1

INTRODUCTION

Embarking on a transformative journey, I had the privilege of completing a three-month

internship at Lourdes Hospital, located in Kochi, Ernakulam. This period, steeped in learning
and professional development, offered me a profound insight into the dynamic world of
dietetics within a hospital setting. The main objectives of this internship were multifaceted; it
was designed to immerse me in the practical realities of a dietitian's role, enhance my
knowledge and expertise in diet and nutritional counseling, and develop essential skills such
as effective patient communication and meticulous diet planning. My roles and responsibilities
during this enriching period were diverse and challenging. Regular rounds through various
hospital wards, including nephrology, urology, cardiology, gynecology, and orthopedics,
provided me with a panoramic view of the nutritional needs and challenges across different
medical specialties. Additionally, engaging in medical record documentation related to the
nutrition department, conducting Subjective Global Assessment (SGA) analysis of dialysis
patients, and participating in food-tasting sessions were integral parts of my day-to-day tasks.
This internship was a crucible of learning, offering insights into the complexities of diseases,
their types, feeding methods, and diet variations tailored to patient needs.

Moreover, it broadened my medical vocabulary and understanding of medications.

Adapting to the hospital environment and mastering its terminologies posed a significant
challenge initially; however, this was overcome through dedication and relentless pursuit of
knowledge. The professional and personal growth I experienced is immeasurable. I emerged
from this internship with a deeper understanding of dietetics, equipped with the knowledge,
skills, and confidence to excel in future academic and professional endeavors. The mentorship
and support provided by the hospital's nutrition department were pivotal in this journey,
enhancing my learning experience and fostering a deep sense of belonging within the dietetics
community.

Reflecting on my time at Lourdes Hospital, this internship was not just an educational
requirement but a pivotal step in my career. It has solidified my foundation in dietetics,
preparing me for future challenges, be it further studies, professional examinations, or job
opportunities. The experiences, knowledge, and skills acquired during these three months will
undoubtedly serve as a guiding light in my pursuit of excellence in the field of dietetics.
 2

CHAPTER 1

LOURDES HOSPITAL, ERNAKULAM

Lourdes Hospital is a premier multispecialty hospital in Ernakulam, the commercial

capital of Kerala. Commenced in the year 1965 under the aegis of the Archdiocese of Verapoly,
Lourdes today attends to around 500 In-patients and 1700 Out-patients daily and attracts
patients not only from all parts of Kerala but from other states of India as well as from abroad.
Lourdes Hospital is also the first mission hospital in Kerala to get the NABH Accreditation for
Quality of Services.
Lourdes Hospital has now around 36 established specialty departments which are growing
steadily, equipped with state-of-the-art equipment’s, and manned by trained and dedicated
staff, many of whom now run training programs. Lourdes Hospital is also a full-fledged
teaching institution conducting postgraduate (DNB) courses in 14 specialties, has a Nursing
College giving BSc, Post BSc & MSc courses, a Nursing School (GNM), a Paramedical
College offering various courses and is an AHA International Training Centre as well.

Their real strength and inṄcentive remain a strong sense of social commitment to providing
affordable, service-oriented, and patient-centered care. They focus on holistic healing
encompassing all dimensions of human life - mind, body, and spirit. For over half a century
they have been committed to serving the less fortunate sections of society irrespective of caste
or creed.
 3

CHAPTER 2

DEPARTMENT OF NUTRITION AND DIETETICS

Nutritional science is a multifaceted field that investigates the constituents of food, the
mechanisms by which the body assimilates these substances, and the intricate interconnections
among diet, health, and illness. Practitioners in this discipline integrate principles from
molecular biology, biochemistry, and genetics to decipher the impact of nutrients on the body’s
functions. Moreover, the study of nutrition concerns itself with leveraging dietary decisions to
diminish disease risk, understanding the implications of nutrient imbalances, and elucidating
the underpinnings of allergic reactions. Nutrients are the substratum of life, comprising
proteins, carbohydrates, fats, vitamins, minerals, fiber, and water.

The domain of nutrition encompasses the scientific examination of food, its nutritive
components, and the processes of digestion, absorption, and metabolic integration within the
organism. Clinical nutrition stands as an independent, empirical science, straddling the
interface of fundamental and pragmatic realms. It addresses the dietary requisites of individuals
afflicted with varying pathological conditions and the formulation of appropriate dietary
regimens. Clinical nutritionists and dietitians play an indispensable role in the prophylaxis of
myriad health conditions. Informed by medical diagnoses and comprehensive nutritional
evaluations, these professionals prescribe tailored diets, ensure the delivery of appropriate
nourishment within clinical settings, and administer dietary counseling to patients.

ABOUT THE DEPARTMENT

The Department of Clinical Nutrition and Dietetics at Lourdes Hospital comprises a cadre of
nutrition professionals including a Chief Dietician, a Senior Dietician, Assistant Dieticians,
Trainees, and Diet Clerks. Responsibilities are apportioned across various wards to address the
diverse requirements presented. The department is dedicated to fulfilling the nutritional needs
of patients, both standard and therapeutic, ensuring comprehensive nutritional screening,
assessment, dietetic planning, adjustments, consultations, and continued monitoring. The
dietitians diligently oversee the culinary aspects of diet preparation, evaluating and ensuring
palatability, and quality, and suggesting necessary modifications to the dietary provisions.
 4

Operational hours within the department are structured as follows:

7 am - 4 pm
8 am - 5 pm
9 am - 6 pm

OBJECTIVES OF THE DEPARTMENT

The department aims to deliver a comprehensive suite of nutritional services, which include:
• Rigorous nutritional assessments to understand and meet patients' dietary needs.
• Operationalizing dialysis nutrition management.
• Strategically devising and dispensing both standard and specialized therapeutic dietary
plans in alignment with established nutritional principles.
• Meticulously recording and analyzing data crucial for the formulation of individualized
nutrition care plans.
• Administering inpatient diet services with precision.
• Offering dietetics training internships that provide practical education to students.
• Engaging proactively in both internal and cross-departmental dialogues, as well as in
Continuing Nutrition Education (CNE) programs.
• Organizing educational exhibitions and seminars on nutrition in conjunction with
globally recognized health observances, such as World Kidney Day, World Heart Day,
National Nutrition Week, and Diabetes Awareness Week.
• Providing comprehensive information on the interactions between medications and
nutrients.
 5

CHAPTER 3
FUNCTIONS OF THE DEPARTMENT

The duties of the department, based on the provided information, include:

1. Conduct nutritional screenings to identify patients at risk of malnutrition and determine the
need for comprehensive nutritional assessments.
2. Reviewing patients' medical profiles upon admission, which involves evaluating
demographic information, BMI, medical history, biochemical data, current medications, and
dietary habits to inform the creation of individualized diet plans.
3. Undertaking regular reassessments of patients' nutritional status, typically every 48 hours,
to monitor health changes and modify therapeutic diet plans as necessary.
4. Providing dietetic consultations for both outpatients and inpatients, aiming to explain and
adjust dietary plans specific to patients' health conditions and to support their understanding
and compliance with therapeutic lifestyle changes.
5. Document the details of outpatient consultations in the diet consultation ledger for ongoing
patient management.
6. Engaging in community outreach and research initiatives to promote the importance of
nutrition and exercise in maintaining a healthy lifestyle, as well as organizing public health
education events.
7. Managing a structured menu system within the hospital that encompasses various therapeutic
diets tailored to the diverse clinical needs of patients.

NUTRITIONAL SCREENING AND EVALUATION

Nutritional screening serves as a preliminary method to identify individuals who are
experiencing malnutrition or are at an elevated risk of such a condition, thereby determining
the necessity for an in-depth nutritional assessment. Upon a patient's admission to the hospital,
the lead dietitian is tasked with reviewing the patient’s medical profile. This review includes
an examination of the patient’s demographic details, body mass index (BMI), chief medical
concerns, historical health data, biochemical indices, current pharmaceutical regimen, and
dietary habits, which collectively inform the prescription of a tailored diet.
 6

NUTRITIONAL EVALUATION FORM

RE-ASSESSMENTS
Reassessments involve a systematic reevaluation of the patient's nutritional status at bi-daily
intervals, or every 48 hours. This process is integral to observing any changes in the patient's
nutritional health during their hospitalization and adjusting their therapeutic diet plan
accordingly, as needed.

DIETETIC CONSULTATIONS FOR OUTPATIENTS AND INPATIENTS

The essence of both outpatient (OP) and inpatient (IP) dietetic consultations is to clarify dietary
requirements tailored to each patient's specific health condition, establish a rapport with the
patient, and facilitate dietary modifications that align with therapeutic lifestyle changes
conducive to optimal nutrition. Outpatient diet consultations may include executive health
evaluations and referrals, either by a physician or through self-initiation. The particulars of
these consultations are recorded in the outpatient diet consultation ledger maintained by the
Department of Clinical Nutrition and Dietetics.
 7

COMMUNITY OUTREACH AND RESEARCH INITIATIVES

The department encompasses a variety of community research programs designed to heighten
awareness about the critical role of nutrition and exercise in maintaining a healthy lifestyle.
Nutrition awareness campaigns and public health education events are orchestrated either by
designated departments or through collaborative efforts with the marketing department.

MENU SYSTEM
In Lourdes Hospital, the clinical nutrition and dietetics department has a well-organized menu
system. There are different types of therapeutic diets. They are as follows:
• Clear fluid diet
• Full fluid diet
• Soft diet / Semi-solid diet
• Normal diet
• Tube feeds [NGT, PEG, PEJ, etc.]
• Parenteral nutrition
• Diabetic diet
• Low salt diet
• Renal diet
• Hepatic diet
• Low protein diet
• High protein diet
• Bland diet

CLEAR FLUID DIET

The clear fluid diet is prescribed in situations where acute illness or surgical procedures result
in severe food intolerance, manifested by symptoms such as nausea, vomiting, anorexia,
abdominal distension, and diarrhea. Under these conditions, a stringent limitation of food
intake is recommended, with provisions made at 1-to-2-hour intervals, progressing to a more
varied diet as tolerance improves.

Indications for a clear fluid diet include:

• Pre-diagnosis in acute infections.
• Acute inflammatory diseases of the gastrointestinal tract.
 8

• Post-surgical recovery, particularly after colon or rectal surgery, minimizes bowel

movements.
• Alleviation of thirst.
• Hydration of bodily tissues.
• Facilitation of gas expulsion.

Comprising purely of transparent liquids that leave minimal residue, this diet is devoid of gas-
producing substances, non-irritating, and does not stimulate the digestive tract. Typically, its
duration should not exceed 24 to 48 hours, starting with restricted fluid volumes of 30-60 ml
per hour and incrementally increasing based on patient tolerance. It provides approximately
300 kilocalories and lacks protein, with dairy omitted. Permissible consumables include black
coffee, tea, clear carbonated beverages, cereal water, and strained fruit juices, serving primarily
to replenish bodily fluids.

FULL FLUID DIET

The full-fluid diet serves as an intermediary between the clear-fluid diet and softer diets. It is
appropriate post-surgery, for acute gastritis, infections, and diarrheal conditions, and is also
suitable for those who can tolerate milk but are unable to consume solid or semi-solid foods
due to illness.

This diet includes food items that are liquid at room temperature or become so upon ingestion.
Meticulously planned, it can provide complete nutritional adequacy over a prolonged period
without risk of deficiencies. Administered every 2-4 hours, this diet supplies roughly 1200
kilocalories and 35 grams of protein. It excludes fiber-rich and irritating substances,
encompassing a range of permissible items like milk, fruit juices, vegetable purees, cream
soups, porridges, plain ice cream, strained meat soups, cocoa, coffee, tea, custard puddings,
plain gelatin desserts, and various types of porridge.

SOFT DIET / SEMI-SOLID DIET

The soft diet, synonymous with a bland diet, consists of easily digestible foods characterized
by a soft texture and low fiber content, aimed at minimizing the need for chewing. Such a diet
typically excludes spicy, fried, or gas-inducing foods and is commonly adopted during
recovery from surgical procedures, particularly after gastric bypass, to gradually reintroduce
 9

the stomach to solid foods. The diet, starting around three to four weeks post-surgery,
prioritizes high-protein, low-fat, low-fiber, low-calorie, and low-sugar foods. Meals often
include tender meats, poultry, fish, and soft or pureed fruits and vegetables. Proper protein
intake is essential to facilitate wound healing and preserve muscle mass.

NORMAL DIET
A normal diet, or a balanced diet, encompasses diverse food types in specific quantities and
proportions essential for the body to function optimally. This includes carbohydrates (starches
and fiber), protein, healthy fats, vitamins, minerals, and antioxidants. A varied and balanced
intake of fruits, vegetables, grains, dairy, and protein sources like meat, eggs, fish, beans, nuts,
and legumes are crucial. Balancing these nutrients and food groups is integral to a healthy diet.

TUBE FEEDS (NGT, PEG, PEJ)

Tube feeding facilitates the direct delivery of nutrition to the stomach or small intestine when
oral consumption is not possible. Nutrients are provided through a tube inserted nasally (NGT
- Nasogastric Tube) or directly into the stomach (PEG - Percutaneous Endoscopic
Gastrostomy) or the small intestine (PEJ - Percutaneous Endoscopic Jejunostomy).

PARENTERAL NUTRITION
Parenteral nutrition is the intravenous provision of nutrition, including proteins, carbohydrates,
fats, minerals, electrolytes, vitamins, and trace elements for patients unable to ingest or absorb
adequate nourishment orally or via tube feeding. Conditions warranting parenteral nutrition
include short bowel syndrome, gastrointestinal fistulas, bowel obstruction, critical illness, and
severe pancreatitis.

DIABETIC DIET
A diabetic diet entails the consumption of the most nutritious foods in controlled portions,
adhering to fixed mealtimes. This dietetic approach is abundantly rich in essential nutrients
while being low in fats and calories. Central to this diet are fruits, vegetables, and whole grains.
Structured around three scheduled meals daily, this regimen is designed to optimize the body's
use of endogenous insulin or that obtained pharmaceutically, incorporating complex
carbohydrates, fiber, proteins, vitamins, and minerals for balanced nutrition.
 10

LOW SODIUM DIET

A low-sodium diet aims to curtail the consumption of high-sodium foods and drinks,
commonly advised by health professionals to manage conditions such as hypertension or
cardiovascular diseases. Sodium pervades most dietary choices, though natural whole foods
like vegetables, fruits, and poultry are notably lower in sodium compared to processed animal-
derived products, including meats and dairy.

RENAL DIET
The renal diet is formulated to be low in sodium, phosphorus, and protein, highlighting the
necessity of ingesting premium-quality protein while generally restricting fluid intake. This
diet may also necessitate a reduction in potassium and calcium, depending on individual health
needs. Collaborating with a renal dietitian is imperative to tailor this diet to the unique
requirements of each patient.

LOW-FAT DIET
The low-fat diet restricts fats, particularly saturated fats, and cholesterol, to diminish the risk
of heart disease and obesity. Comparable in effectiveness to a low-carbohydrate diet for weight
loss, it emphasizes that fats supply nine calories per gram, in contrast to the four calories per
gram from carbohydrates and protein. The Institute of Medicine suggests limiting fat
consumption to a maximum of 35% of total caloric intake to manage saturated fat levels.

LOW PROTEIN DIET

Employed as a therapeutic measure for hereditary metabolic disorders such as phenylketonuria
and homocystinuria, as well as renal and hepatic diseases, the low-protein diet involves
reducing protein intake. This approach has been associated with a decreased risk of bone
fractures, potentially due to alterations in calcium balance. Given the variability of individual
conditions, a standardized definition of 'low protein' is non-existent, necessitating personalized
dietary planning.

HIGH PROTEIN DIET

A high-protein diet, characterized by protein comprising 20% or more of the total daily caloric
intake, is often criticized for promoting misconceptions about carbohydrates and metabolic
 11

health, such as insulin resistance and ketosis, and has been associated with high levels of
saturated fat and restricted carbohydrate consumption.

ANTI-DIARRHEAL/BLAND DIET
The bland diet consists of foods that are soft, low in fiber, cooked rather than raw, and not
spicy, facilitating ease of digestion. This diet avoids potentially irritating foods, such as fried
and fatty items, strong cheeses, and fiber-dense whole grains, as well as certain medications
like aspirin and ibuprofen.

HEPATIC DIET
A hepatic diet is advised for those experiencing liver dysfunction, including conditions like
cirrhosis, liver injury, failure, and encephalopathy. This diet involves reducing animal protein
intake to prevent the accumulation of harmful substances in the liver, balancing carbohydrate
consumption accordingly, and incorporating fruits, vegetables, and lean proteins. Vitamin
supplementation and salt restriction are also integral components of this diet to manage
associated health complications.

MAJOR PROTEIN SUPPLEMENTS

NUTRACEUTICALS NAME PATIENT CATEGORY
FRESUBIN Normal patient
PROHANCE-D Diabetic patient
NEPRO HP Renal patient
DIABETES PLUS Diabetic patient
KABIPRO High protein, whey protein-based
PENTASURE CRITIPEP Whey peptide
PENTASURE HEPATIC Hepatic, whey protein
PENTASURE 2.0 High calorie, high protein, whey protein
MAXVIDA High protein, Whey protein
 12

FOODSERVICE
The food service department, comprising two team leaders and sixteen staff members, operates
with a structured protocol. Team leaders oversee duties and schedules, while staff utilize
checklists corresponding to their designated wards and intensive care units. Dietitians conduct
periodic food tastings and nutritional analyses, communicating any necessary adjustments to
supervisory dietitians. Upon approval, service staff then prepare and distribute meals to
patients. The department operates in five shifts to maintain continuous service.

TUBE FEEDING
Managed by specialized staff, tube feeding ensures nutritional delivery at various intervals
throughout the day, from early morning to late evening, providing tailored nutrient solutions in
volumes of 100, 200, and 250 milliliters. Sugar supplementation is individually adjusted for
patients with diabetes to maintain glycemic control.
 13

DIETARY KITCHEN
Within the dietary kitchen, culinary staff focus on the preparation of two primary diet
categories: the standard diet and the specialized therapeutic diet, the latter being customized to
address the specific health conditions of patients.

KITCHEN LAYOUT
 14

DIETARY ADMINISTRATION
The administrative wing of the dietary department includes two supervisory clerks utilizing a
program named mediNicare to manage food orders. This system color-codes transactions for
clear communication: pink signifies a diet request, green indicates an approved diet request,
orange marks a petition to discontinue a diet, and blue confirms a diet cessation.

PROVISIONS MANAGEMENT
The storeroom is the repository for all culinary ingredients, overseen by personnel responsible
for procurement and storage management. These individuals ensure the acquisition of raw
materials in alignment with menu needs and oversee inventory. An additional two staff
members are designated for billing processes, with one serving as a backup. Procurement of
staples like rice, cereals, and pulses is sourced from three trusted suppliers—Maliyakkal,
Oovatty, and Ash—selected based on cost-effectiveness and quality. Vegetables are sourced
from local vendors in the High Court and Ernakulam markets.

FOOD HYGIENE
Maintaining stringent personal hygiene standards among those who handle food is essential to
prevent foodborne illnesses. All personnel are expected to uphold high hygiene practices and
recognize their pivotal role in safeguarding food safety within the facility.
 15

CHAPTER 4
INTERNSHIP AT LOURDES

DIETETIC INTERNSHIP IN HOSPITAL SETTINGS

The integration of dietetics within healthcare involves a comprehensive application of
nutritional science and dietary management to support individuals' health across various stages
of wellness and illness. The dietetic internship emerges as a pivotal educational journey,
meticulously crafted to equip aspiring dietitians with the multifaceted competencies required
by the dynamic field of dietetics. This intensive training program is dedicated to honing critical
thinking, problem-solving, and decision-making capabilities, all underpinned by a commitment
to evidence-based practice and the pursuit of excellence.

Throughout this immersive learning experience, interns are exposed to a broad spectrum of
dietetic operations, including the intricacies of diet planning, formulation, and execution, as
well as the nuances of personalized diet counseling. The internship serves as a gateway to
understanding the practicalities of menu planning, the adaptation of menus to meet specific
disease-related nutritional needs, and the effective communication of dietary advice to patients.

Diet counseling stands out as a cornerstone of nutritional assessment, aimed at enlightening

patients about their condition, its potential risks, methods of prevention, and the critical
importance of personal hygiene. It encompasses tailored dietary guidance and, when necessary,
specific therapeutic interventions. Through direct patient interactions and clinical exposure,
interns are allowed to refine their expertise and become adept practitioners in the realm of
dietetics.

The objectives of the internship are multifaceted, intending not only to familiarize interns with
the operational scope of hospital dietary departments but also to impart a deep understanding
of the roles and responsibilities that define the dietetic profession. Key learning outcomes
include:

• Gaining insight into the functioning and management of hospital dietary departments.
• Understanding the diverse roles and contributions of the dietetic staff.
• Acquiring knowledge of food production processes and service methodologies.
 16

• Assessing the prevalence and impact of nutrition-related issues within the community.
• Developing proficiency in devising and implementing diet plans tailored to specific
medical conditions.
• Mastering the techniques for conducting thorough nutritional assessments of patients.

This comprehensive approach ensures that interns emerge from their training fully equipped to
navigate the challenges of the dietetic field, ready to make meaningful contributions to public
health and individual patient care.
 17

CASE STUDIES
 18

CASE STUDY – 1

TYPE 2 DIABETES MELLITUS

INTRODUCTION

Diabetes Mellitus (DM) is a chronic metabolic disorder characterized by persistent

hyperglycemia (high blood sugar levels). It stems from defects in insulin secretion, insulin
action, or both, leading to abnormalities in carbohydrate, fat, and protein metabolism. The
prevalence of diabetes is increasing globally, making it a significant public health challenge.

Pathology

The pathology of diabetes varies between its two primary types:

• Type 1 Diabetes: Caused by autoimmune destruction of insulin-producing β-cells in

the pancreas, leading to insulin deficiency. This type often manifests in childhood or
adolescence.
• Type 2 Diabetes: Characterized by insulin resistance and relative insulin deficiency.
Initially, the pancreas compensates by producing more insulin, but over time, insulin
production decreases. This type is more common and is strongly associated with
obesity, physical inactivity, and genetic factors.
Physiology

Insulin, a hormone produced by the pancreas, regulates blood glucose levels by facilitating the
uptake of glucose into cells for energy production and storage. In diabetes, insulin action or
production impairment leads to elevated blood glucose levels. Over time, this hyperglycemia
can damage various body systems, including nerves and blood vessels.

Metabolic Aspects

Diabetes alters the metabolism of carbohydrates, fats, and proteins:

• Carbohydrates: Impaired glucose uptake and utilization lead to hyperglycemia.

• Fats: Increased lipolysis and fatty acid oxidation contribute to dyslipidemia and
ketoacidosis in type 1 diabetes.
• Proteins: Protein degradation can increase, leading to muscle wasting and weight loss,
especially in uncontrolled diabetes.
 19

Complications of Diabetes Mellitus

Complications can be acute or chronic:

• Acute: Diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), and

hypoglycemia.
• Chronic: Microvascular complications (retinopathy, nephropathy, neuropathy) and
macrovascular complications (coronary artery disease, peripheral arterial disease,
stroke). Diabetes also increases the risk of infections, dental problems, and gestational
complications.
Symptoms

Common symptoms include polyuria (frequent urination), polydipsia (increased thirst),

polyphagia (increased hunger), weight loss (type 1 diabetes), fatigue, blurred vision, and slow-
healing wounds. Symptoms may develop rapidly in type 1 diabetes but can be gradual or subtle
in type 2 diabetes.

