Case Study: Patient #8

Caleb Druckenmiller

FN 4340
November 20, 2014

Patient Overview
I chose to write my case study assignment on patient #8. He is a 44 year old African
American male who has been admitted for a laparoscopic cholecystectomy as a result of gall
stones. He has also undergone a roux-en-Y gastric bypass surgery 16 weeks prior to this
admission. The client has a past medical history of obesity, diabetes and hypercholesterolemia.
The patients height is 62 and his current weight is 308 pounds, giving him a body mass index
(BMI) of 39.6, which categorizes him in the obese class II division. The client has lost 39 pounds
from his usual body weight (UBW) of 347 pounds since the roux-en-Y gastric bypass surgery
was performed 16 weeks ago. This has brought him down to 162.1% of his ideal body weight
(IBW) of 190 pounds, based on his height and gender. Although the patient has lost a decent
amount of weight, the physician is not satisfied with the progress. Further improvement is
necessary.
The client is married and lives at home with his wife and two children. The patients wife
does all of the cooking at home, and she has not changed any cooking habits since the surgery
was performed. The patient consumes most of his meals at home, as the couple rarely goes out
to eat. His son is 18 years old and is preparing to begin college, while his daughter is 16 years
old and wishes to obtain her license and purchase her first vehicle soon. The client is a highschool graduate, but has never undergone any higher levels of education himself, and is
currently unemployed. He is unsure what he should be eating in regard to his condition and the
surgeries that have been performed on him. His medical conditions, along with the financial
burden of his surgeries, sons college tuition, and daughters licensing has caused a remarkable
amount of stress on him. Due to all this stress, he has experienced a rather difficult time
adhering to any sort of exercise routine and all of this has affected his self-esteem. He has
never been a very active individual before all of these events took place, and he is struggling to
implement any lifestyle changes now. The patient requires nutritional education to help him with

his condition. He also may need encouragement to boost his self-efficacy in order to ultimately
establish better habits, which will help him reach his goals.
Surgical Procedures
The client has just recently undergone a laparoscopic cholecystectomy. This is a
surgical procedure that is performed to remove ones gallbladder, in the event that he or she
has gall stones [1]. This procedure is carried out by inserting a tube with a small video camera,
called a laparoscope, via a small incision and does not require open surgery [1]. Gall stones can
prevent the flow of bile throughout the digestive system and may result in abdominal pain,
nausea, vomiting, gallbladder infection, and irritation of the pancreas [1]. A laparoscopic
cholecystectomy is considered to be a relatively safe and effective procedure to prevent such
problems [2,3]. In fact, statistics show that laparoscopic cholecystectomies have an overall
complication rate of just 9%, as well as a mortality rate of only 0.04% in patients [3]. This is
considerably lower than that of open cholecystectomies, which require a larger incision rather
than use of a laparoscope, and have a complication rate of 16% and mortality rate of 0.4% in
patients [1,3].
Prior to the laparoscopic cholecystectomy, the patient also underwent a roux-en-Y
gastric bypass surgery. Roux-en-Y gastric bypass surgery is a form of bariatric surgery that
decreases the stomachs size to roughly that of an egg by stapling shut the upper portion of it
[4,5]. It is then attached to the jejunum of the small intestine, directly bypassing part of the
stomach and the duodenum [4,5]. Roux-en-Y gastric bypass surgery has been recognized as an
effective method for clinical management of extreme cases of obesity [6,7]. As with the
cholecystectomy, this procedure can also be performed openly or by use of a laparoscope [4,6].
The aim is to induce weight loss by decreasing the size of the stomach and bypassing areas in
which absorption of nutrients occurs [4,5,6]. In turn, this promotes weight loss and is an effective
last-resort option of treatment in those who are severely obese. Not only is this surgical

