Medical/Surgical Procedures:
Biopsy/polypectomy - Removal of a polyp by surgery. In the case of polyps in the colon,
polypectomy may be done by open abdominal surgery or, more commonly today, by
colonoscopy.
During this a scope was put down to the duodenum and back and found NG tube trauma. NG
tube appeared to pass through the lining of the esophagus into lining of the stomach; NG tube
removed post-procedure.
IVC filter - An IVC filter is a metal device made of either stainless steel or nitinol (nickel
titanium). It is placed in the main vein of the body, the IVC. This vein is located in the abdomen
and drains the blood from the legs and pelvis back to the heart.
Radelos IUC Filter placed at L2 from femoral.
Barium/Gastrografin swallow - A Barium Swallow involves drinking some liquid which shows
up on an X-Ray. This contrast medium shows up as white on a plain X-Ray taken soon after
swallowing. The barium shows up the inside of the esophagus and stomach, and gives an idea of
their lining surfaces.
No evidence of esophageal perforation or leak. No aspiration.
Chest One View Portable - A chest x ray is a procedure used to evaluate organs and structures
within the chest for symptoms of disease. X rays are a form of radiation that can penetrate the
body and produce an image on an x-ray film.
Heart is normal size, right IJ catheter seen with tip in. No evidenced of pneumomediastinum.
Lungs are grossly clean. No pneumothorax.
AP Portable Chest – NG tube and central line catheter remain in stable.
Inferior Vena Cavagram w/ IVC filter placement - An angiogram is an X-ray test that uses a
special dye and camera (fluoroscopy) to take pictures of the blood flow in an artery (such as the
aorta) or a vein (such as the vena cava). An angiogram can be used to look at the arteries or veins
in the arms, legs, chest, or belly.
No evidence of IVC thrombus. Using a micropuncture needle percutaneous entry into right
common femoral vein was performed. Renal veins are at the L1 level.
Portable KUB- no evidence of bowel obstruction.
Lab Data:
Lab Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Na mm/L 134 L 139-140 145-143 138 136 137-136 135
K mm/L 3.9 3.9-3.4 L 2.9 4.2-3.2 3.9-3.5 3.6-3.4 3.6
Cl mm/L 92 L 105-111 112-113 104-103 102-100 99-97 97
CO2 mm/L 26 25-23 27-26 31-30 29 31-32 31
BUN mg/dL 23 25 H 14-8 6-5 4 6-5 10
Creatinine 1.12 0.92-0.83 0.68-0.60 0.63-0.58 0.55 0.55-0.56 0.55
mg/dL
Glucose 206 H 131-139 H 93-78 122-86 91 176-184 120
mg/dL
Ca mg/dL 8.8 7.4-7.2 L 7.7-6.5 7.4-7.5 7.7 7.8-7.9 7.9
Mg mg/dL 1.9 1.9 2.0-1.6 2.2 2.0 2.0-2.1 2.0
Phos mg/dL 4.3 2.9-2.7 2.0-1.5 3.1 2.5 2.5 3.1
Albumin 2.5 L 1.7
g/dL
Prealbumin 12.6 15.9
mg/dL
Day 1
Sodium: The patient was admitted with a blood sodium level of 134 mm/L. This is low and is
common with excessive loss of fluid through diarrhea. As fluid from the body moves into the
intestines sodium is carried with it and lost. The patient currently has a C. diff. infection which
causes a secretion of electrolytes and water from the intestinal epithelium.
Chloride: The patient was admitted with a blood chloride level of 92 mm/L. This is low due
most likely to the patient vomiting. When producing gastric acid the stomach must use a
combination of H+ and Cl-. When there is excessive vomiting the chloride is lost, and when the
stomach produces more acid it cannot reuse the lost chloride.
Glucose: The patient was admitted with a random blood glucose level of 206 mg/dL. This is
high even for a random glucose level, and is most likely attributed to the patients past history of
borderline diabetes mellitus. In diabetes the pancreas is unable to produce insulin or enough
insulin to allow the body’s cells to take up glucose in the blood to utilize for energy. This causes
there to be excess amount of glucose in the blood.
Albumin: The patient was admitted with a albumin level of 2.5 g/dL. The most likely cause of
this is due to the blood loss the patient had due to an upper gastrointestinal bleed.
Day 2
Potassium: The patient has potassium level that drifted from 3.9 to 3.4 mm/L. This was normal,
but then became low. This is associated with the shifting of potassium from the cells into the GI
tract in order to prevent sodium loss during periods of extensive fluid loss such as diarrhea. The
patient currently has a C. diff. infection which causes a secretion of electrolytes and water from
the intestinal epithelium.
