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CASE STUDY – TUBERCULOSIS

Tuberculosis is an infectious disease which is caused by the bacterium, Mycobacterium

tuberculosis and is spread from person to person via airborne droplets (e.g. when an infected

person coughs or sneezes). Tuberculosis primarily affects the lungs (causing pulmonary

tuberculosis), but it can also affect other organs, e.g. central nervous system, lymphatic system,

and circulatory system among others, resulting in extra-pulmonary tuberculosis. When a

person first becomes infected, the tuberculosis bacteria generally lay dormant in the body and

the person will not manifest any symptoms, this is termed “Latent Tuberculosis Infection”.

Persons with Latent Tuberculosis Infection are not infectious. However, in about 10% of

healthy individuals with Latent Tuberculosis Infection, active tuberculosis disease may

eventually develop over their lifetime. The highest risk of progressing to active tuberculosis

disease is in the first two years after initial infection. In persons who are immunocompromised

(e.g. the elderly or those who are human immunodeficiency virus (HIV) positive), the rate of

progressing to active tuberculosis disease will be higher than in healthy individuals. For

example, individuals with untreated HIV co-infection may progress from Latent Tuberculosis

Infection to active tuberculosis disease at the rate of 5-8% per year, with a lifetime risk of

approximately 30%.
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CAUSES:

TB is caused by slow-growing bacteria called Mycobacterium tuberculosis. It is spread

through the air when a person with TB (whose lungs are affected) coughs, sneezes, spits,

laughs, or talks. When these bacteria enter the lungs, they are usually walled off into harmless

capsules (granulomas) in the lung, causing infection but not disease. These capsules may later

wake up weeks, months or decades later causing active TB disease.

People with well-functioning immune systems may not experience TB symptoms, even

though they are infected with the bacteria. This is known as latent or inactive TB infection.

According to WHO, about one-quarter of the world’s population has latent TB. Latent TB isn’t

contagious, but it can become an active disease over time. Active TB disease can make you and

others sick.

PROGRESSION OF TUBERCULOSIS
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SYMPTOMS:

Symptoms are usually mild and tend to present over a period of weeks, months, or

sometimes years. TB disease symptoms are often initially mistaken for a smoker’s cough,

allergies, or chronic bronchitis from a lingering cold or flu infection. TB infection most often

affects the lungs but can cause problems in other parts of the body. The latent TB is

symptomless but the classic symptoms of TB in the lungs include:

 Cough lasting more than three weeks

 Unexplained weight loss

 Low-grade fever

 Night sweats

Tuberculosis usually affects the lungs, but can also affect other parts of the body. When

TB occurs outside of the lungs, the symptoms vary accordingly. Without treatment, TB can

spread to other parts of the body through the bloodstream:

 TB infecting the bones can lead to spinal pain and joint destruction

 TB infecting the brain can cause meningitis

 TB infecting the liver and kidneys can impair their waste filtration functions and lead to blood

in the urine

 TB infecting the heart can impair the heart's ability to pump blood, resulting in a condition

called cardiac tamponade that can be fatal.

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DIAGNOSIS:

Given that latent TB infection is asymptomatic, infection must be diagnosed using a

screening test, either a tuberculin skin test (TST) or a blood test called an interferon gamma

release assay (IGRA). The TB skin test is also called a Mantoux test or a PPD skin test because

the material used in the skin test is called purified protein derivative (PPD). These tests detect

the immune response our body mounts to components of Mycobacterium tuberculosis. A

positive result indicates that a person has been infected with the tuberculosis bacteria at some

point in his or her life. TB disease is suspected clinically when a person presents with the

symptoms mentioned above usually together with abnormal findings on a chest x-ray. If TB

disease is suspected, the person should be isolated from the public until the diagnosis is made

and treatment is started as he or she can be contagious and transmit Mycobacterium

tuberculosis to others. TB disease is often diagnosed by microscopic examination of three

separate samples of sputum (phlegm) often collected on different days. The sputum is first

looked at under a microscope using a special dye (acid fast bacillus AFB stain) to see if any

tuberculosis bacteria can be found. It is not always positive as there may be only a small

number of bacteria so a culture is always needed. Sputum cultures are done to grow the

bacteria to confirm the diagnosis and determine the best combination of drugs for treatment.

Bronchoscopy is sometimes needed to obtain lung samples if a patient is unable to produce

sputum. In addition to these tests, chest X-ray and CT chest imaging are performed to evaluate

for any lung abnormalities. If TB is suspected in a different part of the body, a different sample

or a tissue biopsy may be needed. MDR-TB is more difficult to diagnose than regular TB. It is

also difficult to diagnose regular TB in children.

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AT RISK OF TUBERCULOSIS:

According to WHO, more than 95% of all deaths related to TB cases occur in low and

middle-income countries. People who use tobacco or misuse drugs or alcohol long term are

more likely to get active TB, as are people diagnosed with HIV and other immune system issues.

