Nutrition Database

This assignment is intended to collect information and apply Medical Nutrition Therapy related knowledge to a disease condition. All data will be kept confidential and anonymous, no patient names, initials,

room numbers, birth dates, or other personal identifiers will be collected.

Intern Name Megan Lasko Clinical Core Rotations: Basic / Intermediate / Advanced

Patient Age 32 Sex Male Female Your Assessment Date 12/05/16 Admit date 12/01/16

Admitting Diagnosis Acute pancreatitis

Prior Medical History No prior medical history aside from “anxiety”. Patient presented to the ER because of his severe

conjunctivitis (pink eye) in each eye and associated headaches. Further interview w/ ER medical staff revealed that

patient was experiencing nausea, vomiting, diarrhea, and a severely decreased appetite for 1 month. During ER

interview, suspicions arose that the patient was intoxicated, and it was found that his ETOH lab was 400 mg/dL and

his Lipase lab was 669 u/L. Patient was admitted to the ICU w/ an acute pancreatitis secondary to alcohol abuse

diagnosis. Other diagnoses that the MD charted for this current admission were: 1) acute metabolic encephalopathy

secondary to alcohol abuse, 2) alcohol intoxication, 3) coagulopathy w/ thrombocytopenia, 5) Protein-calorie

malnutrition, 6) allergic conjunctivitis, 7) tobacco abuse, and 8) hypokalemia.

Diet Order Clear Liquid (was NPO until 12/2/16) Supplements None

If applicable, describe food intake since admission or past 5 days (use percentages, expressed as a range or an average,

describe other pertinent issues or if common in facility mark checkbox on right to specify) Good Fair Poor

The patient was admitted NPO due to his acute pancreatitis. On day 2 of his stay, his diet was advanced to clear liquids, but the

patient’s wife @ bedside stated he was too sedated and lethargic to eat anything. Today (12/5/16), day 4 of his admission, patient

was observed consuming 100% of a fruit ice, 100% bowl jello, and 100% of his ginger ale. Patient’s wife at bedside stated it was the

patient’s first day he was eager to eat.

Any Food Allergies / Intolerances? No

Height and Weight: HT (in inches and cm) 68 inches, 173 cm Current WT (in pounds and kg) 157 lb, 71.4 kg

BMI23.93 kg/m2

How was height obtained? Taken by RN How was weight obtained? Scale

Ideal Body Weight (IBW) 154 lb, 70 kg % IBW 102 % Usual Body Weight (UBW) 175 lb, 79.4 kg (per wife @

bedside) % UBW 90%

If the patient had a weight change, indicate this in pound and kg and % gained/lost and the timeframe. Was this

unintentional or intentional? Give the reason(s). Using the cutoff-percentages was this loss/gain significant?

Patient had a 18 lb (8 kg) weight loss in 1 year (per wife at bedside). This was unintentional and due to patient’s

decreased appetite, likely secondary to his alcoholism that started about 1 year ago as a mechanism to cope with his

anxiety (per patient’s H&P note). This amount of weight loss is not significant (>20% in 12 months is considered

significant according to the AND/A.S.P.E.N. guidelines used at my facility).

Nutrition Database

if applicable Dry Weight (in pounds and kg)N/A

if applicable in your facility: What is the patient’s adjusted weight (in pounds and kg) N/A

Social History (occupation, marital status, support system at home, alcohol use, who prepares meal, food secure / insecure, etc.)

Patient is a full-time construction worker. He is married and lives with his wife. During the interview with his wife, it was

revealed that she prepares meals for him despite his progressive lack of appetite that has worsened since the onset

of his alcoholism 1 year ago. Several friends and family members were seen visiting his hospital room throughout

the day, indicating a solid support system.

Advance Directive: Yes No Nutrition related implications?