procedure helpful in obese patients, but after weight loss it may also prove to show significant
clinical improvements in patients with type 2 diabetes mellitus [4,7].
Although roux-en-Y gastric bypass surgery is effective in managing extreme cases of
obesity and type 2 diabetes, it also brings about many risks of its own. Internal bleeding,
infection, blood clotting, leaks from incision cites, and death are possible risks associated with
this procedure [4]. Dumping syndrome may also be experienced after this type of surgery, in
which food drops down into the jejunum rather quickly [4,5]. In fact, roughly 85% of patients
experience it at some point after bariatric surgery [5]. Dumping syndrome, although unpleasant,
may actually serve as a helpful cue to help regulate proper diet via negative feedback, as it is
often experienced with the ingestion of poor food choices. Foods such as refined sugars, highfat and fried foods, as well as dairy products often are responsible for causing dumping
syndrome [5].
Nutritional Considerations
Although the patient has not experienced any of the aforementioned side-effects to the
surgery, an aspect that does require attention is the likelihood of malnutrition, especially since
he has been inconsistent with taking his vitamin supplements. Protein, iron, calcium, vitamin D
and B vitamin deficiencies (specifically B12, folate & thiamin) are common after roux-en-Y
gastric bypass surgery [4,5]. Possible deficiencies of these nutrients are due to two reasons.
Roux-en-Y is a restrictive-malabsorptive form of gastric bypass surgery [5]. This means that it
not only forms a smaller stomach, which makes it harder to consume as much food, but it also
bypasses the area of the gastrointestinal tract that is responsible for absorption of nutrients.
Keeping this in mind, it is very important that the client follows strict nutritional guidelines to
ensure optimal health. In addition to these guidelines, he will likely have to supplement with iron,
calcium, vitamin D and B complex vitamins as well.

For his gastric bypass surgery, he should focus on eating 3-5 small meals each day [5].
Every meal should begin with protein first, as he will get full faster and it is critical that he get
adequate amounts of this macronutrient [5]. Consuming protein first will not only make him
fuller, but also limit his carbohydrate and fat intake. He should also abstain from liquid intake at
least 10 minutes prior to each meal, and 90 minutes after each meal [5]. All liquids he does
consume should be calorie-free, in order to promote weight loss [5]. This is also necessary as
he recovers from losing his gallbladder. He should eat a wide variety of foods and eat at a slow
pace, making sure he chews each bite thoroughly [5]. His focus should be on protein and
complex carbohydrates, while avoiding refined sugars, high-fat or fried foods, and dairy
products which are all likely to cause dumping syndrome [5]. Based on his gender, age, activity
and injury factors, I recommend that he consume a diet consisting of 2000-2200 kcal/day in
order to lose weight. These calories should contain 130 g of protein, which will equal up to 520
kcal of protein (roughly 23-26% of calorie intake). This is based on the rule of 1.5 g/kg IBW.
These numbers were obtained by the following mathematics:
Protein Needs:
IBW = 106 lbs. + 6(14 inches) = 106+84 = 190 lbs. IBW
190 lbs. /2.2= 86.37kg IBW
86.37 x 1.5 = 129.55 g protein/day
Daily Caloric Needs (MSJ equation):
62 = 74 inches x 2.54 = 187.96 cm
10 (86.37kg) + 6.25 (187.96cm) 5 (44) +5 = 863.7 + 1174.75 220 + 5
= 1823.5 REE x 1.0* (AF) x 1.3** (IF)
= 2370 kcal/d. In order to lose weight: 2000-2200 kcal/d
*This activity factor was based on the individuals lack of physical activity: no
exercise routine and no job; sits around most of the day
**This injury factor was based on the surgeries the individual is recovering from

Lab Values
The patients hemoglobin lab value is 12.8 g/dL. This is a protein that binds to oxygen in
red blood cells and carries it throughout the bloodstream [8]. A low hemoglobin lab value
corresponds to 12 g/dL (or less) for women, and 13.5 g/dL (or less) for men [8]. Given the fact
that my patient is a male, his hemoglobin is considered to be a bit low. This may be indicative of
blood loss, possibly due to bleeding from a wound or the digestive tract [8]. It also may be due
to an iron-deficiency, or lack of folate or vitamin B12 [8]. This illustrates the need for the patient
to continue taking an iron supplement, as well as possibly a B complex vitamin supplement.
The clients hematocrit lab value is 38%. This represents the percentage of blood that is
composed of red blood cells [9]. The typical range for men is 38.8-50.0%, while it is normal for
women to be somewhere in between 34.9-44.5% [9]. Since my patient is a male, he is slightly
underneath the normal range. A lower than average hematocrit level may indicate an insufficient
amount of red blood cells in the blood, recent blood loss, and possible vitamin or mineral
deficiencies [9]. This further illustrates the need for my patient to continue taking an iron
supplement.
The patients albumin lab value is 3.6 g/dL. The normal range for albumin is 3.4-5.4 g/dL,
which means he is just on the lower end of the normal range [10]. Decreased albumin levels
may indicate that the body is not absorbing enough nutrients and are typical after weight-loss
surgery [10]. My client may be in the normal range still, but is still on the lower end which may
be further evidence to keep him on a vitamin/mineral supplement.
The clients pre-albumin lab value is 20 g/dL. This is a test to check whether or not one
is receiving proper nutrition from their diet [11]. The normal range for adults is 15-36 mg/dL [11].
This means that my client is within the normal limits, but is still on the lower end, as is the case
with his albumin lab value. It also is an indication of malnutrition, which one again goes to show
why a vitamin/mineral supplement is necessary. Further tests may be helpful for my client, such
as iron, folate and B12 [11]. It would be a good idea to request these as well, if at all possible.

Medications
My patient is currently taking ibuprofen and Lipitor. Ibuprofen is a non-steroidal antiinflammatory drug (NSAID) that is commonly used to reduce pain or inflammation [12]. The
patient is currently on this to help him deal with the post-surgery pain. When taken in high
doses, it may be necessary to increase consumption of vitamins C, K and folate [12]. Lipitor is a
kind of HMG-CoA reductase drug, also known as a statin, and is used to lower cholesterol and
reduce the production of LDL cholesterol [12]. The patient is currently taking this to help control
his hypercholesterolemia. Dietary fat and cholesterol should be limited while on this medication
[12]. Alcohol should be avoided while taking both of these medications [12]. Combining this
knowledge with that of the patients surgical procedures and lab values, it stands to reason that
he should be placed on a low-fat diet with an emphasis on protein and vitamin/mineral
supplements. This conflicts with the current diet order of a regular diet. He should also aim to
avoid refined sugars, fried foods, and dairy products. Calcium, vitamin D, iron, and vitamin B
complex supplements will be required in addition to this diet prescription.
Social Factors
My patient is a husband and father of two children. He eats predominantly at home, but
does not ever cook. He relies on his wife to do all of the cooking, and unfortunately she has not
changed any of her cooking habits since his surgeries. This may be a major problem, which
likely has a negative impact on my clients condition and overall health. Perhaps if he learned to
cook, he would be more capable of consuming healthier food choices. Another alternative could
be persuading his wife to cook healthier meals. It is a positive point that he rarely eats out, as it
is often hard to do so in a healthful manner. Educating the client on how to prepare food in a
nutritious way may be necessary in order for him to continue losing weight. I will provide him
with a handout to educate him on basic cooking principles and go over these with him when we
meet. I will also recommend that he begins using an app to track his food record, as he has

never done so in the past. MyFitnessPal, LoseIt, and Fooducate are examples of apps I may
recommend to the client. These tools will help him remain conscious of his food intake and
overcome some of the problems he has previously had with his diet.

PES Statements
1] P Poor adherence to supplementation related to E nutritional knowledge deficit and
forgetfulness as evidenced by S low lab values of hemoglobin (12.8 g/dL) and
hematocrit (38%) and clients admission of poor adherence to supplement consumption.
2] P Inadequate amount of physical activity related to E exercise knowledge deficit and lack of
self-efficacy as evidenced by S body weight of 309#, unemployment, and self-admitted
failure to maintain exercise routine.
3] P Excessive energy intake related to E undesirable food choices and lack of physical activity
as evidenced by S BMI of 39.6, %IBW of 162.1%, and requirement of weight-loss
surgery.

Intervention Goals
1] Take vitamin/mineral supplements each day: Set an alarm on phone as a reminder. This will
help prevent forgetfulness.
2] Start workout routine back up: Go to the gym 3x per week and meet with personal trainer to
instruct and encourage success. This will teach client basic exercise skills and help him
maintain habit, while boosting his self-efficacy. As he becomes more confident, he will
have an easier time sticking with this lifestyle.
3] Follow 2000-2200 kcal/d low-fat diet: Record daily food intake in a journal and focus on
consuming protein first during each meal. Then emphasize vegetables, fruits, and whole
grains. Avoid refined sugars, high-fat foods, fried foods and dairy products.