TB is the leading killer of people who are HIV-positive, according to WHO. Other risk factors

for getting active TB disease include:

 diabetes

 end-stage kidney disease

 malnourishment

 certain cancers

Medications that suppress the immune system can also put people at risk for developing active

TB disease, in particular medications that help prevent organ transplant rejection. Other

medications that increase your risk of getting TB include those taken to treat:

 cancer

 rheumatoid arthritis

 Crohn’s disease

 psoriasis

 lupus

Traveling to regions where TB rates are high also increases your risk of contracting the

infection. These regions include:

 sub-Saharan Africa

 India

 Mexico and other Latin American countries

 China and many other Asian countries

 parts of Russia and other countries of the former Soviet Union

 islands of Southeast Asia & Micronesia

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TREATMENT:

Many bacterial infections are treated with antibiotics for a week or two, but TB is

different. People diagnosed with active TB disease generally have to take a combination of

medications for six to nine months. The full treatment course must be completed. Otherwise,

it’s highly likely a TB infection could come back. If TB does recur, it may be resistant to

previous medications and be much more difficult to treat.

Treatment of latent TB infection consists of 1 or 2 oral medications that kill the bacteria and

greatly reduces the risk of the infection progressing to TB disease immediately and later in life.

There are several treatment options that include isoniazid taken daily for six to nine months,

rifampin taken daily for 3 to 4 months or isoniazid plus rifapentine taken once weekly for 12

weeks. These medications can affect your liver, so people taking TB medications should be

aware of liver-injury symptoms, such as:

 appetite loss

 dark urine

 fever lasting longer than three days

 unexplained nausea or vomiting

 jaundice, or yellowing of the skin

 abdominal pain

. TB disease is usually treated with 4 anti-TB medications for at least six months. If TB is

in the bones, brain or other hard-to-reach areas, treatment will be longer. This can mean

taking 6-12 pills per day! Many patients find this difficult without the support of workers

trained in providing directly observed treatment (DOT). DOT is the universal standard for

treating TB worldwide. DOT helps detect side effects early and prevents missed doses and

breaks in treatment that reduces the benefit of treatment and can lead to drug-resistant strains

of bacteria.
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PREVENTION:

TB is spread by tiny airborne droplets created by coughing. It is not spread by sharing

food, utensils, and drinks, touching, or having sex. Covering the mouth and nose when

coughing is an important way to stop the spread of TB and other airborne diseases. If you have

TB disease and are coughing, it is important to wear a mask and limit contact with others until

your health care provider tells you that you are no longer contagious while on treatment.

Seeking care right away and finding out you have TB is the best way to stop its spread since

treatment of disease helps you not be contagious, decreasing transmission.

TB vaccination

In some countries, BCG injections are given to children to vaccinate them against tuberculosis.

It is not recommended for general use in the U.S. because it is not effective in adults, and it can

adversely influence the results of skin testing diagnoses.

The most important thing to do is to finish entire courses of medication when they are

prescribed. MDR-TB bacteria are far deadlier than regular TB bacteria. Some cases of MDR-TB

require extensive courses of chemotherapy, which can be expensive and cause severe adverse

drug reactions in patients.

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Name of the hospital : PSG Hospitals

Date of assessment : 09/5/18

Date of admission : 08/5/18

IP no. : I 18014249

OP no. : O 18029049

Ward number : RM/3E

NUTRITIONAL SCREENING ON ADMISSION (date of admission)

1. PATIENT PROFILE

a. Patient name : Kaja Qusain V

b. Age : 73 years

c. Community : Muslims

d. Gender : Male

e. Occupation : Nil

f. No. of family members : 5 members

2. USE OF APPROPRIATE SCREENING TOOL AS PER THE INSTITUTION: (SGA, NRS, STAMP,

etc.)

ANTHROPOMETRIC MEASUREMENT FOR ADULTS

Weight 34Kg

Height 167cms

BMI 12.19Kg/m2

Physical activity (Calculate as per NIN chart) Sedentary

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 BIOCHEMICAL DATA – 08/5/18

TEST NAME RESULT REFERENCE

Total RBC Count 4.93 x 10^6/uL 4 – 4.8 x 10^6/uL

Hemoglobin 13.8g/dL 12-15 g/dL

Hematocrit (PCV) 42.5 % 36 – 46%

MCV 86.2fL 80 – 100 fL

MCH 28.0 pg 27 – 32 pg

MCHC 32.5 g/dL 32 – 35 g/dL

RDW 14.1 % 10-15%

Total WBC count 10.6 x 10^3/uL 4 – 10 x 10^3/uL

Neutrophil % 91.2 % 40 - 80%

Lymphocyte % 5.1 % 20 - 40%

Monocyte % 3.6 % 2 - 10%

Eosinophil % 0.0 % 1 - 6%

Basophil % 0.1 % 0 - 2%

Absolute neutrophil count 9.7 x 10^3/uL 2 – 7x 10^3/uL

Absolute lymphocyte count 0.5 x 10^3/uL 1 – 3 x 10^3/uL

Absolute monocyte count 0.4 x 10^3/uL 0.2 – 1 x 10^3/uL

Absolute eosinophil count 0.0 x 10^3/uL 0.02 – 0.5 x 10^3/uL

Absolute basophil count 0.0 x 10^3/uL 0.02 – 0.1 x 10^3/uL

Platelet count 382 x 10^3/uL 150 – 400 x 10^3/uL

MPV 7.4 fL 7.0 -12.0 fL

PCT 0.284 % 0.200 – 0.500%

PDW 16.7 % 8 – 18%

ESR (1HR) 22 mm 3 – 10 mm
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BIOCHEMICAL DATA – 08/5/18

