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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Describe how a bowel obstruction can lead to nutritional, fluid, and electrolyte abnormalities.

  • Characterize the severity of malnutrition based on subjective and objective patient data.

  • Identify potential complications related to parenteral nutrition (PN) in patients with malnutrition (eg, refeeding syndrome) and steps to avoid or manage such complications.

  • Design a patient-specific PN prescription that is based on the nutritional diagnosis and other subjective and objective patient data.

  • Construct and evaluate appropriate monitoring parameters for a hospitalized patient receiving PN.

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PATIENT PRESENTATION

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Chief Complaint

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“My stomach hurts and I can’t keep down any food or water.”

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HPI

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Steven Brown is a 49-year-old man familiar to the GI Surgery Service with a history of a ventral hernia, hypertension, dyslipidemia, and type 2 DM. He presented to the ED earlier today with abdominal pain, nausea, vomiting, and inability to tolerate PO intake. Approximately 2 months ago, he underwent an exploratory laparotomy with small bowel resection and primary anastomosis for repair of a ventral hernia with incarcerated small bowel. His postoperative course was complicated by an anastomotic leak, peritonitis, and sepsis, and he was ultimately discharged to home after a 3-week hospital stay. For the past 4 days, he has had worsening abdominal pain and has been unable to tolerate any PO intake. His last bowel movement was 6 days ago. He has lost ~25 lb (~11 kg) from his weight prior to his surgery 2 months ago. This weight loss includes ~14 lb (~6.5 kg) since his prior discharge due to poor appetite and limited PO intake at home.

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The surgical team decides to admit Mr Brown to the hospital. On admission, they obtain an abdominal CT scan, which demonstrates dilated loops of small bowel consistent with a small bowel obstruction (SBO) and negative for anastomotic leak or abscess. The team believes this SBO is likely due to adhesions from his prior surgery.

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PMH

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  • Ventral hernia

  • Hypertension

  • Dyslipidemia

  • Type 2 DM

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PSH

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Exploratory laparotomy, small bowel resection with primary anastomosis for repair of ventral hernia with incarcerated small bowel 2 months ago

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FH

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Remarkable for DM in his mother, HTN and CAD in his father

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SH

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Married, lives with his wife; construction worker. Drinks two to three alcoholic beverages per week; quit smoking 2 years ago, 25 pack-year history prior to quitting.

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ROS

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Reports feeling thirsty, no appetite. Complains of moderate abdominal pain, nausea, and vomiting. Also complains his abdomen feels “crampy” and is very bloated. Complains of not passing flatus or having a bowel movement in 6 days; urinating infrequently over the past 2 ...

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