Skin Integrity / Chewing and Swallowing Ability / Misc. Info

Is Patients Skin Intact? Yes No Braden Score 16 PUSH Score

If no, what is present? Surgical Wound Decubitus Ulcer

Does the patient have Edema if pitting, state stage and site Ascites

If decubitus ulcer, list stage (I-IV) and site(s)

If decubitus ulcer, is it Improving? Getting worse?

Incontinent of urine? Yes : Some urinary incontinence until 12/4; resolved over course of stay No

Urinary catheter? Yes No output in mL over past 24 hours 2675 mL

Date of last BM & consistency 12/5/16; consistency not documented Bathroom privileges Yes No

Are any of the following present? Nausea (prior to admission) Vomiting (prior to admission) Diarrhea

(prior to admission) Constipation

Difficulty Chewing Difficulty Swallowing

Own teeth Edentulous

Dentures? Yes No Fit well? Yes No

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Unable to feed self Malabsorption

Early Satiety Taste Changes

Is patient on dialysis? Yes No if yes, what type Schedule

Is patient on a ventilator? Yes No

Most recent blood pressure 120/81 is BP stable? Yes No

Most recent temperature 101.1 °F

Is patient receiving IV Fluids? Yes No if yes, what type / rate / total volume in past 24 hours

Type: Magnesium Sulfate, Rate: 1 g dose/100 mL per hour – over 1 hour (once daily), Vol in

Past 24 hr: 100 mL

Type: Potassium Chloride, Rate: 20 mEq dose/50 mL per hour – over 2 hours (once daily), Vol

in Past 24 hr: 50 mL

Type: Sodium Chloride 0.9% infusion, Rate: 100 mL/hr (continuous), Vol in Past 24 hr: 2400

mL

If applicable, how many g Dextrose and kcal does this provide? N/A

Pertinent Medications (list medications, state what they are used for, and if applicable nutritional implications)

Drug name(s) Indication Nutritional Implication / food Interaction

Acetaminophen (Tylenol) tablet 650 mg

Analgesic (pain relief) Diet Implications: Vitamin C may ↑ risk of toxicity, Caffeine ↑ rate of abs. & effect of drug

Chlordiazepoxide (Librium) capsule 25 mg

Acute Alcohol Withdrawal Treatment (also may have been used for sedative effects with this patient)

Diet Implications: Limit caffeine to <400-500 mg/day (may decrease sedative effect), Sedative herbal products may increase the sedative effects Nutr Symptoms: Anorexia, weight loss, increased appetite, increased thirst Oral/GI Symptoms: Dry mouth, increased salivation, N/V, constipation, diarrhea

Clonidine (Catapres-TTS-3) 0.3 mg/24 hour TD weekly patch

Analgesic (pain relief); also treats withdrawal symptoms of alcohol addiction

Diet Implications: Insure adequate fluid intake/hydration Nutr Symptoms: Increased weight d/t edema, anorexia Oral/GI symptoms: dry mouth, N/V, constipation

Desmedetomidine (Precedex) 200 mcg in

Sedative – this patient was found to be combative on his stay on the Med-Surg floor and was thus moved to the ICU so he could be put on Precedex; was d/c

Oral/GI symptoms: N/V

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sodium chloride 0.9% 50 mL infusion (note: medication was discontinued momentarily before my assessment was performed)

right before my visit w/ this patient and preparations were being made to transfer him back to Med-Surg

Enoxaparin (Lovenox) subcutaneous injection 40 mg

Anticoagulant: Likely used for DVT prophylaxis in this patient; also “coagulopathy w/ thrombocytopenia” charted by MD as active problem

N/A

Folic acid injection 1 mg B Complex Vitamin Supplementation; Folate is one of several micronutrient deficiencies that commonly occur w/ chronic alcoholism

Nutr Implications: RDA for folic acid 400 ug/day

Guaifenesin (Mucinex) 12 hr tablet 600 mg

Expectorant: promote secretion of sputum by air passages, treats coughs

Oral/GI Symptoms: N/V, GI Distress, diarrhea

Ipratropium (Atrovent) 0.02% inhalation solution 0.5 mg

Bronchodilator Oral/GI Symptoms: dry mouth/throat, metallic bitter taste, nausea, dyspepsia

