MINI CASE STUDY

MEREDITH EPLEY
I L L I N O I S S TAT E U N I V E R S I T Y
PATIENT GENERAL INFORMATION

• RP • Left AMA 2/1

• 53 YO M • Admitted on 2/5
• Disabled (overdose)
• 6’ 4” (193cm) • Past medical history
• Anxiety
• 240# (109.1kg)
• Diabetes mellitus (Type 2)
• BMI: 29.28 kg/m2 • High Cholesterol
• Hypertension
• IV drug user
• Sepsis
 INTRODUCTION CONTINUED

• 2/1 • 2/ 5
• Intracranial mass lesions • Acute bacterial
with hemorrhage endocarditis
• Septic verses metastatic • Endocarditis
brain lesions • Brain metastases
• Radiation oncology
(biopsy was planned)
• Infectious disease (recent
diagnosis of endocarditis
and MRSA bacteremia, at
Memorial Hospital)
 INTRODUCTION CONTINUE

• Admission Information 2/5

• Physician: Parth Patel
• Floor: 6 CVCU
• General diet at admit
• No recent or previous hospitalizations
 PURPOSE

• The purpose of the presentation is to educate dietitians

on endocarditis and the nutrition care process for
these patients. 
 PRESENT ADMISSION 2/5​

• MST of 4​ • History of skin lesions with

• Acute bacterial resection of a lower back
lesion in 2018​
endocarditis​
• Biopsy of suspicious
• Melanoma ​ nodules (was supposed to
• Intercranial be scheduled for
hemorrhages ​ first admit)​
• MRSA bacteremia  • Consults of infectious
disease, neurosurgery,
radiation oncology, and
orthopedics. 
 STUDY OF DISEASE​

• Endocarditis- a multisystem disease that results from infection, usually

bacterial, of the endocardial surface of the heart (Hollland, etc. (2016). ​
• Inflammation of the inner linings of the heart's chambers and valves​
• Caused by an infection, bacteria or fungi from another part of the body
such as the mouth spread to the bloodstream.  ​
• Travel to your heart and attach to abnormal heart valves or damaged
heart tissue.​
• A history of illegal IV drug use​
• Elderly​
• Hemodialysis patients
• Incidence of endocarditis ranges from 2.6 to 7 cases per 100,000
population per year (Vilcant, 2020).
 ETIOLOGY AND OCCURRENCE OF
DISEASE 
• Endocarditis​
• Develops slowly (what germs cause infection and underlying
heart complications)​
• Fatigue​
• Aching joints and muscles​
• Swelling​
• Unexplained weight loss (less common)​
• most cases​
• fever ​
• vegetation in echocardiography​
• positive blood culture in some cases
 MEDICAL TREATMENT

• Endocarditis​
• Endocarditis is successfully treated with antibiotics​
• Ceftriaxone​
• Vancomycin (bacteria)​
• Sometimes surgery​
• High doses of IV antibiotics are used to treat endocarditis​
• Continue IV antibiotics with visits to your doctor's office or with
in home care.​
• Fatal disease and most of untreated patients might lose their life
few weeks after the diagnosis
• Long term survival is 50% of 10 years
 MNT

• Nutrition Standards of care​

• DM was used​
• Calories: Mifflin-St Jeor (obese)​
• Protein: 1.5 g/kg IBW​
• Carbohydrate: 50% of total kcal from carbohydrate​
• Fluid: 1 mL/kcal estimated needs
• Medical management of symptoms/side affect control
approach (weight loss)
 ADMIT

• Date of admission: 2/5

• MST score of 4
• Assessment date: 2/8
 BIOCHEMICAL DATA

​ 2/08​/21 2/16/21​
Sodium​ 142​ 140​
Potassium​ 3.4 (L)​ 3.8​
Chloride ​ 109 (H)​ 108 (H)​
CO2​ 25.4​ 25.8​
BUN​ 11​ 16​
Creatinine​ 0.67 (L)​ 0.73​
Glucose​ 129 (H)​ 109 (H)​
Calcium​ 8.5​ 8.8​
 MEDICATIONS
Amitriptyline​ Oral​
buPROPion XL​ 150 mg​
cloNIDine​ 0.1 mg​
dexamethasone​ 4 mg​
gabapentin​ 300 mg​
influenza virus vaccine (QUAD)​ 0.5 mL​
insulin lispro​ 0-6 Units​
lidocaine​ 1 patch​
memantine​ 5 mg​
metoprolol succinate ER​ 25 mg​
normal saline​ 5-10 mL​
rifAMPin​ 300 mg​
vancomycin​ 1,500 mg​
vancomycin pharmacy to dose​ Continue 1500 mg (14.6 mg/kg) q12H ​