Etiology

The causes of diabetes are multifactorial:

• Type 1 Diabetes: Thought to result from an autoimmune reaction to environmental

trigger(s) in genetically susceptible individuals.
• Type 2 Diabetes: Results from genetic factors related to insulin resistance and
environmental influences such as diet, physical activity level, and obesity.
 20

PATIENT PROFILE

ADMISSION

Date of Admission: 21/1/2024

Date of Discharge: 25/1/2024

Total Length of Hospital Stay: 5 days

Length of Stay in ICU Nil

Length of Stay in Ward 5 Days

DEMOGRAPHIC DATA
Name: Mrs. RA

Age: 71 years

Gender: Female

Occupation: Elderly Housewife

Economic Status: Average

Community: Hindu

Level of Physical activity: Sedentary (Bed Ridden)

HEALTH DATA

Chief Complaints: Multiple episodes of vomiting along with frequent

urination and decreased food intake

Diagnosis: Urinary Tract Infection/(R) Pelvic-Ureteric

Junction Calculus/Hydronephrosis

Level of Diagnosis: Stage not mentioned or examined

 21

Disease/ surgery history: Diabetes Mellitus, Hypertension, Glaucoma,

Coronary Artery Disease, Glaucoma, and S/P
Percutaneous transluminal coronary angioplasty

Family history of diseases: H|O Maternal Side Diabetes Mellitus

Mental condition: Dementia/Memory Loss

Medications: Metformin and Diuril

DIETARY DATA

Special Diet Followed: No Special Diet Followed

Alcohol Consumption: Nil

Smoking/Nicotine usage: Nil

Food Allergies/ Intolerances: Nil

Fluid restriction- Nil

Average Fluid Intake: 1-1.5 liter

SGA SCORE: 21

Status During the First Assessment

• Bowel Movement- Medicine-Induced Bowel Movement

• Vomiting- Nil

• Appetite- Normal

• Sleep- 6-7 hrs

Discussion

Mrs. RA, a 71-year-old elderly homemaker with a sedentary, bedridden lifestyle, was admitted
with symptoms including multiple episodes of vomiting, frequent urination, and decreased
food intake, resulting in a 5-day hospital stay. Diagnosed with a urinary tract infection, right
 22

pelvic-ureteric junction calculus, and hydronephrosis, her medical history is further

complicated by diabetes mellitus, hypertension, glaucoma, coronary artery disease, and a
history of percutaneous transluminal coronary angioplasty. With a family history of diabetes
and a current mental condition of dementia/memory loss, her treatment is complex, requiring
careful consideration of her chronic condition and the medications Metformin and Diuril
prescribed to her. Despite no special diet, her fluid intake is maintained at 1-1.5 liters,
significant for her urinary and overall health. This case underscores the challenges of managing
elderly patients with multiple health issues, emphasizing the importance of a comprehensive,
multidisciplinary approach to care that considers the interplay of her chronic conditions, mental
health, and the need for supportive treatments to optimize her health outcomes.
 23

ASSESSMENT

SUBJECTIVE GLOBAL ASSESSMENT

SGA SCORE

Radhamani Amma 22 1 2024

1.5 Months
 24

Parameter Score Remark

A. Weight change 4 Mild weight loss

B. Nutrient intake 3 Sub-optimal Solid Intake

C. Symptoms affecting oral intake 3 Nausea

D. Functional capacity 2 No Change

E. Loss of subcutaneous fat 3 No

F. Loss of muscle mass 2 Mild

G. Presence of oedema/ascites 4 No

Rating Reference

• Severely malnourished: 7-14 points

• Mildly/moderately malnourished: 15-21 points
• Well-nourished: 22-28 points

Discussion

Mrs. RA's total SGA score is 21. According to the SGA rating reference, a score between 15
and 21 categorizes an individual as mildly/moderately malnourished. This classification
suggests that while Mrs. RA is not severely malnourished, she is experiencing nutritional issues
that could impact her health if not addressed. The mild weight loss, sub-optimal nutrient intake,
and symptoms affecting oral intake are areas of concern that need intervention. Given her
condition, a comprehensive approach including nutritional support, symptom management, and
monitoring of her weight and muscle status is necessary to improve her nutritional status and
overall health.
 25

NUTRITIONAL ASSESSMENT

1. ANTHROPOMETRIC MEASUREMENTS

Height: 140 cm

Weight: 49kg

BMI: 25kg/m2

IBW: 42.72kg

Adjustable Body Weight 45.23kg

BMR 1019 calories day

Discussion

Given these measurements, the patient's nutritional and health status indicates they are slightly
overweight, which could impact their overall health and risk for conditions associated with
increased body weight. The difference between the current weight and the IBW suggests a need
for careful nutritional planning to achieve a weight closer to the IBW, which would improve
health outcomes.
 26

2. BIOCHEMICAL ASSESSMENT

Reference Range 22/01/2024 23/1/2024 24/1/2024

HB (gm/dl) 11.5-16.5 gm/dI 10.1

TC (/mm) 4000-11000/mm 8900

ESR (mm/h) 0-7mm/h 89

Platelet (lakh/m) 1-4.4 lakh/m 3.4

Lymphocytes (%) 20%-45% 21

Monocytes (%) 2%-10% 04

Neutrophils (%) 40%-75% 68

FBS (mg/dl) 60 -110 mg/dl 138 94 83

Urea (mg/dl) 10-50 mg/dI 39

Creatinine (mg/dl) 0.6-1.3 mg/dI 1.4 1.0

Uric Acid (mg/dl) 2.4-5.7 mg/dI

Sodium (Meq/L) 135-145 Meq/L 138

 27

Potassium (Meq/L) 3.5-5.5 Meq/L 4.8

Albumin(mg/dl) 3.5-5.5gm/dI 3.8

Globulin (mg/dl) 2.0-3.6gm/dI 2.0

Bilirubin (T) < 1.0 mg/dl 0.3

(mg/dl)

Bilirubin (D) <0.3 mg/dl 0.1

(mg/dl)

Alk.Phosphatase 35-107 U/L 111

(U/L)

SGOT (U/L) Up to 40 U/L 13

SGPT (U/L) Up to 40 U/L 12

Discussion

The biochemical assessment of Mrs. RA reveals several key insights into her health, pointing
towards areas requiring medical attention and management. Her hemoglobin level indicates
anemia, a condition that could contribute to symptoms of fatigue and general weakness,
common in the elderly with chronic health issues. The significantly elevated ESR level
suggests an ongoing inflammatory process, possibly linked to her urinary tract infection or
other underlying conditions, highlighting the need for targeted anti-inflammatory treatment.
While initial kidney function tests showed elevated creatinine levels, indicating potential renal
impairment likely related to her hydronephrosis, subsequent tests show an improvement,
suggesting a positive response to treatment but necessitating continued monitoring. The fasting
blood sugar levels, initially indicative of diabetic conditions, improved throughout her hospital
stay, reflecting effective glucose management. All other biochemical markers, including liver
function tests and electrolyte balance, are within normal ranges, offering some reassurance
about her metabolic status.
 28

3. CLINICAL ASSESSMENT

Past Medical History: Mrs. RA, a patient with a complex medical history, including
Diabetes Mellitus, Hypertension, and cardiovascular disease, underwent coronary artery
bypass graft surgery in 2022. Recently, she was admitted to an external medical facility due
to a urinary tract infection, though the specifics of the diagnosis and treatment regimen
remain undisclosed. Additionally, Mrs. RA has been managing dementia and hearing
impairment over the past four years. Her medical record also notes a previously diagnosed
Pelvi-Ureteric Junction (PUJ) calculus, which resulted in hydronephrosis. On the day of her
latest admission, she presented with symptoms of fever, cough, respiratory distress,
abdominal pain, and diarrhea.

Previous Medications: She was taking Metformin for treating diabetes mellitus and Diuril
for treating her cases of HTN and for removing calculus.

Presenting Complaints: She was admitted to the hospital due to the case of Multiple
episodes of vomiting, decreased food intake, and frequent urination.

Diagnosis: diagnosed with Urinary Tract Infection along with (R)PUJ Calculus resulting in
Hydronephrosis

Disease signs and symptoms: Mrs. RA is presenting signs and symptoms of hypertension,
including an elevated blood pressure of 140/80. Additionally, she has a respiratory rate of 22
breaths per minute and a pulse of 68 beats per minute. She is also showing signs and
symptoms of diabetes, such as blurred vision and polyuria.
 29

NFPE

PROGNOSIS OF NFPE

The NFPE findings for Mrs. RA, highlighting symptoms of itching, burning, and corneal
inflammation in her eyes, along with diminished taste, suggest possible deficiencies in key
nutrients like Vitamin A, riboflavin, niacin, and zinc. These symptoms are particularly relevant
given her existing medical conditions. Vitamin A deficiency could exacerbate her eye health
issues, which is a concern considering her history of glaucoma. Moreover, deficiencies in B
vitamins and zinc can impact her immune function, potentially compounding the risk of
infections such as the urinary tract infection she has been diagnosed with. The diminished taste
could be a result of zinc deficiency, which might contribute to her sub-optimal nutrient intake
and subsequent weight loss, as a diminished sense of taste can lead to reduced food intake.
 30

OTHER PARAMETERS

Parameter Normal Date Remark

Range
22/1/24 23/1/24 24/1/24

Blood 120/80 130/80 110/80 130/80 Mildly Elevated

Pressure mmHg

Pulse 72/mt 68 /mts 86 /mts 94 / mts Mild

Tachycardia

Respiration 20 22 br/mts 20 br/mts 10 br/mts Normal

Oxygen >96% 98% 99% 96% Normal

Saturation

Discussion

During her hospital stay from the 22nd to the 24th of January, Mrs. RA exhibited mildly
elevated blood pressure readings of 130/80 mmHg on the first and last days, with a
normalization to 110/80 mmHg on the 23rd. Her pulse showed a gradual increase from a normal
68 beats per minute to a mild tachycardia at 94 beats per minute by the end of the monitoring
period. Her respiratory rate was slightly elevated at 22 breaths per minute initially but
decreased to a normal rate of 20 breaths per minute on the second day. Notably, on the 24th,
her respiration dropped to an unusually low rate of 10 breaths per minute. Throughout this time,
Mrs. RA's oxygen saturation levels remained within the normal range, indicating adequate
oxygenation.
 31

MEDICATIONS

Name Dosage Mechanism of Drug Drug–nutrient

interaction
Tab. Torglip M 50 Glimepiride stimulates Alcohol can increase the
insulin release from the risk of lactic acidosis
pancreas, while Metformin with Metformin and
decreases glucose hypoglycemia with
production in the liver and Glimepiride. Vitamin
improves insulin sensitivity. B12 absorption may be
impaired with long-term
Metformin use.

Tab.Telekast It is a leukotriene receptor Specific interactions are

antagonist used for asthma not well-known, but they
and allergies. should be taken
consistently concerning
meals for the best effect.
Tab.Clearance 600mg An antibiotic that inhibits Dairy products can
bacterial protein synthesis. interfere with the
absorption of
Clarithromycin.
Tab.Atorva 40mg Lowers cholesterol by Grapefruit juice can
inhibiting HMG-CoA increase drug levels,
reductase. risking side effects. It may
reduce Coenzyme Q10 in
the body.
Tab.Glycomet Trio Combination of drugs to As with Torglip-M,
2 control blood sugar levels in alcohol can increase the
type 2 diabetes. risk of lactic acidosis and
hypoglycemia
Tab.Brilinta 90mg An antiplatelet drug that High doses of omega-3
prevents blood clots. fatty acids or other blood
thinners can increase
bleeding risk
 32

Tab.Telma 20mg An angiotensin receptor Potassium-rich foods

blocker (ARB) that lowers should be monitored as
blood pressure. Telmisartan can increase
potassium levels
C.Essar D Cap Supplement for calcium and They can interact with
vitamin D. certain medications like
steroids and can affect the
absorption of other drugs
C.Pregaba 75mg An anticonvulsant and Alcohol can enhance the
neuropathic pain agent. CNS depressant effects of
Pregabalin.
T. Ecospirin 75mg Aspirin works by inhibiting Aspirin can increase the
cyclooxygenase, an enzyme risk of gastrointestinal
involved in prostaglandin bleeding, especially when
synthesis, leading to taken with alcohol or
reduced inflammation and certain supplements like
pain, and acting as a blood fish oil or Ginkgo biloba.
thinner. Also, it may interfere
with vitamin C and folic
acid absorption.

Tab.Nifas 100mg calcium channel blocker that Grapefruit juice can

relaxes heart muscles and significantly increase the
blood vessels. levels of Nifedipine,
potentially leading to side
effects.
 33

4. DIETARY ASSESSMENT

FOOD FREQUENCY

Discussion
Mrs. RA's food frequency table reflects a diet with room for improvement in managing her
diabetes. While the regular inclusion of cereals, grains, and vegetables provides necessary
nutrients, the types of cereals chosen, and cooking methods used need scrutiny to better align
with her diabetic condition. The diet is commendable for its low intake of fast foods and sweets,
yet the protein sources appear limited, especially from meat and poultry, which could hinder
 34

adequate protein intake. The daily consumption of fruits is positive, but specific attention to
the sugar content is essential to avoid blood glucose spikes. Weekly consumption of nuts and
fish is beneficial; however, these could be optimized to enhance the intake of omega-3 fatty
acids and protein. The limited use of oils and fats is prudent, yet it's critical to ensure quality
and quantity are consistent with diabetic dietary fats recommendations. Overall, the diet could
be better tailored to meet the carbohydrate, protein, and fat balance that is vital for a diabetic
patient, particularly one who is overweight.

24-Hour Diet Recall Method

Time Food Quantity Ingredients Weight Energy CHO Protein Fat Fiber
Item (g) (Kcal) (g) (g) (g) (g)
8:00 Puttu 1/4 cup Rice flour 30 gm 105.47 23.15 2.34 0.17 1.12
am

Green Onion 5 gm 2.4 0.48 0.08 0.12

Peas ¼ cup Tomato 5 gm 0.98 0.14 0.05 0.02 0.09
Curry Green Peas 15 gm 45.5 7.34 3.06 0.28 2.55

Milk tea 1 cup Milk 100 ml 72.9 4.94 3.26 4.48

1:30 Rice 1 cup White Rice 33 gm 116.02 25.46 2.58 0.18 1.23
pm
Ash ½ cup Ash gourd 35 gm 6.11 0.99 0.28 0.05 1.18
gourd Buttermilk 10 ml 6.2 0.49 0.32 0.33
Curry

Carrot ¼ cup Carrot 8 gm 2.66 0.44 0.08 0.04 0.33

Thoran
 35

4:30
pm Milk tea 1 cup Milk 100 ml 72.9 4.94 3.26 4.48

8:00 Chappathi 1 Nos Wheat 25 gm 80.14 2.64 0.38 0.38 2.84

pm Flour

Egg ½ cup Egg 50 gm 73.85 6.72 5.27

Curry Onion 5gm 2.4 0.48 0.08 0.03
Total 677.53 71.49 22.49 15.68 9.49

DISCUSSION

NUTRITIONAL EVALUATION OF HOME RECALL DIET

ENERGY: 677.53Kcal

CARBOHYDRATES: 71.49g

PROTEIN:22.49g

FAT: 15.68g

FIBER: 9.49g

FLUID REQUIREMENTS: 1-1.5 liters

Mrs. RA's nutritional intake, as gleaned from a 24-hour diet recall, raises concerns about her
overall health, with her caloric consumption at 677.53 kcal falling substantially short of both
the estimated requirement of 1019 kcal and the RDA's 1500 kcal benchmark. Such a deficit
could aggravate her weight loss issues and worsen her health, especially in the context of her
age and sedentary lifestyle. The fiber intake recorded at 9.49 g is less than half of the RDA
recommended 25 g, a shortfall that could affect both her digestive wellness and glucose
management—a key concern given her diabetic status. The recall also revealed a protein intake
 36

of 22.49 g, not meeting her specific needs of 50.95 g or even the RDA guideline of 46 g, which
may lead to muscle mass deterioration and impede her healing and immune functions.
Furthermore, the fat intake stood at 15.68 g, again lower than her required 28.3 g and the RDA
of 46.6 g, potentially leading to a deficiency in essential fatty acids vital for nutrient absorption
and energy. Carbohydrate consumption was also below par at 71.49 g, a stark contrast to her
need of 140.1125 g and the RDA of 225 g, further contributing to her inadequate energy levels
and complicating her body's primary fuel provision.
 37

NUTRITIONAL PROBLEMS AND RISK

Mrs. RA has several nutritional problems and risks, such as malnutrition, Anemia,
hypertension, protein-energy wasting, hyperglycemia, Anemia, Potential Hydration Concerns,
Micronutrient Deficiencies

NUTRITIONAL DIAGNOSIS

As evidenced by 24-hour dietary recall the nutritional Diagnosis includes:

• Excessive sodium intake related to high-sodium foods and seasonings is evidenced by

hypertension, edema, and high sodium intake.
• Altered nutrition-related laboratory values related to diabetes, and hypertension as
evidenced by elevated FBS and Blood Pressure
• Inadequate oral food/beverage intake related to dysphagia, and low appetite as
evidenced by low energy intake.
• Inadequate energy intake related to decreased food and beverage consumption as
evidenced by a 24-hour dietary recall indicating an intake of only 677.53 kcal,
significantly below her estimated requirement based on BMR (1019 kcal) and EAR
(1500 kcal).
• Protein-energy malnutrition related to suboptimal nutrient intake and chronic
conditions as evidenced by the reported protein intake of 22.49 grams, far below her
adjusted need of 50.95 grams, coupled with signs of mild weight loss and muscle mass
depletion.
• Risk of micronutrient deficiencies related to limited dietary variety and specific health
conditions as evidenced by clinical signs such as itching, burning, and corneal
inflammation in her eyes, and diminished taste, suggesting potential deficiencies in
vitamins A, B-vitamins, and zinc.
• Inadequate fiber intake related to insufficient consumption of fruits, vegetables, and
whole grains as evidenced by a fiber intake of 9.49 grams, which is significantly lower
than the RDA of 25 grams, potentially contributing to gastrointestinal issues and
impacting blood sugar control.
• Altered nutrition-related laboratory values (anemia and inflammation) related to
inadequate dietary intake and underlying health conditions as evidenced by low
hemoglobin levels (10.1 gm/dl) and elevated ESR (89 mm/h), indicating a state of
nutritional deficiency and systemic inflammation.
 38

NUTRITION INTERVENTION

1. Energy Requirement Adjustment: Increase caloric intake to meet her estimated energy
requirement of 1019 kcal/day, with a gradual approach to reach the RDA of 1500 kcal/day,
considering her current health status and activity level. High-energy, nutrient-dense foods,
and snacks should be incorporated to help achieve this goal without significantly increasing
the volume of food consumed.

2. Protein Supplementation: Enhance protein intake to meet and exceed the adjusted need
of 50.95 grams/day to support muscle maintenance, healing, and overall metabolism. This
can be achieved through the inclusion of lean meats, dairy products, legumes, and protein
supplements if necessary.

3. Micronutrient Focus: Given the signs of potential micronutrient deficiencies, provide a

diet rich in vitamins and minerals. This includes foods high in zinc, vitamin A, B vitamins
(especially B12 and folate), iron, and vitamin D. Consideration for micronutrient
supplementation should be given based on blood test results and in consultation with a
dietitian.

4. Dietary Fiber: Increase fiber intake to reach the recommended 25 grams/day to support
digestive health and blood sugar management. Sources like whole grains, fruits, vegetables,
and legumes should be integrated into meals and snacks.

5. Fluid Management: Ensure adequate hydration, aiming for at least 1.5 to 2 liters of fluid
per day, unless contraindicated due to her medical condition. This is crucial for preventing
dehydration, especially with increased fiber intake and potential diuretic use.

6. Special Considerations for Diabetes: Tailor the meal plan to manage blood glucose levels
effectively, emphasizing balanced meals with complex carbohydrates, fiber, lean protein, and
healthy fats. Blood glucose monitoring should guide the adjustment of dietary intake.

7. Special Consideration Hypertension: Limit sodium intake to less than 2000 mg per day,
focusing on fresh, unprocessed foods to manage blood pressure effectively.

GOALS OF MNT

The Goals of the MNT of Mrs. RA included Restoring nutritional balance, enhancing muscle
mass and strength, improving the management of chronic conditions, addressing micronutrient
deficiencies, promoting a healthy body weight, and managing fluid and electrolyte balance.
 39

MONITORING AND EVALUATION

DIET ORDERS

1. Diabetic Low Salt Diet (22/01/2024)

2. Diabetic Low Salt Diet (23/01/2024)

3. Diabetic Low Salt Diet (24/01/2024)

HOSPITAL DIET DAY 1

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8 AM Idiyappam 2 nos Rice 50 175.79 38.58 3.91 0.28 1.87

Bengal ¼ cup Bengal 25 71.76 9.89 4.69 1.28 6.31

Gram Gram
curry
1 PM Rice ¼ cup Brown Rice 25 88.43 18.7 2.29 0.31 1.11

Sambhar ¼ cup Onion 5 2.4 0.48 0.08 0.12

Tomato 5 0.98 0.14 0.05 0.02 0.09
Carrot 5 1.66 0.28 0.05 0.02 0.21
Lentils 5 14.89 2.4 1.14 0.03 0.83
Drumsticks 5 1.47 0.19 0.13 0.01 0.34

Cabbage ¼ cup Cabbage 15 3.23 0.49 0.2 0.02 0.41

Upperi
4 PM Kozhukkat 1 nos Rice 20 70.32 15.43 1.56 0.11 0.75

Carrot 10 3.32 0.5 0.1 0.05 0.42

8 PM Wheat ¼ cup Wheat 35 119.62 24.17 3.79 0.51 3.08
kanji
 40

Moru ¼ Cup Buttermilk 20 12.4 0.98 0.64 0.66

Curry
Total 667.33 110.75 18.54 3.3 16.39
Cooking Oil Used:12g.

HOSPITAL DIET DAY 2

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8AM Ragi Dosa 2 no Ragi 50 192.45 40.09 4.3 1.15 6.71

Sambhar ¼ cup Onion 5 2.4 0.48 0.08 0.12

Tomato 5 0.98 0.14 0.05 0.02 0.09
Carrot 5 1.66 0.28 0.05 0.02 0.21
Lentils 5 14.89 2.4 1.14 0.03 0.83
Drumsticks 5 1.47 0.19 0.13 0.01 0.34

10 AM Oats in milk ½ cup Oats 50 187 31.4 6.8 3.8 1.75

Milk 100 72.9 4.94 3.26 4.48

1PM Rice ¼ cup Brown Rice 20 70.75 14.96 1.83 0.25 0.89

Moru Curry ¼ cup Buttermilk 20 12.4 0.98 0.64 0.66

Vendakka
Upperi ¼ cup Ladies Finger 10 2.75 0.36 0.21 0.02 0.41
4 PM Kozhukkatt 1 nos Rice 20

Carrot 10 3.32 0.5 0.1 0.05 0.42

 41

8 PM Chappathi 1 nos Wheat Flour 25 80.14 16.04 2.64 0.38 2.84

Green peas
curry ½ cup Green Peas 15 45.5 7.34 3.06 0.28 2.55

Total 834.84 128.8 25.13 11.0 16.79

Cooking Oil Used:12g.

HOSPITAL DIET DAY 3

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8 AM Idiyappam 2 nos White Rice 50 117.79 38.58 3.91 0.28 1.87

Kadala ½ cup Bengal 15 43.06 5.93 2.82 0.77 3.78

curry Gram
10 AM Oats in 150 ml Oats 50 187 31.4 6.8 3.8 1.75
milk
Milk 100 72.9 4.94 3.26 4.48
1 PM Red Rice ¼ cup Brown Rice 20 70.75 14.96 1.83 0.25 0.89

Achinga ¼ cup French 10 2.44 0.27 0.25 0.03 0.44

upperi Beans

¼ cup Onion 5 2.4 0.48 0.08 0.12

Sambhar Tomato 5 0.98 0.14 0.05 0.02 0.09
Carrot 5 1.66 0.28 0.05 0.02 0.21
Lentils 5 14.89 2.4 1.14 0.03 0.83
Drumsticks 5 1.47 0.19 0.13 0.01 0.34
4 PM Aval ¼ cup Rice Flakes 15 53.06 11.51 1.12 0.17 1.73
 42

8 PM Chappathi 2 nos Wheat

Flour 50 160.24 32.08 5.28 1.14 5.68

Vegetable ¼ cup Potato 5 3.49 0.74 0.08 0.09

stew Green Peas 5
Beans 5 2.44 0.27 0.25 0.03 0.44
Carrot 5 3.32 0.56 0.1 0.05 0.42
Total 952.34 157.09 29.77 11.26 18.75
Cooking Oil Used:10g.