Lactulose 20 g/30 mL oral solution 20 g

Laxative used to treat high Ammonia levels (pt presented w/ elevated ammonia @ 76 umol/L; also prevents/treats portal-systemic encephalopathy (MD charted for acute metabolic encephalopathy secondary to alcohol abuse)

Diet Implications: To prevent constipation should be given w/ high fiber and 1500-2000 mL fluid/day. Should not be taken concomitantly w/ antacids, Ca, or Mg supplements Nutr Implications: Increases the absorption of Ca and Mg Oral/GI symptoms: N/V, belching, cramps, borborygmi, diarrhea, flatulence

Levalbuterol (Xopenex) inhalation solution 1.25 mg

Antiasthma, bronchodilator Diet Implications: Limit caffeine/xanthine Nutr Implications: Increased appetite or anorexia Oral/GI symptoms: Peculiar taste, sore/dry throat

Lorazepam (Ativan) 2 mg/mL injection 2 mg

Benzodiazepine – like Librium – see info for “Chlordiazepoxide (Librium) capsule 25 mg” above

Nicotine (Nicoderm CQ) 21 mg/24 hr TD 24 hr patch 21 mg

Pt indication: regular smoker outside of hospital

Odansetron (Zofran) injection 4 mg

Anti-emetic/anti-nauseate Oral/GI symptoms: dry mouth, abdominal pain, constipation, diarrhea

Nutrition Database

Oxycodone (Roxicodone) IR tablet 5 mg

Analgesic (Pain Relief) Diet Implications: Caution w/ grapefruit Nutrition Implications: Anorexia Oral/GI Symptoms: dry mouth, dyspepsia, gastritis, N/V, diarrhea, constipation

Pantoprazole (Protonix) injection 40 mg

Anti-GERD, Anti-secretory Diet Implications: May decrease the absorption of iron, decreases the absorption of B12 Oral/GI Syptoms: nausea, abdominal pain, diarrhea

Piperacillin-tazobactam (Zosyn) 3.375 g in sodium chloride 0.9% 50 mL IVBP

Antibiotic Nutr Implications: Anorexia Oral/GI Symptoms: black hairy tongue, dry mouth, taste changes, oral candidiasis, N/V, epidgastric distress, diarrhea, flatulence

Potassium chloride (K-dur, Klor-con) CR tablet 40 mEq

Electrolyte, Mineral Supplement (to treat patient’s hypokalemia upon admission)

Diet Implications: Do not take w/ salt substitutes Nutr Implications: No RDA for K Oral/GI Symptoms: GI Irritation, N/V, abdominal pain, diarrhea, flatulence

Rifaximin (Xifaxan) tablet 550 mg

Antibiotic; traveler’s diarrhea treatment Oral/GI Symptoms: Nausea, stomach pain

Thiamine (Vitamin B1) injection 100 mg

B Complex Vitamin Supplementation; B1 is one of several micronutrient deficiencies that commonly occur w/ chronic alcoholism; used to prevent Wernicke/Korsakoff Syndrome d/t chronic alcohol abuse

Nutr Implications: Increased thiamin requirement w/ high CHO intake; RDA: 1.2 mg/day Oral/GI Symptoms: Nausea can occur w/ IV administration

Tramadol (Ultram) tablet 50 mg

Analgesic (pain relief) Diet Implications: Caution w/ SJW Nutr Implications: Anorexia Oral/GI Symptoms: dry mouth, dyspepsia, N/V, abdominal pain, constipation, diarrhea, flatulence

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Nutrition related laboratory values

Lab Test

Lab values list all that are available –

indicate if abnormal high or low ( or )

and if applicable, state if they are

trending up or down.

