Nutritional assessment and optimizationDownloads

A 69-year-old man is brought to the emergency room by his daughter due to confusion. She reports that her father did not remember who she was yesterday, and his refrigerator was completely empty when she tried to make him lunch. She states that he was acting like himself when she visited him last week. She also notes that he has struggled with alcoholism for many years and has not seen a doctor in over two decades. She is unsure if he has any other chronic medical conditions. In the emergency room, the patient’s temperature is 101.2°F (38.4°C), pulse is 103/min, respirations are 22/min, and O2 saturation is 92% on room air. His BMI is 17.1 kg/m^2. Physical exam reveals an extremely thin and frail man who is not oriented to person, place, or time. As he is being examined, he becomes unresponsive and desaturates to 84%. He is intubated and admitted to the intensive care unit for what is found to be pneumonia, and the patient is started on total parental nutrition as he is sedated and has a history of aspiration from a prior hospitalization. Two days later, physical exam is notable for new peripheral edema. Laboratory tests at that time reveal the following: Serum: Na+: 133 mEq/L Cl-: 101 mEq/L K+: 2.4 mEq/L HCO3-: 24 mEq/L BUN: 22 mg/dL Glucose: 124 mg/dL Creatinine: 1.1 mg/dL Phosphate: 1.1 mg/dL Mg2+: 1.0 mg/dL Which of the following could have prevented the complication seen in this patient?

Four days after admission to the hospital for anorexia nervosa, a 20-year-old woman has new-onset palpitations and paresthesias in all four limbs. Prior to admission, she was found unconscious by her parents on the floor of a residential treatment center. The patient was started on a trial of nutritional rehabilitation upon arrival to the hospital. Her temperature is 36°C (96.8°F), pulse is 47/min, and blood pressure is 90/60 mmHg. She is 160 cm tall and weighs 35 kg; BMI is 14 kg/m2. The patient appears emaciated. Examination shows lower leg edema. A 2/6 holosystolic murmur is heard over the 5th intercostal space at the midclavicular line. An ECG shows intermittent supraventricular tachycardia and QTc prolongation. Serum studies show: Day 2 Day 4 Potassium (mEq/L) 3.5 2.7 Calcium (mg/dL) 8.5 7.8 Magnesium (mEq/L) 1.2 0.5 Phosphorus (mg/dL) 3.6 1.5 Which of the following is the most likely underlying cause of this patient's condition?