Day Wise Distribution

DAY ENERGY (Kcal) CHO (g) PROTEIN(g) FAT(g) FIBRE(g)

DAY 1 667.33 110.75 18.54 3.3 16.39

DAY 2 834.84 128.8 25.13 11 16.79

DAY 3 952.34 157.09 29.77 11.26 18.75

DISCUSSION

Analyzing Mrs. RA's dietary intake during her hospital stay reveals her adherence to the
diabetic low-salt diet and showcases the effort to balance her macronutrient intake within the
constraints of her medical conditions. Here's a constructive analysis of the day-wise
distribution:

Day 1

On the first day, Mrs. RA's diet is tailored to gently introduce her system to a balanced
nutritional intake, providing 667.33 kcal. The focus on higher carbohydrates (110.75 g) ensures
her body's energy needs are met without causing spikes in blood glucose levels, crucial for her
 43

diabetes management. Protein is kept at a moderate level (18.54 g) to support bodily functions
without overloading her system, while fat is minimized (3.3 g) to account for her overweight
status and associated cardiovascular risks. The diet is rich in fiber (16.39 g), supporting
digestive health and contributing to blood sugar regulation.

Day 2

By the second day, the diet plan incrementally increases the energy to 834.84 kcal, reflecting a
deeper understanding of Mrs. RA's recovery and energy requirements. Carbohydrate intake is
slightly enhanced (128.8 g), maintaining the energy supply for her needs. Protein is
significantly increased to 25.13 g, promoting tissue repair and muscle maintenance, which is
beneficial for her overall recovery. The fat content sees a more substantial rise (11 g),
introducing essential fatty acids and improving meal satisfaction. Fiber intake (16.79 g)
remains high, continuing to support gastrointestinal and glycemic health.

Day 3

The third day marks the highest increase in nutritional provision, with the total energy reaching
952.34 kcal. This escalation is mirrored in carbohydrates (157.09 g) and protein (29.77 g),
optimizing her diet for energy supply and recovery needs. The careful balance of fat (11.26 g)
supports her dietary requirements without compromising her cardiovascular health. The fiber
content (18.75 g) is at its peak, emphasizing the importance of a high-fiber diet in managing
diabetes and enhancing digestive wellness.
 44

DISCHARGE DIET

DIET PLAN

Time Food Quantity Ingredients Weight Energy CHO Protein Fat Fiber
Item (g) (kcal) (g) (g) (g) (g)
6 AM Chia Seed 100 ml Chia Seed 5 24.3 2.11 0.83 1.54 1.72
Water
8 AM Ragi Puttu 2 Piece Ragi 60 192.45 40.09 4.3 1.15 6.71

Lentil ½ cup Moong Dal 4 119.12 19.16 9.15 0.24 6.66

Curry
10 Egg
AM White 1 Nos Egg 50 73.85 6.72 5.27

1 AM Brown ½ cup Brown Rice 33 116.73 24.68 3.02 0.41 1.46

Rice

Fish 1cup Mackerel 90 90.99 19.36 1.38

Curry Onion 5 2.4 0.48 0.08 0.12

Spinach
and green ½ cup Spinach 20 4.88 0.41 0.43 0.13 0.48
beans Green 20 4.88 0.54 0.5 0.05 0.88
Upperi Beans
4 AM Black Tea

Cashews 5 nos Cashew 8 2.04 1.5 3.62 0.31

46.62

8 AM Chapati 2 Wheat 50 160.23 32.09 5.29 0.77 5.68

Flour
Green
Gram Dal ½ cup Green 40 117.75 18.45 9.01 0.46 6.82
Curry Gram
 45

Cucumber
Salad ¼ cup cucumber 25 4.9 0.87 0.18 0.04 0.54
Total 1040.8 142.41 51.93 28.46 31.46
Cooking Oil used:14g.

Nutrient Distribution

Nutrients RDA Patient Requirement Discharge Diet

Provided
Energy (Kcal) 1500(EAR) 1019 1040.8
Dietary Fiber 25 25 31.46
Protein(g) 46.0 50.95 51.93
Fat(g) 46.6(28% of Energy) 28.3 28.46
Carbohydrate(g) 225(60% of Energy) 140.1 142.41

DISCUSSION

The discharge diet provided to Mrs. RA appears to be well-considered, with a nutritional

composition that aligns more closely with her health needs.

The total energy provided stands at 1040.8 kcal, which is a careful increase from her in-hospital
intake and closer to her estimated energy requirement of 1019 kcal. This caloric content
supports a gradual advancement toward maintaining her weight, given her BMI indicates an
overweight status, and the aim is to manage her energy balance effectively.

With a fiber content of 31.46 g, the diet exceeds both the general and her specific fiber
requirements, which is commendable. A high-fiber diet is particularly beneficial for patients
with diabetes as it aids in blood sugar control and promotes satiety, which can help prevent
 46

overeating. The provision of adequate fiber also supports digestive health and can contribute
to the management of cholesterol levels, crucial for cardiovascular health.

The diet contains 51.93 g of protein, which satisfactorily meets her increased needs of 50.95
g and provides the necessary macronutrients for tissue repair, muscle maintenance, and overall
metabolic health. This level of protein intake is crucial for an elderly patient who is recovering
from illness and at risk of muscle wasting.

Fat is included at a level of 28.46 g, which aligns well with her requirements of 28.3 g and
offers a balance between providing essential fatty acids and not exceeding the recommended
intake for someone with a cardiovascular history and diabetes. These fats must be sourced from
heart-healthy options like monounsaturated and polyunsaturated fats.

The carbohydrate content is set at 142.41 g, which is appropriate for managing Mrs. RA's
diabetes and provides sufficient energy without overwhelming her system. These
carbohydrates must come from complex sources, with a low glycemic index to avoid rapid
spikes in blood glucose levels.
 47

OVERALL SUMMARY

Mrs. RA, a 71-year-old female with a history of multiple chronic conditions including
diabetes mellitus, hypertension, coronary artery disease, and glaucoma, was admitted to the
hospital presenting with multiple episodes of vomiting, frequent urination, and decreased
food intake. Her hospital stay was characterized by a detailed evaluation of her nutritional
status, medical management of her conditions, and careful planning for her discharge diet to
ensure continuity of care.

Upon admission, Mrs. RA's anthropometric measurements indicated a BMI of 25 kg/m²,

classifying her as overweight. Her Subjective Global Assessment (SGA) highlighted mild
weight loss and sub-optimal nutrient intake, pointing towards a mild to moderate malnutrition
status. Biochemical assessments revealed anemia and signs of inflammation, with initial
concerns about kidney function that showed improvement over her hospital stay. Her dietary
intake during hospitalization was significantly below her estimated requirements, reflecting
challenges in meeting her nutritional needs.

The discharge diet planned for Mrs. RA aimed to address her nutritional deficiencies and
manage her chronic conditions. It provided 1047 kcal, closely aligning with her estimated
energy requirement of 1019 kcal, calculated based on her basal metabolic rate (BMR). This
careful calibration was crucial considering her overweight status and the need to manage her
weight effectively. The diet exceeded her protein requirement, providing 50.59 grams, and
closely matched her needs for dietary fiber and fats, ensuring a balanced approach to support
her overall health and recovery. Carbohydrate intake was tailored to manage her diabetes,
focusing on complex carbohydrates to maintain stable blood glucose levels.

Overall, Mrs. RA's case underscores the importance of a multidisciplinary approach in

managing elderly patients with multiple health issues. The nutritional intervention, alongside
medical management, aimed to address her immediate health concerns and set a foundation for
improved health outcomes post-discharge. The discharge plan, including a diabetic low-salt
diet with careful consideration for caloric and macronutrient balance, was designed to support
her transition back to daily life while managing her chronic conditions and nutritional status.
This case highlights the critical role of nutrition in the comprehensive care of patients with
complex health needs, emphasizing the need for ongoing monitoring and adjustment of dietary
plans to meet individual health goals and improve quality of life.
 48

CASE STUDY – 2

HEPATITIS

Introduction

Hepatitis C is a viral infection that causes liver inflammation. It is caused by the hepatitis C
virus (HCV) which chronically infects over 71 million people globally. Over decades, HCV
can progress to serious liver disease including cirrhosis and liver cancer.

Pathology

HCV is spread through contact with infected blood. Major transmission routes are injection
drug use, needlestick injuries, childbirth from an infected mother, or exposure to unsterilized
medical equipment. HCV specifically infects and replicates in hepatocytes, the main functional
liver cells. This direct viral infection and replication in hepatocytes causes cell damage and
death, triggering an inflammatory response. Sustained inflammation drives progressive
scarring of the liver tissue known as fibrosis.

Physiology

HCV is a single-stranded RNA virus that enters hepatocytes through receptor-mediated

endocytosis. Once inside cells, the viral genome is translated and replicated by host cell
machinery. HCV has extremely high mutation rates, allowing it to frequently evolve new
strains that can evade and undermine anti-viral immune responses. This enables HCV to
establish chronic, difficult-to-clear infections. The immune system still mounts innate and
adaptive responses to try and control the virus, but HCV persists.

Metabolic Aspects

Chronic HCV infection dysregulates several metabolic pathways in the liver that compound
disease severity. One hallmark is hepatic steatosis, an accumulation of excess fat in the liver.
HCV disrupts lipid metabolism promoting storage of lipids in hepatocytes. HCV also increases
insulin resistance and the risk of type 2 diabetes through impairments in glucose and lipid
metabolism. Furthermore, chronic HCV can cause excess iron accumulation in the liver leading
to increased oxidative stress and damage of liver tissue.
 49

Complications

Sustained liver inflammation stimulates progressive scarring known as fibrosis, which over 20-
30 years advances to widespread cirrhosis in 10-20% of chronic HCV cases. Cirrhosis causes
failure of normal liver functions. Increased blood pressure in the portal vein supplying the liver
also develops, which can dilate veins called varices prone to rupturing and bleeding. Easy
bruising, abnormalities in blood proteins, and fluid retention also occur. Those with cirrhosis
have a heightened risk of developing liver cancer.

Symptoms

30% of acute HCV cases cause jaundice, fatigue, nausea, fever, and abdominal pain. 70% of
acute infections are asymptomatic. Chronic HCV is often asymptomatic until advanced liver
disease occurs. Symptoms reflect failing liver function including jaundice, fluid retention,
variceal bleeding, confusion, etc.

Etiology

HCV has 7 primary genotypes with over 50 different subtypes distributed variably across the
world - genotype 1 is the most common globally. Coinfection with HIV or hepatitis B can
accelerate HCV disease progression. Alcohol abuse also synergizes with HCV, worsening
fibrosis/cirrhosis.
 50

PATIENT PROFILE

ADMISSION

Date of Admission: 22/1/2024

Date of Discharge: 26/1/2024

Total Length of Hospital Stay: 5 days

Length of Stay in ICU Nil

Length of Stay in Ward 5 days

DEMOGRAPHIC DATA

Name: Mr. AM

Age: 44 Years

Gender: Male

Occupation: Not Working for the past two months

Economic Status: Average

Community: Christian

Level of Physical activity: Sedentary

HEALTH DATA

Chief Complaints: History of fever and dry cough for past 3 days with
high-grade fever at night

Diagnosis: Lower Respiratory Tract Infection

Level of Diagnosis: Stage Not Diagnosed

Disease/ surgery history: Chronic Liver Disease (Hepatitis C), Alcohol

Dependence Syndrome, Uncontrolled Diabetes
 51

Mellitus. Also, he was admitted to the hospital last

week for Delirium and aspirational Pneumonia

Family history of diseases: No Family History of Diseases

Mental condition: Alcoholic Dependence Syndrome and Delirium

Medications: Nil

. DIETARY DATA

Special Diet Followed: Normal Diet

Alcohol Consumption: Yes

Smoking/Nicotine usage: Nil

Food Allergies/ Intolerances: Nil

Fluid restriction- Nil

Average Fluid Intake: 2-3 liters

SGA SCORE: 19

Status During the First Assessment

• Bowel Movement- Medicine-Induced Bowel Movement with the color

difference in Faecus

• Vomiting- Nil

• Appetite- Normal

• Sleep- 2-3 hrs

 52

Discussion

Mr. AM, a 44-year-old male with a history of chronic liver disease, alcohol dependence
syndrome, and uncontrolled diabetes mellitus, was admitted to the hospital for a Lower
Respiratory Tract Infection (LRTI) after presenting with symptoms of fever and dry cough. His
sedentary lifestyle and recent unemployment likely compounded his complex health issues,
including a background of delirium and aspiration pneumonia. Despite these challenges, his
hospital stay did not necessitate ICU care, focusing instead on managing the LRTI and his
chronic conditions over five days. The absence of a special diet and continued alcohol
consumption, alongside his sedentary lifestyle, underscores the need for a holistic approach to
his care.
 53

ASSESSMENT

SUBJECTIVE GLOBAL ASSESSMENT

 54

Parameter Score Remark

A. Weight change 2 Weight Loss

B. Nutrient intake 3 Sub-optimal Solid Intake

C. Symptoms affecting oral intake 4 None

D. Functional capacity 2 None (Improved)

E. Loss of subcutaneous fat 2 Mild

F. Loss of muscle mass 2 Mild

G. Presence of oedema/ascites 4 No

Rating Reference

• Severely malnourished: 7-14 points

• Mildly/moderately malnourished: 15-21 points
• Well nourished: 22-28 points

Discussion

Mr. AM's total SGA score of 19 places him within the "mildly/moderately malnourished"
category. This suggests that while Mr. AM is not severely malnourished, there are significant
nutritional concerns that need to be addressed. The sub-optimal nutrient intake and weight loss
indicate a need for nutritional intervention to prevent further decline in his nutritional status.
Despite the absence of symptoms affecting oral intake and the presence of edema/ascites, the
mild loss of muscle mass and subcutaneous fat points to an ongoing issue with nutritional
inadequacy or absorption.
 55

1. ANTHROPOMETRIC MEASUREMENTS

Height: 165 cm

Weight: 60 kg

BMI: 22 kg/m2

IBW: 60.7kg

Adjustable Body Weight 61 kg

BMR 1700 calories day

Discussion

Overall, Mr. AM's anthropometric measurements suggest that he is within a healthy weight
range for his height, with a balanced BMI and a weight close to his ideal body weight. However,
considering his mild to moderate malnutrition status as indicated by the SGA score, it is
important to focus on the quality of his diet, ensuring it meets his nutritional needs to support
his health, manage his chronic conditions, and aid in recovery from any acute illnesses.
 56

2. BIOCHEMICAL METHODS

Reference Range 22/01/2024 23/1/2024 24/1/2024

HB (gm/dl) 13-18 gm/dI 11.6

TC (/mm) 4000-11000/mm 10,100

ESR (mm/h) 0-5mm/h 7.4

Platelet (lakh/m) 1-4.4 lakh/m 1.8

Lymphocytes (%) 20%-45% 13

Monocytes (%) 2%-10% 2

Neutrophils (%) 40%-75% 85

FBS (mg/dl) 60 -110 mg/dL 95 75 63

Urea (mg/dl) 10-50 mg/dI 20

Creatinine (mg/dl) 0.6-1.3 mg/dI 0.7

Uric Acid (mg/dl) 2.4-5.7 mg/dI 2.5

Sodium (Meq/L) 135-145 Meq/L 126

 57

Potassium (Meq/L) 3.5-5.5 Meq/L 4.5

Albumin(mg/dl) 3.5-5.5gm/dI 2.8 3.2

Globulin (mg/dl) 2.0-3.6gm/dI 3.1

Bilirubin (T) < 1.0 mg/dl 1.4 1.1

(mg/dl)

Bilirubin (D) <0.3 mg/dl 1.0 0.9

(mg/dl)

Alk.Phosphatase 40-129 U/L 103 104

(U/L)

SGOT (U/L) Up to 40 U/L 36 28

SGPT (U/L) Up to 40 U/L 31 22

Discussion
Mr. AM's biochemical profile reflects a complex interplay of his acute LRTI, underlying
chronic liver disease, and uncontrolled diabetes. The trend in FBS levels necessitates close
monitoring to manage his diabetes effectively, especially in the context of his fluctuating health
status. The hyponatremia warrants investigation for its etiology, which could be related to his
liver disease, medication effects, or SIADH.

The liver function tests suggest some degree of hepatic involvement, likely linked to his chronic
liver disease, with some parameters showing slight improvement. This improvement could be
attributed to the medical management he received during his hospital stay.
 58

3. CLINICAL ASSESSMENT

Past Medical History: Mr. AM, with a disease history of ADS, Chronic Liver Disease
(Hepatitis C), and uncontrolled DM was admitted to the hospital with Presenting complaints
of fever for the past 3 days, with high-grade fever at night. He has also had a dry cough for
the past 3 days. He was admitted to the hospital last week for aspiration pneumonia and
delirium, he had no history of vomiting, abdominal pain, loose stool, standing difficulty, etc.
His appearance was pallor and showed signs of icterus with yellowish eyes.

Previous Medications: He was not taking any medications.

Presenting Complaints: he was admitted to the hospital due to a case of Fever for the past 3
days, which reached a high grade during the night.

Diagnosis: - He was diagnosed with LRTI

Disease signs and symptoms: Mr. AM is presenting signs and symptoms of Hepatitis C,
including Bilirubin Levels and clinical symptoms like pallor and yellow eyes. She is also
showing signs and symptoms of diabetes, such as blurred vision and polyuria. Even if he
didn’t have a long history of diabetes, the last time he was admitted he also showed
uncontrolled diabetes, with RBS 217mg/dl.
 59

NFPE

PROGNOSIS OF NFPE

Given Mr. AM's history of chronic liver disease and alcohol dependence syndrome, it is also
critical to consider that some of these clinical signs could be related to his underlying medical
conditions. For instance, the yellowing of the skin might be more related to his liver condition
than nutritional deficiencies. The pallor could be a sign of anemia due to his chronic disease or
poor nutrient intake.

OTHER PARAMETERS

Parameter Normal Date Remark

Range
22/1/24 23/1/24 24/1/24

Blood 120/80 120/80 120/80 100/60 Normal

Pressure mmHg

Pulse 72/mt 80/mt 100/mt 104/mt Mild

Tachycardia
 60

Respiration 20 20/mt 20/mt 20/mt Normal

Oxygen >96% 96% 99% 99% Normal

Saturation

Discussion

Mr. AM's cardiovascular and respiratory parameters were largely within normal limits, except
for a mild tachycardia and a decrease in blood pressure on the last day. These findings suggest
a generally stable condition but warrant ongoing observation, especially in the context of his
recent LRTI and chronic health conditions. The mild tachycardia could be related to his
infection or other underlying factors and should be evaluated in conjunction with his overall
clinical progress.
 61

MEDICATIONS

Name Dosage Mechanism of Drug Drug–nutrient

interaction
Inj Tazmac 4.5g Combines piperacillin, a May reduce vitamin K
penicillin antibiotic that absorption and impact
disrupts bacterial cell wall blood clotting factors
synthesis, with tazobactam,
a beta-lactamase inhibitor
that prevents antibiotic
degradation by bacteria.
Inj. Amikacin 500mg An aminoglycoside Can cause decreased
antibiotic that binds to absorption of calcium,
bacterial ribosomal subunits, magnesium, and
inhibiting protein synthesis phosphorus
and leading to cell death.
Tab. Uribact It works by stopping the interference with B
action of a bacterial enzyme vitamins and magnesium
called DNA-gyrase. This absorption.
prevents the bacterial cells
from dividing and repairing,
thereby killing them.
Tab. Resof contains sofosbuvir, which Generally well-tolerated
acts as an HCV NS5B with no significant
polymerase inhibitor, nutrient interactions, but
disrupting viral RNA alcohol should be avoided
replication.
Tab. Hyponat 15 mg a diuretic or hormone that May cause imbalances in
regulates sodium and water sodium and potassium
balance.
Tab. Mucocite 30mg it contains acetylcysteine, it May interact with
acts as a mucolytic by nitroglycerin, increasing
breaking disulfide bonds in the risk of vasodilatory
effects.
 62

mucus, making it less

viscous.
Syrup. Ascoric contains ascorbic acid Vitamin C can increase
(Vitamin C), which is iron absorption and affect
necessary for the growth, the metabolism of other
development, and repair of drugs.
body tissues.
Tab. Azulix it contains glimepiride, Alcohol can enhance
which increases insulin hypoglycemic effects;
secretion from the pancreas. fiber-rich foods may
delay glucose absorption.
Tab. Seremace It works by preventing interact with caffeine and
dopamine, a chemical alcohol.
messenger in the brain that
influences thoughts and
emotions, from acting.
Tab. Microdo LB 100mg a probiotic that helps restore Antibiotics can reduce the
the natural balance of gut effectiveness of
bacteria. probiotics.
Tab. Quitipon it acts as an antipsychotic by High-calorie meals may
altering neurotransmitter increase the absorption of
function in the brain. quetiapine.
Tab. Zolcalm it works by enhancing Food can delay the onset
GABA effects in the central of action; alcohol can
nervous system, inducing increase sedative effects.
sleep.
Tab. Clearnac 600mg An acetylcysteine May interact with
preparation is used as a activated charcoal,
mucolytic agent. reducing its effectiveness.
Tab. Thiamine Vitamin B1 that is essential Alcohol consumption can
for glucose metabolism and severely deplete thiamine
nerve, muscle, and heart levels.
function.
 63

Inj. Cefobrbs Forte 1.5g cephalosporins work by cephalosporins can affect

inhibiting bacterial cell wall vitamin K synthesis by
synthesis, leading to cell gut bacteria and may also
lysis and death interact with alcohol,
leading to a disulfiram-
like reaction
Inj. Pantop 40mg Pantoprazole is a proton PPIs can decrease the
pump inhibitor (PPI) that absorption of vitamin
irreversibly binds to the B12, calcium, iron, and
hydrogen/potassium ATPase magnesium due to the
enzyme system on the reduced acidity in the
gastric parietal cells, stomach. Long-term use
reducing gastric acid may be associated with an
secretion. increased risk of nutrient
deficiencies, particularly
magnesium and vitamin
B12.
 64

4. DIETARY ASSESSMENT

FOOD FREQUENCY TABLE

 65

Discussion

The individual's dietary pattern demonstrates a foundation of regular meals based on cereals,
fruits, and vegetables, with moderate inclusion of protein sources from animal and dairy
products. The absence of nuts and seeds stands out as an area where dietary quality could be
improved, by adding more unsaturated fats and diverse proteins to the diet. The regular
consumption of alcohol is the most pressing concern, and cessation or reduction should be
strongly considered to reduce health risks. While the occasional intake of sweets and bakery
items is part of a flexible eating pattern, the frequency and quantity should be monitored.
Increasing the frequency of pulses and legumes could offer health benefits, particularly for
heart health and glycemic control.

24-Hour Diet Recall Method

Time Food Quantity Ingredients Weight Energy CHO Protein Fat Fiber
Item (g) (kcal) (g) (g) (g) (g)
8:00 Wheat Wheat
am Puttu 2 Piece Flour 40 128.23 25.67 4.23 0.61 4.54

Green
Gram ¼ cup Green gram 20 58.75 9.23 4.51 0.23 3.41
Curry Onion 5 2.4 0.4 0.08 0.12

Milk Tea 1 Glass Milk 100 72.9 4.94 3.26 4.48

10:00 Tender 1 Glass Tender 100 15.3 3.16 0.26 0.16

AM Coconut Coconut
Water Water
 66

1:30 Rice 1 cup White Rice 60 210.95 46.3 4.69 0.33 2.24
pm
Egg ½ cup Egg 50 73.85 6.72 5.27
Curry

4:30 Tender Tender

pm Coconut Coconut
Water 1 Glass Water 100 15.3 3.16 0.26 0.16

Apple 1 nos Apple 100 62.6 13.11g 0.29 0.64 2.59

8:00 Chappathi 1 ½ NOS Wheat 38 121.82kcal 24.38 4.02 0.58 4.32
pm Flour
Egg ½ cup 50 73.85kcal 6.72 5.27
Curry Egg
Total 835.99 130.43 35.04 17.73 17.22
Cooking Oil Used:14g.