Nutritional significance if abnormal Can a nutrition intervention help to correct this abnormal lab value? How?

Na 139 (WNL-stable)

K 3.5 (WNL-trending up)

BUN

3 (Low-trending up)

Nutritional Significance of Low BUN: BUN is sometimes used in nutritional care as a marker of hydration status; a low BUN can indicate over-hydration. A low BUN can also indicate a negative N balance, as might occur with malnutrition and malabsorption. Can a Nutrition Intervention Help?: For this patient, malnutrition and malabsorption may be a problem, secondary to his chronic alcoholism. Adjustment in his diet regimen and nutrition education can help to correct these issues. Also, if low BUN becomes a significant problem, the RD can assess the patient’s fluid needs to ensure he or she is not being overhydrated w/ IV fluids and oral fluid intake.

CREAT 0.69 (WNL-stable)

GFR >60.0 ml/min/1.732 (WNL)

Albumin

2.1 (Low-trending down)

Nutritional Significance of Low Albumin: A low albumin is indicative of acute or chronic inflammation, and is likely indicative of an increased resting energy expenditure. Can a Nutrition Intervention Help?: While nutrition intervention may not be able to help w/ the inflammation, energy needs can be adjusted to meet the increased needs of patients with acute/chronic inflammation.

Prealb

CRP

Glucose 90 mg/dL (WNL-trending up)

HgbA1C N/A

H/H 12.3/36.5 (WNL-trending up)

MCV

99 fL (slightly high-trending up)

Nutritional Significance of High MCV: May indicate macrocytic anemia. Can a Nutrition Intervention Help?: Not necessary because value is only one above normal limit and was trending up.

MCH 33.2 pg (WNL-stable)

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Iron (Fe) N/A

Transferrin Sat (%) N/A

Ferritin N/A

Vitamin B12 N/A

Folate N/A

Ca

7.9 mg/dL (low – trending down)

Nutritional Significance of Low Calcium: Hypocalcemia is a common manifestation in pancreatitis. It can indicate malabsorption. Can a Nutrition Intervention Help?: A multi-vitamin can be recommended to enhance this patient’s daily calcium intake. Would be used w/ caution b/c patient is on lactulose which increases Ca absorption.

Phos N/A

Mg 1.6 (WNL – trending down)

Total Cholesterol N/A

LDL N/A

HDL N/A

TG N/A

ALT 43 U/L (WNL-stable)

AST

114 U/L (High-trending down)

Nutritional Significance of High AST: Indicative of liver damage or acute hepatitis Can a Nutrition Intervention Help?: Provision of liver/pancreatitis diet education, if well-perceived and applied by the patient, may help improve a patient’s overall clinical stability including lab values

Alkaline Phos 246 U/L (high- trending down)

Total Bilirubin

4.15 (high- fluctuating frequently)

Nutritional Significance of High Bilirubin: Liver/Pancreatic Problems Can a Nutrition Intervention Help?: Similar to AST in that liver/pancreatitis diet education, if well-perceived and applied by the patient, may help improve a patient’s overall clinical stability including lab values

Amylase N/A

Lipase

335 u/L (WNL- trending down was 669 u/L on admission)

BNP N/A

Troponin or CK N/A

Other relevant labs (e.g. ammonia, blood gases, AIDS/HIV related, etc.)

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ETOH 400 mg/dL (normal range 0-3 mg/dL)

Ammonia 76 umol/L (normal range 11-35 umol/L)

Protime 17.5 seconds (normal range 12.0-14.3 seconds)

Nutritional Needs

What weight will you be using to calculate needs and why? 71.9 kg (158 lb). This is the patient’s current body weight

and the weight I will use to calculate needs. There is no documentation or physical evidence of fluid build-up and this

has been the patient’s somewhat stable weight since major weight loss began 1 year ago.

