Rationale for Pertinence of Facts

Facts that are not necessarily related to the hypotheses regarding nutritional 
diagnosis:

Crohn's Disease AKA Regional Enteritis

Crohn's disease is an autoimmune disease of the entire gastrointestinal tract, 
associated with inflammation and numerous complications that could potentially 
affect nutritional status.  In particular, nutrient losses through fistulas are 
of concern.  Malabsorption and increased nutrient loss is a common occurrence, 
and is likely to be affecting this patient, given that he complains of chronic 
and frequent diarrhea that appears to be unremitting, regardless of dietary 
alterations. Inflammatory state may increase energy requirements, as well as 
protein requirements. This disease state, in and of itself, would predispose 
someone to malnutrition, particularly over time as the disease progresses.

Diarrhea

Associated with increased nutrient losses; is most likely due to inflammation 
and consequent malabsorption with a compromised GIT.  Diarrhea will also 
increase fluid requirements.  I would want to talk to the patient to ascertain 
if he is malabsorbing fat- i.e. I would inquire as to the characteristics of the 
diarrhea (whether or not a foul smell is present, whether or not the stool 
appears oily or frothy, etc.,).  

Crampy abdominal pain

This will impact the patient's ability to eat, and is reflective of the 
inflammatory process occurring in his GIT, the malabsorption and diarrhea, 
etc.,.  He reports that his appetite is 
poor, and that eating is associated with pain.  This is not unusual at all in 
patients with Crohn's disease.  Many individuals will severely limit the 
frequency and quantity of meals, in order to minimize the pain associated with 
eating.  

Poor appetite

Pain associated with eating, crampy pain, frequent diarrhea... all would decrease 
appetite, in addition to fears about the disease process.  I would want to ask 
the patient about mouth ulcerations as well, as these will frequently interfere 
with appetite and food intake.  It is also very likely that the patient would be 
avoiding fruits and vegetables, given that high fiber foods are problematic if 
strictures (narrowing of the GI lumen with inflammation) are present.  Actually, 
it is the fiber content, in addition to the potential exacerbating effect on 
diarrhea that would lead many patients to avoid them.  Obviously, poor appetite 
over time is going to lead to inadequate energy and protein intake, setting the 
patient up for marasmus.

Fever

This will increase both fluid and energy requirements, and is indicative of 
acute inflammation.  

Enterocutaneous Fistula

Once the patient presents with an enterocutaneous fistula, I immediately wonder 
about the fistula output.  Low output fistulas are handled more conservatively 
than higher output ones, because the low output fistulas will often undergo 
spontaneous closure.  This patient has a high output fistula that will likely 
require ~3 -4 weeks to close, and may require surgery for resolution before it's 
all over.  This has serious implications for my decisions regarding nutrition 
support; namely that TPN will be required to allow the fistula to heal and to 
minimize nutrient losses via the fistula.  The protein lost via a fistula, in 
addition to the precipitating disease exacerbation (inflammation) will set this 
patient up for kwashiorkor, due to the triggered metabolic stress response.

Labs:

A low bicarb (CO2), with an elevated chloride, and a high normal potassium may be clinical signs of metabolic acidosis, which might be expected with a GI fistula.  

Elevated blood glucose is indicative of the inflammatory process and metabolic 
stress response- the patient likely is experiencing the insulin resistance 
associated with metabolic stress.

Medication:  Azulfidine

This is a folate antagonist, so it places the patient at risk for folate 
deficiency. 


Data to use for assessing nutrient requirements:

REE = 1850

I will use this for determining energy requirements, once I make a nutritional 
diagnosis.  I also calculated BEE by the Harris-Benedict equation in order 
to determine by comparison whether or not the patient is hypermetabolic.  
REE/BEE = 1850/1632 = 113%
The patient is hypermetabolic.  This means that I will definitely be using 
measured REE to determine caloric requirements, as I have a more accurate 
picture of his energy requirements because of the availability of indirect 
calorimetry data.

Ht, age, admission weight - 

These will be useful when I calculate requirements, 
and when I determine ideal or desirable weight, BEE, etc., Weight will be used 
for comparison with usual weight to determine how much the patient has lost, and 
with desirable weight to see how the patient's current weight measures up to 
healthy reference data for a man his height and age.