TEST NAME RESULT REFERENCE

Glucose random 106 mg/dL 70 – 139 mg/dL

Urea (serum)

Result 47 mg/dL 14 – 40 mg/dL

BUN (calculated) 21.96 mg/dL 6.5 – 18.7 mg/dL

Creatinine (serum) 0.54 mg/dL 0.66 – 1.09 mg/dL

Liver Function Test

Direct Bilirubin 1.3 mg/dL 0 – 2 mg/dL

Indirect Bilirubin 0.4 mg/dL 0.2 – 0.8 mg/dL

Total Bilirubin 1.7 mg/dL 0.2 – 0.1 mg/dL

SGPT (ALT) (serum) 60 U/L 5 – 31 U/L

SGOT (ALP)(serum) 120 U/L 5 – 32 U/L

Alkaline Phosphatase(serum) 113 U/L 3 – 104 U/L

Proteins (serum)

Albumin (BCG, Dye Bind) 2.1 g/dl 3.4 – 4.8 g/dL

Globulin (calculated) 3.8 g/dl 1.8 – 3.6 g/dL

Total (biuret, Endpoint) 5.9 g/dl 6.4 – 8.3 g/dL

GGT (serum) 29 U/L 5 – 39 U/L

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BIOCHEMICAL DATA – 10/5/18

Electrolytes

Magnesium (serum) 1.6 mEq/L 1.3 – 2.1 mEq/L

Sodium (serum / plasma) 129 mEq/L 136 – 146 mEq/L

Potassium (serum / plasma) 3.05 mEq/L 3.5 – 5.0 mEq/L

Chloride (serum / plasma) 86 mEq/L 102 – 109 mEq/L

Bicarbonate (serum / plasma) 33.0 mEq/L 22 – 30 mEq/L

Ionized Cal (serum / plasma) 1.006 m mol/L 1.1 – 1.3 m mol/L

ARTERIAL BLOOD GASES

Lactate 2.0 m mol/L 0.9 – 1.7 mol/L

HCO3 33.0 mEql/L 22 – 30 mEql/L

FiO2 29.00 % -

tCO2 34.6 m mol/L 22 – 29 m mol/L

tHb 13.0 g/dL 12 – 16 g/dL

pCO2 52.2 mm Hg 35 – 45 mm Hg

Temperature 37.00C -

pO2 83.3 mm Hg 67 – 104 mm Hg

pH 7.419 7.35 – 7.45

sO2 96.6 % 95 – 98%

BIOCHEMICAL DATA – 11/5/18

TEST NAME RESULT REFERENCE

Potassium (serum / plasma) 3.05 mEq/L 3.5 – 5.0 mEq/L

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BIOCHEMICAL DATA – 12/5/18

Liver Function Test

Direct Bilirubin 1.0 mg/dL 0 – 2 mg/dL

Indirect Bilirubin 0.3 mg/dL 0.2 – 0.8 mg/dL

Total Bilirubin 1.3 mg/dL 0.2 – 0.1 mg/dL

SGPT (ALT) (serum) 74 U/L 5 – 31 U/L

SGOT (ALP)(serum) 71 U/L 5 – 32 U/L

Alkaline Phosphatase(serum) 152 U/L 3 – 104 U/L

Proteins (serum)

Albumin (BCG, Dye Bind) 1.5 g/dl 3.4 – 4.8 g/dL

Globulin (calculated) 3.5 g/dl 1.8 – 3.6 g/dL

Total (biuret, Endpoint) 5.0 g/dl 6.4 – 8.3 g/dL

GGT (serum) 50 U/L 5 – 39 U/L

Electrolytes

Sodium (serum / plasma) 130 mEq/L 136 – 146 mEq/L

Potassium (serum / plasma) 3.39 mEq/L 3.5 – 5.0 mEq/L

Chloride (serum / plasma) 91 mEq/L 102 – 109 mEq/L

Bicarbonate (serum / plasma) 31.9 mEq/L 22 – 30 mEq/L

Ionized Cal (serum / plasma) 0.990 m mol/L 1.1 – 1.3 m mol/L

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BIOCHEMICAL DATA – 12/5/18

ARTERIAL BLOOD GASES

Lactate 3.8 m mol/L 0.9 – 1.7 mol/L

FiO2 29.00 % -

tHb 13.3 g/dL 12 – 16 g/dL

PROTHROMBIN TIME

INR 1.55

CONTROL 10.5 seconds 9 – 12 seconds

TEST 15.7 seconds 9 – 12 seconds

VITALS:

PULSE RATE BP INPUT OUTPUT TEMP

DATE RESPIRATION RATE (bpm)
(bpm) (mmHg) (ml) (ml) (Fo)
8/5/18 - 102 - 106 90 - - 24 - 24 22 - 90/70 100/60 - - 98.4o

