ALUMNA: Cinthia Ivonne Cob Pech

Universidad Anáhuac Cancún

Lic. Médico cirujano
ID: 00165771

CASE 1
1. What are PJ ́s risk factors for a stroke? History of arterial hypertension, smoking as it damages the wall of
the Vass blood, diebetes.

2. What fluid and electrolyte abnormalities does PJ have? How can they be corrected? Hpocalemia of
3.2 meq, administer KCl at doses of 0.5 and 1 meq/kg/dose, (maximum dose: 40-60 mEq) Repeating it every 4
to 6 hours according to need and serum potassium controls.

3. What risks are associated with feeding PJ regular food? Because of the risk of broncoaspiracion, since
Fluoroscopy showed that there was such a risk.

4. Assuming that PJ has a nasogastric tube for enteral feeding, how can his nutrient needs be
estimated? as PJ is a diabetic patient it is recommended complete polymeric formula with distribution of
macronutrients (Fats 40%, proteins 20%).

5. What are PJ’s long-term feeding-tube-placement options? What types of long-term feeding tube are
available, and what are the benefits and disadvantages? Nasogastric tube: Advantages: More physiological,
Trophic effect on the intestinal light, It maintains the barrier effect, It can provide specific nutrients for
maintenance of the intestinal structure. Disadvantages: uncomfortable and unsightly for the patient, Possibility
of eschar and nasal erosion, frequent involuntary withdrawal.

Gastrostomy tube: Advantages: Comfortable and aesthetic for the patient, Lower risk of reflux and aspiration
than the tube, nasogastric, Less risk of involuntary extubation. Disadvantages: Contraindications described,
Possibility of alteration in the stoma healing.

Balloon probe: Advantages: Preserves the digestive stage, Allows administering in bolus, The large caliber
(15-28 FR) prevents. obstructions, allows prolonged use, does not alter too much body image. Disadvantages:
Contraindications described, Possibility of alteration in the cicatrization of the stoma.

6. What factors may have caused PJ ́s seizure? Severe hypoglycemia.

7. Why did PJ develop hypoglycemia, and what can be done to prevent its recurrence in the future?

8. What drug-nutrient interaction accounts for PJ ́s low phenytoin level? Food can reduce its
bioavailability, alternating the alteration of the administration schedule or dose adjustment, to avoid the use of
subtherapeutic doses. An hour's rest for enteral nutrition after the dose of phenytoin increases serum
phenytoin levels by almost 90%, and helps maintain the therapeutic level.

CASE 2
1. From this history, it is obvious that RD ́s diet was very inadequate for 3 months and he was therefore
malnourished. What physiologic adaptations probably occurred in response to this period of
malnutrition? abnormal sodium and fluid level, changes in fat, glucose, or protein metabolism, thiamine
deficiency, hypomagnesemia (low magnesium), hypokalemia (low potassium). During starvation mode, the
body’s metabolism switches from an anabolic state which means the body is breaking down tissue, including
fat and muscle, in attempt to garner the energy needed to sustain bodily functions.

2. Based on the physical exam and laboratory data, what clinical and biochemical manifestations of
malnutrition does RD exhibit? apathetic and emaciated, dry skin, and dermatitis, alopecia, thinning hair
lacking in luster, muscles wasting, low calcium, magnesium, potasium and albumin at 2.7g/dL.

3. What metabolic and physiologic changes occur as RD begins to eat again (that is, when refeeding is
initiated)? Why are his electrolyte abnormalities of primary concern? hypokalemia, low magnesium, low
potasium. Once refeeding begins, metabolism switches back to an anabolic state, increasing the uptake of
electrolytes such as potassium, phosphate, and magnesium.

4. Based on RD ́s physical exam and laboratory data, what complications of refeeding does he exhibit?
Tachycardia, tachypnea, arterial hypotension.
ALUMNA: Cinthia Ivonne Cob Pech
Universidad Anáhuac Cancún
Lic. Médico cirujano
ID: 00165771

5. How could the complications of refeeding that RD experienced have been minimized or avoided? It
could be prevented by very gradually increasing RD’s nutritional intake.

CASE 3
1. What do DR´s symptoms and laboratory values indicate about his glycemic control? A bad
management of diabetes, he has developed mild diabetic retinopathy, diabetic neuropathy, increased
polidipsia, and poliuria. The Serum glucose of 285 mg/dL and Hemoglobin A1c: 9.5%

2. What is a reasonable weight goal for DR? What information may be useful in making this
determination? How many calories should he consume for weight loss? The loss goal is 5-10% of
bodyweight or 6.5 kg per week and It has been shown that even a moderate amount of weight loss (5 percent
body weight) can improve the action of insulin and reduce fasting sugar levels. He must reduce energy in take
by 500-1000 kcal.