DISCUSSION

EVALUATION OF HOME RECALL DIET AND FOOD FREQUENCY TABLE

ENERGY: 835.99 kcal

CARBOHYDRATES: 130.43g

PROTEIN: 35.04g

FAT: 32.06g

FIBER:17.22g

FLUID INTAKE:2-3 liters

In evaluating Mr. AM's dietary intake against his nutritional needs, his caloric consumption of
approximately 836 kcal is significantly deficient compared to the recommended 1700 kcal,
potentially hindering recovery from his chronic liver disease and recent illness. His protein
intake at 35.04 grams is markedly low, not meeting the adjusted requirement of 85 grams
 67

necessary for tissue repair and immune function, especially crucial in the context of muscle
mass depletion. Fat consumption, though below the 45 grams suggested for his condition, is
less of an immediate issue but still warrants attention to ensure adequate intake of fat-soluble
vitamins. Fiber intake, at 17.22 grams, falls short of the 30 grams recommended, which may
adversely affect his digestive health, considering his history of medication-induced bowel
issues. Carbohydrate intake is also below the individualized requirement of 230 grams, risking
the use of protein for energy rather than for muscle maintenance, thus compounding his
nutritional challenges.
 68

NUTRITIONAL PROBLEMS AND RISK

Mr. AM's nutritional profile reveals caloric deficiency, protein-energy malnutrition,

micronutrient deficiencies, risk of anemia, inadequate fiber intake, hyponatremia, potential
glucose management issues, and suboptimal fat intake.

NUTRITIONAL DIAGNOSIS

As evidenced by 24-hour dietary recall the nutritional Diagnosis includes:

• Excessive Alcohol intake related to ADS and Liver Problems are evidenced by the
Food Frequency Table
• Altered nutrition-related laboratory values related to Hepatitis as evidenced by
elevated SGPT, SGPT, and Bilirubin Levels
• Inadequate oral food/beverage intake related to dysphagia, and low appetite as
evidenced by low energy intake.
• Inadequate energy intake related to insufficient consumption as evidenced by an intake
of 836 kcal, which is significantly below the estimated requirement based on BMR
(1700 kcal) and EAR (1920 kcal).
• Protein-energy malnutrition related to acute illness and suboptimal nutrient intake as
evidenced by the reported protein intake of 35.04 grams, far below the adjusted need
of 85 grams, and signs of mild muscle mass loss.
• Risk of micronutrient deficiencies related to chronic liver disease and alcohol
dependence syndrome as evidenced by clinical signs of pallor and diminished taste,
suggesting potential deficiencies in zinc, iron, folate, and vitamin B12.
• Altered nutrition-related laboratory values (hyponatremia and mild anemia) related to
inadequate dietary intake and chronic health conditions as evidenced by a sodium level
of 126 Meq/L and hemoglobin of 11.6 gm/dl.
 69

NUTRITION INTERVENTION

1. Energy Requirements: Mr. AM's caloric intake should be adjusted to meet his basal
metabolic rate (BMR) needs, which are estimated at 1700 kcal/day. Considering his
current intake is significantly lower than this, a gradual increase in calories is
recommended to avoid refeeding syndrome.
2. Protein Intake: With an intake of 35.04 grams and a requirement of 85 grams, Mr.
AM's protein needs are not being met. High-quality protein sources should be
incorporated into each meal to help repair tissue, support immune function, and
preserve lean body mass.
3. Macronutrient Balance: Adjustments should be made to ensure an appropriate
balance of carbohydrates, fats, and proteins to meet energy needs while also managing
his diabetes. Fats should primarily come from monounsaturated and polyunsaturated
sources to support cardiovascular health.
4. Micronutrient Supplementation: Given the clinical signs of potential nutrient
deficiencies (e.g., pallor and yellowing of the skin), supplementation of iron, vitamin
B12, and folate may be necessary after confirming deficiencies through lab tests.
5. Hydration and Electrolyte Balance: Hydration status must be monitored, particularly
considering his hyponatremia. Fluid intake should be tailored to his needs, and
electrolytes should be balanced, especially sodium and potassium, in the context of his
liver disease and potential for diuretic therapy.
6. Fiber Intake: To meet the recommended 30 grams of fiber per day, his diet should
include a variety of fiber-rich foods, such as fruits, vegetables, whole grains, and
legumes. This will aid gastrointestinal health and regularity, which is particularly
important given his history of medicine-induced bowel movements.
7. Alcohol and Liver Health: Mr. AM should continue to avoid alcohol to prevent further
damage to his liver and to improve his ability to manage his hepatitis C and uncontrolled
diabetes mellitus.
GOALS

The goals of Medical Nutrition Therapy (MNT) for Mr. AM include enhancing his overall
nutritional status, supporting his immune function, meeting his metabolic demands, stabilizing
his blood glucose levels, preventing muscle wasting, optimizing liver function, managing his
fluid and electrolyte balance, reducing systemic inflammation, improving gastrointestinal
health, and addressing his specific nutrient deficiencies.
 70

MONITORING AND EVALUATION

DIET ORDERS

1. Diabetic Hepatic Diet (22/01/2024)

2. Diabetic Hepatic Diet (23/01/2024)

3. Diabetic Hepatic Diet (24/01/2024)

HOSPITAL DIET DAY 1

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8 AM Idiyappam 3 nos Rice Flour 45 158.21 34.72 3.51 0.25 1.68

Egg Curry ½ Cup Egg 50 73.85 6.72 5.27

1 PM Rice ½ cup White Rice 25 87.89 19.29 1.95 0.14 0.94

Morru ¼ cup Buttermilk 25 15.5 1.22 0.8 0.83

Curry

Beetroot ¼ cup Beetroot 10 3.56 0.62 0.2 0.01 0.33

Upperi

4 PM Milk Tea 1 glass Milk 100 72.9 4.94 3.26 4.48

Egg White 1 nos Egg 50 26.29 6.19

8 PM Broken ½ cup Broken Rice 30 104.7 23.4 2.4 0.15 1
Rice Kanji

Total 637 84.19 25.03 11.1 3.95

Cooking Oil Used:5g.
 71

HOSPITAL DIET DAY 2

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8 AM Wheat 3 Nos Wheat Flour 75 240.43 48.13 7.93 1.15 8.52

Dosa ½ cup Carrot 10 3.32 0.56 0.1 0.05 0.42

Sambhar Drumstick 10 2.94 0.38 0.26 0.01 0.68
Lentil 10 29.78 4.79 2.29 0.06 1.67
Tomato 10 1.96 0.27 0.09 0.05 0.18
Onion 10 4.8 0.96 0.15 0.25

Milk Tea 1 Glass Milk 100 72.9 4.94 3.26 4.4

10 AM Grapefruit ¼ nos Grapefruit 25 10.5 2.67 0.19 0.04 0.4
kiwi 1 Nos Kiwi 50 29.54 7.13 0.54 0.22
1 PM Rice ¾ cup White Rice 50 175.79 38.58 3.91 0.28 1.87

Morru ½ cup Buttermilk 50 31 2.44 1.6 1.65

Curry

Vegetable ¼ cup Green

Upperi Banana 10 12.2 3.18 0.13 0.03
Beans 5 1.22 0.13 0.12 0.01 0.22

4 PM Milk Tea 1 Glass Milk 100 72.9 4.94 3.26 4.48

Egg White 2 nos Egg 50 26.29 6.19
8 PM Broken ¾ cup Broken 50 174.5 39 4 0.25
Wheat Wheat Rice
Kanji
Total 953.07 158.1 34.02 12.6 16.21
Cooking Oil Used:7g.
 72

HOSPITAL DIET DAY 3

Meal Menu Serving Size Ingredients Weight Energy CHO Protein Fat Fiber
(g) (kcal) (g) (g) (g) (g)
8 AM Ragi Puttu ¾ cup Ragi Flour 60 192.45 40.09 4.3 1.15 6.71

Green
Gram ½ cup Green
Curry Gram 20 64.15 9.23 4.51 0.23 3.41

Milk Tea
1 Glass Milk 100 72.9 4.94 3.26 4.48
10 AM Apple 1 Nos Apple 100 62.64 13.11 0.29 0.64 2.59
1 PM Rice 1 cup White Rice 65 228.53 50.15 5.08 0.36 2.43

Salad ½ cup Carrot 10 3.32 0.56 0.1 0.05 0.42

Cucumber 20 3.92 0.7 0.14 0.03 0.43
Onion 10 4.8 0.96 0.15 0.25

Ivy Gourd ¼ cup Ivy Guard 25 4.36 0.5 0.35 0.06

Upperi

Vegetable ¼ cup Beans 10 2.44 0.27 0.25 0.03 0.44

Curry Green Peas 20 60.66 9.79 4.09 0.38 3.4
Carrot 5 1.66 0.28 0.05 0.02 0.21
4 PM Egg 2 nos Egg 50 52.58 12.37 0.26

8 PM Broken 1 cup Broken 65 226.85 50.7 5.2 0.33 4

Wheat Wheat
Kanji

Lentil
Curry 2 Tbsp Lentil 20 59.56 9.58 4.57 0.12 3.33
Total 1130.82 190.86 44.71 8.08 27.62
Cooking Oil Used:10g.
 73

Day Wise Distribution

DAY ENERGY (Kcal) CHO (g) PROTEIN(g) FAT(g) FIBER(g)

DAY 1 637 84.19 25.03 3.95 3.95

DAY 2 953.07 158.1 34.02 12.6 16.21

DAY 3 1130.82 190.86 44.71 8.08 27.62

DISCUSSION

Day 1

• The nutritional intake on the first day is notably low across all macronutrients,
providing only 637 kcal. This level of intake is significantly below his energy
requirements, suggesting that Mr. AM may have had a reduced appetite, limited access
to preferred foods, or possibly experienced symptoms that hindered his ability to
consume more food. The very low-fat intake might also indicate a lack of energy-dense
foods in his diet, which could help increase caloric intake without significantly
increasing volume.
Day 2

• On the second day, there is a marked improvement in his intake, with energy levels
reaching 953.07 kcal. While this is an improvement, it still falls short of meeting its
estimated needs. The increase in carbohydrates and protein is positive, suggesting
perhaps a better tolerance for food or an improved effort to meet one’s nutritional needs.
However, the fat intake, although higher, suggests that the diet could still benefit from
the inclusion of more energy-dense foods.
Day 3

• By the third day, Mr. AM's intake further increases to 1130.82 kcal, showing a positive
trend. This increase is encouraging, yet it still does not meet his calculated needs,
especially in the context of his recovery and the management of his chronic conditions.
The proportions of carbohydrates and protein on this day are closer to meeting his
needs, reflecting a potentially more balanced approach to his diet.
 74

DISCHARGE DIET

Time Food Quantity Ingredients Weight Energy CHO Protein Fat Fiber
Item (g) (kcal) (g) (g) (g) (g)
8 AM Ragi 4 Nos Ragi 100 320.74 66.82 7.16 1.92 11.18
Dosa

Sambar ½ cup Drumstick 10 2.94 0.38 0.26 0.01 0.68

Onion 10 4.8 0.96 0.15 0.25
Lentil 20 59.56 9.69 4.5 0.13 3.36
Tomato 20 3.92 0.54 0.18 0.09 0.35
Carrot 10 3.32 0.56 0.1 0.05 0.42
Okra 10 2.75 0.36 0.21 0.02 0.41
Potato 5 3.49 0.74 0.08 0.09
Yam 5 4.22 0.87 0.13 0.01 0.21

Coffee 1 Glass Milk 100 72.9 4.94 3.26 4.48

Egg 1 Egg 50 73.85 6.72 5.27

10AM Guava 1 nos Guava 100 32.27 5.13 1.44 0.32 8.59

1 AM Rice 1 cup Brown Rice 80 282.98 59.84 7.33 0.99 3.54

Fish ½ Cup Fish 90 90.99 19.36 1.38

Curry Onion 10 4.8 0.96 0.15 0.25

Cabbage
Upperi ¼ cup Cabbage 50 10.76 1.63 0.68 0.06 1.38
4 AM Green 1 Glass Green Tea
Tea

Walnuts 5 nos Walnuts 15 100.71 1.52 2.24 9.64 0.81

 75

Egg 2 Egg 100 147.71 13.43 10.54

8 AM Chapati 4 nos Wheat Flour 80 256.46 51.34 8.46 1.22 9.09

(Whole
Wheat)

Green
Gram ¼ cup Green Gram 40 117.5 18.45 9.01 0.46 6.82
Dal
Curry

Mixed ½ Cup Cucumber 20 3.92 0.7 0.14 0.03 0.43

Vegetable Spinach 10 2.44 0.21 0.21 0.06 0.24
Salad: Onion 10 4.8 0.96 0.15 0.25
Carrot 10 3.32 0.56 0.1 0.05 0.42

9 AM Low-Fat 1 Glass Milk 100 72.9 4.94 3.26 4.48

Milk
TOTAL 1684.05 232.08 88.71 41.21 48.77

RECOMMENDED DIETARY ALLOWANCE

Nutrients RDA Patient Requirement Discharge Diet

Provided
Energy (Kcal) 1920 kcal (EAR) 1700kcal (BMI) 1684.05
Dietary Fiber(g) 30g 30g 48.77g
Protein(g) 49.8g 85g 88.71g
Fat(g) 64g 45g 41.21g
Carbohydrate(g) 288g 230g 232.08g
 76

DISCUSSION

The discharge diet provided for Mr. AM is structured to accommodate both his diabetic and
hepatic conditions while also aiming to meet his daily nutritional requirements. The diet
comprises a variety of food items distributed across the day to ensure a balanced intake of
macronutrients and fiber. Here's an analysis based on the Recommended Dietary Allowance
(RDA) and Mr. AM's specific nutritional needs:

The Discharge diet Provided: 1684.05 kcal of energy. The total caloric intake of the discharge
diet nearly meets Mr. AM's estimated requirements based on his BMI, indicating a well-
calibrated effort to provide enough energy to support his daily activities without exacerbating
his conditions.

The Diet Provided 48.77g of dietary fiber. The fiber content significantly exceeds the
recommended and required amounts, which is beneficial for Mr. AM's gastrointestinal health,
potentially aiding in glucose regulation and providing a sense of satiety, which can help with
weight management.

The diet provided 88.71g of protein. Protein intake is appropriately above the requirement,
which is crucial for Mr. AM given his need for muscle maintenance, liver function support, and
overall recovery. High-quality protein sources, including eggs, fish, and green gram dal, are
incorporated to meet this goal.

The Diet also delivers 41.21g of fat. The fat content is slightly below the required amount but
within a reasonable range to support Mr. AM's health without overburdening his liver. The
focus on healthier fats, particularly from sources like walnuts, supports cardiovascular health
while also being mindful of his hepatic condition.

The Distributes about Diet Provided 232.08g of carbs. Carbohydrate intake aligns closely
with the requirement, suggesting careful planning to manage Mr. AM's blood glucose levels.
The inclusion of complex carbohydrates and fiber-rich foods like brown rice, whole wheat
chapati, and guava helps ensure a steady glucose supply and supports overall dietary balance.
 77

Overall Summary

Mr. AM, a 44-year-old male, has a history fraught with health challenges including chronic
liver disease due to Hepatitis C, alcohol dependence syndrome, uncontrolled diabetes mellitus,
and hospital admissions related to delirium and aspiration pneumonia. His recent hospital stays,
prompted by a Lower Respiratory Tract Infection and symptoms like high-grade fevers and
cough, also brought to light his sedentary lifestyle and mild to moderate malnutrition. The
hospital's nutritional assessment unveiled his insufficient caloric and protein intake, which
could hamper recovery efforts and optimal management of his long-standing health issues.
Medical Nutrition Therapy (MNT) was carefully strategized to counteract these deficiencies
by focusing on enhancing caloric intake, ensuring adequate high-quality protein to combat
muscle wasting, and regulating blood glucose through careful carbohydrate management. The
MNT also incorporated elements crucial for its specific conditions, such as sodium restriction
to manage fluid retention, hydration maintenance, alcohol avoidance, and necessary
micronutrient supplementation. As he was discharged, Mr. AM received a diet plan designed
to continue his recovery trajectory and maintain his health, encompassing an array of food
groups and focused on meeting his energy and nutrient requirements. This case epitomizes the
imperative role that integrated, multidisciplinary care plays in the holistic treatment of patients
with complex medical needs, highlighting how customized dietary planning is paramount in
not just addressing immediate health concerns but also paving the way for sustained well-being.
The collaborative efforts of healthcare providers, along with vigilant monitoring, patient
education, and post-discharge follow-up, are crucial to ensuring that patients like Mr. AM can
manage their conditions and improve their quality of life.
 78

CASE STUDY – 3

ACUTE KIDNEY INJURY

Introduction

AKI is a common and potentially life-threatening condition that can occur due to various
causes. It is characterized by a rapid decrease in the glomerular filtration rate (GFR), which is
the measure of the kidney's ability to filter waste products from the blood.

Pathology

AKI can be classified into three categories based on the underlying cause: a. Prerenal AKI:
Caused by decreased blood flow to the kidneys, such as dehydration, hemorrhage, or heart
failure. b. Intrinsic AKI: Damage to the kidney itself, such as acute tubular necrosis,
glomerulonephritis, or acute interstitial nephritis. c. Postrenal AKI: Obstruction of the urinary
tract, such as kidney stones, tumors, or an enlarged prostate.

Physiology

The physiology of the kidneys is significantly impaired in Acute Kidney Injury (AKI). There
is a decreased glomerular filtration rate (GFR), leading to the accumulation of waste products
and fluid in the body. The tubular reabsorption and secretion processes are disrupted, causing
electrolyte imbalances. Additionally, the kidneys' ability to regulate acid-base balance is
impaired, resulting in metabolic acidosis. AKI can also lead to decreased erythropoietin
production, potentially causing anemia. Furthermore, the metabolism of vitamin D is disrupted,
affecting calcium and phosphate homeostasis.

Metabolic Aspects

AKI is associated with various metabolic disturbances. Azotemia, or the buildup of nitrogenous
waste like urea and creatinine, occurs due to decreased excretion by the kidneys. Electrolyte
imbalances, such as hyperkalemia (elevated potassium levels), are common. Metabolic
acidosis can develop due to impaired acid-base regulation by the kidneys. Fluid overload and
edema may occur because of decreased urine output and impaired fluid regulation. Uremic
toxicity can arise from the accumulation of uremic toxins, leading to systemic complications.
Additionally, the disruption of hormone regulation, including erythropoietin, vitamin D, and
 79

parathyroid hormone, can lead to imbalances in calcium, phosphate, and red blood cell
production.

Complications

AKI can lead to several complications, including a. Fluid overload and pulmonary edema b.
Electrolyte imbalances (e.g., hyperkalemia, metabolic acidosis) c. Uremic complications (e.g.,
pericarditis, encephalopathy, bleeding) d. Increased risk of acute and chronic kidney disease
prog.

Symptoms

The symptoms of AKI can vary depending on the underlying cause and severity. Common
symptoms include a. Decreased urine output and b. Swelling (edema) in the legs, feet, or around
the eyes c. Fatigue and weakness d. Nausea and vomiting e. Confusion or decreased level of
consciousness.

Etiology

AKI can be caused by various factors, including a. Decreased renal blood flow (e.g.,
dehydration, sepsis, heart failure) b. Exposure to nephrotoxins (e.g., contrast dyes, certain
medications) c. Acute glomerulonephritis d. Acute tubular necrosis (e.g., due to ischemia or
toxins) e. Urinary tract obstruction (e.g., kidney stones, tumors) f. Rhabdomyolysis
(breakdown of muscle fibers) g. Immune disorders (e.g., lupus nephritis)
 80

PATIENT PROFILE

ADMISSION

Date of Admission: 03/02/2024

Date of Discharge: 12/02/2024

Total Length of Hospital Stay: 9 days

Length of Stay in ICU 1 Day

Length of Stay in Ward 8 days

DEMOGRAPHIC DATA
Name: Mr. SR

Age: 29 Years

Gender: Male

Occupation: Electrician

Economic Status: Above Average

Community: Hindu

Level of Physical activity: Heavy to Moderate

HEALTH DATA

Chief Complaints: Complaints of pain in right loin, nausea, vomiting,

and fever for last 7 days. Also decreased urine
output for the past 2 days,

Diagnosis: Bilateral Ureteric Calculi+Right Renal

Calculi+Acute Kidney Injury

Level of Diagnosis: Post Renal Acute Kidney Injury

Disease/ surgery history: History of Renal Calculi 2 years Back

 81

Family history of diseases: No Family History of Diseases

Mental condition: Stressed

Medications: Nil

DIETARY DATA

Special Diet Followed: Normal Diet (Reduced Red Meat)

Alcohol Consumption: Occasionally

Smoking/Nicotine usage: Nil

Food Allergies/ Intolerances: Nil

Fluid restriction- 1 ½ liters

Average Fluid Intake: 1-2 liters

SGA SCORE: 14

Status During the First Assessment

• Bowel Movement- Normal

• Vomiting- Yes (Involuntary)

• Appetite- Very Low

• Sleep- 2 Hours

Discussion

Mr. SR, a 29-year-old male electrician with an average economic status and belonging to the
Hindu community, was admitted to the hospital due to complaints of right loin pain, nausea,
vomiting, fever for the last 7 days, and decreased urine output for the past 2 days, resulting in
a 9-day hospital stay. Diagnosed with bilateral ureteric calculi, right renal calculi, and post-
renal acute kidney injury—a condition likely exacerbated by his heavy to moderate physical
activity levels—his treatment presents a complex challenge. With a history of renal calculi and
 82

currently experiencing significant stress, Mr. SR's management plan must address both the
physical obstructions causing his AKI and his psychological well-being. His dietary regimen,
which includes a normal diet with reduced red meat and fluid restriction of 1 ½ liters, plays a
crucial role in his treatment and recovery. Given his occasional alcohol consumption and
absence of tobacco or nicotine use, along with no food allergies or intolerances, dietary
management focuses on preventing further renal complications and promoting recovery.
 83

ASSESSMENT

SUBJECTIVE GLOBAL ASSESSMENT

 84

Parameter Score Remark

A. Weight change 2 Weight Loss

B. Nutrient intake 1 Minimal Intake, Clear Fluids, and Starvation

C. Symptoms affecting oral intake 3 Vomiting, Nausea, Feels Full Quickly

D. Functional capacity 2 None (Improved)

E. Loss of subcutaneous fat 2 Mild

F. Loss of muscle mass 2 Mild

G. Presence of oedema/ascites 2 Mild

Rating Reference

• Severely malnourished: 7-14 points

• Mildly/moderately malnourished: 15-21 points
• Well nourished: 22-28 points

Discussion

With these scores, Mr. SR's total SGA score is 14, placing him at the boundary between severely
malnourished (7-14 points) and mildly/moderately malnourished (15-21 points). This indicates
that Mr. SR is severely malnourished, which is a critical factor that could complicate his
recovery from acute kidney injury and management of renal calculi.
 85

1. ANTHROPOMETRIC MEASUREMENTS

Height: 179 cm

Weight: 78 kg

BMI: 24.3 kg/m2

IBW: 71 kg

Adjustable Body Weight 76 kg

BMR 2726 calories day

Discussion

Mr. SR's anthropometric data, featuring a height of 179 cm and weight of 78 kg resulting in a
BMI of 24.3 kg/m^2, positions him within the normal weight range, indicating a generally
healthy body composition before the onset of his acute kidney injury (AKI) and renal calculi.
His ideal body weight (IBW) calculated at 71 kg, compared to his actual weight, suggests a
slight excess, with an adjusted body weight of 76 kg tailored to his condition and nutritional
needs, highlighting the importance of a precise nutritional strategy. The basal metabolic rate
(BMR) of 2726 calories per day reflects his energy requirements, influenced by his physically
demanding occupation and elevated due to his heavy to moderate activity levels. This BMR
emphasizes the critical need for a nutritional plan that not only addresses the severe
malnutrition identified by his SGA score but also supports his energy needs during recovery
from AKI and renal calculi.
 86

2. BIOCHEMICAL METHODS

Reference Range 04/02/2024 05/02/2024 06/02/2024 07/02/2024

HB (gm/dl) 13-18gm/dI 12.5 14.3

TC (/mm) 4000-11000/mm 12,100 10,100

ESR (mm/h) 0-5 mm/h 37

Platelet (lakh/m) 1-4.4 lakh/m 2.9 4.2

Urea (mg/dl) 10-50mg/dI 96 80 51 46

Creatinine (mg/dl) 0.6-1.3 mg/dI 11.1 8.5 2.6 1.8

Uric Acid (mg/dl) 3.4-7 mg/dI 9.0 4.4

Sodium (Meq/L) 135-145 Meq/L 135 138 139

Potassium (Meq/L) 3.5-5.5 Meq/L 4.3 4.5 4.6

Albumin(mg/dl) 3.5-5.5 gm/dI 4.4

Globulin (mg/dl) 2.0-3.6gm/dI 3.1

 87

DISCUSSION

Mr. SR's biochemical test results throughout his hospital stay provide valuable insights into his
condition and the effectiveness of the treatment being administered for his acute kidney injury
(AKI) and renal calculi. Initially, his urea and creatinine levels were significantly elevated (urea
at 96 mg/dl and creatinine at 11.1 mg/dl), far beyond the normal ranges (10-50 mg/dl for urea
and 0.6-1.3 mg/dl for creatinine), indicating severe kidney dysfunction. These levels gradually
improved over the following days, with urea decreasing to 46 mg/dl and creatinine to 1.8 mg/dl,
suggesting a positive response to treatment and partial recovery of kidney function.