Additional Q&A
Q: What supplements are you currently taking (or supposed to be)?
A: Calcium, Vitamin D, and Iron
Q: What obstacles have prevented you from taking these supplements routinely?
A: I forget sometimes
Q: Do you understand the importance of taking these supplements?
A: Not really, I already eat too much
Q: Is it okay if I educate you on the importance of these supplements?
A: Please do
Q: Where do you typically eat meals/snacks?
A: At home. I hardly ever go out to eat
Q: Would you be willing to learn to cook?
A: Only if it will help me lose weight
Q: Who do you eat with?
A: Usually my wife. Sometimes my two children as well.
Q: What foods do you frequently consume?
A: Pizza, ice cream, kit kats, snickers, candy, cheeseburgers
Q: Are there any foods you absolutely will not eat?
A: Parsnips and sauerkraut. Why does that stuff even exist? Im never touching either of those.
Q: What are some of your favorite foods?
A: Pizza, chocolate bars, green beans, broccoli, cheeseburgers
Q: Do you have any food allergies?
A: I wish. Maybe then itd be easier to lose weight.
Q: Do you smoke?
A: No, thats bad for you.
Q: Do you drink alcohol?
A: Just an occasional glass of wine
Q: Do you follow any exercise routine? If so, what types of exercises do you perform?
A: No. I tried lifting weights and really liked it when I did, but it only lasted for a week.

Q: Are you willing to implement exercise into your daily life?

A: Yeah but I might need someone to guide me.
Q: On a scale of 1-10, how confident are you that you can stick with this?
A: 2
Q: Why did you choose this number, rather than a higher one?
A: It takes a lot of effort and I dont really know what Im doing.
Q: What can I do to help you improve this number?
A: Go to the gym with me
Q: Would you be willing to meet with a personal trainer?
A: Yeah. I really want to lose this weight.
Q: Do you have a job that requires physical activity?
A: No, I am currently unemployed. Prior to bariatric surgery I worked a full-time desk job.
Q: Have you ever kept a food record before? Would you be comfortable doing so?
A: I never have in the past. I would like to start, since this may help me lose weight.

References
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2014 November 19]. Available from:
http://my.clevelandclinic.org/health/treatments_and_procedures/laparoscopicsurgery/hic_Laparoscopic_Cholecystectomy
2] Gal I, Szivos J, Jaberansari MT, & Szabo Z. Laparoscopic cholecystectomy: risk of missed pathology on
other organs. Surg Endosc (1998); 12: 825-827.
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cholecystectomy. J Minim Invasive Surg Sci (2014); 3(2): Published online.
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November 19]. Available from:
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/roux-eny_gastric_bypass_weight-loss_surgery_135,65/
5] Tucker-Falconer R. Gastric bypass [lecture notes]. Bowling Green State University. Notes provided at
lecture given 2014 November 18.
6] Wittgrove AC & Clark GW. Laparoscopic gastric bypass, roux en-Y 500 patients: technique and results,
with 3-60 month follow-up. Obesity Surgery (March 2000); 10: 233-239.
7] Schauer PR, Burguera B, Ikramuddin S & et. al. Effect of laparoscopic roux-en Y gastric bypass on type
2 diabetes mellitus. Ann Surg (2003); 238(4): 467-485.
8] Symptoms: Low Hemoglobin Count [internet]. Mayo Clinic. 2012. [cited 2014 Nov 19]. Available from:
http://www.mayoclinic.org/symptoms/low-hemoglobin/basics/definition/sym-20050760
9] Hematocrit test [internet]. Mayo Clinic. 2013. [cited 2014 Nov 19]. Available from:
http://www.mayoclinic.org/tests-procedures/hematocrit/basics/definition/prc-20015009
10] Albumin- blood serum [internet]. Medline Plus. 2013. [cited 2014 Nov 19]. Available from:
http://www.nlm.nih.gov/medlineplus/ency/article/003480.htm
11] Pre-albumin (Blood) [internet]. University of Rochester Medical Center. [cited 2014 Nov 19].
Available from:
http://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=167&ContentID=p
realbumin
12] Nutrient-Drug Interactions and Food [internet]. Colorado State University. 2013. [cited 2014 Nov 19].
Available from: http://www.ext.colostate.edu/pubs/foodnut/09361.html