End Stage Liver Disease with GERD and Bleeding Esophageal Varices FSHN 450 Fall 2016

Due Date: October 28, 2016 Admission Data: 57 year old male admitted from ES c/o N&V, and abdominal pain radiating to Rt side. Patient presented with scleral icterus, increased abdominal girth secondary to ascites, black stools. Current Dx: Upper GI Bleed, Cirrhosis MedHx: Htn, cholecystectomy, alcoholism Social: Divorced for past 15 years. Mother living. Father died at age 65 from CHF. 4 living siblings: brother 53 has atherosclerotic heart disease, brother 40 and sister 46 in apparent good health, sister age 48 is obese. Medications at home: TUMS, Zantac, Lisinopril Medications: Lactulose, Octreotide, Vitamin K, Compazine, Morphine, albumin iv, furosamide iv Physical: Ht. 5'7” Current BW 190 # BP 128/80 Pulse 90 RR 16 Temp 98.9 Hospital Course: 6/17 Admission Laboratory: Na 120 mEq/L K 4.7 mEq/L Cl 87 mEq/L CO2 19.3 mmol/L Glu 91 mg/dl BUN 13 mg/dl Creat 1.6 mg/dl PTT 43.1 seconds (reference: 23.7 - 32.7 seconds) RBC 2.88 x106/mm3

Hgb 9.1g/dl Hct 26.9 % Albumin 2.3 g/dl Triglycerides 325 mg/dl Total Cholesterol 250 mg/dl HDL-Cholesterol 40 mg/dl Physical and Neurological Exam: 0 Asterixis 0 edema of extremities Gastroscopic Examination showed bleeding esophageal varices

Diet History reveals the following usual intake: 8am 1 cup black coffee with 1 shot bourbon 10 am 1cup cornflakes with ½ c 2% milk 12 noon 1 hot dog on bun with relish and mustard 2 cans beer 30 potato chips 2 pm 1 snickers bar Afternoon 3 shots bourbon 6 pm 1 cup pasta or baked macaroni and cheese 2 cans beer Evening 2 cans beer 3 shots bourbon 6/28 Patients’s condition continues to deteriorate. Current BW : 194 pounds. Diet: NPO. Surgical jejeunostomy tube placed and nutrition support consult ordered. What was the cause of the weight gain???? What is the purpose of each of the patient’s medications? List any important drug:nutrient interactions. Why was a surgical jejeunostomy tube placed? Evaluate the patient’s nutrient needs and prescribe a tube feeding including type and brand name, total volume and rate. Include a start rate and progression. Include ONLY the Assessment section of the ADIME at this point. 7/1 Laboratory Na 122 mEq/L K 4.1 mEq/L Cl 98 mEq/L CO2 10 mmol/L Glu 93 mg/dl BUN 18 mg/dl Creat 1.6 mg/dl PTT 43.1 seconds (reference: 23.7 - 32.7 seconds) RBC 2.88 x106/mm3 Hgb 9.1 g/dl Hct 26.9 % Albumin 2.6 g/dl Tube feeding is not well tolerated. Patient disoriented to time and place. Mild asterixis and 2+

edema present. Patient transferred to ICU. Tri-luminal catheter placed and nutrition support consult ordered for TPN with Hepatamine®, limit 1500 ml. List the probably reasons for the tube feeding intolerance in this patient? You do not need to calculate a TPN but you should reevaluate protein and Kcal needs. Why was Hepatamine® ordered and what at is the drawback to using this product? 7/11 Patient stabilized. TPN tapered and patient diet order changed to clear liquid progressing to oral diet as tolerated. Fluid restricted to 2000 ml/day, 2300 mg sodium, soft diet. Prepare to discharge to home. Dx: chronic alcoholic cirrhosis with stable encephalopathy and esophageal varices. Why was a soft diet ordered? Conduct a follow-up nutrition assessment and report in ADIME format for transition to oral diet (on 7/11) Develop three PES statements, one in each domain and plan an intervention and follow-up for each nutrition diagnosis. *** DO NOT forget to answer all the questions.