The initial high uric acid level of 9.0 mg/dl, which is above the normal range of 2.4-5.7 mg/dl,
also indicates kidney stress or damage, as uric acid is another waste product that kidneys filter
out of the blood. This level improved to 4.4 mg/dl, returning to within normal limits, which
further supports the recovery trend.

His Hemoglobin (HB) level showed an increase from 12.5 gm/dl to 14.3 gm/dl, remaining
within the normal range (11.5-16.5 gm/dl), which is good for oxygen transport and overall
health. The Total Count (TC) of white blood cells was initially high at 12,100 /mm, indicating
a possible infection or inflammation, likely related to his AKI or the renal calculi, but then
decreased to 10,100 /mm, moving within the normal range (4000-11000/mm), suggesting the
resolution of any acute inflammatory or infectious process.

The Erythrocyte Sedimentation Rate (ESR) was elevated at 37 mm/h, exceeding the normal
range (0-7 mm/h), which typically indicates inflammation or infection. This parameter,
however, is not always specific to kidney function but reflects overall bodily stress.

His Platelet count improved from 2.9 lakh/m to 4.2 lakh/m, staying within the normal range
(1-4.4 lakh/m), which is crucial for blood clotting and healing processes. Electrolyte levels of
Sodium and Potassium were maintained within normal ranges throughout (135-145 Meq/L for
Sodium and 3.5-5.5 Meq/L for Potassium), essential for fluid balance, nerve, and muscle
function. Finally, Albumin and Globulin levels were within normal limits (3.5-5.5 gm/dl for
Albumin and 2.0-3.6 gm/dl for Globulin), indicating adequate liver function and nutritional
status.
 88

3. CLINICAL ASSESSMENT

Past Medical History: History of Renal Calculi 2 years back and was on conservative
management.

Previous Medications: He was not taking any medications.

Presenting Complaints: Complaints of pain in right loin, nausea, vomiting, and fever for the
last 7 days. Also decreased urine output for the past 2 days.

Diagnosis: - He was diagnosed with Bilateral Ureteric Calculi and right Renal Calculi. Acute
Kidney Injury.

Disease signs and symptoms: The main signs and symptoms included elevated Uric Acid,
Urea, and Creatinine. Right Renal Angle Tenderness was present. Elevated Blood Pressure
and Pulse rates were also noted.

NFPE

PROGNOSIS OF NFPE

The Nutrition-Focused Physical Exam (NFPE) findings for Mr. SR, including easily plucked,
dull hair and a diminished sense of taste, suggest deficiencies in protein, energy, essential fatty
acids, iron, zinc, and biotin. These deficiencies are not only indicative of inadequate nutritional
intake but also have direct implications for his acute kidney injury (AKI). In the context of
 89

AKI, the body's impaired ability to metabolize and utilize nutrients exacerbates these
symptoms. Protein and energy are essential for cellular repair and maintenance, affecting hair
health and recovery capacity. Deficiencies in iron, zinc, and biotin, crucial for hair growth and
maintenance, can lead to alopecia, while zinc's role in taste perception affects food intake,
potentially worsening nutritional status.

OTHER PARAMETERS

Parameter Normal Date Remark

Range
04/03/2024 05/03/2024 06/03/2024

Blood 120/80 160/90 140/80 120/80 Normal

Pressure mmHg

Pulse 72/mt 96 88 74 Mild

Tachycardia

Respiration 20 20 20 20 Normal

Oxygen >96% 99% 98% 99% Normal

Saturation

Discussion

From March 4th to March 6th, 2024, Mr. SR's health parameters showed marked improvement,
aligning with his recovery from acute kidney injury (AKI) and renal calculi. Initially, his blood
pressure was elevated at 160/90 mmHg, indicating potential stress from his condition, but
progressively improved to the normal range of 120/80 mmHg by March 6th, reflecting better
kidney function and effective management. His pulse rate also decreased from a high of 96
beats per minute to a near-normal 74 bpm, suggesting reduced stress or pain. Meanwhile, his
respiration rate remained stable at 20 breaths per minute, and oxygen saturation levels were
consistently high (98-99%), indicating good respiratory function and adequate oxygenation.
These improvements in vital signs are encouraging signs of recovery, highlighting the
effectiveness of his treatment regimen for AKI and underlying renal issues.
 90

MEDICATIONS

Name Dosage Mechanism of Drug Drug–nutrient

interaction
Tab Dolo 650gm Tab Dolo typically refers to Paracetamol has minimal
a formulation of direct nutrient
paracetamol interactions, but chronic
(acetaminophen), which use or high doses can
works by inhibiting the increase the risk of liver
synthesis of prostaglandins damage, potentially
in the central nervous affecting the metabolism
system and blocking pain of nutrients. Alcohol
impulses. It also has consumption should be
antipyretic properties, minimized as it increases
meaning it can reduce fever the risk of liver damage.
Tab Pantop 40mg Pantoprazole, found in Tab Long-term use of
Pantop, is a proton pump pantoprazole can decrease
inhibitor (PPI). It works by stomach acid, potentially
irreversibly blocking the leading to decreased
H+/K+ ATPase pump in the absorption of vitamin
stomach lining, reducing the B12, magnesium, and
production of gastric acid. calcium, affecting their
levels in the body.
Tab Ultracet Ultracet is a combination of tramadol can interact with
tramadol, an opioid foods that contain
analgesic, and tyramine and may
acetaminophen. Tramadol increase serotonin levels
works by binding to the mu- if taken with certain
opioid receptor and supplements like St.
inhibiting the reuptake of John's Wort, increasing
serotonin and the risk of serotonin
norepinephrine, which helps syndrome
in pain relief.
 91

4. DIETARY ASSESSMENT

FOOD FREQUENCY TABLE

 92

Mr. SR's dietary habits, characterized by daily consumption of fast foods and bakery items high
in sodium and unhealthy fats, alongside infrequent intake of nutrient-dense foods like fruits
and vegetables, may have significantly impacted his acute kidney injury (AKI) and renal
calculi. The high intake of processed foods likely exacerbated hypertension and kidney strain,
while the limited consumption of protective nutrients found in whole foods could have hindered
his renal health. Regular intake of animal proteins and dairy might have also contributed to
calcium oxalate stone formation, further complicating his kidney condition. Overall, Mr. SR's
diet, rich in sodium and low in nutritional quality, played a critical role in the development and
severity of his renal issues.

24-Hour Diet Recall Method

Time Food Quantity Ingredients Weight Energy CHO Protein Fat Fiber
Item (g) (kcal) (g) (g) (g) (g)
6:00 Milk Tea 1 Glass Milk 100 72.9 4.94 3.26 4.48
am

8:00 Milk Tea 1 Glass Milk 100 72.9 4.94 3.26 4.48
am
Dosa 2 Nos Rice 37.5 131.84 28.94 2.93 0.21 1.4
Black Gram 12.5 36.42 5.5 2.75 0.2 2.55

Coconut ¼ cup Coconut 25 102.23 1.58 0.96 10.35 2.61

Chutney
1:30 Orange 1 Glass Orange 100 47 23.5 1.88 0.24 2
pm juice

Total 463.29 57.64 14.1 19.83 8.96

 93

DISCUSSION

EVALUATION OF HOME RECALL DIET AND FOOD FREQUENCY TABLE

ENERGY: 463.29 Kcal

CARBOHYDRATES: 57.64g

PROTEIN: 14.1g

FAT: 19.83g

FIBER:8.96g

FLUID INTAKE: 2-3 liter

Mr. SR's nutritional intake before hospital admission revealed through a 24-hour diet recall,
coupled with his daily consumption habits and creatine supplementation without adequate
hydration, presents significant concerns in the context of his acute kidney injury (AKI) and
renal calculi. The caloric intake of 463.29 kcal is markedly lower than recommended for an
adult male, especially one with a physically demanding job, potentially contributing to
malnutrition. The protein intake is insufficient for tissue repair and immune function, while
daily consumption of fast food, bakery items, and high amounts of spices may have exacerbated
his condition by increasing sodium intake and straining the kidneys. Additionally, regular
consumption of milk and dairy products without a balanced diet could increase the risk of
calcium oxalate stones, and the use of creatine supplements without sufficient hydration likely
contributed to renal issues. Overall, Mr. SR's dietary habits and supplementation could have
significantly impacted his kidney health, highlighting the need for a carefully balanced diet
with adequate hydration to support recovery and prevent future complications.
 94

NUTRITIONAL PROBLEMS AND RISK

Some of the nutritional problems for Mr. SR include Energy and Macronutrient Intake,
Micronutrient Deficiencies, Hydration and Kidney Function, Weight and Muscle Mass
Concerns, Biochemical Indicators of Nutritional Risk, Blood Pressure and Electrolyte
Imbalance.

NUTRITIONAL DIAGNOSIS

1. Inadequate energy intake related to insufficient consumption of calories as evidenced by a

reported daily intake significantly below recommended levels, and severe malnutrition status
per SGA.

2. Protein-energy malnutrition related to low protein and energy intake as evidenced by marked
reductions in protein and overall caloric consumption, and biochemical indicators of muscle
mass loss

3. Fluid intake deficiency related to inadequate consumption of fluids as evidenced by creatine

supplementation without proper hydration, leading to acute kidney injury and renal calculi.

4. Risk of nutrient imbalances related to high intake of processed foods and low intake of fruits
and vegetables as evidenced by daily consumption of fast food, bakery items, and limited
dietary variety.

5. Potential for hypertension and further renal damage related to excessive sodium intake from
processed foods and condiments as evidenced by initial high blood pressure readings and
dietary recall indicating daily consumption of high-sodium foods.

6. Altered GI function related to symptoms of nausea, vomiting, and feeling full quickly as
evidenced by complaints leading to admission and clinical observations.
 95

NUTRITION INTERVENTION

1. Caloric Needs: Calculate his total energy needs considering his Basal Metabolic Rate
(BMR) and physical activity level to support recovery while preventing excessive weight gain

2. Protein Intake: Adjust protein intake to a level that supports kidney function and tissue
repair. For AKI patients, protein needs might be slightly higher during the recovery phase but
should be carefully balanced to avoid exacerbating kidney strain.

3. Carbohydrates and Fats: Focus on complex carbohydrates (whole grains, fruits, and
vegetables) for sustained energy and dietary fibers. Include healthy fats (omega-3 fatty acids
from fish, olive oil, and nuts) to support overall health without overburdening the kidneys.

4. Hydration: Encourage adequate fluid intake to help prevent further renal calculi formation
and support kidney function, adjusting the amount based on his current kidney function, urine
output, and any fluid restrictions due to AKI.

5. Electrolytes: Monitor and manage electrolyte intake, especially sodium, potassium, and
phosphorus, to maintain electrolyte balance and avoid complications associated with AKI and
renal calculi.

6. Limit Oxalates: If the renal calculi are oxalate-based, reducing oxalate-rich foods
(spinach, rhubarb, beets) may help prevent stone recurrence.

7. Calcium Intake: Ensure adequate dietary calcium intake to bind with oxalates in the gut
and reduce oxalate absorption, rather than limiting calcium which could potentially increase
stone risk.

8. Reduce Sodium: Lower sodium intake to help manage blood pressure and minimize calcium
excretion in the urine, which can contribute to stone formation.

9. Avoidance of Nephrotoxic Substances: Educate on the risks of certain supplements and

the importance of consulting healthcare providers before starting any new supplement,
especially those that can affect kidney health like creatine.
 96

GOALS

The goals of Medical Nutrition Therapy (MNT) for Mr. SR focus on supporting recovery from
acute kidney injury and renal calculi, correcting severe malnutrition, ensuring adequate
hydration, and balancing nutrient intake. MNT aims to optimize energy and protein
consumption to support bodily repair and muscle maintenance, reduce sodium intake to manage
blood pressure and enhance diet quality through increased intake of fruits, vegetables, and
whole grains.
 97

MONITORING AND EVALUATION

DIET ORDERS

1. Renal Diet (04/02/2024)

2. Renal Diet (05/02/2024)

3. Renal Diet (06/02/2024)

HOSPITAL DIET DAY 1

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8 AM Appam 2 Nos Rice 50 175.79 38.58 3.91 0.28 1.87

Veg ¼ cup Potato 5 3.49 0.74 0.08 0.09

Kuruma Green Peas 5 15.17 2.45 1.02 0.09 0.85
Beans 5 1.22 0.13 0.12 0.01 0.22
Carrot 5 1.66 0.28 0.05 0.02 0.21
Coconut Milk 5 21.5 0.6 0.17 2.05
10AM Egg White 1 Nos Egg 25 13.15 3.09 0.07
1 PM Rice ½ cup Brown rice 33 116.73 24.68 3.02 0.41 1.46

Moru ¼ cup Buttermilk 25 15.5 1.22 0.8 0.83

Chaaru

4 AM Apple 1 Nos Apple 100 62.64 13.11 0.29 0.64 2.59

8 PM Chappathi 1 Nos Wheat Flour 25 80.14 16.04 2.64 0.38 2.84

Chicken ¼ cup Chicken 30 50.48 6.54 2.7

Curry

Total 600.6 97.83 21.74 7.48 10.13

Cooking Oil Used:5g.
 98

HOSPITAL DIET DAY 2

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8 AM Putt ½ cup Rice 50 175.79 38.58 3.91 0.28 1.87

Egg ¼ cup Egg 25 13.15 3.09 0.07

Curry onion 5 2.4 0.48 0.08 0.12
1 PM Rice ¾ cup Brown Rice 50 176.86 37.4 4.58 0.62 2.22

Cabbage ¼ cup Cabbage 25 5.38 0.81 0.34 0.03 0.69

Upperi

Chicken ¼ cup Chicken 50 84.13 10.91 4.5

Curry

4 PM Apple 1 Nos Apple 100 62.64 13.11 0.29 0.64 2.59

Egg 1 Nos Egg 25 13.15 3.09 0.07

White
8 PM Chappat 2 Nos Wheat 50 160.29 32.09 5.29 0.77 5.68
hi Flour

Chana ¼ cup Chickpea 25 90 14.18 4.8 1.55

Masala
Total 829 136.16 36.29 8.51 13.9
Cooking Oil Used:5g.
 99

HOSPITAL DIET DAY 3

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fibe
Size (g) (Kcal) (g) (g) (g) r
(g)
8 AM Idiyappam 3 Nos Rice 75 263.68 57.87 5.86 0.41 2.81

Bengal Gram ¼ cup Bengal 25 71.76 9.89 4.69 1.28 6.31

Curry Gram

10AM Egg white 1 Nos Egg 25 13.15 3.09 0.07

1 PM Rice 1 cup Brown Rice 66 233.46 49.37 6.05 0.82 2.92

Vendakka ¼ cup Ladies 25 6.87 0.91 0.52 0.06 1.02

Upperi Finger

Moruchaaru ½ cup Buttermilk 30 18.6 1.46 0.96 0.99

4 PM 1 and ½ Apple 1 and ½ Apple 150 93.96 19.67 0.43 0.96 3.89
Nos

1 Guava 1 Nos Guava 100 32.27 5.13 1.44 0.32 8.59

8 PM Chappathi 3 Wheat 75 240.43 48.13 7.93 1.15 8.52
Flour

Fish Curry ½ cup Mackerel 90 90.99 19.36 1.38

Total 1157 201.6 51.44 8.06 30.86

Cooking Oil Used:8g.
 100

Day Wise Distribution

DAY ENERGY CHO (g) PROTEIN(g) FAT(g) FIBRE(g)

(Kcal)

DAY 1 600.6 97.83 21.74 7.48 10.13

DAY 2 829 136.16 36.29 8.51 13.9

DAY 3 1157 201.61 51.44 8.06 30.86

DISCUSSION

The nutritional intake data for Mr. SR during his hospital stay shows a positive progression in
his diet, reflective of the careful planning and adjustments made through the renal diet provided
to him. Over three days, there was a noticeable increase in energy, carbohydrate, protein, and
fiber intake, while maintaining a low to moderate fat intake, which is beneficial for his
condition.

• Day 1 started with a foundational intake of 600.6 kcal, providing a balanced distribution
of macronutrients with 97.83 grams of carbohydrates, 21.74 grams of protein, and a
low-fat content of 7.48 grams, alongside 10.13 grams of fiber. This initial setup aimed
to gently reintroduce Mr. SR to a more nourishing diet without overwhelming his
system, especially considering his acute kidney injury and recent malnutrition status.
• Day 2 saw an increase in all dietary components: 829 kcal of energy, 136.16 grams of
carbohydrates, 36.29 grams of protein, 8.51 grams of fat, and 13.9 grams of fiber. This
gradual increase is indicative of a strategy to boost his nutritional intake in a controlled
manner, ensuring that his body adapts to the higher levels of nutrients effectively,
supporting his energy needs and promoting renal health.
• By Day 3, his intake improved significantly to 1157 kcal, with substantial increases in
carbohydrates (201.61 grams) and protein (51.44 grams), alongside an impressive
intake of 30.86 grams of fiber, while keeping fat intake relatively low at 8.06 grams.
This progression demonstrates a successful dietary adjustment to meet his increasing
nutritional requirements for recovery, with a special focus on high fiber intake to
improve gastrointestinal health and potentially aid in the management of kidney
function by reducing constipation and facilitating the elimination of toxins.
 101

DISCHARGE DIET

Time Food Quantity Ingredients Weight Energy CHO Protein Fat Fiber
Item (g) (kcal) (g) (g) (g) (g)
8 AM Putt ¾ cup White Rice 75 263.68 57.87 5.86 0.41 2.81

Chicken ½ cup Chicken 50 84.13 10.91 4.5

Curry

10 Egg 2 Nos Egg 50 26.29 6.19 0.13

AM Whites

Sago 1 cup Sago 100 351 87.1 0.2 0.2

Porridge
Coconut 50 215 5.95 1.7 20.5
Milk

Psyllium 10 35 8 7
Husk
1 AM Rice ¾ cup Brown Rice 50 176.86 37.4 4.58 0.62 2.22

Cabbage ¼ cup Cabbage 30 6.45 0.98 0.41 0.04 0.83

Upperi

Green ¼ cup Green Beans 30 7.31 0.8 0.75 0.08 1.31

Beans

Fish 1 cup Mackerel 90 90.99 19.36 1.38

Curry
4 AM Apple 1 Nos Apple 100 62.64 13.11 0.29 0.64
 102

Arrowroot ¼ cup Arrowroot 25 83.5 20.78 0.05 0.03

Porridge Flour
Psyllium 5 17.5 4 3.5
Husk
6 AM Apricot, 4 Nos Apricot 20 63.21 14.53 0.63 0.15 0.66
dried
8 AM Sago 1 cup Sago 100 351 87.1 0.2 0.2

Coconut 50 215 5.95 1.7 20.5

Milk

Psyllium 10 35 8 7
Husk

Bengal ½ cup Bengal 40 114.82 15.82 7.51 2.04 10.09

Gram Gram

Salad ½ cup Cucumber 50 9.8 1.74 0.36 0.08 1.07

Olive Oil 15 132.6 15

Total 2466 370.41 60.48 82.48 38.57

Cooking Oil Used: 16g.

RECOMMENDED DIETARY ALLOWANCE

Nutrients RDA Patient Requirement Discharge Diet

Provided
Energy (Kcal) 3276 2470 2466
Dietary Fiber(g) 40 40 38.57
Protein(g) 64.74 61 60.48
Fat(g) 116.48 82 82.48
Carbohydrate(g) 491.4 370.5 370.41
 103

DISCUSSION

The discharge diet prepared for Mr. SR, with a nutritional distribution closely aligned to his
health condition and specific nutritional requirements, reflects a well-thought-out approach to
his continued recovery and health management post-discharge.

This dietary plan supports Mr. SR's recovery from acute kidney injury (AKI) and management
of renal calculi by ensuring adequate energy intake for his daily activities and bodily functions,
while not overwhelming his kidneys. The carbohydrate level is set to provide sufficient energy
throughout the day, which is crucial for someone recovering from AKI and ensures his body
has the necessary fuel for healing and daily activities.

Protein intake is optimized at 60.48 grams, close to the ideal 61 grams, to support tissue repair
and muscle maintenance without overburdening his kidneys, a key consideration in AKI
recovery. This level of protein supports his bodily needs while minimizing the risk of
exacerbating his renal condition.

The fat content of the diet is calculated to provide essential fatty acids and calories, helping
Mr. SR maintain a healthy weight and supporting cellular health, without excessively taxing
his kidneys. The amount of fat is kept in check to avoid cardiovascular strain, considering the
potential risk associated with kidney disease.

Fiber intake is particularly noteworthy at 38.57 grams, slightly under the 40-gram target,
indicating a focus on gastrointestinal health and regularity, which can be compromised in
patients with renal issues. Adequate fiber helps in managing blood sugar levels, reducing
cholesterol, and ensuring smooth digestion, which can significantly impact overall well-being
and kidney health.
 104

OVERALL SUMMARY

This case study provides a comprehensive overview of Mr. SR, a 29-year-old electrician, who
was admitted to the hospital with acute kidney injury (AKI) and renal calculi, amid concerns
about severe malnutrition and unhealthy dietary habits. Throughout his hospitalization, a
multidisciplinary approach was employed to address his condition, focusing on Medical
Nutrition Therapy (MNT), dietary adjustments, Dialysis in the early days of admission, and
monitoring of clinical parameters to guide his recovery process.

Upon admission, Mr. SR presented with severe malnutrition, as evidenced by his low energy
and protein intake, and a diet high in fast food, bakery items, and inadequate hydration,
especially concerning given his creatine supplement intake. Anthropometric measurements
revealed mild weight and muscle mass loss, while biochemical markers indicated significant
kidney dysfunction, with elevated urea and creatinine levels, suggesting a substantial
impairment of kidney function.

During his stay, dietary interventions were carefully implemented, showing a positive
progression. Nutritional intake gradually increased, focusing on improving energy,
carbohydrate, protein, and fiber levels, with careful management of fat intake. This approach
aimed to support Mr. SR's bodily needs for healing and recovery, considering his AKI and
renal calculi, without overwhelming his kidneys.

Lab values and clinical parameters showed notable improvement over time. Urea and
creatinine levels decreased significantly, indicating an improvement in kidney function.
Blood pressure was normalized, and electrolyte balances were maintained within normal
ranges, both crucial indicators of improved renal health and overall physiological stability.
These positive changes in lab values and clinical parameters were reflective of the effective
management of Mr. SR's condition through dietary and medical interventions.

Upon discharge, a specifically tailored diet was prescribed, closely aligning with his
nutritional needs to support ongoing recovery and kidney health. This discharge diet aims to
 105

provide adequate energy, optimize protein intake for tissue repair without overburdening the
kidneys, manage fat intake to avoid cardiovascular strain, and include sufficient fiber for
digestive health.

The case study underscores the importance of a comprehensive, nutrition-focused approach in

managing AKI and renal calculi, highlighting the significant impact of dietary interventions on
improving clinical outcomes. Through careful monitoring, tailored dietary planning, and
adjustments based on Mr. SR's recovery progress, his case illustrates the critical role of
nutrition in supporting kidney function, enhancing patient recovery, and laying a foundation
for long-term health and disease prevention.
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CASE STUDY – 4

HELLP Syndrome

Introduction

Peripartum Cardiomyopathy is a form of heart failure that typically occurs in the last month of
pregnancy or up to five months postpartum. It is characterized by the dilation and weakening
of the heart's chambers, leading to an inability to pump blood efficiently.

HELLP Syndrome is a rare complication of pregnancy, usually considered a variant of pre-

eclampsia, and involves Hemolysis (the breaking down of red blood cells), Elevated Liver
enzymes (indicating liver damage), and Low Platelet count. Both conditions are serious and
can be life-threatening if not promptly diagnosed and treated.

Pathology and Physiology

The exact pathology of PPCM remains partially understood but involves a combination of
factors including genetic predisposition, inflammation, autoimmunity, and viral myocarditis.
These factors lead to cardiac muscle damage, reduced heart function, and, eventually, heart
failure.

In HELLP Syndrome, the pathology is closely related to the abnormal placental development
that also underlies preeclampsia. This abnormal development leads to endothelial cell
dysfunction, a pro-inflammatory state, and activation of the coagulation pathway, which
together contribute to the syndrome's triad of hemolysis, elevated liver enzymes, and low
platelet count.

Metabolic Aspects

Both PPCM and HELLP Syndrome involve complex metabolic alterations. In PPCM, there is
evidence of altered lipid metabolism in the heart, which may contribute to the energy deficit in
heart muscle cells. Metabolic stress during pregnancy, along with inflammatory cytokines, can
exacerbate these metabolic disruptions.

HELLP Syndrome's metabolic implications include the destruction of red blood cells, which
causes a release of free hemoglobin into the bloodstream, leading to further endothelial damage
and a cascade of metabolic disturbances affecting the liver and coagulation system.
 107

Complications

The complications of PPCM include chronic heart failure, arrhythmias, thromboembolism, and
in severe cases, death. For HELLP Syndrome, complications can include liver rupture, acute
renal failure, pulmonary edema, and disseminated intravascular coagulation, among others.

Symptoms and Etiology

Symptoms of PPCM may include fatigue, shortness of breath, swelling of the ankles and feet,
and increased urination at night. These symptoms are often mistaken for normal pregnancy
discomforts, leading to delayed diagnosis.

HELLP Syndrome symptoms can include nausea, vomiting, upper abdominal pain, headache,
and general malaise. These, too, can be mistaken for typical pregnancy issues.

The etiology of both conditions is multifactorial. Genetic predisposition, immune system

dysfunction, nutritional factors, and previous cardiac or liver conditions can all play a role. In
PPCM, viral myocarditis, autoimmunity, and the stress of pregnancy on the cardiovascular
system are key factors. For HELLP Syndrome, the etiology is closely tied to the factors causing
preeclampsia, including vascular endothelial dysfunction and an imbalanced immune response
to pregnancy.

Interconnection and Interrelation

The interconnection between PPCM and HELLP Syndrome lies in the stress and demands
pregnancy places on the body, leading to significant physiological changes and potential
pathologies. While they affect different systems (cardiac for PPCM and hematologic/liver for
HELLP), both conditions highlight the importance of close monitoring during and after
pregnancy, understanding the signs and symptoms, and the interplay between genetic,
metabolic, and environmental factors in their etiology and progression.
 108

PATIENT PROFILE

ADMISSION

Date of Admission: 08/2/2024

Date of Discharge: 20/2/2024

Total Length of Hospital Stay: 12 days

Length of Stay in ICU Nil

Length of Stay in Ward 5 days

DEMOGRAPHIC DATA
Name: Mrs. SF

Age: 25 Years

Gender: Female

Occupation: Housewife

Economic Status: Average

Community: Muslim

Level of Physical activity: Sedentary

HEALTH DATA

Chief Complaints: 24-year-old P2L2 underwent normal delivery on

07/02/24 following which she had excessive
bleeding PV and inverted uterus patient went into
shock for which she underwent manual
repositioning of the uterus under GA, extubation
patient had saturation fall and was intubated and
was given 5 units of PRBC Transfusion.
 109

Diagnosis: Post Partum Cardiomyopathy, HELLPs Syndrome,

Severe Liver Dysfunction, Severe Pulmonary
Edema

Level of Diagnosis: Stage Not Diagnosed

Disease/ surgery history: Hypothyroidism,

Family history of diseases: No Family History of Diseases

Mental condition: Normal

Medications: Thyronorm Tablets

DIETARY DATA

Special Diet Followed: Normal Diet

Alcohol Consumption: Nil

Smoking/Nicotine usage: Nil

Food Allergies/ Intolerances: Nil

Fluid restriction- Nil

Average Fluid Intake: 2-3 liters

SGA SCORE: 18

Status During the First Assessment

• Bowel Movement- Medicine-Induced Bowel Movement

• Vomiting- Nil

• Appetite- Normal

• Sleep- 4-5 hrs

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Discussion

Mrs. SF, a 25-year-old sedentary housewife with a history of hypothyroidism, experienced a

severe postpartum complication following a normal delivery, characterized by excessive
bleeding, an inverted uterus, and subsequent shock. These complications led to the diagnosis
of Postpartum Cardiomyopathy, HELLP Syndrome, severe liver dysfunction, and severe
pulmonary edema, requiring intensive management including intubation and PRBC
transfusion. The absence of a family history of diseases and her normal mental condition post-
recovery highlights the acute nature of her condition, emphasizing the importance of vigilant
postpartum care for early detection and management of potential complications.
 111

ASSESSMENT

SUBJECTIVE GLOBAL ASSESSMENT

 112

SGA SCORE:

Parameter Score Remark

A. Weight change 3 Mild Weight Loss

B. Nutrient intake 3 Sub-optimal Solid Intake

C. Symptoms affecting oral intake 3 Feels Full Quickly

D. Functional capacity 3 None (Improved)

E. Loss of subcutaneous fat 2 Mild

F. Loss of muscle mass 2 Mild

G. Presence of oedema/ascites 2 Mild

Rating Reference

• Severely malnourished: 7-14 point

• Mildly/moderately malnourished: 15-21 points
• Well nourished: 22-28 points

Discussion

Mrs. SF's Subjective Global Assessment (SGA) score categorizes her as mildly/moderately
malnourished, with a total score of 18. This evaluation, incorporating factors like mild weight
loss, sub-optimal solid intake, feeling full quickly, improved functional capacity, and mild loss
of subcutaneous fat and muscle mass, alongside mild edema, or ascites, highlights the
multifaceted nature of her malnutrition. Despite her complex medical conditions, including
postpartum cardiomyopathy and HELLP Syndrome, the SGA score emphasizes the necessity
of an integrated nutritional management approach. Tailoring her dietary intake to address these
nutritional deficiencies and managing symptoms affecting her oral intake is critical for her
recovery, underscoring the interplay between nutrition and overall health in postpartum
recovery and disease management.
 113

1. ANTHROPOMETRIC MEASUREMENTS

Height: 145cm

Weight: 46 kg

BMI: 21.9kg/m2

IBW: 43.3kg

Adjustable Body Weight 44.4kg

BMR 1296kcal

Discussion

The patient's anthropometric measurements indicate a generally healthy weight status with her
weight being slightly above the ideal but well within a normal and healthy range. Managing
her nutritional intake by her BMR will be key in maintaining this balance, particularly if she
faces health challenges that could affect her metabolic rate or overall nutritional needs.
 114

2. BIOCHEMICAL METHODS

Reference Range 12/02/24 13/02/24 14/02/24 15/02/24 16/02/24

HB (gm/dl) 11.5-16.5 gm/dI 11 11.9 11.8 12 12.1

TC (/mm) 4000-11000/mm 9500 8700 11400 14600 15000

ESR (mm/h) 0-7 mm/h 38 31 34 25 21

Platelet (lakh/m) 1-4.4 lakh/m 55,000 1.1 75000 1.4 1.5

Lymphocytes 20%-45% 21
(%)

Monocytes (%) 2%-10% 3

Neutrophils (%) 40%-75% 66

FBS (mg/dl) 60 -110 mg/dL 87 137 120 118 82

Urea (mg/dl) 10-50mg/dI 60 59 61

Creatinine 0.6-1.3 mg/dI 1 0.7 0.6

(mg/dl)

Uric Acid (mg/dl) 2.4-5.7 mg/dI 7.9 6.9

Sodium (Meq/L) 135-145 Meq/L 136 137 137 136

 115

Potassium (Meq/L) 3.5-5.5 Meq/L 3.4 3.6 3.4 3.5

Albumin(mg/dl) 3.5-5.5gm/dI 2.3 2.5 3

Globulin (mg/dl) 2.0-3.6gm/dI 2.1 2.3

2.3

Bilirubin (T) < 1.0 mg/dl 0.8 0.4 0.5

(mg/dl)

Bilirubin (D) <0.3 mg/dl 0.5 0.3 0.3

(mg/dl)

Alk.Phosphatase 40-129 U/L 83

(U/L)

SGOT (U/L) Up to 40 U/L 776 101 71

SGPT (U/L) Up to 40 U/L 1426 653 390

Discussion

Mrs. SF's biochemical parameters from February 12th to February 16th, 2024, reveal a mix of
within-normal-range results and deviations indicative of various health concerns, likely related
to her postpartum complications and underlying conditions. Here's an analysis:

Hemoglobin (HB): Initially below the normal range, indicating mild anemia, which is not
uncommon postpartum, especially following excessive bleeding. The gradual increase suggests
recovery or the effect of transfusions and improved iron intake.

Total Count (TC): Fluctuations with an initial within-normal range, followed by a transient
increase beyond the upper limit, which could indicate infection or inflammation, possibly
linked to her postpartum state or other complications. The increase to 14,600 and 15,000/mm
indicates a marked leukocytosis, typically reflective of an acute inflammatory or infectious
process.
 116

Platelet Count: Starting significantly below normal, indicative of thrombocytopenia, which

could be associated with HELLP Syndrome, a severe form of preeclampsia. The count
improves over time, likely reflecting the resolution of the acute phase of her condition.

Fasting Blood Sugar (FBS): Shows fluctuations, with values initially within the normal range,
then a spike, which could reflect stress, medication effects, or possibly gestational diabetes.
The subsequent decrease back to the normal range is positive.

Urea and Creatinine: Both start above normal ranges, indicating potential acute kidney injury
(AKI) or stress on the kidneys, which is plausible given her condition. The improvement over
time is encouraging, suggesting renal recovery.

Uric Acid: Initially high, which could be related to renal stress or cellular turnover, common
in conditions like preeclampsia or HELLP Syndrome.

Electrolytes (Sodium and Potassium): Show slight fluctuations but largely remain within the
normal range, indicating effective management of electrolyte balance amidst her condition.

Albumin and Globulin: Both show hypoalbuminemia, which can be due to inflammation,
malnutrition, or liver dysfunction. Given her severe liver dysfunction diagnosis, this is
expected. The slight improvement in albumin levels suggests gradual recovery.

Bilirubin (Total and Direct): The initial total bilirubin is within the normal range but with a
direct bilirubin elevation, which could suggest liver dysfunction, aligning with her diagnosis.
An improvement over time is noted.

Liver Enzymes (SGOT, SGPT): Both are significantly elevated initially, indicating severe
liver injury or dysfunction, likely related to her HELLP Syndrome diagnosis. The substantial
decrease in these enzymes over the days suggests improving liver function.

Overall, Mrs. SF's biochemical parameters indicate a complex interplay of postpartum

cardiomyopathy, HELLP Syndrome, potential acute kidney and liver injury, and recovery
trends over the assessed period. The initial deviations from normal ranges, followed by gradual
normalization or improvement in most parameters, reflect both the severity of her condition
upon admission and the effectiveness of the medical interventions provided during her hospital
stay.
 117

3. CLINICAL ASSESSMENT

Past Medical History: Apart from hypothyroidism, which is under treatment, she gave birth
on the day of 7 which led to such complications to occur.

Previous Medications: She was taking thyronorm to treat hypothyroidism.

Presenting Complaints: 24 Year P2L2 underwent normal delivery on 07/02/24 following

which she had excessive bleeding PV and inverted uterus patient went into shock for which
she underwent manual repositioning of the uterus under GA, extubating patient had a
saturation fall and was intubated and was given 5 units of PRBC Transfusion

Diagnosis: - She Was diagnosed with Post Partum Cardiomyopathy, HELLPs Syndrome,
Severe Liver Dysfunction, Severe Pulmonary Edema

Disease signs and symptoms: Signs and symptoms included decreased saturation level,
elevated liver-related metabolic values, and difficulty in breathing.

NFPE
 118

PROGNOSIS OF NFPE

Yellowing of eyes and skin was visible, most probably due to excess bilirubin, due to Liver
problems.

OTHER PARAMETERS

Parameter Normal Date Remark

Range
12/02/24 13/02/24 14/02/24 15/02/24 16/02/24

Blood 120/80 100/50 100/60 110/70 120/80 110/70 Low BP

Pressure mmHg

Pulse 72/mt 90 82 60 65 62 Mild

Bradycardia

Respiration 20 24 22 20 20 20 Normal

Oxygen >96% 94% 94% 94% 99% 99% Normal

Saturation

Discussion

Vital signs from February 12th to February 16th, 2024, illustrate a trend toward stabilization
and recovery, particularly in the patient's blood pressure and oxygen saturation levels. Initially,
the blood pressure was low at 100/50 mmHg, gradually increasing to a normal range of 120/80
mmHg by February 15th, and slightly decreasing to 110/70 mmHg on February 16th, which
still falls within acceptable limits. The pulse rate decreased from a high of 90 bpm to a more
stable range of 60-65 bpm, indicating a reduced strain on the heart. Respiration rates improved
to a normal rate of 20 breaths per minute by February 14th and remained stable, suggesting
effective respiratory function. Oxygen saturation levels were initially slightly low at 94% but
improved significantly to 99% by February 15th, indicating improved oxygenation.
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MEDICATIONS

Name Dosage Mechanism of Drug Drug–nutrient

interaction
Tab Carvedilol 25 mg This beta-blocker reduces Enhanced absorption with
heart rate, blood pressure, food; may mask signs of
and cardiac workload by low blood sugar in
blocking adrenergic Recep diabetics.
Tab Lisinopril 20mg As an ACE inhibitor, it Can raise potassium
dilates blood vessels to levels, making
lower blood pressure and monitoring and potential
decreases cardiac workload. adjustment of potassium
intake necessary.
Tab Spironolactone 25 mg This potassium-sparing Risk of hyperkalemia
diuretic counters fluid (high potassium levels),
retention and hypertension especially when
without causing potassium combined with other
depletion. medications that increase
potassium; dietary
potassium should be
monitored.
Tab Furosemide 80 mg A loop diuretic that helps May deplete the body of
reduce fluid buildup by potassium, magnesium,
increasing urine output. and calcium, suggesting a
need for monitoring and
possible supplementation.
Tab Metoprolol 25 mg Another beta-blocker that Absorption can be
decreases heart rate and increased with meals; like
blood pressure, reducing the carvedilol, it may also
workload on the heart. mask signs of
hypoglycemia
 120

4. DIETARY ASSESSMENT

FOOD FREQUENCY TABLE

 121

Discussion

If we investigate the Food frequency assessment, no such visible irregular and bad dietary
habits are seen. Even though she follows an average healthy diet her intake of fruits and
vegetables is somewhat less or under recommended levels. Her intake of pickles is somewhat
unhealthy but, none of this could have led to the disease condition as her state mainly depended
on physiological problems.

24-Hour Diet Recall Method

Time Food Quantity Ingredients Weight Energy CHO Protein Fat Fiber
Item
8:00
am Milk Tea 1 nos Milk 36.45 2.47 1.63 2.24
50ml

2.59
Apple 1 nos Apple 62.6 13.11 0.29 0.64
100g

1:30 Rice ¼ cup White Rice 15g 52.74 11.57 1.17 0.08 0.56
pm
Fish ¼ cup Sardine 25g 38.06 4.48 2.25
Curry
4:30 Milk Tea 1 Glass Milk 50ml 36.45 2.47 1.63 2.24
pm
Total 244.32 29.62 9.2 9.45 3.15

DISCUSSION

EVALUATION OF HOME RECALL DIET AND FOOD FREQUENCY TABLE

ENERGY: 244.32kcal

CARBOHYDRATES: 29.62g

PROTEIN: 9.2g
 122

FAT: 9.45g

FIBER:3.15g

The very low dietary intake, with a total energy of 244.32 kcal, is significantly below the
nutritional requirements for a recovering postpartum woman. The insufficient dietary intake,
characterized by low levels of protein (9.2g), carbohydrates (29.62g), fats (9.45g), and an
adequate amount of fiber (3.15g), could be linked to several factors associated with her
postpartum state and medical issues. Appetite suppression or gastrointestinal discomfort,
common in the postpartum period or due to medical complications like HELLP Syndrome,
which involves liver dysfunction, could have contributed to her suboptimal food intake.
Moreover, psychological factors such as stress, anxiety, or postpartum depression might have
also played a role in reducing her desire or ability to eat adequately.
 123

NUTRITIONAL PROBLEMS AND RISK

A comprehensive view of her health and nutritional status, highlighting several nutritional
problems and risks like Energy and Macronutrient Deficiency, Micronutrient Deficiency Risk,
Protein-Energy Malnutrition (PEM), Postpartum Recovery Complications, Anemia and Blood
Health, Liver Function, Kidney Function, Fluid and Electrolyte Imbalance Risk

NUTRITIONAL DIAGNOSIS

1. Mrs. SF's inadequate energy and macronutrient intake is due to suboptimal food
consumption exacerbated by postpartum appetite changes, significantly evidenced by
her daily intake of only 244.32 kcal.
2. She is at risk for micronutrient deficiencies resulting from a lack of dietary diversity,
specifically a limited intake of fruits, vegetables, and whole grains, potentially leading
to vitamin and mineral deficits crucial for postpartum recovery.
3. Mrs. SF's condition of protein-energy malnutrition is caused by an inadequate intake of
protein and overall low energy consumption, as evidenced by her status of
mild/moderate malnutrition and loss of muscle mass.
4. Her nutritional recovery postpartum is complicated by severe conditions like HELLP
Syndrome and cardiomyopathy, which impact her nutrient needs and absorption,
requiring tailored nutritional support due to manifestations such as severe liver
dysfunction and pulmonary edema.
5. There is a risk of anemia for Mrs. SF, stemming from excessive postpartum bleeding
and a potential deficiency in iron intake, as indicated by her below-normal hemoglobin
levels and mild anemia diagnosis.
6. The altered nutrient metabolism associated with Mrs. SF's severe liver dysfunction
affects her protein and fat processing capabilities, which is reflected in her elevated
liver enzymes (SGOT, SGPT) and hypoalbuminemia.
7. Impaired kidney function, suggested by elevated urea and creatinine levels, affects
Mrs. SF's nutritional status, and necessitates careful management of her protein and
fluid intake to prevent further renal stress.
8. Mrs. SF is at risk of fluid and electrolyte imbalance due to compromised kidney and
liver function, influencing her fluid regulation, as demonstrated by the presence of
edema/ascites.
 124

NUTRITION INTERVENTION

1. Energy and Macronutrient Replenishment: Increase Mrs. SF's caloric intake to meet her
elevated metabolic demands due to postpartum recovery and medical complications. A
balanced distribution of macronutrients (carbohydrates, proteins, and fats) should be ensured
to support energy needs, muscle repair, and overall health. Target a gradual increase in caloric
intake, monitor for gastrointestinal tolerance, and adjust as necessary to achieve a minimum
intake that supports weight maintenance and recovery.
2. Protein Quality and Quantity: Emphasize high-quality protein sources for wound
healing, immune function, and muscle maintenance. Given her mild protein-energy
malnutrition, aim for an intake of 1.2-1.5g of protein/kg body weight/day, adjusting based on
renal function and tolerance.
3. Micronutrient Supplementation: Address potential deficiencies with a focus on iron,
calcium, vitamin D, B vitamins, and other essential micronutrients to support recovery and
prevent anemia. Consider supplementation based on blood levels and dietary intake,
particularly if dietary restrictions limit food-based approaches.
4. Liver Function Support: Adapt the diet to support liver health, incorporating foods high
in antioxidants and limiting substances that strain liver function. Monitor protein intake
carefully, considering the liver's role in protein metabolism, and adjust based on liver enzyme
levels and clinical status.
5. Kidney Function Monitoring: Given the signs of renal stress, monitor fluid and
electrolyte balance closely. Adjust protein intake if necessary, considering renal function, and
ensure adequate hydration while avoiding overhydration.
6. Fluid and Electrolyte Management: Manage fluid intake to address risks of fluid and
electrolyte imbalances. Individualize fluid recommendations based on current kidney and
liver function, presence of edema or ascites, and daily fluid balance assessments.
 125

GOALS

The goals of Medical Nutrition Therapy (MNT) for Mrs. SF are to correct energy and nutrient
deficiencies to support her postpartum recovery, manage complications associated with
HELLP Syndrome, and liver and kidney function, and ensure optimal healing and health.
This includes achieving a balanced macronutrient intake, addressing micronutrient
deficiencies through diet and supplementation, and maintaining fluid and electrolyte balance
to support physiological functions and overall well-being.
 126

MONITORING AND EVALUATION

DIET ORDERS

1. Hepatic Soft Diet (12/02/2024)

2. Hepatic Soft Diet (13/02/2024)

3. Hepatic Soft Diet (14/02/2024)

4. Hepatic Diet (15/02/2024)

5. Low Fat Soft Diet (16/02/2024)

HOSPITAL DIET DAY 1

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8 AM Ragi 1 Nos Ragi 25 80.19 16.7 1.79 0.48 2.8
Idiyappam

Egg White 1 Nos Egg 25 13.15 3.09 3.09 0.07

Orange ½ Nos Orange 50 23.5 5.88 0.47 0.06 1.9

10 AM Protein 1 Glass Pentasure 100 100 16.2 3 2.24

Powder Hepatic
1 AM Wheat ¼ Cup Wheat 50 170.89 34.53 5.42 0.73 4.41
Kanji

Cabbage ¼ Cup Cabbage 20 4.3 0.65 0.27 0.02 0.55

4 AM Protein 1 Glass Pentasure 100 100 16.2 3 2.24
Powder Hepatic

Kozhukatt 1 Nos Rice 20 70.32 15.43 1.56 0.11 0.75

 127

Carrot 10 3.32 0.56 0.1 0.05 0.42

8 AM Wheat ¼ Cup Wheat 50 170.89 34.53 5.42 0.73 4.41
Kanji

Spinach ¼ Cup Spinach 10 2.44 0.21 0.21 0.06 0.24

Upperi

Egg White 1 Nos Egg 25 13.15 3.09 3.09 0.07

Total 786 140.8 27.43 6.85 14.76

Cooking Oil Used:5g.
 128

HOSPITAL DIET DAY 2

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8 AM Wheat 2 Nos Wheat 50 160.29 32.09 5.29 0.77 5.68
Dosa

Green ¼ Cup Green Peas 20 60.66 9.79 4.09 0.38 3.4

Peas Curry

Egg White 1 Nos Egg 25 13.15 3.09 3.09 0.07

10 AM Protein 1 Glass Pentasure 100 100 16.2 3 2.24
Powder Hepatic
1AM Wheat ¼ Cup Wheat 50 170.89 34.53 5.42 0.73 4.41
Kanji

Moru ¼ Cup Buttermilk 20 12.4 0.98 0.64 0.66

Chaaru
4 AM Kozhukatt 1 Nos Rice 20 70.32 15.43 1.56 0.11 0.75
Carrot 10 3.32 0.56 0.1 0.05 0.42

Protein 1 Glass Pentasure 100 100 16.2 3 2.24

Powder Hepatic
8 AM Wheat ¾ Cup Wheat 75 256.33 51.8 8.13 1.09 6.61
Kanji

Ivy Guard ¼ Cup Ivy guard 20 3.82 0.48 0.24 0.05 0.65
Upperi

Egg White 1 Nos Egg 25 13.15 3.09 0.07

Total 1027 178 37.65 8.43 21.91
Cooking Oil Used:7g.
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HOSPITAL DIET DAY 3

