University of Maryland
College Park
Dietetic Internship
2020-2021 MINI CASE STUDY
1. The preceptor assigns the intern a mini case study patient as per 8-week clinical calendar.
2. The intern will be the primary dietitian for that case. The intern must perform at least the
initial and possibly subsequent assessments. As possible has completed chart note and/or
diet instructions.
3. The preceptor dietitian, responsible for the patients on the floor where the case is located,
will be the primary resource person.
4. The case should simple, not complex. Examples of a mini case study include patients
with hypertension, chronic obstructive pulmonary disease (COPD), congestive heart
failure (CHF), gastric surgery, and cancer.
5. Review the literature related to the case. Consider the medical, social, surgical,
laboratory, pharmaceutical, nutritional, etc. aspects of this specific case. Review the mini
case study example that is attached. Remember to use the NCP manual, the online
nutrition care manual and (as possible) the Evidence Analysis Library.
6. The case study will be presented at a clinical dietitian meeting. The presentation should
take no more than 20 minutes.
7. For the presentation, develop and distribute a one-page typed outline of the case with a
limited discussion on the back page along with a few selected references. Handout can be
no longer than one piece of paper with typing on both sides. Make sure to practice
presentations before the set date. Make sure you can pronounce all medical terms
correctly. Ask for help if you need it.
8. The presentation will be evaluated by facility dietitians and/or the internship director.
9. Format to use
Nutrition Assessment: Medical Diagnosis – Bleeding pressure ulcer
Age: 74 Nutrition Related Labs:
Gender: F (3/2021)
Weight: 120.2 kg (264#) BUN 26 (H)
Ideal Body Weight: 57kg (125.4#) Creatinine 1.5 (H)
Height: 5 ft 5 in (65in) Glucose 110 (H)
BMI: 44.1 (obese) Ca 8.1 (L)
% IBW change Fe 13 (L)
% UBW change
As of FUP -
(3/ 2021)
PMH Creatinine 1.6 (H),
Morbid obesity and decreased mobility, Glucose 117 (H)
Arthritis, CKD Stage 3, Hyperthyroidism, Ca 8.2 (H)
Hypertension
Medications:
Symptoms IVF
Skin : Stage III R.buttock that began Synthroid
excessively bleeding, Stage II L.buttock, Protonix
skin tear to abdomen.
As of FUP - Meds listed as: Colace,
(3/17) Per chart review, constipation. Last Synthroid, Protonix
BM unknown.
Diet History Current Diet
Food Allergies - NKFA Clear Liquids
Weight History - 131.6 kg (290#) as of Intake = 100%
4/2020. Intake provides:
743 calories, 10g protein
As of FUP / Advanced to Regular
Intake = 100%
Intake provides:
1094-2188 calories, 57-114 g protein
Nutrition Diagnosis – utilize PES Statements
1.) Increased nutrient needs r/t skin/ tissue breakdown AEB presence of Stage III and
Stage II pressure ulcers.
2.) Inadequate energy intake (Acute) r/t increased nutrient needs secondary to wound
healing AEB <75% estimated energy, protein needs.
Nutrition Intervention – Nutrition prescription, Interventions with goals
Nutrition Prescription Intervention with goals
Using current & ideal body wt - 57kg - Encourage PO intake
(125.4#) - Food& Nutrient Delivery - Will
Calories = 1705 per day using 30 kcals recommend and order Ensure Clear
(BMI>30) TID. Ensure clear provides 240
Protein = 85-114gm per day using 1.5- kcals 8g pro
2.0gm/kg (BMI>30, wound healing) - Coordination of Care - RD Will
Fluid = 1705 ml per day using 1ml/kg monitor PO intake, wt
- As of FUP - Food & Nutrient
Delivery - Will recommend and
order Ensure Enlive 1/Day. Will
D/C Ensure Clear because of Pt
preferences. Ensure Enlive provides
350 kcals 20g pro
Nutrition Monitoring and Evaluation
Indicator Criteria
1. Energy Intake 1. Pt will continue to meet >75%
estimated nutrient needs by next
RD assessment.
Source Kcal requirements Protein requirements Fluid requirements
Facility standards 1705 kcal/day 85-114gm protein/day 1705 ml fluids/day
(Kcal – Mifflin St. Jeor (Using IBW for obesity (Using 1 ml/kcal)
using IBW and 30 kcals and factors 1.5-2 for
for BMI>30) wound healing
EAL n/a – nothing found* n/a – nothing found* n/a – nothing found*
Other Source - 1710-1,750 kcal/day - 85-114gm protein/day 1705 ml fluids/day
Morrison using IBW 30-35 BMI (Using IBW for obesity (Using 1 ml/kcal)
30-40) and factors 1.5-2 for
wound healing
References:
