This case involves an elderly male patient who had recently undergone gastrointestinal surgery who presented to the hospital with nausea, vomiting, as well as a significant decrease in appetite. While at the hospital, doctors performed a battery of tests, including an endoscopy and CT scan of his abdomen which showed a contracted stomach. A few days after being discharged from the hospital, the patient presented to his family medicine physician with ongoing complaints of nausea and vomiting, however his doctor did not order any additional follow up. A month later, the patient presented to the emergency room with significantly altered mental status. Eventually, the patient was diagnosed with a severe vitamin D deficiency due to malnutrition, which resulted in a brain injury.
Question(s) For Expert Witness
- 1. How often do you treat patients with similar presentations?
- 2. What kind of follow up or measures should a family physician take for a patient presenting with persistent vomiting and altered mental status post surgery?
Expert Witness Response E-143720
I have cared for patients both in the outpatient clinical setting and those who have been hospitalized since 1994 in the US. Nausea and vomiting are arguably the most common side effects to prescription medication and are very common presenting symptoms of illness, including infection, metabolic derangement, intestinal conditions, inter alia. Following any abdominal surgery, gastroenterological (GI) symptoms are extremely common, including bowel irregularity, nausea, vomiting. Persistence of these symptoms beyond 2 days warrants a thorough investigation. I see patients on a regular basis with these issues. Family physicians should order blood tests, routine ones first, including cbc, metabolic tests (electrolytes, calcium, glucose, kidney and liver function) and others depending on medical history and meds being taken. If normal, other tests that would be warranted include magnesium, phosphorus blood tests. Imaging of the abdomen is also considered standard of care, including abdominal series initially, then ultrasound if gallstones are suspected, CT scan of abdomen if cancer or other diseases are suspected, then a GI evaluation. Stool testing is not usually done unless the patient has diarrhea. Altered mental status following any condition/surgery or on its own warrants a neurological evaluation, CT of head, perhaps MRI of head, neurological consultation from a specialist, and depending on history (alcohol excess, drug use, etc.), urine drug screening, vitamin B12, B6 and other B vitamin testing, and serum ammonia.
Expert Witness Response E-021702
I have over 10 years experience in Primary Care and I routinely see, evaluate, and treat post-operatively Gastric Bypass patients. This is clearly a case of severe vitamin deficiency in the setting of acquired malabsorption insufficiency from presumed gastric bypass surgery. Many vitamins and minerals will be empirically low in a gastric bypass patient including Iron, B6, B12, Folic Acid, Calcium, Vitamin D, etc. and must be chronically supplemented preferably in oral form (liquid, sublingual or less efficiently non-capsule tabs). Family physicians usually take the lead soon after surgery to educate patients who are usually left without much of the required education and training from the gastric bypass surgical team. Persistent vomiting and altered mental status requires urgent evaluation in the hospital setting via Emergency room for prompt work up, imaging, IV fluids and aggressive vitamin supplementation.