Meal Menu Serving Size Ingredients Weight Energy CHO Protein Fat Fiber
(g) (kcal) (g) (g) (g) (g)
8 AM Idiyappam 3 Nos Rice 75 263.68 57.87 5.86 0.41 2.81

Bengal ¼ Cup Bengal 25 71.76 9.89 4.69 1.28 6.31

Gram Gram
Curry

Egg White 1 Nos Egg 25 13.15 3.09 0.07

10 AM Protein 1 Glass Pentasure 100 100 16.2 3 2.24
Powder Hepatic

1 AM Rice Kanji ½ Cup Rice 33 116.02 25.46 2.58 0.18 1.23

Cabbage
Thoran ¼ Cup Cabbage 20 4.3 0.65 0.27 0.02 0.55
4 AM Rice ¼ Cup Rice Flakes 30 106.12 23.03 2.23 0.34 1.04
Flakes

Orange 1 Nos Orange 100 47 11.75 0.94 0.12 1.9

Banana 1 Nos Banana 100 112 25.1 1.2 0.3 2.2

Protein 1 Glass Pentasure 100 100 16.2 3 2.24

Powder Hepatic
8 AM Rice Kanji ½ Cup Rice 33 116.02 25.46 2.58 0.18 1.23

Moru ¼ Cup Buttermilk 30 18.6 1.46 0.96 0.99

Curry

Egg White 1 Nos Egg 25 13.15 3.09 0.07

Total 1183 229.3 33.41 8.14 15.57
Cooking Oil Used:5g.
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Hospital Diet Day 4

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8 AM Wheat Dosa 3 Nos Wheat 75 256.33 51.8 8.13 1.09 6.61

Vegetable ¼ cup Potato 10 6.98 1.49 0.15 0.19 0.17

stew Green Peas 10 30.33 4.89 2.04 0.03 1.7
Beans 10 2.44 0.27 0.25 0.05 0.44
Carrot 10 3.52 0.56 0.1 0.42
0.07
Egg White 1 Nos Egg 25 13.15 3.09
10 AM Protein 1 Nos Pentasure 100 100 16.2 3 2.24
Powder Hepatic

1 PM Red Rice ¾ Cup Red Rice 50 176.86 37.4 4.58 0.62 2.22
Kanji

Beans ¼ Cup Yard long 25 6.09 0.67 0.62 0.07 1.1

Upperi Beans
4 PM Protein 1 Glass Pentasure 100 100 16.2 3 2.24
Powder Hepatic

Apple 1 nos Apple 100 62.64 13.11 0.29 0.64 2.59

Orange 1 nos Orange 100 47 11.75 0.94 0.12 1.8

8 PM Rice Kanji ½ Cup Red Rice 66 232.04 50.93 5.15 0.36 2.47

Kumbalam ¼ Cup Ash Guard 25 4.36 0.71 0.2 0.04 0.84

Curry

Egg 1 Nos Egg 25 13.15 3.09 0.07

Total 1117.99 200.74 35.59 10.89 23.31
Cooking oil used:6g.
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Hospital Diet Day 5

Meal Menu Serving Size Ingredients Weight Energy CHO Protein Fat Fiber
(g) (kcal) (g) (g) (g) (g)
8AM Appam 4 Nos Rice 100 351.58 77.16 7.81 0.55 3.74

Sambhar ½ Cup Onion 10 4.8 0.96 0.15 0.25

Tomato 10 1.96 0.27 0.09 0.05 0.18
Carrot 10 3.32 0.56 0.1 0.05 0.42
Lentils 10 29.78 4.79 2.29 0.06 1.67
Drumsticks 10 6.74 0.56 0.64 0.16 0.82

Egg 1 Nos Egg 25 13.15 3.09 0.07

10 AM Protein 1 glass Pentasure 100 100 16.2 3 2.24
Powder Hepatic

1 PM Rice 1 cup Rice 66 232.04 50.93 5.15 0.36 2.47

Sambhar ½ Cup Onion 10 4.8 0.96 0.15 0.25

Tomato 10 1.96 0.27 0.09 0.05 0.18
Carrot 10 3.32 0.56 0.1 0.05 0.42
Lentils 10 29378 4.79 2.29 0.06 1.67
Drumsticks 10 6.74 0.56 0.64 0.16 0.82
Beans
Upperi ¼ cup Yard long 25 6.09 0.67 0.62 0.07 1.1

4 PM Wheat 1 Nos Wheat 25 85.44 17.27 2.71 0.36 2.2

Dosa

Protein 1 glass Pentasure 100 100 16.2 3 2.24

Powder Hepatic

Egg 1 Nos Egg 25 13.15 3.09 0.07

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8PM Rice ¾ Cup Rice 50 175.79 38.58 3.91 0.28 1.87

Churakka ¼ Cup Bottle

Upperi Guard 25 3.23 0.56 0.12 0.03 0.53

Fish ½ Cup Mackerel 90 90.99 19.36 1.36

Curry
Total 1388.85 230.24 56.93 13.14 18.92
Cooking Oil Used:10g.

Day Wise Distribution

DAY ENERGY (Kcal) CHO (g) PROTEIN(g) FAT(g) FIBRE(g)

DAY 1 786 140.8 27.43 6.85 14.76

DAY 2 1027 178 37.65 8.43 21.91

DAY 3 1183 229.3 33.41 8.14 15.57

DAY 4 1117.99 200.74 35.59 10.89 23.31

DAY 5 1388.85 230.24 56.93 13.14 18.92

DISCUSSION

Day 1

On the first day, Mrs. SF's diet provided 786 kcal of energy, focusing on initiating her
postpartum recovery with a careful balance of macronutrients: 140.8g of carbohydrates for
energy, 27.43g of protein to support tissue repair, and a low-fat intake of 6.85g to ease her
digestive system back into regular functioning. The fiber content was notably high at 14.76g,
likely aimed at supporting gastrointestinal health from the outset.
 133

Day 2

By the second day, her intake was increased to 1027 kcal, with significant enhancements across
all nutritional parameters: carbohydrates were raised to 178g, protein to 37.65g, and fat to
8.43g, while fiber saw a substantial increase to 21.91g. This adjustment suggests a strategy to
gradually escalate energy and nutrient intake to support healing, with a continued emphasis on
digestive health through high fiber levels.

Day 3

The third day marked further increases in energy to 1183 kcal, driven primarily by a rise in
carbohydrates to 229.3g, indicating a focused effort to boost energy supply for recovery.
Protein intake slightly decreased to 33.41g, and fat remained modest at 8.14g, with fiber
adjusted to 15.57g, balancing the need for energy with the importance of maintaining gut
health.

Day 4

On day four, there was a minor reduction in total energy to 1117.99 kcal, with a more nuanced
adjustment in macronutrients: carbohydrates were slightly reduced to 200.74g, while protein
and fat were increased to 35.59g and 10.89g, respectively. The fiber content was notably high
at 23.31g, reflecting a continued focus on supporting Mrs. SF's digestive system as her
nutritional intake became more robust.

Day 5

The fifth day saw a significant uptick in nutrition provision: energy reached 1388.85 kcal,
carbohydrates to 230.24g, protein peaked at 56.93g, and fat to 13.14g, with fiber at 18.92g.
This comprehensive increase underscores an intensified effort to meet Mrs. SF's recovery needs
fully, emphasizing protein to support muscle repair and immune function alongside sufficient
energy and carbohydrates for healing and daily activities.
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DISCHARGE DIET

Time Food Quantity Ingredients Weight Energy CHO Protein Fat Fiber
Item (g) (kcal) (g) (g) (g) (g)
8 AM Milk Tea 1 Glass Milk 100 72.9 4.94 3.26 4.48

Wheat 3 Nos Wheat 75 240.43 48.13 7.93 1.15 8.52

Dosa

Bengal ¼ Cup Bengal 30 86.11 11.87 5.63 1.53 7.57

Gram Gram
Curry

Egg
White 1 Nos Egg 25 13.15 3.09 0.07
10 Avocado 1 Nos Avocado 100 160 8.53 2 14.66 6.69
AM
1 AM Rice 1 cup Brown Rice 66 232.04 50.93 5.15 0.36 2.47

Cabbage ¼ Cup Cabbage 25 5.38 0.81 0.34 0.03 0.69

upperi

Moringa ½ Cup Drumstick 25 16.85 1.41 1.6 0.41 2.05

Curry Leaves
4 AM Walnuts 10 Nos Walnuts 20 134.27 2.03 2.98 12.85 1.08

Milk 1 Glass Milk 100 72.9 4.94 3.26 4.48

8 AM Wheat 1 cup Wheat 200 683.56 138.12 21.68 2.9 17.62
Kanji

Fish 1 cup Mackerel 90 90.99 1.55 19.36 1.38

Curry
 135

Beetroot ¼ Cup Beetroot 25 8.9 0.49 0.04 0.83

Upperi

Egg 1 Nos Egg 25 13.15 3.09 0.07

White
1843 268.93 81.85 48.98 45.7

Cooking oil used:5g.

RECOMMENDED DIETARY ALLOWANCE

Nutrients RDA Patient Requirement Discharge Diet

Provided
Energy (Kcal) 1794 1800 1843
Dietary Fiber(g) 40 40 45.7
Protein(g) 52.44 72 81.85
Fat(g) 55g 48 48.98
Carbohydrate(g) 269g 270 268.93

DISCUSSION

The discharge diet prepared for Mrs. SF, with a nutritional distribution of 1843 kcal of
energy, 45.7g of fiber, 81.85g of protein, 48.98g of fat, and 268.93g of carbohydrates, is
meticulously designed to support her recovery, particularly considering her postpartum state
and recovery from HELLP syndrome. This diet demonstrates a thoughtful consideration of
her health requirements, ensuring a balanced and nutritious intake that aligns well with her
nutritional needs.

Firstly, the energy provision of 1843 kcal is slightly above the standard recommendation for
an average sedentary adult woman. Still, it is appropriately adjusted to meet the increased
metabolic demands associated with Mrs. SF's recovery from childbirth and the complications
 136

arising from HELLP syndrome. This energy level is crucial for supporting the healing process
and replenishing energy stores depleted during her hospital stay.

The protein content at 81.85g exceeds the general daily recommendations, catering well to
Mrs. SF's enhanced requirements for tissue repair, immune function strengthening, and the
overall recovery process. Protein is vital for healing and the restoration of muscle mass,
especially after the physical stress of childbirth and associated medical conditions.

The diet's fiber content at 45.7g is notably high, surpassing typical dietary recommendations,
which are advantageous for gastrointestinal health, promoting regular bowel movements, and
aiding in the prevention of constipation—a common concern postpartum. High fiber intake is
also beneficial for cardiovascular health, which is particularly important in the context of
Mrs. SF's recovery from postpartum cardiomyopathy.

Fat content is moderated to 48.98g, focusing on healthy fats to support hormonal balance,
inflammation reduction, and overall health without overburdening her liver, considering the
liver dysfunction associated with HELLP syndrome. This moderate fat intake ensures that
Mrs. SF receives essential fatty acids necessary for recovery while preventing excessive fat
consumption that could stress her liver.

Lastly, the carbohydrate provision of 268.93g ensures a steady supply of energy throughout
the day, supporting Mrs. SF's overall energy needs and aiding in her recovery. Carbohydrates
are crucial for replenishing glycogen stores and providing energy for daily activities, including
caring for her newborn.
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OVERALL SUMMARY

This case study revolves around Mrs. SF, a 25-year-old postpartum woman with a history of
severe medical complications including HELLP syndrome, postpartum cardiomyopathy,
severe liver dysfunction, and pulmonary edema. Her hospital stay was necessitated by these
conditions following childbirth, with a focus on stabilizing her health through medical and
nutritional interventions.

Upon admission, Mrs. SF's nutritional status was compromised, as highlighted by a

Subjective Global Assessment (SGA) score indicating mild to moderate malnutrition.
Anthropometric measurements and dietary recalls before hospitalization revealed inadequate
energy and macronutrient intake, suggesting significant nutritional deficiencies. Her
biochemical parameters showed signs of anemia, liver stress, and potential renal stress,
further complicating her recovery process.

A tailored Medical Nutrition Therapy (MNT) plan was crucial for addressing Mrs. SF's
energy and nutrient deficiencies, supporting her postpartum recovery, and managing the
complications arising from her conditions. The MNT goals focused on correcting these
deficiencies, ensuring optimal healing, and supporting overall health. The discharge diet,
carefully designed to meet her nutritional needs, provided a balanced intake of energy,
proteins, fats, carbohydrates, and fiber, considering her postpartum state and recovery from
HELLP syndrome. Traditional Kerala cuisine was incorporated into her diet plan to align
with her cultural preferences and ensure palatability, promoting better dietary adherence.

Throughout her hospital stay, Mrs. SF's vital signs and biochemical markers indicated gradual
improvement toward stabilization. The diet provided during her hospital stay aimed at
progressively increasing her intake to support her recovery, with a final discharge plan that
included a comprehensive and balanced dietary approach to meet her increased nutritional
requirements.
 138

CASE STUDY – 5

CAD-Triple Vessel Disease

Introduction

Total Vessel Disease (TVD) is a severe form of CAD, characterized by the presence of
significant atherosclerotic plaque buildup in multiple major coronary arteries, including the
left main coronary artery, left anterior descending artery, left circumflex artery, and right
coronary artery. TVD represents an advanced stage of CAD, where the entire coronary artery
system is affected by extensive narrowing or blockages.

Pathology

In TVD, the pathological process of atherosclerosis affects multiple coronary arteries

simultaneously. The formation of atherosclerotic plaques, composed of cholesterol, calcium,
and other substances, occurs within the walls of these arteries, leading to their narrowing or
complete blockage.

Physiology

The heart relies on a constant supply of oxygen and nutrients through the coronary artery
network. In TVD, the severe narrowing or blockage of multiple coronary arteries
compromises the blood flow to a significant portion of the heart muscle, leading to ischemia
(reduced blood flow) and potentially causing extensive damage or heart attack.

Metabolic aspects

TVD is closely linked to metabolic disorders, such as diabetes, obesity, and dyslipidemia,
which can contribute to the acceleration of atherosclerosis and the development of diffuse
coronary artery lesions. These metabolic conditions promote inflammation, oxidative stress,
and the accumulation of plaque within the coronary arteries.

Complications

Patients with TVD are at a high risk of developing serious complications, such as myocardial
infarction (heart attack), heart failure, and arrhythmias. The extensive nature of the disease
increases the likelihood of these complications occurring, as a significant portion of the heart
muscle may be deprived of adequate blood supply.
 139

Symptoms

The primary symptom of TVD is typically angina pectoris (chest pain or discomfort), which
may be more frequent, severe, or occur at rest due to the widespread coronary artery
involvement. Other symptoms may include shortness of breath, fatigue, palpitations, and
potential signs of heart failure.

Etiology

The development of TVD is multifactorial, involving both modifiable and non-modifiable risk
factors. Modifiable risk factors include smoking, unhealthy diet, physical inactivity, obesity,
high blood pressure, high cholesterol levels, and diabetes. Non-modifiable risk factors include
age, gender (male), and family history of CAD.
 140

PATIENT PROFILE

1. ADMISSION

Date of Admission: 22/1/2024

Date of Discharge: 31/1/2024

Total Length of Hospital Stay: 10 days

Length of Stay in ICU 2 Days

Length of Stay in Ward 8 days

2. DEMOGRAPHIC DATA
Name: Mr. SS

Age: 71 Years

Gender: Male

Occupation: NIL

Economic Status: Average

Community: Hindu

Level of Physical activity: Sedentary

3. HEALTH DATA

Chief Complaints: He was advised for CABG from another hospital

Diagnosis: Coronary Artery Disease, left main disease with

triple vessel disease.

Level of Diagnosis: • The left main artery has a distal segment

with 70% narrowing.
• There's a very severe, almost complete
blockage (99%) in the mid part of the LAD,
 141

which has resulted in severely reduced

blood flow downstream (TIMI I flow)
• The posterior descending artery (PDA),
which comes off the RCA, has a 90%
blockage in the ostio-proximal segment.

Disease/ surgery history: Hypertension, Dyslipidemia, and Gout

Family history of diseases: Nil

Mental condition: Normal

Medications: TAB. ECOSPIRIN, TAB XTOR, TAB BETALOC,

TAB AMLODAC

4. DIETARY DATA

Special Diet Followed: Normal Diet

Alcohol Consumption: No

Smoking/Nicotine usage: Nil

Food Allergies/ Intolerances: Nil

Fluid restriction- Nil

Average Fluid Intake: 2 liters

SGA SCORE: 23

Status During the First Assessment

• Bowel Movement- Normal

• Vomiting- Nil

• Appetite- Low Appetite

• Sleep- 5 hrs
 142

Discussion

Mr. SS, a 71-year-old male with a sedentary lifestyle, was admitted to the hospital on January
22, 2024, and discharged on January 31, 2024, after a total hospital stay of 10 days, including
a 2-day stay in the ICU and an 8-day stay in the ward. At the time of admission, Mr. SS was
diagnosed with coronary artery disease, specifically left main disease with triple vessel disease.
The diagnosis revealed a distal segment of the left main artery with 70% narrowing, a mid-part
of the LAD with a 99% blockage resulting in severely reduced blood flow downstream (TIMI
I flow), and a 90% blockage in the ostio-proximal segment of the posterior descending artery
(PDA), which comes off the RCA. His medical history includes hypertension, dyslipidemia,
and gout, but no family history of diseases. His mental condition was noted as normal. Before
admission, Mr. SS was taking TAB. ECOSPIRIN, TAB XTOR, TAB BETALOC, and TAB
AMLODAC.
 143

ASSESSMENT

SUBJECTIVE GLOBAL ASSESSMENT

 144

Parameter Score Remark

A. Weight change 3 Mild Weight Loss

B. Nutrient intake 4 Solid Intake

C. Symptoms affecting oral intake 3 Pain in Eating, Feeling full Quickly, Less
appetite

D. Functional capacity 3 Some Difficulties

E. Loss of subcutaneous fat 3 Mild

F. Loss of muscle mass 3 Mild

G. Presence of oedema/ascites 4 No

Rating Reference

• Severely malnourished: 7-14 points

• Mildly/moderately malnourished: 15-21 points
• Well-nourished: 22-28 points

Discussion

Upon evaluating Mr. SS's Subjective Global Assessment (SGA) with parameters including
mild weight loss, solid nutrient intake, pain upon eating and early satiety, some difficulties in
functional capacity, mild loss of subcutaneous fat and muscle mass, along with no presence of
edema or ascites, his total score amounts to 23 points. This score categorizes him as "Well-
nourished" according to the SGA rating reference. Despite experiencing mild weight loss,
difficulties in eating, and slight declines in physical function and body composition, Mr. SS's
overall nutrition status is considered adequate, indicating that his current dietary intake and
nutrient absorption are sufficient to meet his basic nutritional needs.
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1. ANTHROPOMETRIC MEASUREMENTS

Height: 151 cm

Weight: 58 kg

BMI: 25.4 kg/m2

IBW: 50 kg

Adjustable Body Weight 53 kg

BMR 1409 calories day

Discussion

The anthropometric assessments of Mr. SS, a 71-year-old male, at the time of his hospital
admission, included a height of 151 cm and a weight of 58 kg. These measurements result in a
Body Mass Index (BMI) of 25.4 kg/m^2, placing him in the overweight category according to
standard BMI classifications. His Ideal Body Weight (IBW) was calculated to be 50 kg, with
an Adjustable Body Weight (ABW) of 53 kg, which is used in certain medical and nutritional
assessments to adjust drug dosages and dietary needs for those not at their ideal body weight.
His Basal Metabolic Rate (BMR) was determined to be 1409 calories per day,
 146

2. BIOCHEMICAL METHODS

Reference Range 22/01/2024 24/1/2024 25/1/2024 26/01/2024 27/01/2024

HB (gm/dl) 13-18 gm/dI 12.5 12.3 10.3 11.6 11.9

TC (/mm) 4000-11000/mm 6300 23300 13400 11,100

ESR (mm/h) 0-5 mm/hg 26

Platelet (lakh/m) 1-4.4 lakh/m 3

Urea (mg/dl) 10-50mg/dI 29

Creatinine (mg/dl) 0.6-1.3 mg/dI 1.0 1.1

Magnesium 1.8-2.8 mg/dI 2 2.7 1.9 2.3

(mg/dl)

Calcium (mg /L) 8.5-11 mg/dl 8.3 8.8

Potassium (Meq/L) 3.5-5.5 Meq/L 2.8 3.6 4.3 4.8

Albumin(mg/dl) 3.5-5.5gm/dI 4.5

Globulin (mg/dl) 2.0-3.6gm/dI 2.8

Bilirubin (T) < 1.0 mg/dl 0.5

(mg/dl)

Bilirubin (D) <0.3 mg/dl 0.2

(mg/dl)

Alk.Phosphatase 40-129 U/L 88 84

(U/L)
 147

SGOT (U/L) Up to 40 U/L 26 46 35

SGPT (U/L) Up to 40 U/L 34 43 31

Discussion

The biochemical profile of Mr. SS surrounding his Coronary Artery Bypass Grafting (CABG)
surgery on January 24, 2024, suggests a positive and resilient physiological response to the
procedure. His hemoglobin levels, while experiencing a temporary decline post-surgery likely
due to operative blood loss, began showing signs of recovery by January 27, indicating
effective post-operative management and resilience. The substantial increase in total
leukocyte count immediately after surgery is a normal inflammatory response to surgical
stress, demonstrating an adequate immune response that gradually normalized, reflecting
successful post-operative recovery without signs of persistent infection. Pre-operative
concerns, such as slightly elevated ESR, were effectively managed, underscoring the body's
ability to handle surgical stress.

Electrolyte management, a critical component of postoperative care, especially in cardiac

patients, was adeptly handled, as seen in the normalization of potassium levels from initially
low levels, ensuring cardiac stability. The maintenance of magnesium and calcium within
therapeutic ranges further supports the notion of meticulous electrolyte and metabolic
management. Liver function tests remained stable or showed minimal fluctuations within
normal limits, indicating that Mr. SS's liver function was robust, supporting his overall
recovery process. Additionally, stable albumin and globulin levels pre-surgery suggest a good
nutritional status, which is fundamental for wound healing and recovery.

Overall, Mr. SS's biochemical markers reflect a favorable adaptation to the surgical
intervention and post-operative care, highlighting the effectiveness of the medical management
provided. This positive analysis underscores the importance of comprehensive perioperative
care and the potential for a successful recovery following major cardiac surgery.
 148

3. CLINICAL ASSESSMENT

Past Medical History: He has a history of dyslipidemia, hypertension, and elevated uric
acid-related problems.

Previous Medications: The medications include Ecosprin, Enoxaparin, Xtor, Betaloc,

Amlodac, Pantodac, and Veltam.

Presenting Complaints: Mr. SS was evaluated for angina at a private hospital in Kottayam.
He underwent a coronary angiogram there on 03.01.2024 which revealed the left main
disease with triple coronary artery disease. He was advised for CABG.

Diagnosis: - Coronary artery disease, Left main Disease with triple vessel disease. The left
main artery has a distal segment with 70% narrowing. There's a very severe, almost complete
blockage (99%) in the mid part of the LAD, which has resulted in severely reduced blood
flow downstream (TIMI I flow) The posterior descending artery (PDA), which comes off the
RCA, has a 90% blockage in the ostio-proximal segment.

Disease signs and symptoms: The main sign was elevated blood pressure of
160/70mmHg.Other than this no clinical signs were shown.
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NFPE

PROGNOSIS OF NFPE

There were no visible physical signs of Nutrition deficiency.