9/5/18 100 100 98 102 98 - 22 22 22 22 22 - 110/70 110/70 1450 1000 98.4o

10/5/18 100 110 102 100 98 - 22 22 22 22 22 - 110/60 100/60 2000 1300 98.4o

11/5/18 100 120 108 100 110 - 22 22 22 22 22 - 100/60 100/70 2350 1600 98.4o

12/5/18 98 120 108 100 102 - 22 22 22 22 22 - 100/60 100/60 1775 1200 98.4o

13/5/18 110 100 116 102 84 - 20 20 20 20 20 - 100/60 120/70 1925 1650 98.4o

14/5/18 98 100 - - - - 20 20 - - - - 100/80 - 1300 950 98.4o

DIABETIC MONITORING

DATE & TIME BLOOD SUGAR TREATMENT

9/5/18

6.30 am 103 N/C

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 CLINICAL DATA

 Present complaints (clinical signs and symptoms)

 Productive cough x 15 days

 Breathlessness x 15 days

 Difficulty in Swallowing x 15 days

 Past medical history

 Cough x 3 years

 Final medical diagnosis

 Smear positive pulmonary tuberculosis (on modified ATT since 10/5/18)

 Chronic obstructive pulmonary disorder (COPD)

 Moderate pulmonary arterial hypertension (PAH)

 Type II Respiratory Failure – On Home Oxygen

 Adjustment disorder

 Possible chronic liver disease

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DIAGNOSTIC, BLOOD AND OTHER INVESTIGATIONS:

ENDOSCOPIC DIAGNOSIS:

USG ABDOMEN

Impression:

 Bilateral increased renal cortical echoes

 Correlate with RFT

 Left renal cortical cyst.

NOTES:

8/5/18

 LV - 35/22

 EF - 66%

 Mild TR (RVSP – 48mm Hg)

9/5/18

 C/O cough with purulent sputum

 Poor appetite and intake

10/5/18

 Difficulty in having solid foods

 Bed wetting

 C/O sleeplessness

 Use of Nicotine and non-withdrawal of Alcohol

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12/5/18

 Presence of Cough and Abdominal pain

 Poor intake

 Suggested on shifting the patient to high protein diet

13/5/18

 Better intake

 High protein diet

14/5/18

 Cough ċ sputum reduced

 Intake was improved - Mashed diet

 On home oxygen

 Medication / Treatment

Medication Dosage Mechanism of action

Inj. Emeset 4mg It is an antiemetic (anti-nausea medicine). It inhibits the action of

serotonin, a chemical messenger that can trigger nausea and vomiting.

Syp. Alex 10ml It is a cough suppressant that relieves cough by reducing the activity

of cough center in the brain.

T. Doxozet 400mg It is a bronchodilator. It works by relaxing the muscles of the airways.

This opens the airways and makes breathing easier.

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T. Amitriptyline 10mg It is used for preventive treatment of migraine, neuropathic pain

and depression. It is used in patients intolerant of or unresponsive to

alternative treatment options for depression.

Syp. Mucaline Gel 10ml It is used in the treatment of acidity, heartburn and stomach ulcers.

Ipravent Q6H It is a Nebulizer works by decreasing the activity of acetylcholine on

the lung. This relaxes and opens up the air passages to make breathing

easier.

Inj. Ceftriaxone 1g It Ceftriaxone is used in the treatment of bacterial infections. It is used

for short-term treatment of bacterial infections of urinary tract, skin

and soft-tissue, ear, bone, blood, abdomen, genital and lungs

(pneumonia). It is also used to prevent infections after surgery.

T. Pan 40mg It is a proton pump inhibitor (PPI). It works by reducing the amount of

acid in the stomach which helps in relief of acid-related indigestion

and heartburn.

T. Domstal 10mg It is used in the treatment of nausea and vomiting.

T. Benadon 40mg It is used for Neurological disturbances, Anemia, Mental

problems, Convulsions, Pregnancy complications,

Homocystinuria, Convulsion and other conditions

T. Dolo 650mg It is a pain reliever (analgesic) and fever reducer (antipyretic). It

works by blocking the production of the chemical messengers

(prostaglandins) that transmit pain signals and induce fever.

Levolin Q4H It is a bronchodilator. It works by relaxing the muscles in the airways

and makes breathing easier.

T. Rcin 300mg It is an antibiotic. It works by inactivating a bacterial enzyme (rna-

polymerase) which is required by TB bacteria to make essential

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proteins and to reproduce

T. Combutol 800mg It is an antibiotic. It works by slowing the growth of bacteria that

causes tuberculosis.

T. Solonex 100mg It is an antibiotic. It works by killing the bacteria that causes

tuberculosis.

T. Udiliv 300mg It is used in the treatment and prevention of gallbladder stones.

T. Thiamine 100mg It is used in the treatment of nutritional deficiencies. It’s used in

conditions including beriberi and inflammation of the nerves (neuritis)

associated with pellagra or pregnancy.

T. Renerve plus It is used for Nerve damage, Pain in neurological disorders, Numbness

and tingling, Diabetic

polyneuropathy, Osteoarthritis, Anemia, Diabetes, Burning mouth

syndrome, Acute respiratory distress syndrome, HIV and other

conditions.