Kills bacteria or prevents the growth

 WEIGHT HISTORY

• UBW 300# (136.4kg)​

• Patient states weighing 260# (118.2kg)​now
• Weight loss over the past 3 months​
• EMR​
• 11/20/20 weight: 134.5 kg
• 02/05/21 (admit) weight: 117.7
• Weight loss: 16.8 kg (12.5% in the past 3 months (severe)
 DIET HISTORY PTA

• 1 meal a day​
• Usually eats dinner​
• Couldn’t recall foods he eats, "eats everything"​
• Poor appetite, patient was unsure of when the the poor appetite
started or when changes in his diet occurred.
• No chewing or swallowing problems
 ANTHROPOMETRIC DATA

• Admission weight: 117.9 kg (259#) Stated​

• Height: 193 cm​
• ABW: 114.3 kg​
• IBW: 91.6 kg (ABW is 125% of IBW)​
• UBW: 136.4 kg (ABW is 84% of UBW)​
• DW: 114.3 kg​
• BMI: 30.67 kg/m² (Obesity Class I)
 ESTIMATED NEEDS

• Calories: 2089 kcal/day based on Mifflin-St Jeor​​

• Protein: 137 gm/day based on 1.5 gm/kg, using IBW​​
• Carbohydrate: 261 gm/day based on 50% of total kcal from
carbohydrate​​
• Fluid: 2089 mL/day based on 1 mL/kcal estimated needs
 NFPE

• NFPE deferred at this time due to conserve PPE.

• Patient in isolation
 PES STATEMENT 

• Severe acute disease-or injury- related malnutrition related

to inadequate or intake secondary to decreased appetite as
evidence by PO intake meeting less than or equal to 50% of
estimated energy requirement for at least 1 month and
unintended weight loss of > 7.5% in 3 months (severe)
 NUTRITION INTERVENTION 

• NPO at time of assessment ​

• Continue NPO for procedure and advance diet back to
previous diet of , CHO ​60gm/meal. Encourage good
PO intake.​
• Provide Chocolate Glucerna at lunch. 
• Weigh patient twice weekly
 MONITORING AND EVALUATION

• PO intake will meet at least 90% of estimated kcals/protein

needs based on 3-day average intake per review of EMR and
MyDining to follow up.
• Weight stable within 2% of current weight (114.3 kg) at follow
up.
 REASSESSMENT 2/17

• Biopsy of R flank area revealed metastatic melanoma​, skin

nodules
• Stage IV ​
• Brain radiation 2/12 and 2/15​(brain metastases)
• Outpatient immunotherapy after completion of radiation 
ESTIMATED NEEDS REASSESSMENT 

• Cancer
• Calories: 2290-2748 kcal/day, based on 25-30 kcal/day, using
IBW of 91.6 kg​
• Protein: 123-153 gm/day based on 1.2-1.5 gm/day, using ABW​
• CHO: 286-343 gm/day based on 50% of total kcal from CHO​
• Fluid: 2290 mL/day based on 1 mL/kcal estimated needs
 CURRENT INTAKE

• Cardiac, 60gm/meal​CHO
• 3-day review of PO intake per EMR and MyDining​
• 971 kcals/day (42% of estimated needs)​
• 54 gm/day (44% of estimated needs)​
• Patient likes food​
• Dislikes Glucerna 
 PES STATEMENT

• Continued malnutrition PES​

• Inadequate oral intake related to increased calorie/protein
needs secondary to cancer as evidence by patient consuming
<50% of estimated needs. 
 NUTRITION INTERVENTION

• Encourage PO intake​
• Discontinued Glucerna​
• Added magic cup at B & D
 MONITOR AND EVALUATION

• PO intake will meet at least 90% of estimated kcal/protein​

• Weight stable within 2% of current weight (114.3 kg) at
follow-up. 
 IN CONCLUSION

• What would I have done differently?

• Asked more questions about history​(Phone)
• Patient seemed annoyed on phone​
 REFERENCES

• https://www.mayoclinic.org/diseases-conditions/endocarditis/symptoms-causes/syc-
20352576
 ​
• Hosseini, S. M., Bakhshian, R., Moshkani Farahani, M., Abdar Esfahani, M.,
Bahrami, A., & Sate, A. (2014). An observational study on infective endocarditis:
a single center experience. Research in cardiovascular medicine, 3(4), e18423. 
• Netzer, R. O., Altwegg, S. C., Zollinger, E., Täuber, M., Carrel, T., & Seiler, C.
(2002). Infective endocarditis: determinants of long term outcome. Heart (British
Cardiac Society), 88(1), 61–66.
• Tackling G, Lala V. Endocarditis Antibiotic Regimens. [Updated 2020 Apr 30].
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020
Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542162/
• Vilcant V, Hai O. Bacterial Endocarditis. [Updated 2020 Aug 10]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK470547/