Brittany Pinkos, a 54-year-old female with a history of gastrointestinal and mental health conditions including gastroenteritis, irritable bowel syndrome, bipolar disorder, and depression, presented with severe abdominal pain and vomiting. She had lost weight and appeared thin. Her medications could cause side effects like loss of appetite and diarrhea. The nutrition assessment found inadequate oral intake due to inability to consume enough due to pain. The plan was to continue her gluten-free and low milk protein diet, add a FODMAP diet, provide a nutritional supplement to prevent further weight loss and increase intake. Follow up would monitor weight and symptom changes but the patient was discharged before further evaluation.

1. CASE STUDY Brittany Pinkos

2. ASSESSMENT
54 y/o female
Caucasian, Married, lives at home with husband
Presented to Adventist ED with severe abdominal pain with N/V/D
Current diagnosis: Gastroenteritis
PMH: GERD, IBS, Bipolar Disorder, Depression, Fibromyalgia, Small
Bowel Obstruction, Asthma

3. ANTHROPOMETRICS
Height: 162.6 cm
Weight: 52 kg WNL
BMI: 19.68 WNL
IBW: 54.5 kg
% IBW: 95% WNL

4. FOOD/NUTRITION RELATED HX
No food allergies, chewing, dental or swallowing problems
Hx of IBS and small bowel obstruction
Decreased eating habits
Current appetite: poor
N/V/D
Past Diet prescriptions: Gluten Free, Low milk protein, No sucralose
No 24 hr recall available- pt was NPO

5. NUTRITION FOCUSED PHYSICAL
ASSESSMENT
Physical appearance: thin, wasting
Muscle and fat wasting: slightly apparent
Swallowing function: Normal
Appetite: poor
Affect: sleepy, lethargic, stomach pain

6. LABORATORY DATA
Laboratory Test Normal Values Date: 3/25 3/26 3/27
Diet order NPO CLD Full liquids/
regular diet
Height 162.6 162.6 162.6
Weight 52 52 52
Blood Pressure 120/80 101/47 104/46
Albumin >3.5 3.6
I&O 1418.7ml / 0ml

7. DISCUSSION OF LABORATORY
DATA
Patients laboratory data in WNL
Intake and output are not balanced
 Could be due to SOB
 Could be do to emesis

8. MEDICATIONS
Date: Medication & Amount: Purpose or Function: Significant Nutritional Implications
3/24/15 NS 1000 ml @
100ml/hr
Used to mix or dilute
medications
None known
3/24/15 NaCl @ 125 ml/hr Replacing fluids None known
3/25/15 Bupropion Anti-depressant Vomiting, loss of appetite, weight
loss, constipation, Difficulty
breathing/swallowing
3/25/15 Docusate Stool Softener Diarrhea, throat irritation, bitter taste,
cramping, bloating
Prednisone
3/day @ noon, 1 wk
Steroid Nausea, vomiting, loss of appetite,
unusual weight gain
Formoterol- Mometaso
2 puffs BID
Combo: corticosteroid and
long-acting beta antagonist
Shortness of breath/trouble
breathing, sore mouth or tongue
Lexapro
2 tabs daily
Treat anxiety and MDD Increased thirst, shortness of breath,
constipation, diarrhea, dry mouth, gas
in stomach, bloated or full feeling,
decreased appetite

9. DISCUSSION OF MEDICATIONS
Medications will relieved symptoms of depression/anxiety
Depression/anxiety can cause constipation or diarrhea leading to
pain
Mineral oils can increase the absorption rate of Docusate
Pt is not experiencing any major side effects of medications, diarrhea
and constipation can be related to medication but in this case is most
likely related to her conditions.