BUN: The patient had a BUN of 25 mg/dL. This is high and BUN concentrations may be
elevated when there is excessive protein breakdown (catabolism), significantly increased protein
in the diet, or gastrointestinal bleeding (because of the proteins present in the blood). The
increased protein metabolism is due to ketoacidosis because as the body is unable to absorb
glucose into the cells it will attempt to metabolize protein stores into ketones for an alternate
form of energy.
Glucose: The patient had a fasting glucose level of 131-139 mg/dL. This is high, and is most
likely attributed to the patients past history of borderline diabetes mellitus. It is much lower than
the patients’ admitted blood glucose level due to the insulin treatment being provided. In
diabetes the pancreas is unable to produce insulin or enough insulin to allow the body’s cells to
take up glucose in the blood to utilize for energy. This causes there to be excess amount of
glucose in the blood.
Calcium: The patient had a calcium level of 7.4-7.2 ,g/dL. This is low, and is due to possibly to
a false low calcium level reflecting the patients low albumin levels because 50% of calcium is
protein bound.
Day 3
Potassium: The patient has potassium level of 2.9 mm/L. This is low. This is associated with the
shifting of potassium from the cells into the GI tract in order to prevent sodium loss during
periods of extensive fluid loss such as diarrhea. The patient currently has a C. diff. infection
which causes a secretion of electrolytes and water from the intestinal epithelium.
Chloride: The patient had blood chloride level of 112-123 mm/L. This is high due most likely to
the patient diarrhea. Chloride is excreted with cations during massive diuresis from any cause
and are lost form the GI tract when vomiting, diarrhea, or intestinal fistulas occur. However,
during metabolic acidosis there is a reciprocal rise in chloride concentration when bicarbonate
concentration drops. When aldosterone causes an increase in the absorption of sodium an indirect
effect is the increased absorption of chloride as well.
Calcium: The patient’s calcium level was again low ranging from 7.7-6.5 mg/dL which again
can be associated with the patients’ low albumin levels.
Phosphorus: The patient had a phosphorus level of 2.0-1.5 mg/dL. This is low and is most likely
due to the excessive diarrhea the patient is experiencing. Vomiting and diarrhea cause
hypophosphatemia. Initially, the kidneys compensate by decreasing urinary phosphate excretion;
however, a continuous inadequate intake of phosphorus results in extracellular fluid shift to the
cells in order to replace phosphorus loss in the intracellular fluid.
Day 4
Potassium: The patient has potassium level of 4.2-3.2 mm/L. This is low. This is associated with
the shifting of potassium from the cells into the GI tract in order to prevent sodium loss during
periods of extensive fluid loss such as diarrhea. The patient currently has a C. diff. infection
which causes a secretion of electrolytes and water from the intestinal epithelium.
Glucose: The patient had an initially high glucose of 122 but then dropped to 86 later on. This is
most likely due to inadequate levels of insulin being administered to the patient.
Calcium: The patient’s calcium level was again low ranging from 7.4-7.5 mg/dL which again
can be associated with the patients’ low albumin levels.
Albumin: The albumin was low again at 1.7 g/dL. This is most likely due to the patient being
unable to absorb enough protein due to excessive diarrhea.
Prealbumin: Prealbumin is low at 12.6 mg/dL which shows signs of malnutrition in the patient.
This can be determined due to the short half-life of prealbumin of 2 days.
Day 5
Potassium: The patient has potassium level of 3.9-3.5 mm/L. This is low. This is associated with
the shifting of potassium from the cells into the GI tract in order to prevent sodium loss during
periods of extensive fluid loss such as diarrhea. The patient currently has a C. diff. infection
which causes a secretion of electrolytes and water from the intestinal epithelium.
Chloride: The patient had blood chloride level of 100-99 mm/L. This is low due most likely to
the patient diarrhea. Chloride is excreted with cations during massive diuresis from any cause
and are lost form the GI tract when vomiting, diarrhea, or intestinal fistulas occur.
Calcium: The patient’s calcium level was again low ranging from 7.7 mg/dL which again can be
associated with the patients’ low albumin levels.
Day 6
Potassium: The patient has potassium level of 3.6-3.4 mm/L. This is low. This is associated with
the shifting of potassium from the cells into the GI tract in order to prevent sodium loss during
periods of extensive fluid loss such as diarrhea. The patient currently has a C. diff. infection
which causes a secretion of electrolytes and water from the intestinal epithelium.
Chloride: The patient had blood chloride level of 99-97 mm/L. This is low due most likely to the
patient diarrhea. Chloride is excreted with cations during massive diuresis from any cause and
are lost form the GI tract when vomiting, diarrhea, or intestinal fistulas occur.
Glucose: The patient had a high glucose level of 176-184 mg/dL. This is most likely due to
inadequate levels of insulin being administered to the patient overnight or possibly the dawn
phenomenon where the body’s hormones cause the breakdown of glycogen into glucose during
the night.