T. Quetiapine 25mg It is used in the treatment of schizophrenia and mania.

T. Levoflox 500mg It is an antibiotic. It kills bacteria by preventing them from

reproducing and repairing themselves. This treats your infection.

Threptin Diskettes They are high-calorie protein supplements helpful for the growth of

body. Patients who have a lack of essential protein in their body due to

faulty diets or illness take this biscuit. It can be easily digested and can

be tolerated by almost all patients. This protein supplement is also

known to supply enough calories to the body which is essential for the

body to recuperate after prolonged illness

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 DIET HISTORY

24-hour recall + empty calories intake from food frequency table (as given below)

Veg / Non – veg / Ova-Vegetarian

ENERGY PROTEIN CARBS FAT

MEAL MENU QTY EX
(Kcal) (g) (g) (g)

E.M tea 100ml 1 66 3.07 4.205 4

idly 4 nos 4 340 8 80 -

B.F tomato chutney ½ cup 1 30 - 6 -

sambhar ½ cup ½+¼+¼ 65 3.75 12 -

M.M tea 100ml 1 66 3.07 4.205 4

rice 300g 3 255 6 60 -

L sambhar ½ cup ½+¼+¼ 65 3.75 12 -

Brinjal poriyal ½ cup 1 30 - 6 -

tea 100ml 1 66 3.07 4.205 4

E
bread 2 nos 1 85 2 20 -

idly 2 nos 2 170 4 40 -

D tomato chutney ½ cup 1 30 - 6 -

sambhar ½ cup ½+¼+¼ 65 3.75 12 -

B.T milk 100ml 1 65 3 4 4

Oil 20ml 2 ex 180 - - 20

Sugar 20g - 80 - 20 -

TOTAL 1658 43.46 290.615 36

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Sample table provided + Food frequency table

TOTAL EMPTY
FOOD ITEMS DAILY WEEKLY FORTNIGHT MONTHLY
CALORIE

Pickle 

Papad 

Chats

Fast foods

Carbonated Beverages

Bakery foods 

Fried foods 

Sweets 

NUTRITION CALCULATION OF HOME DIET RECALL

 Energy : 1658 Kcal

 Protein : 43.46 Gms (10.5%)

 Carbohydrates : 290.62 Gms (70%)

 Fat : 36gms (19.5%)

 Fluid requirement : 3700 ml

 Other relevant disease specific nutrients (Ca, Fe, Na, K, Fibre, etc.,)
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NUTRITIONAL DIAGNOSIS (PES Statement)

Critical thinking: to determine MNT regime with Nutrition principles

 Increased nutrient needs due to chronic infection (Tuberculosis) that is evidenced by

weight loss of more than 10%

NUTRITIONAL INTERVENTION

Medical Nutrition Therapy (regime)

DIET ORDER:

High Protein diet

SHORT TERM GOAL:

 An adequate diet, containing all essential macro- and micronutrients is essential to

reduce risk of complications

 Meals should be provided at frequent intervals to increase the amount of food intake

 To provide a high protein diet

LONG TERM GOAL:

 To improve and prevent the weight loss of the patient

 To give them counselling regarding the importance of food

 To improve the quantity and quality of food intake

 To manage the symptoms of the TB drugs such as anorexia, diarrhea and altered taste
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INTERVENTION:

ENERGY : 45 Kcal/Kg current body weight ⇒1530 Kcal

PROTEIN : 1.5 g/Kg current body weight ⇒ 51g (10%)

CARBOHYDRATES : 60% of total calories ⇒ 229g

FAT : 27% of total calories ⇒ 46g

SODIUM : 2400 mg

POTASSIUM : 4700 mg

FLUID : 3.7 litre/day

NNC/NPC : 1326 Kcal

CALORIE: N2 RATIO : 189:1

DETAILED PRESCRIBED HOSPITAL MENU:

TIMING 9/5/18 – 11/5/18 12/5/18

6am Ensure 15g + 150ml milk Ensure 15g + 150ml milk
idly – 2 nos idly – 2 nos
8am Bland Sambhar (2 cup) Bland Sambhar (2 cup)
(Mixie mashed diet) (Mixie mashed diet)
10am Veg soup – 100ml
Mashed dal rice – 1 cup Mashed curd rice – 1 cup
Lunch Mashed rasam rice – 1 cup Mashed dal rice – 1 cup
Mashed veg A – 1 cup Mashed veg A – 1 cup
4pm Ensure 15g + 150ml milk Ensure 15g + 150ml milk
Idly – 2 nos idly – 2 nos
Dinner Bland sambhar (2 cup) Bland Sambhar (2 cup)
(Mixie mashed diet) (Mixie mashed diet)
`Bed time Ensure 15g + 150ml milk Ensure 15g + 150ml milk
11pm Ensure 15g + 150ml milk
(Midnight - egg white – 3 nos
snack) 75g paneer
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THREE PRESENT DAYS HOSPITAL MENU

Day – 1 [9/5/18 → Wednesday]