3. What are the current nutritional goals for patients with type 2 diabetes? Have a caloric distribution of
10-20% of proteins (in absence of nephropathy), <10% saturated fat, 10% Of polyunsaturated fat, and 60-70%
distributed among Monounsaturated fat and carbohydrates, contribute to normalize blood glucose levels.

4. Is DR´s eating style appropriate for a patient with type 2 diabetes? What recommendations are
indicated for DR based on his current diet?

His diet is not benefical, consuming many carbohydrates raises the level of sugar in the blood. The
recommendations should be eating five times per day, reduce the fat, eat more vegetables, avoid sweeteners,
improve 30 minutes of exercise, monitoring glucose levels, reduce salt intake, oils, avoid fruit.

5. How can DR´s progress be evaluated when he returns to the doctor´s office 1 month later? With
blood chemistry, glycosylated hemoglobin and daily glycemic control.

6. What additional treatment modalities are indicated for DR at this time?Physical activity, adequate
dietary control, psychological control, B complex.

7. DR often snacks on cookies containing unsweetened fruit juice and sugar-free candy. He asks the
doctor whether he can eat these foods on a regular basis. What is the appropriate response? Usually
fruits contain a level of fructose that can alter glycemic levels. The intake would not be totally prohibited but it is
recommended to consume it once a week for better control.

CASE 4
1. Does PD´s percent weight change indicate a significant weight loss? She lost 28 pounds last year
(15% ) significant weight loss relative to time is defined as: the loss of 5 pounds (approximately 2 kg) in 1
month, 5% weight loss in 1 month, 7.5% weight loss in 3 months, 10% weight loss in 6 months.

2. Estimate PD´s calories needs using the Harris-Benedict equation including a stress factor for COPD

• REE: 655.1 +(9.6 x 66.8 kg) + (1.8 x 168 cm) – (4.7 x 53)
• REE: 1349.58
• Stress factor for COPD: 1.30
• 1349.58 x 1.30= 1754.454 kcal/day
ALUMNA: Cinthia Ivonne Cob Pech
Universidad Anáhuac Cancún
Lic. Médico cirujano
ID: 00165771

3. What factors have contributed to PD´s weight loss? Progressively dyspnea, Use of tobacco, an
inadequate diet.

4. Based on PD´s history, what may account for her severe fatigue? The history of the show an important
intake of cigarettes. The poor balance of the diet does not help, it has high cholesterol and does not favor it
due to hypertension.

5. How does poor nutritional status compromise pulmonary function? A diatragm needs energy to be
able to carry out amplification and amplification, because it has the type II fibers of the skeletal muscle of the
glycolytic metabolism, the loss of active body weight a loss of muscle mass.

6. Discuss the impact of current medications on nutritional status and the need for medical nutrition
therapy Certainly in COPD, its necessary to take several medications to improve the symptoms present by the
disease and can modify the nutritional status of the body, but not taking them would generate severe
complications. The medical nutrition therapy can help patients faster recover and have fewer complications.

7. What are appropriate medical nutrition therapy goals for PD, including specific recommendations to
improve her nutritional and fluid status? have a contribution of carbohydrates between 40-50% of the total
daily energy value. Proteins should be 1 to 2 grams of protein per kilo of body weight per day. The
consumption of fats is important since it involves a lesser effort of ventilation than when consuming
carbohydrates (produces less CO2). Intake of vitamin C, E, beta carotene and selenium, for being beneficial in
lung function. Improve Exercise, Avoid a place with environmental pollution or contaminants that alter your
breathing.

CASE 5
1. Based on AB´s history, what is the most likely diagnosis? Hipertensive crisis, chronic
glomerunephritis, anemia, heart facture

2. What additional laboratory tests or studies help confirm your diagnosis? Elevation of heart
enzymes, signs of pulmonary edema in a thorax x-ray, elevation of urea and creatinine in a 24-
hour urine collection, hematuria in a urinary test, and Kidney biopsy and Renal ultrasound.