OTHER PARAMETERS

Parameter Normal Date Remark

Range
22/1/24 23/1/24 24/1/24 25/1/24 26/1/24

Blood 120/80 160/70 140/80 100/60 127/72 114/62 Low Bp

Pressure mmHg

Pulse 72/mt 70 75 86 88 89 Tachycardia

Respiration 20 23 22 18 15 20 Normal

Oxygen >96% 98% 99% 100% 97% 96% Normal

Saturation
 150

Discussion

Mr. SS's physiological parameters before and after his CABG surgery on January 24, 2024,
show a successful recovery and effective management. His blood pressure, initially high,
normalized after the surgery despite a temporary drop on the day of the procedure, indicative
of careful fluid and anesthesia management. His pulse showed a slight post-operative increase,
aligning with expected responses to surgery and stress, but remained well controlled.
Respiration rates, initially high, stabilized post-surgery, reflecting good pain and respiratory
management. Oxygen saturation levels remained excellent throughout, starting at 98% and
never falling below 96%, ensuring optimal oxygenation and lung function. These observations
suggest a strong recovery, supported by proficient post-operative care.
 151

MEDICATIONS

Name Dosage Mechanism of Drug Drug–nutrient interaction

Tab Duolin Duolin is typically a combination inhaler There are no direct nutrient
containing ipratropium bromide and interactions, but hydration is
levosalbutamol. Ipratropium bromide is an essential as anticholinergics
anticholinergic that works by inhibiting the can cause dry mouth. A
muscarinic cholinergic receptors in the balanced diet can help manage
airways, leading to bronchodilation. potential side effects like
Levosalbutamol is a beta-2 agonist that constipation.
stimulates beta-2 adrenergic receptors,
causing muscle relaxation and further
bronchodilation.
Tab 10g Rosuvastatin belongs to the statins class, Grapefruit juice can increase
Rosuvastatin which works by inhibiting HMG-CoA rosuvastatin levels in the
reductase, an enzyme involved in cholesterol blood, potentially leading to
synthesis in the liver. This leads to a decrease side effects. Coenzyme Q10
in LDL (bad cholesterol) and triglycerides and levels might be decreased by
an increase in HDL (good cholesterol). rosuvastatin and other statins,
so supplementation may be
considered
Tab Dolo 650mg Tab Dolo typically refers to a formulation of Paracetamol has minimal
paracetamol (acetaminophen), which works direct nutrient interactions, but
by inhibiting the synthesis of prostaglandins chronic use or high doses can
in the central nervous system and blocking increase the risk of liver
pain impulses. It also has antipyretic damage, potentially affecting
properties, meaning it can reduce fever. the metabolism of nutrients.
Alcohol consumption should
be minimized as it increases
the risk of liver damage.
Tab Betaloc 25mg Betaloc contains metoprolol, a beta-blocker. It Metoprolol absorption can be
works by blocking beta-adrenergic receptors increased with food,
in the heart, reducing heart rate, blood particularly high-protein
pressure, and the heart's demand for oxygen.
 152

meals. It may also deplete

Coenzyme Q10 is like statins.
T Dytor Plus 10mg Dytor Plus is a combination of torsemide, a High-potassium foods should
loop diuretic, and spironolactone, a be consumed in moderation
potassium-sparing diuretic. Torsemide works with spironolactone to avoid
by inhibiting the reabsorption of sodium and hyperkalemia. Loop diuretics
water in the kidneys, increasing urine output. increase the excretion of
Spironolactone blocks the action of potassium, magnesium, and
aldosterone, preventing sodium retention and calcium, so monitoring these
potassium loss. nutrients is essential.
 153

4. DIETARY ASSESSMENT

FOOD FREQUENCY TABLE

Before his CABG surgery, Mr. SS's diet revealed both strengths and areas for improvement.
His regular intake of cereals, grains, fish, and seafood is beneficial for heart health, particularly
if the grains are whole and the seafood is rich in omega-3 fatty acids. However, his infrequent
 154

consumption of nuts, seeds, vegetables, and particularly green leafy vegetables, misses
essential nutrients beneficial for cardiovascular health. While his intake of dairy and eggs is
moderate, focusing on low-fat options and ensuring meat and poultry are lean would further
benefit his heart. Daily use of oils suggests a need to emphasize unsaturated fats. Enhancing
the variety and frequency of heart-healthy foods like fruits, vegetables, and whole grains could
greatly improve his dietary regimen, aiding in the management of his coronary artery disease
and supporting his recovery.

24-Hour Diet Recall Method

Time Food Quantity Ingredients Weight Energy CHO Protein Fat Fiber
Item (g) (kcal) (g) (g) (g) (g)
6 AM Tea 1 Glass Tea Powder
Sugar 5 20.05 4.98 4.98 0.02
8 AM Idli 3 nos Black Gram 18.75 54.63 8.25 4.12 0.3 3.83
Rice 56.25 197.76 43.4 4.39 0.31 2.1

Coconut ¼ cup Coconut 10 35.4 1.52 0.33 3.35 0.9

Chutney
1 PM Rice ¾ cup White Rice 50 175.79 38.58 3.91 0.28 1.87

Fish ½ cup sardine 20 27.2 12 14.3 3.6

Curry
4 PM Tea 1 Glass Tea Powder
Sugar 5 20.05 4.98 4.98 0.02

8 PM Rice ½ cup White Rice 33 116.02 25.46 2.58 0.18 1.23

Carrot ¼ cup Carrot 20 6.64 1.11 0.19 0.09 0.84
Thoran Coconut 10 40.89 0.63 0.38 4.14 1.04
Total 717.93 140.2 30.29 13.06 11.95
Cooking oil used:2g.
 155

DISCUSSION

EVALUATION OF HOME RECALL DIET AND FOOD FREQUENCY TABLE

ENERGY: 717.93 Kcal

CARBOHYDRATES: 140.2 g

PROTEIN: 30.29 g

FAT: 13.06 g

FIBER:11.95 g

FLUID INTAKE:2-3 liters

the 24-hour diet recall and food frequency assessment for Mr. SS was conducted on the day of
his admission to the hospital on January 22, 2024, and reflects his dietary intake before
admission, the analysis indicates several nutritional concerns that could impact his recovery
from surgery and overall health. The low energy intake of 717.93 kcal is particularly alarming,
significantly below what is required for an adult male, and even more so for someone
recovering from major surgery like CABG, which increases metabolic demands for healing.
His protein intake of 30.29g is insufficient for supporting tissue repair, immune function, and
recovery processes, while the fat intake of 13.06g does not meet the needs for essential fatty
acids and the absorption of fat-soluble vitamins. Although his fiber intake is adequate,
suggesting a positive aspect of his diet in terms of digestive health, the overall diet lacks variety
and balance. The infrequent consumption of key food groups—only monthly meat, poultry,
nuts, and seeds, and thrice-weekly consumption of dairy, fruits, and vegetables—points to
potential deficiencies in vital nutrients such as vitamins, minerals, and essential amino acids.
This dietary pattern, assessed right before his hospital admission, underscores the importance
of nutritional intervention to address these deficiencies and ensure a diet that supports his
recovery, healing, and long-term cardiovascular health.
 156

NUTRITIONAL PROBLEMS AND RISK

Energy and Protein Deficiency, Imbalanced Macronutrient Distribution, Inadequate

Micronutrient Intake, and Risk of Cardiovascular Complications.

NUTRITIONAL DIAGNOSIS

1. Mr. SS's inadequate energy intake is related to his significantly low daily calorie
consumption, as evidenced by a 24-hour diet recall indicating only 717.93 kcal, which is below
the recommended levels for his recovery from Coronary Artery Bypass Grafting (CABG)
surgery.

2. He is at risk of protein-energy malnutrition due to inadequate protein intake, stemming from

limited consumption of protein-rich foods such as meat, poultry, and dairy products, further
complicated by symptoms like pain upon eating and early satiety, leading to mild weight loss
and muscle mass reduction.

3. There is a risk of micronutrient deficiencies in Mr. SS's diet due to an unbalanced intake
characterized by infrequent consumption of fruits, vegetables, dairy, and meat products,
potentially resulting in essential vitamin and mineral deficiencies, as inferred from his limited
dietary variety and clinical signs.

4. Mr. SS potentially faces a risk of fluid and electrolyte imbalance, likely related to post-
surgical changes and initially low potassium levels, alongside an inconsistent intake of fluid-
rich and potassium-rich foods, as shown by fluctuations in his biochemical potassium levels.

5. His inadequate dietary fiber intake is attributed to consumption patterns that include limited
fruits, vegetables, and whole grains, crucial for preventing post-operative constipation and
maintaining gastrointestinal health, especially given his sedentary lifestyle.
 157

NUTRITION INTERVENTION

1. Enhance Caloric Intake: Increase daily calories with nutrient-dense foods and healthy
fats like avocados and olive oil to meet energy requirements for recovery.
2. Boost Protein Consumption: Aim for 1.2 to 1.5g/kg body weight daily from sources
like lean meats, dairy, and legumes to support healing and maintain muscle mass.
3. Ensure Micronutrient Sufficiency: Diversify his diet with fruits, vegetables, whole
grains, and lean meats to cover vitamin and mineral needs, targeting at least 5 servings
of fruits and vegetables per day.
4. Manage Fluids and Electrolytes: Monitor and adjust fluid intake to 2-3 liters per day
and include potassium-rich foods to maintain electrolyte balance, consulting with
healthcare providers for individualized recommendations.
5. Increase Fiber Intake: Incorporate more whole grains, legumes, and vegetables to
enhance fiber for better digestive health, alongside adequate hydration.

GOALS

The Goals of MNT include Promoting wound healing and recovery, achieving, and maintaining
optimal nutritional status, optimizing body weight and composition, supporting cardiovascular
health, ensuring adequate hydration, managing blood glucose levels, improving gastrointestinal
health, and customizing nutrition care.
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MONITORING AND EVALUATION

DIET ORDERS

1. Low Salt Diet (22/01/2024)

2. Low Salt Diet (23/01/2024)

3. NPO (24/01/2024)

4. High Protein Liquid Diet (25/01/2024)

5. Low Fat High Protein Diet (26/01/2024)

HOSPITAL DIET DAY 1

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8 AM Appam 2 Nos Rice 50 175.79 38.58 3.91 0.28 1.87

Bengal gram ¼ cup Bengal 25 71.76 9.89 4.69 1.28 6.31

Curry Gram

Milk Tea 1 Glass Milk 100 72.9 4.94 3.26 4.48

1 PM Rice ¾ cup Rice 50 175.79 38.58 3.91 0.28 1.87

Beetroot ¼ cup Beetroot 25 8.9 1.55 0.49 0.04 0.83

upperi

Moru Curry ¼ cup Buttermilk 20 12.4 0.98 0.64 0.66

 159

4 PM Egg white 1 Nos Egg 25 13.15 3.09 0.07

8 PM Rice ¾ cup Rice 50 175.79 38.58 3.91 0.28 1.87

Beans Upperi ¼ cup French 25 6.09 0.67 0.62 0.07 1.1

Beans
Chicken
Curry ¼ cup Chicken 50 84.13 10.91 4.5

Total 810 134.6 33.49 11.3 13.49

Cooking Oil Used:4g.
 160

HOSPITAL DIET DAY 2

Meal Menu Serving Ingredients Weight Energy CHO Protein Fat Fiber
Size (g) (kcal) (g) (g) (g) (g)
8 AM Putt ½ cup Rice 50 175.79 38.58 3.91 0.28 1.87

Green ¼ cup Green Gram 25 73.43 11.53 5.63 0.28 4.26

Gram
Curry

Milk Tea 1 Glass Milk 100 72.9 4.94 3.26 4.48

1 PM Rice ¾ cup Rice 50 175.79 38.58 3.91 0.28 1.87

Brinjal ¼ cup Brinjal 25 5.92 0.79 0.36 0.09 0.93

Vendakka ¼ cup Ladies 30 10.44 1.38 0.79 0.08 1.55

upperi Finger

Moru ¼ cup Buttermilk 20 12.4 0.98 0.64 0.66

curry
4 PM Egg White 1 Nos Egg 25 13.15 3.09 0.07
8 AM Wheat ½ cup Wheat 75 256.33 51.8 8.13 1.09 6.61
Kanji

Kovakka ¼ Cup Ivy Guard 25 4.76 0.6 0.31 0.06 0.81

Upperi
Total 1019 190.3 35.11 7.99 20.26
Cooking Oil Used:5 g.
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HOSPITAL DIET DAY 3

Meal Menu Serving Size Ingredients Weight Energy CHO Protein Fat Fiber
8 AM NPO

1 PM NPO

4 PM NPO

8 PM NPO

Cooking Oil Used:0g.

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Hospital Diet Day 4

Meal Menu Serving Size Ingredients Weight Energy CHO Protein Fat Fiber
(g) (kcal) (g) (g) (g) (g)
6 AM Milk 1 cup Milk 100 72 5 3 4.5

8 AM Oats 1 cup Oats and 200 112 18 3.9 2 1.05

Porridge Milk 72 5 3 4.5
10 AM High 1 cup Kabi pro 1 scoop 43.5 4.92 5 0.36
Protein Egg white 1 13.15 3.09 0.07
Drink milk 100ml 72 5 3 4.5
12 PM Banana 1 cup Banana and 200 160 25 4 4 1.6
Milkshake Milk
2 PM Health 1 cup Health MIX 200 117 21 5.5 1
Mix
4 PM Protein 1 cup Fresubin 200 184 13
Powder powder
Milk
6 PM KABI pro 1 cup Kabi Pro 200 87 9.84 10 0.72
Protein
8 PM Rice 1 cup Rice 200 104 20 3.9 2 1.12
Kanji
Thick
10 PM Protein 1 cup Fresubin 200 184 13
Powder Protein
milk Powder
Total 1220 113.76 70.39 23.65 3.77
Cooking Oil Used:0g.
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Hospital diet day 5

Meal Menu Serving Size Ingredients Weight Energy CHO Protein Fat Fiber
(g) (kcal) (g) (g) (g) (g)
8 AM Dosa 2 Nos Rice 37.5 131.84 28.94 2.93 0.21 1.4
2.55
Black Gram 12.5 36.42 5.5 2.75 0.2

Sambhar ½ Cup Onion 10 2.4 0.48 0.08

0.12
Tomato 10 1.96 0.27 0.09 0.05 0.18
0.42
Carrot 10 3.32 0.56 0.1 0.05
Lentils 10 29.78 4.79 2.29 0.06 1.67
0.68
Drumsticks 10 2.94 0.38 0.26 0.01

Milk Tea 1 Glass Milk 100 72.9 4.94 3.26 4.48

10 Am Egg 1 Nos Egg 25 13.15 3.09 0.07

Apple 1 Nos Apple 100 62.64 13.11 0.29 0.64 2.59

1 PM Rice Kanji ¾ Rice 50 175 38.58 3.91 0.28 1.87

Kovaika ¼ Ivy Gourd 25 4.78 0.6 0.31 0.06 0.06

upperi

Beans ¼ French 25 6.09 0.67 0.62 0.07 1.1

Upperi Beans

Moru ½ Buttermilk 30 18.6 1.46 0.96 0.99

Curry

4 PM Wheat 1 Nos Wheat 25 80.14 16.04 2.64 0.38 2.84

Appam Flour

Milk Tea 1 Glass 100 72.9 4.94 3.26 4.48

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8 PM Wheat ½ cup Wheat 75 256.33 51.8 8.13 1.09 6.61

Kanji

Fish Curry ½ cup Mackerel 75 75.82 16.13 1.15

Churaka ¼ Cup Bottle 25 2.75 0.42 0.13 0.03 0.53

Paripp Gourd

Egg White 1 Nos Egg 25 13.15 3.09 0.07

Total 1054 157.9 51.74 13.96 20.65

Cooking Oil Used:10g.

Day Wise Distribution

DAY ENERGY (Kcal) CHO (g) PROTEIN(g) FAT(g) FIBRE(g)

DAY 1 810 134.6 33.49 11.3 13.49

DAY 2 1019 190.3 35.11 7.99 20.26

DAY 3 NPO

DAY 4 1220 113.76 70.39 23.65 3.77

DAY 5 1054 157.9 51.74 13.96 20.65

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DISCUSSION

Day 1

Nutritional values: 810 kcal, 134.6g carbohydrates, 33.49g protein, 11.3g fat, 13.49g fiber. The
low salt and balanced nutrient intake are essential for managing blood pressure and fluid
retention, preparing the body for surgery by ensuring stable nutritional status.

Day 2

Nutritional values: 1019 kcal, 190.3g carbohydrates, 35.11g protein, 7.99g fat, 20.26g fiber.
Continuing the low salt approach, the slight increase in calories and protein supports enhanced
nutritional reserves, vital for facing the metabolic demands of surgery and beginning the
recovery process.

Day 3

Mr. Sasi was kept NPO, signifying no intake of food or drink. This is a crucial preparation for
CABG surgery to avoid the risks associated with anesthesia, ensuring the stomach is empty to
prevent aspiration, a common safety protocol in surgical procedures.

Day 4

Nutritional values: 1220 kcal, 113.76g carbohydrates, 70.39g protein, 23.65g fat, 3.77g fiber.
The high-protein liquid diet aids in recovery by providing essential amino acids for tissue repair
without taxing the digestive system, ensuring nutrients are efficiently absorbed during the
critical initial recovery phase.

Day 5

Nutritional values: 1054 kcal, 157.9g carbohydrates, 51.74g protein, 13.96g fat, 20.65g fiber.
Transitioning to a low-fat, high-protein diet supports ongoing recovery, with protein essential
for healing and fat limited to reduce cardiovascular strain. The increased fiber aids in improving
digestive function after surgery.
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DISCHARGE DIET

Time Food Item Quantity Ingredients Weight Energy CHO Protein Fat Fiber
(g) (kcal) (g) (g) (g) (g)
8 Appam 2 Nos Rice 50 175.79 38.58 3.91 0.28 1.87
AM
Lentil curry ¼ cup Lentil 25 74.45 11.98 5.72 0.15 4.17

orange 1 Nos Orange 100 47 11.75 0.94 0.12 2.4

1 Banana 1 Nos Banana 50 44.5 11.45 0.55 0.17 1.3
AM
Oats in milk ½ cup Oats 40 149.6 25.12 5.44 3.04 1.4
4.94
Milk 100 72.9 3.26 4.48

1 Brown Rice ¼ cup Rice 33 116.02 25.46 2.58 0.18 1.23

AM

Spinach curry ¼ cup Spinach 30 7.31 0.61 0.64 0.19 0.71

Carrot Upperi Carrot Carrot 30 9.97 1.67 0.29 0.14 1.25

4 Egg white 2 Nos Egg 50 84.12 10.91 4.5
AM
Walnuts 6 Nos walnut 30 201.41 3.04 4.48 19.28 1.62
8 chappati 2 Nos Wheat 50 160.29 32.09 5.29 0.77 5.68
AM Flour

Salad ½ cup Cucumber 50 9.8 1.74 0.36 0.08 1.07

Fish Garlic ½ cup Mackerel 90 90.99 19.36 1.38

Curry
Garlic 5 6.19 1.1 0.35 0.01 0.26
1234 168.72 59.76 35.61 23.19
Cooking oil used 6g
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RECOMMENDED DIETARY ALLOWANCE

Nutrients RDA Patient Requirement Discharge Diet

Provided
Energy (Kcal) 1700 1220 1234
Dietary Fiber(g) 30 30 23.19
Protein(g) 54 60 59.76
Fat(g) 52 35 35.61
Carbohydrate(g) 250 166 168.72

DISCUSSION

The discharge diet provided to Mr. SS, with its nutritional composition of 1234 calories, 23.19g
of fiber, 59.76g of protein, 35.61g of fat, and 168.72g of carbohydrates, is thoughtfully crafted
to support his continued recovery post-discharge. This balanced diet is tailored to meet his
nutritional needs while promoting cardiovascular health and aiding in the healing process.

The calorie level is set to ensure an adequate energy supply without overwhelming his system,
supporting gradual weight management and recovery. The high fiber content is particularly
beneficial for digestive health, promoting regular bowel movements and potentially aiding in
the management of blood sugar levels, which is crucial for a heart-healthy diet.

Protein is pivotal in the healing process, aiding in the repair of tissues and the maintenance of
muscle mass post-surgery. The amount provided in this diet supports these needs without
placing undue stress on the kidneys, fostering optimal recovery. The calculated fat content,
focusing on heart-healthy sources, supports energy needs and nutrient absorption while
contributing to cardiovascular health by maintaining healthy blood lipid levels.

Carbohydrates are carefully balanced to provide energy throughout the day, supporting Mr.
SS's overall activity levels and bodily functions. This macronutrient mix ensures that his diet
is not only nourishing but also conducive to his recovery and long-term health objectives.

Overall, the discharge diet for Mr. SS is designed with a holistic approach to nutrition,
considering his recent surgery, ongoing recovery needs, and the importance of cardiovascular
health. This diet offers a solid foundation for Mr. SS to continue improving his health status,
providing a well-rounded mix of nutrients essential for his recovery and well-being.
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OVERALL SUMMARY

This case study revolves around Mr. SS, a 71-year-old male who underwent Coronary Artery
Bypass Grafting (CABG) surgery, detailing his hospital stay, nutritional management, and
recovery process. Upon admission, his diet and nutritional status were meticulously assessed,
revealing a sedentary lifestyle with existing conditions of hypertension, dyslipidemia, and gout,
and medications that included TAB. ECOSPIRIN, TAB XTOR, TAB BETALOC, and TAB
AMLODAC. Pre-operative assessments included anthropometric measurements indicating a
BMI of 25.4 kg/m^2 and a series of biochemical tests highlighting concerns such as elevated
total leukocyte count and slightly low potassium levels, suggesting inflammation and potential
electrolyte imbalance.

Nutritional interventions played a critical role throughout Mr. SS's hospital stay. Pre-surgery,
he was placed on a low-salt diet to manage blood pressure and fluid retention, gradually
increasing caloric and protein intake to prepare his body for the demands of surgery and
recovery. Post-surgery, nutritional strategies included a high-protein liquid diet to support
tissue repair in the immediate recovery phase, transitioning to a low-fat, high-protein diet to
continue recovery, ensuring nutrient intake supported healing, and minimizing strain on the
cardiovascular system.

Mr. SS's discharge diet was carefully designed to promote continued recovery and
cardiovascular health, with a balanced intake of calories, protein, fat, carbohydrates, and a high
fiber content. This comprehensive approach aimed to address his immediate post-operative
needs and provide a foundation for long-term health improvement.

Throughout the case study, the significance of a tailored nutritional approach in the context of
major cardiac surgery recovery was evident. Each phase of Mr. SS's diet plan—from pre-
operative preparation through to post-discharge—was strategically developed to optimize his
healing process, manage existing health conditions, and mitigate potential complications. The
focus on balancing energy, macronutrients, and micronutrients illustrates the critical role of
diet in surgical recovery and highlights the importance of integrating medical nutrition therapy
into overall patient care plans for optimal health outcomes.
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CONCLUSION
Over the course of an enriching three-month internship at Lourdes Hospital in Kochi,
Ernakulam, I embarked on a journey of profound professional and personal development within
the field of dietetics. Aimed at bridging the gap between theoretical knowledge and practical
application, the internship equipped me with invaluable insights into the roles and
responsibilities of a dietitian in a hospital setting. My primary objectives were to gain firsthand
experience in dietary and nutritional counseling, enhance my understanding of various medical
conditions and their dietary implications, and develop essential skills such as patient
communication and diet planning.

Throughout the internship, I was actively involved in diverse and critical activities, including
conducting rounds in various wards such as nephrology, urology, cardiology, gynecology, and
orthopedics, which enabled me to assess and address the nutritional needs of patients across
different medical specialties. Other key responsibilities included managing nutrition-related
documentation, performing nutritional assessments for dialysis patients, and evaluating
hospital food through tasting sessions.

The learning curve was steep, as I navigated through the complexities of diseases, different
feeding methods, and the customization of diets to meet individual patient needs. Moreover,
adapting to the hospital environment and familiarizing myself with medical terminologies and
medications presented initial challenges. However, through persistent effort and guided
learning, I overcame these obstacles, significantly enhancing my competence and confidence
in the field.

The mentorship and support provided by the hospital's nutrition department played a crucial
role in my growth, offering guidance, encouragement, and valuable insights that enriched my
internship experience. This nurturing environment not only facilitated my professional
development but also fostered lasting relationships with mentors, guides, and fellow trainees.

Reflecting on my internship, I recognize it as a pivotal milestone in my career path in dietetics.

It has not only expanded my knowledge and skills but also solidified my commitment to
pursuing excellence in this field. As I move forward, the lessons learned, and the growth
experienced at Lourdes Hospital will continue to inspire and guide me in my journey as a
dietetics professional.
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