Any stress factors 1.1, placement in the intensive care unit and pancreatic inflammation indicate a need for a 10%

increase in energy needs related to stress, activity factors to consider? 1.2 (what my facility uses as an activity factor

for patient’s confined to bed, as this patient was at the time of assessment)

Note: Understand the difference between resting energy expenditure and total energy expenditure. If you have a stressed

patient, you are likely to use a stress factor. If your patient is in bed moving around and alert, you will likely have to pick an

activity factor for Harris Benedict and Mifflin St.Jeor.

Calculate Total Energy needs using three of the five methods below. Show your work. (Work shown below)

1) Harris-Benedict ------------------------------------ 2150 kcal

2) Mifflin St. Jeor -------------------------------------- 2150 kcal

3) kcal/kg ----------------------------------------------- 1785-2142kcal

4) Ireton Jones (only use in critically ill) ------- kcal

5) Penn State 2010 equation ---------------------- kcal

Work:

Weight in kg: 71.4 kg

Height in cm: 172.7 cm

Harris-Benedict: Men: RMR = 66.47 + 13.75 X weight + 5.0 X height – 6.75 X age

RMR=66.47 + (13.75 X 71.4) + (5 X 172.7) – (6.75 X 32)

RMR=66.47 + (981.75) + (863.5) – (216)

RMR= 1629 kcal/day=RMR

TE: RMR X AF 1629 X 1.2 X 1.1=2150.28 kcal/day – rounded to nearest 50 kcal 2150 kcal/day=TE needs

Mifflin St.Jeor: Men: RMR = 9.99 X weight + 6.25 X height – 4.92 X age + 5

RMR=(9.99 X 71.4) + (6.25 X 172.7) – (4.92 X 32) + 5

RMR=(566.433) + (1016.875) – (123) + 5

RMR= 1640 kcal/day=RMR

TE: RMR X AF 1640 X 1.2 X 1.1=2164.8 kcal/day – rounded to nearest 50 kcal 2150 kcal/day=TE needs

Kcal/kg:

25-30 kcal/kg

TE: as a range

25 X 71.4=1417.5 – to nearest 50 kcal 1785 kcal/d

30 X 71.4=1701 – to nearest 50 kcal 2142 kcal/d

As a range rounded to nearest 50: 1800-2150 kcal/d

Nutrition Database

What formula did you ultimately use for the Pt & why? 25-30 kcal/kg (1800-2150 kcal/d). Pancreatitis

recommendations at my facility are set at 25 kcal/kg, while the pre-set option for our electronic software includes

this in a range, as 25-30 g/kg, and so this is the range of energy needs chosen. This range is also recommended on

the Academy of Nutrition and Dietetics Nutrition Care Manual (NCM). The NCM web page for Pancreatitis states

“energy requirements are approximately 25 kcal/kg/day to 35 kcal/kg/day” based on the International Consensus

Guidelines for Nutrition Therapy in Pancreatitis.

Reference: Pancreatitis. Academy of Nutrition and Dietetics Nutrition Care Manual website.

https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=19869&ncm_toc_id=19869&n

cm_heading=&. Accessed December 6, 2016.

Calculate Protein needs

How many g/kg would you use & why? 1.2-1.5 g/kg body weight; This range was chosen as it is recommended by the

Academy of Nutrition and Dietetics (found in their web page on pancreatitis – reference listed above), and is also the

range used for acute pancreatitis in my facility

Show your work:

1.2 g protein x 71.4 grams body weight=86 grams

1.5 g protein x 71.4 grams body weight=107 grams

Protein needs: 86-107 grams

87-107 g/day

Calculate Fluid needs using two of the four methods below. Show your work. (Work shown below)

1) ml/kg depending on age ----------------- 2142-2499 ml/day

2) Holliday-Segar method ------------------- ml/day

3) RDA method --------------------------------- 1785-2142 ml/day

4) urine output (urine out +500ml/day)- ml/day

WORK:

1.) Ml/kg depending on age:

Nutrition Database

a. Average adult: 30-35 mL/kg (patient is 32 years old)

b. 30 x 71.4=2142 mL/day, 35 x 71.4=2499 mL/day

2.) RDA method: 1 mL/kcal needs

a. Kcal needs: 1785-2142 kcal

b. Fluid needs: 1785-2142 mL/day

What formula did you ultimately use for the Pt & why? I used the RDA method as this is commonly used in my facility

and is recommended by the Academy on their Nutrition Care Manual’s Pancreatitis web page (referenced above).