10. CURRENT: GASTROENTERITIS
Also known as the stomach flu Stomach flu
Inflammation of the lining of the intestines caused by a virus, bacteria
or parasite
Symptoms include diarrhea, abdominal pain, vomiting, headache,
fever and chills
Most common problem is dehydration- not replacing fluids lost
Pathophysiology: Rotavirus infections induce malabsorption of CHO
and their accumulation in the intestinal lumen, malabsorption of
nutrients and inhibition of water reabsorption leading to diarrhea
http://www.nlm.nih.gov/medlineplus/gastroenteritis.html
http://my.clevelandclinic.org/health/diseases_conditions/hic_Gastroenteritis
http://emedicine.medscape.com/article/176515-overview#a0104

11. CURRENT: IRRITABLE BOWEL
SYNDROME
Recurrent abdominal pain or discomfort at least 3 days/month in at
least 3 months that started 6 months before diagnosis, cannot be
explained by a structural or biochemical abnormality, and is
associated with one of the following: improvement with defecation,
onset associated with a change in frequency of stool, and onset
associated with a change in form of stool
No physiological mechanism
Biopsychosocial disorder resulting from an interaction of a variety of
factors
 Visceral hyperalgesia, genetic and environmental factors, infection, inflammation,
gut motility, psychological factor
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroente
rology/irritable-bowel-syndrome/Default.htm

12. PAST: BIPOLAR DISORDER
Chronic recurrent illness associated with high rates of morbidity,
disability, and premature death from suicide
Pathophysiology in under investigation
Lines of evidence point to one or more mitochondrial energy production
defects as a basis
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-
psychology/bipolar-disorder/

13. PAST: DEPRESSION
Mood disorder that causes persistent feeling of sadness and loss of
interest, affects how you feel, think, and behave and can lead to a
variety of emotional and physical problems
Pathophysiology: not clearly defined
 Disturbance in CNS serotonin activity
 Vascular lesions- disrupt the neural networks involved in emotion regulation
 Decrease metabolic activity in neurocortical structures and increased activity in
limbic structures
http://www.mayoclinic.org/diseases-conditions/depression/basics/definition/con-
20032977
http://emedicine.medscape.com/article/286759-overview#aw2aab6b2b3

14. PAST: FIBROMYALGIA
Characterized by widespread musculoskeletal pain accompanied by
fatigue, sleep, memory and mood issues
Pathophysiology includes neuroendocrine problems, autonomic
nervous system problems genetic factors, psychosocial factors,
environmental factors
Co-morbid conditions include: IBS, major depressive or anxiety
disorders
http://www.mayoclinic.org/diseases-conditions/fibromyalgia/basics/definition/con-
20019243
http://www.news-medical.net/health/Fibromyalgia-Pathophysiology.aspx

15. PAST: ASTHMA
http://www.mayoclinic.org/diseases-conditions/asthma/basics/definition/con-
20026992
http://emedicine.medscape.com/article/296301-overview#aw2aab6b2b4
Condition in which the airways narrow, swell and produce excess
mucus making breathing difficult and trigger coughing, wheezing and
SOB
Pathophysiology involves inflammation of the airway, intermittent
airflow obstruction, and bronchial hyper-responsiveness
 Antigen presentation by dendritic cells with the lymphocyte and cytokine response
can lead to inflammation of the airway and symptoms of asthma

16. PAST: SMALL BOWEL
OBSTRUCTION
When either the small or large intestine is either partially or
completely blocked
Blockage prevents food, fluid and gas from passing through the
intestines, can cause severe pain
Tumors, scar tissue, twisting or narrowing of the intestines from
diverticulitis or IBD, hernias, Crohn’s disease, cancer, severe
constipation, foreign objects
http://www.webmd.com/digestive-disorders/tc/bowel-obstruction-topic-overview

17. PAST: SMALL BOWEL
OBSTRUCTIONPathophysiology: SBO leads to proximal dilation of intestines due to
accumulation of GI secretions and swallowed air, dilation stimulates
cell secretory activity leading to more fluid accumulation
 leads to increase in peristalsis above and below obstruction resulting in frequent
loose stools and flatus at the beginning of its course
Vomiting can occur if obstruction is located in proximal SI, increasing
SB distention leads to increased intraluminal pressure causing
compression of mucosal lymphatics (bowel wall lymphedema)
 Increased hydrostatic pressure leads to high pressure in capillaries resulting in
massive third spacing of fluid, electrolytes and protein into intestinal lumen,
leading to fluid loss and dehydration
Strangulated SBO associated with adhesions and occur when a loop of
distended bowel twists to the mesenteric pedicle
 Can result in bowel ischemia and necrosis
http://emedicine.medscape.com/article/774140-overview#aw2aab6b2b2aa

