized nations have displaced a once high fiber diet with more refined food items that are lower in fiber and these changes may not be compatible with human digestive abilities.50-60%in patients older than age 80 yearsAge related changes in collagen composition or lack of exercise have been suggested as risc factors for the diseaseConstipation caused by low fiber diet may cause people to strain when passing stool during bowel movement, which may increase pressure in the colonThe increased pressure may cause the colon lining to bulge out through weak spots in the colon wall.2
  • Diverticulosis is generally asymptomatic and usually diagnosed when individuals undergo gastrointestinal tests such as colonoscopy.Some pt may have elevated white blood cell count or gastronintestinal bleedingPain is Severe and comes onsuddenley
  • Treatment of Divericulosis includes nutrition therapy focused on fiber intake and probiotic and prebiotic supplementation Medical treatment for diverticulitis includes an order for nothing by mouth with complete bowel restAntibiotics to treat infection if presentDietary fiber contributes to both fecal bulk and a decreased stool transit time.
  • High fiber diet causes more frequent bowel movements and that increases the risk of diver
  • Probiotic prevent attacks of diverticulitis completely or significantly reduce frequency of attacks an increase of 6-10 g fiber above the recommended amount fo 25-35 g a day is not easy and dietitions need to talk to their pt to advice them ways to increase their fiber intake.
  • Major case study

    1. 1. Vehik Nazaryan Dietetic Intern University of Maryland College Park January, 30, 2014
    2. 2. Overview      Case Report • General Information • Social History • Medical History • Nutritional History • Medical Course of the Patient Case Discussion Implications of Findings to the Practice of Dietetics References Questions
    3. 3.     The Patient: “MS”, 66 year old obese Caucasian female Admitted with abdominal pain, nausea, vomiting and acute diverticulitis with suspected colorectal bladder fistula She was diagnosed with diverticulitis and colovaginal fistula ( the probable cause of continued urinary infections) Total hospital stay – 8 days • admitted on 09/30/2013 and was discharged to home on 10/07/2013 8days
    4. 4.  Education: High school education  Occupation: Retired  Marital Status: Divorced with one daughter and brother  Smoker: Tobacco history of 40+ years of 1-2 packs of cigarettes a day, prior cessation a month ago was reported
    5. 5.  Past medical Hx includes: • Hypercholesterolemia( 10+years) • Barrett Esophagus ( 10 Years) • Chronic pain with possible fibromyalgia • Chronic Bronchitis with Asthma • Dyslipidemia • Lumbar Degeneration • Morbid Obesity • Chronic Obstructive Pulmonary Disease (COPD) • Depression • Chronic Back Pain Barrett’s Esophagus
    6. 6. Surgical History •Total abdominal Hysterectomy (1995) •Cholecystectomy (1975) •Abdominal Hernia Repair (1990) •Bilateral cataract Surgery (2011 and 2013) Urinary Tract History •20+ UTI with most recent MUMH visit ~2 weeks ago •Symptoms in past several months include progressive lower abdominal pain Some chills Suprapubic discomfort
    7. 7.   Esophagogastroduodenoscopy + colonoscopy demonstrated no colovesical fistula caused by diverticulitis Pt denies • Hematuria, • Urinary urgency, frequency or dysuria.