1. What Medications are indicated to manage his clinical condition at this time?
- Oxygenation support, Monitoring of the BP and heart rate, Periodic evaluation of the level of
consciousness and neurological constants, Bladder catheter for diuresis time measurement, B Complex,
antihypertensive, erythropoietin, Iron.
4. ¿Base on AB´s physical exam, should his correct body weight be used to estimate his caloric and
protein needs?
-No, because of his peripheral edema. We should use the dry weight that we get post- diuresis.
(Weight without edema= Dry weight + - ( ided – dry) x 0.25)

5. How can AB´s caloric end protein requirements be estimated?

Using the “Thumb rule” : 25-35 kcal/kg
: 5 (70.5)
:2,467.5 kcal per day
Protein: 15 g/kg
: 1.5 g (70.5)
ALUMNA: Cinthia Ivonne Cob Pech
Universidad Anáhuac Cancún
Lic. Médico cirujano
ID: 00165771

: 107 kcal
2468: 100%
107 k: 5%

6. What dietary recommendations are indicated before dealysis base don his current laboratories
values and what fluide and electrolyte management does AB require?A Dietary based in vegetable
and polyunsaturated fats, potassium restriction, eat less chicken, nuts, sodium and dairy products
and their derivatives.
.
7. What are the inmediate and long-term treatmetn modalities you would recommend? Peritoned
dialysis.

8. Whats modifications in phospate bindings medication should be made once AB´s Phospate level
becomes aceptable? There are no modifications.

9. What dietary modifications are indicated once AB begins receivings CAPD?Protein intake.

CASE 6
1. List MH, S possible medical problems demonstrated by her overall clinical picture: Pancreatitis, or cystic
fibrosis.

2. What are the possible etiologies of MHs chronic relapsing pancreatitis? 70 to 90% is due to alcohol
intake, 10 to 30% are chronic idiopathic pancreatitis, Chronic hereditary pancreatitis, Increase in calcium or
triglycerides, Cystic fibrosis, Autoimmune, Acute or recurrent acute pancreatitis.

3. Explain why amylase, lipase and calcium, and glucose levels are abnormal in patients with pancreatitis:
Acute pancreatitis (AP) is an acute inflammatory process of the pancreas, begins with intrapancreatic fusion
between lysosomes and vacuoles containing zymogens, by the action of cathepsin B, in the presence of
CALCIUM, the transformation of trypsin occurs, which once activated it can not be inhibited. The levels of
trypsin progressively increase inside the vacuole, until they rupture, freeing themselves to the pancreatic
interstitium. The released trypsin, activates more trypsin and other enzymes activate the inflammatory
cascade and when the pancreas becomes inflamed, the levels of amylase and lipase (pancreatic enzymes) in
the blood increase. So high levels of calcium promote inflammation, but in one third of cases, acute
pancreatitis is accompanied by hypocalcemia by reduction of the degree of protein binding by
hypoalbuminemia that leads to a decrease in total serum calcium levels, or calcium sequestration in areas of
fat necrosis (saponification), which produces a reduction in ionic calcium.

Also, glucagon levels increase and insulin levels decrease, which is an expression of lesion of the islets of
Langerhans, which, in addition to the increase in cortisol due to organic stress, manifests itself with transient
hyperglycemia, increased lipolysis and elevation of the plasma concentration of free fatty acids not
esterified.

4. What additional evidence from MHs physical exam could be used to asses her nutritional status prior to
initiating TPN? A test of abdominal auscultation to know if there is presence of paralytic ileus.
ALUMNA: Cinthia Ivonne Cob Pech
Universidad Anáhuac Cancún
Lic. Médico cirujano
ID: 00165771

5. What is the primary concern with regard to MHs nutritional status at this time? The malnutrition that
presents by the loss of weight caused by pancreatitis.

6. Why is TPN the most appropriate form of nutritional intervention at this point in MHs clinical
course?Because the gut is not functioning, gut is not accessible, enteral or oral feeding is not reach the
nutritional target.

7. Using the Harris Benedict equation, calculate Mhs resting energy expenditure (REE); also calculate MHs
protein requirement, and maximum carbohydrate and lipid oxidation rate. How much dextrose and lipid
should be order in the TPN.

655 + (9.6 X 48 Kg) + (1.85 x 168 cm) – (4.68 x 45)

655 + (460-8) + (310.8) – (210.6)

1426.6 -210.6

REE: 1216 kcal 1216 x 1.2=14592 kcal

58 g of protein (dicry)

Cal necessary: 1448 kcal

Carbohydrates: 144 g/day

Lipids: 96 g/day

Dextrose: 68 mg/dl

8. What other nutrients should be added to the TPN in addition to amino acids, dextrose, and
lipid?Combine parenteral nutrition with a small content of a polymeric diet ( 10-30 ml/h), and add
glutamine, zync, vitamins, protein, mineral, etc.

9. What biochemical laboratory data should be used to monitor MH while she i son TPN? Direct bilirrubin,
indirect bilirrubin and total bilirrubin. Calcium, Lypase, Amylase, Lipids, Glucose.

10. After MHs pancreatitis began to resolve and her bowel sounds showed increased activity, her
physician decided that she should begin an oral diet. How should MHs feeding begin and what
recommendations are approach upon discharge? Patien should go under a soft diet free of
cholecystokinetics, eat frequently, don’t drink any alcohol.