Meal Menu Qty ex energy protein carbs fat

E.M milk 100ml 1 65 3 4 4

idly 2 nos 2 170 4 40 -

B.F sambhar 1 cup 1+½+½ 130 7.5 24 -

ridge gourd chutney ½ cup 1 30 - 6 -

M.M milk 100ml 1 65 3 4 4

mashed dal rice ½ cup ¾+¼ 148.75 4.5 33.75 -

mashed rasam rice ½ cup ¾+¼ 71.25 1.5 16.5 -

L
mashed curd rice ½ cup ¾+¼ 80 2.25 16 1

mashed veg A ½ cup 1 30 - 6 -

E milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 2 nos 2 170 4 40 -

D sambhar 1 cup 1+½+½ 130 7.5 24 -

onion chutney ½ cup 1 60 3 12 -

BT milk + ensure 150ml - 158.55 6.63 14.7 7.9

Oil 20ml 2 180 - - 20

Sugar 20g - 80 - 20 -

TOTAL 1727.1 53.51 275.65 44.8

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Day – 2 [10/5/18 →Thursday]

Meal Menu Qty ex energy protein carbs fat

E.M milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 2 nos 2 170 4 40 -

B.F sambhar 1 cup 1+½+½ 130 7.5 24 -

tomato chutney ½ cup 1 30 - 6 -

M.M Veg soup ½ cup 1 45 1.5 9 -

mashed dal rice ½ cup ¾+¼ 148.75 4.5 33.75 -

L mashed rasam rice ½ cup ¾+¼ 71.25 1.5 16.5 -

mashed veg A ½ cup 1 30 - 6 -

E milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 2 nos 2 170 4 40 -

D sambhar 1 cup 1+½+½ 130 7.5 24 -

dal chutney ½ cup 1 85 6 15 -

BT milk + ensure 150ml - 158.55 6.63 14.7 7.9

Oil 20ml 2 180 - - 20

Sugar 20g - 80 - 20 -

TOTAL 1746 56.39 278.4 43.7

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Day – 3 [11/5/18 →Friday]

Meal Menu Qty ex energy protein carbs fat

E.M milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 2 nos 2 170 4 40 -

B.F sambhar 1 cup 1+½+½ 130 7.5 24 -

radish chutney ½ cup 1 55 3 10 -

M.M Veg soup ½ cup 1 45 1.5 9 -

mashed dal rice ½ cup ¾+¼ 148.75 4.5 33.75 -

L mashed rasam rice ½ cup ¾+¼ 71.25 1.5 16.5 -

mashed veg A ½ cup 1 30 - 6 -

E milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 2 nos 2 170 4 40 -

D sambhar 1 cup 1+½+½ 130 7.5 24 -

chow- chow chutney ½ cup 1 30 - 6 -

BT milk + ensure 150ml - 158.55 6.63 14.7 7.9

Oil 20ml 2 180 - - 20

Sugar 20g - 80 - 20 -

TOTAL 1715.7 53.4 273.4 43.7

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Day – 4 [12/5/18 →Saturday]

Meal Menu Qty ex energy protein carbs fat

E.M milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 2 nos 2 170 4 40 -

B.F sambhar 1 cup 1+½+½ 130 7.5 24 -

onion chutney ½ cup 1 60 3 12 -

M.M ragi koozh 200ml 1 85 2 20 -

mashed dal rice ½ cup ¾+¼ 148.75 4.5 33.75 -

L mashed curd rice 1 cup - 160 4.5 32 2

mashed veg A ½ cup 1 30 - 6 -

E milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 2 nos 2 170 4 40 -

D
sambhar 1 cup 1+½+½ 130 7.5 24 -

BT milk + ensure 150ml - 158.55 6.63 14.7 7.9

egg white 3 nos. 3 45 12 - -

M.N
paneer 75g - 198.8 13.73 0.9 15.6

Oil 20ml 2 180 - - 20

Sugar 20g - 80 - 20 -

TOTAL 2063.2 82.62 296.75 61.3

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MONITORING AND ASSESSMENT:

Day – 1 [9/5/18 → Wednesday]

Meal Menu Qty ex energy protein carbs fat

E.M milk 100ml 1 65 3 4 4

idly 1.5 nos 1.5 127.5 3 30 -

B.F
sambhar ½ cup ½+¼+¼ 65 3.75 12 -

M.M milk 100ml 1 65 3 4 4

mashed dal rice ½ cup ¾+¼ 148.75 4.5 33.75 -

mashed rasam rice ½ cup ¾+¼ 71.25 1.5 16.5 -

L
mashed curd rice ½ cup ¾+¼ 80 2.25 16 1

mashed veg A ½ cup 1 30 - 6 -

E milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 1.5 nos 1.5 127.5 3 30 -

D
sambhar ½ cup ½+¼+¼ 65 3.75 12 -

Oil 20ml 2 180 - - 20

Sugar 20g - 80 - 20 -

TOTAL 1263.55 34.38 198.95 36.9

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Day – 2 [10/5/18 →Thursday]

Meal Menu Qty ex energy protein carbs fat

E.M milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 1.5 nos 1.5 127.5 3 30 -