    8. 8.  MS was admitted with following medications: • Zantac 300mg, BID • Pravachol 40mg, daily • Neurontin 400mg BID • Escitalopram 20mg,
    9. 9.  MS was admitted to MUMH Weight :127kg, 280lb Temperature: 36.4C Blood Pressure: 119/65 mmHg Pulse: 91 beats/minute Respiration:18 Alert and orientedx3 Abdomen: obese, mildly tender over suprapubic area • Laboratory studies: within normal limits except Glucose:163 • • • • • • •
    10. 10. Day Day 1 Date 09/30/2013 Diagnostic Test Results 1.Chest, PA and LAT 1.No active pulmonary disease 2.Esaophagogastroduodenoscopy plus colonoscopy 2. Acute diverticulitis • Medical treatment, Day 1 Zosyn 3.375g IV, every 6 hr for acute diverticulitis Pt was placed on cardiac monitor, no arrhythmias Stool culture sent for C.diff Diet=NPO +ice chips + D5.NS at 100ml/hr
    11. 11. Day Date Diagnostic Test Day 2 10/01/2013 Surgical Pathology 1.Duodenum, Biopsy 2. Stomach, Biopsy 3.GEJ, Biopsy Results 1. Normal findings 2. Mild inflammation, negative for H-Pylori 3. Epithelial changes consistent with GERD 4. Colon, Biopsy (distal Sigmoid) 5. Rectal Biopsy 4. Normal findings CT Abdomen Pelvis 1. Unchanged appearance of acute diverticulitis of the sigmoid colon. 2. Contrast suggests colovaginal fistula 5. Normal Findings •Medical Treatment, Day 2 Diet= NPO+ Ice Chips+ D5.NS at 100ml/hr
    12. 12. Day Date Diagnostic Test Results Day 3 10/02/2013 Echocardiogram/ECHO Ejection fraction of 60% otherwise normal Day 4 10/03/2013 Chest X-ray, PA and LAT Normal findings
    13. 13. Medical Treatment, Day 3, No acute findings Gynocologist surgeon, the fistula may close on its own with bowel rest Diet: NPO, started PSS/PPN Zosyn continues IV dilaudid for significant pain D5.NS at 100ml/hr Day 4 Diet: NPO +PSS/PPN, No acute findings Day5 Diet: NPO +PSS/PPN, No acute findings Day6 Diet: Breakfast: Full Liquid, Lunch: GI Soft, Dinner: Regular No acute findings, Fistula presumed to have healed Day7 Diet: Regular, Pt was discharged
    14. 14.  • • • • • Diet History Eating a regular diet with no restrictions Eating less lately, having nausea for ~3months Drinking Vanilla Ensure once a day Last Po intake= ½ of an apple, 2 days before admission Cultural Attitudes that may affect intake: Non reported • Weight history 12-13lbs weight loss in one month BMI:44, morbidly Obese UBW:294lbs  Physical Activity= Sedentary  • •
    15. 15. Obese Adults [(kg body weight -20] + 1.500 = 3,105 ml
    16. 16. Obese Adults [(kg body weight -20] + 1.500 = 3,105 ml
    17. 17. Initial Nutrition Consult: 10/01/2013 Diagnosis, 10/01/2013 1-Inadequate energy-protein intake related to diet order as evidenced by pt NPOx2days with h/o limited intake PTA. 2- Involuntary weight loss related to decreased intake as evidenced by self reported 13lbs weight loss in a month PTA  Diet Recommendation: Advance pt diet to clear liquid and then to low residue /low fiber as tolerated.
    18. 18. Nutritional Interventions: • Recommend physician order a general low residue/low fiber diet. • Add commercial beverage • provide diet education for diverticulitis and fistula Nutritional goals • Goal1: Pt receive adequate PO/nutrition support within next 1-2 days • Goal2: Achieve normal GI function • Goal 3: meet 70% Kcal and nutrient needs by next day • Goal 4: Pt will be able to describe why a diet is necessary and list at least two foods to avoid or eat in limited amounts.
    19. 19. Diagnosis, 10/04/2013 Inadequate energy-protein intake related to NPO/CLD x 5days as evidenced by diet order that does not meet estimated energy needs. Diet Recommendation: Advance pt diet to clear liquid and then to low residue /low fiber as tolerated.
    20. 20. Nutritional Interventions: • Recommend physician order a general low residue/low fiber diet. • Add commercial beverage (Ensure x 1/d) • provide diet education for diverticulitis and fistula Nutritional goals • Goal1: Pt receive adequate PO/nutrition support within next 1-2 days • Goal 2: meet 70% Kcal and nutrient needs by next day • Goal 3: Pt will be able to describe why a diet is necessary and list at least two foods to avoid or eat in limited amounts.