The web page states “unless other comorbid conditions exist (renal/liver failure, septic shock, etc.), fluid intake and

status are similar to that for normal health adults”, and goes on to suggest either: 1) 1 mL fluid per kcal needs, or 2)

body weight/age-dependent method.

Interaction with the IDT (Interdisciplinary Team)

Indicate if you had interactions with any of these other health care team members while providing nutrition care / patient care

Describe interactions with or referrals made to any of these health care team professionals:

Nursing (RN)

Because this patient was being treated in the Intensive Care Unit, I was required to meet with the ICU nursing staff and a hospital social worker for “rounds” before interviewing him. His RN was able to tell me about his presentation to the ER, his reason for admission, and an overview of his PO intake over the past few days. He also provided me with client history in greater detail than what was charted for this patient.

Physician (MD)

After observing the patient’s tolerance of clear liquids during my interview, I spoke with the doctor about diet advancement. The doctor agreed to assess and advance the diet by the end of the day if appropriate (which he did – the patient was on a surgical soft/lite meal diet by the next day).

Social Worker (SW)

Because this patient was being treated in the Intensive Care Unit, I was required to meet with the ICU nursing staff and a hospital social worker for “rounds” before interviewing him. The social worker and I discussed the importance of alcohol rehabilitation for this patient.

Speech Therapist (ST/SLP)

N/A

Physical Therapist (PT)

N/A

Occupational Therapist (OT)

N/A

Respiratory Therapist (RRT)

N/A

Woundcare / Ostomy Nurse

N/A

Physician’s Assistant (PA)

N/A

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Other

N/A

Nutrition Diagnosis (P-E-S) Statement (write 2)

Problem: Inadequate protein-energy intake

related to (Etiology): inadequate diet

as evidenced by Signs and Symptoms: NPO status/Clear Liquid diet x 4 days.

*This PES statement is based on the immediate, clinical hospital problem.

Problem: Food and nutrient-related knowledge deficit

related to (Etiology): no prior exposure to pancreatitis diet education, new pancreatitis diagnosis

as evidenced by Signs and Symptoms: per interview with patient’s wife: she and patient (her husband) are unsure of the

make-up of a low-fat eating plan appropriate for pancreatitis.

Interventions (your recommendation as a dietetic intern)

To improve protein-energy adequacy of patient’s diet, recommend advancing to “Surgical Soft/Lite Meal” diet.

Patient with improved tolerance to clear liquids today, monitor for continued tolerance and advance as soon as

deemed medically appropriate

To improve protein-energy adequacy of patient’s diet, recommend obtaining information on any nutritional

supplemental preferences of patient (i.e. Ensure, Boost, etc.) after diet advancement occurs.

Dietetic intern provided verbal nutrition education to patient’s wife on low-fat, pancreatitis menu planning.

Reviewed high-fat foods not recommended, a list of recommended foods, the benefit of providing small,

frequent meals, and the importance of alcohol avoidance.

Dietetic intern provided nutrition education to patient’s wife via Pancreatitis Medical Nutrition Therapy

handouts, which contained a list of recommended foods, foods not recommended, and a sample 3-day meal

plan appropriate for individuals with pancreatitis.