18. MEDICAL CONDITIONS/DIAGNOSIS
INTER-RELATIONSHIPS
Fibromyalgia most likely due to diagnosis of IBS (77%) and depression
Inflammation from IBS can lead to SBO
People with IBS frequently suffer from anxiety and depression,
possibly bipolar disorder
 50-90% chance of untreated IBS pts have psychiatric disorders such as anxiety or
depression
IBS onset is likely after a bout of gastroenteritis
Depression symptoms can be common in those with asthma

19. REFERENCES FOR
INTERRELATIONSHIPS OF MEDICAL
CONDITIONS/DIAGNOSIS
ttp://www.adaa.org/understanding-anxiety/related-
illnesses/irritable-bowel-syndrome-ibs
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1409087/pdf/annsur
g00933-0005.pdf
http://www.aboutibs.org/site/what-is-ibs/intro-to-ibs/post-
infectious-ibs
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181132/
http://www.currentpsychiatry.com/the-publication/past-issue-
single-view/irritable-bowel-syndrome-and-psychiatric-illness-
three-clinical-challenges/c49b2264ef7ffd2ef0c2ce7de4a9ed6d.html

20. ASSESSMENT OF NUTRITION
NEEDS
Calories= 52 kg, 30-35 kcal/kg bw
52 kg x 30 kcal = 1560 kcal
52 kg x 35 kcal= 1820 kcal
1560- 1820 kcal/ day
Rationale: pt is losing weight and seems to be wasting, increase calories to avoid losing
additional weight.
Protein= 52 kg, 1.0-1.2 g/kg bw
52 kg x 1.0 g = 52
52 kg x 1.2 g = 64
52-64 g PRO/ day
Rationale: Pt appears to be wasting, increase protein to gain back protein stores and
recovery
Fluid= 52 kg, 1560-1820 kcal/day
1ml/kcal= 1560-1820 ml/day

21. Domain Check if Pt.
presents with this
characteristic
If checked, explain
INTAKE
Energy Balance X Pt is not consuming enough energy d/t nausea and
pain
Oral or Nutrition Support
intake
Fluid intake X Pt is unable to consume enough fluid d/t nausea
Bioactive substance intake
Nutrient intake X Pt is on restrictive diet due to IBS
CLINICAL
Functional
Biochemical
Weight X Pt is losing weight d/t restrictive diet and pain
BEHAVIOR-
ENVIRONMENTAL
Knowledge & beliefs

22. NUTRITIONAL DIAGNOSIS
Inadequate oral intake related to inability to consume sufficient energy
as evidenced by weight loss, severe abdominal pain, IBS, Hx of small
bowel obstruction

23. INTERVENTION PLAN
Current diet: Gluten Free, Milk protein free, Sucralose free
My recommendation: Continue current diet with addition of FODMAP
diet and Nutritional supplement: ensure
Goal: Prevent further weight loss, increase oral intake (50-75%),
relieve symptoms of IBS and gastroenteritis
Education: NCM handout on IBS, WedMD handout on FODMAP diet
 Pt was highly motivated, compliance was unmeasurable
 Educated Pt and husband
 No known barriers to learning

24. NUTRITION PRESCRIPTION
Date: Diet prescription/order
3/25/15 CLD
3/25/15 NPO
3/26/15 CLD, advance as tolerated
3/27/15 Full liquid diet, advance as tolerated
3/27/15 Regular diet, advance as tolerated
Discussion:
Pt was originally on CLD, regressed to NPO on accident per pt, progressed to regular diet
quickly with being able to tolerate clear liquids and full liquids nicely.

25. HEALTH CARE OUTCOME
Intervention Health & Disease
Outcomes
Cost Outcomes Patient Outcomes
FODMAP diet Relieve symptoms
of IBS
Cost of food Improved quality of
life
Nutritional
Supplement
Prevent weight loss,
prevent deficiencies
Cost of Supplement Improved quality of
life, decreased
hospital visits

26. MONITOR AND EVALUATION
Weight will be used to measure weight gain or loss
Pt reported symptoms will measure diet tolerance
Was unable to f/u with patients because of discharge