    21. 21.  Diverticulosis: • A gastrointestinal disease that affects the colon • Disease of Western Civilization because of its geographic preponderance • Rare in rural Africa and Asia, highest prevalence in the USA, Europe and Australia • Caused 814,000 hospitalization and 2, 889 deaths(2010)  Diverticular disease: • Diverticulosis=Presence of pouches(diverticulas) in the colon • Diverticulitis= when pouches become inflamed or infected (cause of inflammation is not clear, may be fecal bacteria
    22. 22.  • • • • • Risk Factors: Age Low fiber diet Obesity Sedentary life style Note: MS is positive for all four of them Symptoms: • Most common symptom= abdominal pain • May experience nausea, vomiting, fever, chills, loss of appetite  Diagnosis: • Most common diagnostic test= CT scan • Colonoscopy, digital rectal exam, blood test, stool sample 
    23. 23. Medical Treatment: • Intravenous antibiotics • Bowel rest NPOClear liquid diet for few days  adding soft solids regular diet) • Colon resection for patients with recurrent, resistant DV Nutritional Therapy (DV) • Focused on fiber intake and probiotic and prebiotic • To reduce the luminal trauma, avoid high-residue foods( such as nuts, seeds, popcorn) Norte: Recent literature has indicated that these recommendations are controversial and that avoidance is not necessary
    24. 24.   Many clients use Complementary and Alternative Medications(CAM) Common CAM therapies:  Glutamin, omega-3 fatty acids, prebiotics, herbs,  wild yam, marshmallow, chamomile, licorice  Homeopathy  Acupuncture
    25. 25. • Evidence suggesting that high fiber diet can help prevent diverticular disease is based largely on observational, epidemiological studies and few small clinical studies. • Recent study found high fiber diet may increase the prevalence of diverticulosis. • Not enough evidence to support general recommendation of low fiber diet during diverticulitis flare-ups
    26. 26. • New studies purport that pt may benefit from consumption of probiotic. • Based on review of available research it is reasonable to recommend high-fiber diet until large scale, well conducted randomized controlled longitudinal studies demonstrate a clear benefit of failure of this practice • Dietitians need to teach patients how to increase their fiber intake
    27. 27. References Diverticular Disease: University of Maryland Medical Center. Source: Accessed November 11, 2013. National Digestive Diseases Information Clearinghouse (NDDIC). Source: Accessed December 13, 2013. Painter N, Burkitt D. Diverticular disease of the colon: A deficiency disease of Western civilization. BMJ. 1971; 2:450–454. Diverticulosis and Diverticulitis: National Institute of Diabetes and Digestive and Kidney Diseases. Source: Accessed December 31, 2013. Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004; 363: 631-639. Brodribb AJ. Treatment of symptomatic diverticular disease with a high-fiber diet. Lancet 1977; 1: 664–66. Strate L, Yan L, Walid A, Sapna S, Edward L. Giovannucci. Obesity Increases The Risks Of Diverticulitis And Diverticular Bleeding. Gastroenterology. 2009; 136(1):115-122. Tursi A. The current and evolving treatment of colonic diverticular disease. Alimentary Pharmacology & Therapeutics. 2009; 30: 532-546. Rees Carol. Diverticular Disease: Evidence for Dietary Intervention? Nutrition Issues In Gastroenterology. 2007; 47: 41-46. Schechter S, Mulvey J, Eisenstat TE. Management of uncomplicated acute diverticulitis: results of a survey. Dis Colon Rectum 1999; 42: 470– 475 Dietary Guidelines for Americans 2010: Fiber. Source: Accessed December 6, 2013 Academy of Nutrition and Dietetics, Nutrition Care Manual. Diverticular Conditions. 0Care. Accessed January 29, 2014.
    28. 28. Thank You!