Nutrition Prescription

2000 kcal diet*, 55% CHO (275 g), 25% PRO (125 g), 20% Fat (44 g), 4% SFA (8 g), 7% PUFA (16 g), 9% MUFA (20

g), Thiamin 100 mg, Folate 1 mg, General Multivitamin, Alcohol Abstinence

o *Mean for range used: 25-30 kcal/kg: 1800-2150 kcal/d (1800+2150)/2=1975 – rounded up to 2000

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Nutrition Goals

Patient will improve protein-energy intake by 50-75% within the next 48 hours (as obtained by dietary recall

during nutrition review with dietetic intern/RD).

Patient’s wife (and patient if in a less sedative state) will demonstrate understanding of nutrition education at 2-

day nutrition review by verbalizing information provided during nutrition education, including: 1.) Identification

of 3 foods not recommended w/ pancreatitis (will mention alcohol) 2.) Identification of 3 recommended foods

for pancreatitis, 3.) Verbalization of 2 single, full meals that would be appropriate for patients w/ pancreatitis

and 4.) Identification of a proper meal pattern w/ pancreatitis (i.e. frequent, low fat).

Monitoring and Evaluation (how do you monitor this patient, how do you measure progress?)

Nutrition team will document any diet advancements/toleration of current diet after 2-day nutrition review.

Nutrition team will document protein-energy intake as obtained through dietary recall during 2-day nutrition

review; foods eaten will be obtained and charted as a percentage.

Patient’s wife/patient will verbally identify 3 foods not recommended and 3 foods recommended for patients w/

pancreatitis at 2-day nutrition review.

Patient’s wife/patient will verbally identify 2 single, full meals that would be appropriate for serving patient w/

pancreatitis.

Patient’s wife/patient will verbally identify a proper meal pattern for patient w/ pancreatitis (i.e. frequent, low-

fat).

Discharge Planning (if applicable): List your recommendations / interventions / plan if your patient is being

discharged back home to live alone or with family or if transferred to an assisted living / long-term care facility.

The patient was not approaching readiness for discharge at the time of my assessment, but his wife expressed

great interest in learning what foods to prepare for him when the time came for him to be discharged home.

Therefore, after providing pancreatitis diet education, I had an in-depth discussion with the patient’s wife about

meal preparations, with the incorporation of foods the couple commonly eats. The wife was very receptive.

Because of her high interest, I also provided her with a pamphlet for my facility’s outpatient medical nutrition

therapy services, and informed her she could set something up with our outpatient dietitian if she was interested

in an even more in-depth, individualized approach for the nutritional management of her husband’s disease state.

Because this patient’s alcoholism was affecting his nutritional status (decreasing his appetite, damaging his

pancreas), I participated in discussions with the social worker about facilitating alcohol rehab for this patient. The

patient’s wife was reluctant to agree to this idea, and I am unsure of the status of this component of this patient’s

care plan.

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Anything else interesting about this patient (e.g. any lab tests or surgical procedures/tests that you were not

familiar with)?

This is nothing particularly mind-blowing – but I did get to learn about certain medications that a patient can

only receive in the ICU. This patient was initially admitted on a regular, Med-Surg floor, but because of

combative behavior (potentially due to alcohol withdrawal), he was admitted to the ICU to enable the

administration of Precedex (a sedative).

Also interesting was the doctor’s documentation of metabolic encephalopathy and the detection of some

starting signs of liver damage. As we have learned, encephalopathy can occur when a damaged liver does not

efficiently convert ammonia to urea, and thus nitrogenous compounds build up in the blood, eventually crossing

the blood-brain barrier and altering neurotransmission. This patient’s ammonia levels were 76 umol/L (normal

range 11-35 umol/L), and thus I was able to identify the reason for his encephalopathy. When I visited the

patient’s room, I spoke primarily with the patient’s wife, because the patient did not seem “all there” (which

also probably had to do with the sedatives). Nonetheless, it was interesting to see a patient experiencing some

acute encephalopathy first hand. With pancreatitis, liver damage, and encephalopathy all secondary to

alcoholism, this patient provided an educational experience consistent with the demands of my intermediate

clinical rotation.