post RNY 5 yr malnourished

[Guest guest]

I have a patient that had RNY 5 yrs ago (and I wonder if it was

distal but she doesn't know), but she is still on at least 20

medications (including insulin) and I get the impression she may not

have been really good about MVI intake due to all these meds. She

wasn't very forthcoming but I am worried she might be having a memory

issue) She has recent fractures and MD dx her with bone mineral

disease. I am concerned she may have neuropathy of some sort given

her instability on her feet/memory. She almost fell over when she

stood up. Thiamine was not checked...She has had iron deficiency (MD

prescribed ferrous sulfate - not the best choice right?)and has been

on B12 shots. Her recent labs: Digoxin .6 (low), Mg 1.6(nml),

Phosphate 2.5 (nml), Zinc 89 (nml), protoporphyrin zinc 103 (H)

Chromium .6 (nml), ionized calcium 4.6 (L), Ceruloplasmin 11.3 (L),

Ferritin is normal and Iron was 48, Iron binding capacity was 281,

Iron saturation 171; Homocysteine and MMA were normal; PPT times were

high, Copper was 38 (L) and Vitamin D 14 (L) and PTH 94.5 (H)

Her Cholesterol 80 and Alb 2.7 and A1C 7.4

Pt was taking Centrum Silver (which I found was likely not the best

choice of formulation) and Caltrate D 600 (recently added this one)

daily. MD told pt pills aren't absorbed in RNY pts... He wants to

know my recommendations regarding bariatric advantage. From what I

have reviewed in recent resources it appears there may be more

consensus regarding using liquid, chewable vs. necessarily specialty

vitamins; and making sure pt is using adequate preparation - perhaps

2 doses of the MVI per day from what I have gleaned from various

resources. Has ASBS come out with these new guidelines I am reading

about yet?

I was going to recommend pt change calcium to citrate; take 2 Centrum

complete chewables per day; Recommend MD prescribe 50,000 IU

ergocalciferol weekly until levels replete for Vitamin D and I'd

recommend check thiamine levels. I'd also like to see if this

medication list can be downsized! Any thoughts on how Copper gets

repleted - will it replete from Copper in the MVI? What if thiamine

is low?

Pt is eating about 1500 kcal per day/60-70 gms protein from foods, no

N/V/D.She does need to improve her snacking habits, but she didn't

seem to interested in changing her diet and frankly, seemed a bit

like " what are you going to do to take care of me " kind of attitude.

It was strange. She does not exercise - but from what I saw wouldn't

want her to. Her Ht 67 " Wt: 159 lbs (wt regain of 12 lbs in past 2

yrs).

As you can tell I am stressing out about this. I will continue to

read and research, but like to hear from experienced bariatric RD's

in case I am missing something!

Thanks, Theresa