Calcium: The patient’s calcium level was again low ranging from 7.8-7.9 mg/dL which again
can be associated with the patients’ low albumin levels.
Day 7
Chloride: The patient had blood chloride level of 97 mm/L. This is low due most likely to the
patient diarrhea. Chloride is excreted with cations during massive diuresis from any cause and
are lost form the GI tract when vomiting, diarrhea, or intestinal fistulas occur.
Glucose: The patient had a high glucose level of 120 mg/dL. This is most likely due to
inadequate levels of insulin being administered to the patient overnight or possibly the dawn
phenomenon where the body’s hormones cause the breakdown of glycogen into glucose during
the night.
Calcium: The patient’s calcium level was again low ranging from 7.9 mg/dL which again can be
associated with the patients’ low albumin levels.
Prealbumin. The patient had a low prealbumin of 15.9 mg/dL; however this was an increase
from the previous prealbumin of 12.6. This can indicate that the patient is beginning to recover
from malnutrition.
Calculating Energy Needs
Patients BMI = 160 lbs/ 66”2 x 703 = 25.8 patient is slightly overweight
Harris-Benedict
66.5 + 13.8 (72.7) + 5 (167.6) – 6.8 (85) = 1329.8 x 1.2 (confined to bed) x 1.4 (sever infection)
= 2234.1 kcal
72.7 x 25 kcal/kg = 1817.5 x 1.2 x 1.4 = 3053.4 kcal
Total kcal needed = 3053.4 + 2234.1 /2 = 2643.8 kcals
Protein needs:
72.7 kg x 1.5 g/kg = 109.1 grams protein
72.7 kg x 2.0 g/kg = 145.4 grams protein
The patient requires a protein intake of 109.1-145.4 grams of protein. This is due to both
his low albumin levels (Day 4 1.7 g/dL) and his impaired ability to absorb nutrients from
diarrhea induced by a C. diff. bacterial infection. His caloric need are also heightened from his
GI bleed, and the bacterial infection.
Eating Pattern:
The patient has a consistent eating pattern eating the same meals daily with little
variation. Breakfast consists of a cereal of some sort with fruit and fruit juice, Lunch will be a
sandwich made up of the previous nights leftovers, and a glass of fruit juice. At night there will
be a meat dish such as shepard’s pie or hamburger with vegetables for a side. For a dessert
cookies or cake will be eaten. He currently lives with his wife in a nursing home, but it does not
have an effect on his current diet.
Summary
S: Patient was complaining of abdominal pain. Patient denies previous history of GI bleed.
Patient denies dysuria. Complains of some epigastric pain today. Denies headache or neck pain.
O: Admitted with an upper gastrointestinal bleed. 85 year old Caucasian male, ht. 5’ 6”, wt 160,
weight history 159-169 lbs, IBW 142, % IBW 112%, BMI 25.8, past history of diabetes mellitus,
hypertension, MI, C. diff. colitis January 9 to present, recent pulmonary embolus. Currently
taking Labetalol 10 mg, nitroglycerin ointment 1 in, nystatin powder, benzocaine, heparin flush
20 units, nitroglycerin 0.4 mg, pantoprazole 40 mg, acetaminophen liquid 650 mg, insulin, zosyn
100 ml/3.375 mg, vancomycin 100 ml/1 gm, metronidazole 100 ml/500 mg, potassium chloride
100 ml/20 meq, fentanyl, midazolam, metoprolol tartrate 5 mg. Allergic to Accupril.
A: 1. Inadequate protein intake RT upper gastrointestinal bleed AEB albumin level of 1.7 g/dL
Energy Needs
Patients BMI = 160 lbs/ 66”2 x 703 = 25.8 patient is slightly overweight
Harris-Benedict
66.5 + 13.8 (72.7) + 5 (167.6) – 6.8 (85) = 1329.8 x 1.2 (confined to bed) x 1.4 (sever infection)
= 2234.1 kcal
72.7 x 25 kcal/kg = 1817.5 x 1.2 x 1.4 = 3053.4 kcal
Total kcal needed = 3053.4 + 2234.1 /2 = 2643.8 kcals
Protein needs:
72.7 kg x 1.5 g/kg = 109.1 grams protein
72.7 kg x 2.0 g/kg = 145.4 grams protein
The patient requires a protein intake of 109.1-145.4 grams of protein. This is due to both
his low albumin levels (Day 4 1.7 g/dL) and his impaired ability to absorb nutrients from
diarrhea induced by a C. diff. bacterial infection. His caloric need are also heightened from his
GI bleed, and the bacterial infection.
P: Patient is to receive a minimum of 109-145.4 grams of protein. Patient’s albumin and
prealbumin should be checked every 4 days from previous testing.