B.F
sambhar ½ cup ½+¼+¼ 65 3.75 12 -

M.M Veg soup ½ cup 1 45 1.5 9 -

mashed dal rice ½ cup ¾+¼ 148.75 4.5 33.75 -

L mashed rasam rice ½ cup ¾+¼ 71.25 1.5 16.5 -

mashed veg A ½ cup 1 30 - 6 -

E milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 1.5 nos 1.5 127.5 3 30 -

D
sambhar ½ cup ½+¼+¼ 65 3.75 12 -

BT milk + ensure 150ml - 158.55 6.63 14.7 7.9

Oil 20ml 2 180 - - 20

Sugar 20g - 80 - 20 -

TOTAL 1415.65 40.89 213.35 43.7

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Day – 3 [11/5/18 →Friday]

Meal Menu Qty ex energy protein carbs fat

E.M milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 2 nos 2 170 4 40 -

B.F sambhar ½ cup ½+¼+¼ 65 3.75 12 -

radish chutney ½ cup 1 55 3 10 -

M.M Veg soup ½ cup 1 45 1.5 9 -

mashed dal rice ½ cup ¾+¼ 148.75 4.5 33.75 -

L mashed rasam rice ½ cup ¾+¼ 71.25 1.5 16.5 -

mashed veg A ½ cup 1 30 - 6 -

E milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 2 nos 2 170 4 40 -

D sambhar ½ cup ½+¼+¼ 65 3.75 12 -

chow- chow chutney ½ cup 1 30 - 6 -

BT milk + ensure 150ml - 158.55 6.63 14.7 7.9

Oil 20ml 2 180 - - 20

Sugar 20g - 80 - 20 -

TOTAL 1585.65 45.89 249.35 43.7

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Day – 4 [12/5/18 →Saturday]

Meal Menu Qty ex energy protein carbs fat

E.M milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 2 nos 2 170 4 40 -

B.F sambhar 1 cup 1+½+½ 130 7.5 24 -

onion chutney ½ cup 1 60 3 12 -

M.M ragi koozh 100ml ½ 42.5 1 10 -

mashed dal rice ½ cup ¾+¼ 148.75 4.5 33.75 -

L
mashed curd rice 1 cup - 160 4.5 32 2

E milk + ensure 150ml - 158.55 6.63 14.7 7.9

idly 2 nos 2 170 4 40 -

D
sambhar 1 cup 1+½+½ 130 7.5 24 -

BT milk + ensure 150ml - 158.55 6.63 14.7 7.9

egg white 1 no. 1 15 4 - -

M.N
paneer 75g - 198.8 13.73 0.9 15.6

Oil 20ml 2 180 - - 20

Sugar 20g - 80 - 20 -

TOTAL 1960.7 73.62 280.75 61.3

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HOSPITAL RECALL

Day Energy (Kcal) Protein (g) Carbs (g) Fat (g)

Day-1 1263.55 34.38 198.95 36.9

Day-2 1415.65 40.89 213.35 43.7

Day-3 1585.65 45.89 249.35 43.7

Day-4 1960.7 73.62 280.75 61.3

Total 6225.55 194.78 942.4 185.6

Average 1556.39 48.7 235.6 46.4

% MET 86% 79% 84% 96%

DISCHARGE DIET:

1. TYPE OF DIET : Soft diet

2. ENERGY : 1876Kcal @ 28Kcal/Kg IBW

3. PROTEINS : 87g@1.3 g/Kg IBW → 18.5%

4. CARBOHYDRATES : 57% of total calories → 267g

5. FATS : 24.5% of total calories → 51g

6. SODIUM : 2400mg

7. POTASSIUM : 4700mg

8. NNC/NPC : 1528Kcal

9. CALORIE : N2 RATIO : 136:1

10. FLUID REQUIREMENTS : 3.7 litres

11. RECOMMENDATIONS :Iron : 8 mg/day

Vitamin B : 2.4g/day

Zinc : 11 mg/day

Vitamin D : 20g/day

Vitamin E : 15 mg/day

Selenium : 55g/day
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EXCHANGE LIST OF PRESCRIBED MEDICAL NUTRITION THERAPY (REGIME)

FOOD GROUP EXCHANGE(Nos.) ENERGY(Kcal) PROTEIN(g) CARBS(g) FAT(g)

cereals 9 765 18 180 -

pulses 2 170 12 30 -

oil 2 180 - - 20

egg white 5 75 20 - -

milk & pdts 4 260 12 16 16

veg A 1 30 - 6 -

veg B 1 55 3 10 -

paneer 70g 185.5 12.81 0.84 14.56

sugar 20g 80 - 20 -

TOTAL 1800.5 77.81 262.84 50.56

Percentage 96% 90% 99% 99%

MEAL DISTRIBUTION

FOOD ITEMS EXCHANGE EM BF MM L SN ME D BT

cereals 9 3 3 3

pulses 2 1 ½ ½

oil 2 split for the whole day

egg white 5 1 3 1

milk & pdts 4 1 1 1 1

veg A 1 1

veg B 1 ½ ½

paneer 70g 35g 35g

sugar 20g split for the whole day

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SAMPLE MENU:

Meal Menu Qty ex energy protein carbs fat

EM milk 100ml 1 65 3 4 4

idly 3 nos 3 255 6 60 -

BF dal sambhar ½ cup 1 85 6 15 -

boiled egg white 1 1 15 4 - -

MM paneer blend 200ml - 157.75 9.4 4.4 11.3

Twice boiled rice 300g 3 255 6 60 -

L radish sambhar ½ cup ½+½ 67.5 4.5 12.5 -

egg white curry ½ cup 3 45 12 - -

ME cucumber slice ½ cup 1 30 - 6 -

SN paneer blend 200ml - 157.75 9.4 4.4 11.3

idly 3 nos 3 255 6 60 -

D carrot sambhar ½ cup ½+½ 67.5 4.5 12.5 -

egg white omelette 1 1 15 4 - -

BT milk 100ml 1 65 3 4 4

Oil 20ml 2 180 - - 20

Sugar 20g - 80 - 20 -

TOTAL 1800.5 77.81 262.84 50.56

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EVALUATION AND FOLLOW UP:

Anthropometry:

There was no change in the weight of the patient. The patient seemed to be

undernourished from the time of admission.

Biochemical parameters:

The ESR rate seemed to be high at the time of admission. The liver function tests also

showed abnormal ranges in its normal values. The sodium level was low at the time of

admission and then it was improved during the hospital stay.

Clinical signs and symptoms:

The patient seemed to be very weak at the time of admission and his health was

improved a little during his hospital stay.

Diet compliance:

The patient’s intake was very low at the time of admission and his intake was slowly

improved. The patient was then shifted to high protein diet and his intake slowly improved.

SUMMARY:

The patient was a 73 year old with complaints of cough, breathlessness and difficulty in

swallowing for about 15 days. He was diagnosed with pulmonary tuberculosis (on modified

ATT since 10/5/18), chronic obstructive pulmonary disorder (COPD), Moderate pulmonary

arterial hypertension (PAH), Type II Respiratory Failure (On Home Oxygen), Adjustment

disorder, possible chronic liver disease. He seemed to be very malnourished and weak. His

intake was also poor at the time of admission and slowly improved well, but didn’t meet his

daily needs.
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NUTRITION ASSESSMENT (SGA)

(To be filled by the dietitian within 24 hours of admission)

DIETARY INTAKE
1.  No Change; Adequate
2. Inadequate; Duration Of Inadequate Intake Soft diet
Suboptimal Solid Diet Full Fluids or Oral Nutrition Supplements Minimal-Intake, Clear Fluids or Starvation
3. Dietary Intake In Past 2 Weeks
Adequate 1500Kcal Improved but not adequate ________ No Improvement or Inadequate
WEIGHT Usual weight 62 kg Current weight 44 kg Height 167 cms

1. Non fluid weight change in past 6 months Weight loss (Kg) 10Kg
 <5% loss or weight stability 5-10% loss without stabilization or increase >10% loss and ongoing
If above not known, has there been a subjective loss of weight during the past 6 months?
None or Mild Moderate Severe
2. Weight change In the past 2 weeks Amount (if known) 5Kg
Increased No Change Decreased
SYMPTOMS (Experiencing symptoms affecting oral intake)
1. Pain on eating Anorexia Vomiting Nausea Dysphagia Diarrhea
Dental problems Feels full quickly Constipation Decreased intake & appetite
2. None Intermittent/mild/few Constant/severe/multiple
3. Symptoms in the past 2 weeks
Resolution of symptoms Improving No change or worsened
FUNCTIONAL CAPACITY (Fatigue & Progressive loss of function)
1. No dysfunction
2. Reduced capacity, duration of change _____________
Difficulty with ambulation / Normal activitiesBed / Chair-ridden
3. Functional capacity in the past 2 weeks
Improved No change Decreased
METABOLIC REQUIREMENT
High metabolic requirement No Yes

PHYSICAL EXAMINATION
Loss of body fat No Mild/Moderate Severe
Loss of muscle mass No  Mild/Moderate  Severe
Presence of edema/ascites No  Mild/Moderate  Severe

CACHEXIA
No Yes

SGA RATING
A – Well-nourished B – Mildly/ Moderately malnourished C- Severely malnourished
Normal Some progressive nutritional loss Evidence of wasting & Progressive symptoms

A – Detailed assessment not required (follow up after 3 days/ at the time of Discharge
B – To continue detailed assessment (review once in 2 days)
C – To continue detailed assessment (review everyday)
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NUTRITION CARE PLAN

Nutritional Diagnosis (PES Statement)

1. Problem : Decreased appetite

Etiology: Poor intake
Signs & Symptoms: 24 hour recall

2. Problem :
Etiology:
Signs & Symptoms:

3. Problem :
Etiology:
Signs & Symptoms:

Diet order in case sheet:

High protein diet

NUTRITION INTERVENTION:
Nutrition prescription:

Energy (Kcal) : 1530Kcal [45 Kcal/Kg (IBW/CW/ABW)]

Protein (g) : 51g [1.5 g/Kg) →13%

CHO (g) : 229g [60% of total calories)]

Fat (g) : 46g [27% of total calories)]

Salt (g) : Normal

Fluid (ml) : Normal

Other restriction : _______________

Goals : To provide adequate nutritional support

Food & drug interaction explained to patient – yes / not applicable

Will be review every day