Vision

A leading center of excellence in clinical nutrition specialist

programme in 2025

Missions

Clinical Nutrition Specialist Programme will provide a

comprehensive clinical training programme that embodies the
following characteristic:
1. Uphold scientific and medical profession ethic
2. Meet national & international standard of clinical
competence
3. Implement research in contribution towards basic and
clinical nutrition science
4. Provide high quality clinical nutrition service
CLINICAL NUTRITION CONFERENCE
Neurology Ward–June 14th, 2021

dr. Laode Jumadil Jaya Sentosa

dr Silvia
dr. Yemima Wandia Christiani
dr. Ni Luh Eka Suprapti*
dr. Wanty Arruan
dr. Maya Rosmaria Puspita
dr. Rury Laila Saptari
 Patient identity
Mr. P, 62 y.o. (male)
MR number
. 937119
Date of birth December 12th 1958
Admission Date June 9th 2021
Consultation Date June 10th 2021

Medical diagnosis
Clinical Nutrition Diagnosis : Moderate Protein Energy Malnutrition (SGA Score B)
Neurology Diagnosis : Non Traumatic Intracerebral Hemorrhage + Hemiplegia affecting right
non dominant side + Dysarthria
Nephrology Diagnosis : Acute On CKD + Essential Hypertension + Type 2 Diabetes Mellitus
 Subjective
(History taking)
Since 4 days ago due to swallowing disorder.
Chief Complaint There was history decreased of oral intake since
History taking
Decreased of oral intake a year ago due to pain at right upper abdomen
and feeling his stomach early satiety
Headache
No history Swallowing Pain and swallowing
disorder
Nausea & Vomiting He had swallowing disorder since 4 days ago
No history
Epigastric Pain
Fever and Seizure No history
No history Weight loss
There was history of unintentional weight loss
Cough and Shortness of Breath
since a year ago for about 21 %
No history
 Subjective
(History taking)

Defecation Urination
Last defecation was 4 days ago. He urinated via diapers, changed 2-3
Seemed to be normal times/day
 Patient Family
Cerebrovascular disease Cerebrovascular disease
No history His brother had stroke

Cardiovascular disease Cardiovascular disease

He had Hypertension since 5 years ago, taking His brother had hypertension
amlodipine 10 mg/day, regularly
Kidney and urinary disease Kidney and urinary disease
No history
No history
Hyperuricemia, hypercholesterolemia,.DM
He had DM since 4 years ago, taking metformin Hyperuricemia, hypercholesterolemia, DM
500mg/day, regularly No history

Others
Others
There was history of hepatitis since 1 year
ago. No history
 History of PRESENT Illness
A year 4 days 2 days
ago ago ago

He complained pain
He suddenly feel
at his right upper
weakness at the
abdomen and feeling
right hand and leg.
his stomach early He referred to
He had difficulty to
satiety. He brought Wahidin
speak and
to Polewali Hospital Sudirohusodo
swallowing disorder.
and diagnosed Hospital, for further
Then he brought to
Hepatitis. Then he treatment
Mamuju Hospital
underwent outpatient
and treated for 2
treatment at that
days.
hospital
 01 Job and Occupation
He is a retired of civil servant
Psychosocial history
02 Smoking
Active smoker since he was young (1 pack per
day), stopped since 4 days ago

03 Drugs and alcohol

He drinks a glass of beer/wee when he was
young
Dietary History
Typical intake and usual amount of food: (before admitted to the hospital)
Intake:
Via oral
Quantity:
He eats regularly 3 times per day,1-2 portions of white rice with variety of side dishes and vegetables
Quality:
He likes to eat honey 1 spoonful per day, he likes to eat sweet food, salty food, instant noodle 2 times per
week.

 A year ago, he ate 3 times per day, ½ portion of white rice with ½ portion of side dishes, no
vegetables
 4 days ago, he ate 3 times per day, ½ portion of porridge with ½ portion of side dishes, no vegetables
 No history of food allergy and lactose intolerance
 OBJECTIVE
Moderate illness appearance
GCS E3M6V5

Vital signs Anthropometry

01 02
Blood pressure : 170/90 mmHg Body height : 165 cm
Pulse : 72 beats/minute IBW : 58.5 kg
Respiratory rate : 20 times/minute MUAC : 23 cm
Temperature : 36.5 °C MUAC Body Weight : 51.15 kg

Food Recall 24 hours via oral : 04 Functional Capacity :

03 Energy : 600 kcal (33,33%) Left hand HG strength: 11.3 kg
Protein : 13 g (8,6 %)
Carbohydrate : 137 g (91,3%)
Fat : 0 g (0%)
 Physical examination
HEAD AND NECK
Conjunctiva was anemic, sclera was not icteric
Oxygen support was not applied
Nasogastric tube was not inserted
No enlargement of lymph nodes and thyroid gland

CHEST
Inspection : Symmetric, there was loss of subcutaneous fat
Palpation : no tenderness
Percussion : sonor
Auscultation : Vesicular breathing sound. There were no rhonchi or wheezing
 Physical examination
ABDOMEN
Inspection : Flat appearance
Auscultation : Peristaltic normal
Palpation : No tenderness
Percussion : Tympanic

EXTREMITY
There was wasting at the lower extremities
There was no edema at all extremities
 LABORATORY FINDINGS
Laboratory June 10th, 2021 June 9th, 2021 Normal Value

HB - 11,1 12,0 - 16,0 gr/dL

WBC - 6,1 4,0 - 10,0 x 103/μL
TLC - 1012 1.5-4 x 103/μL
PLT - 107000 150 – 400 x103 /mm3
MCV - 92 80 -100 μm3
MCH - 29 27 - 32 pg
MCHC - 31 32 - 36 g/dl
HbA1C 6,4 - 4-6 %
Fasting blood Glucose 109 - 110 mg/dl
ALT - 27 < 38 U/L
AST - 29 <41 U/L
Ureum - 84 10-50 mg/dl
Creatinine - 2.35 M(< 1,3), W (<1.1)
Sodium - 140 136-145 mmol/l
Potassium - 5.5 3,5-5,1 mmol/l
Chloride - 118 97-111 mmol/l
 RADIOLOGY FINDINGS
MSCT Brain(June 9th, 2021)
 Intracerebral hemorrhage in the lentiform nucleus and left external capsule
with an estimated bleeding volume of +/- 21.22 cc
 Brain atrophy
 Rhinitis atroficans
 Deviation of the nasal septum to the left
 MEDICATION FROM OTHER DIVISION

Neurologist (June 10th, 2021) Kidney Hipertension Disease(June 10th, 2021)

• Citicholine 250 mg/12hours/intravenous • Low Protein Diet 0.6 – 0.8 g/kg IBW/day
• Mecobalamin • Low Purine Diet
500mg/24hours/intravenous • Low Sodium Diet <2g/day
• Perdipine 0,5 mg/kgbb (9,7cc/hours/SP) • Resfar 500mg/12hours/intravenous
• Metformin 500mg/12hours/oral • Kalitake 1 sachet/8hours/oral
• Amlodipine 10mg/24hours/oral
• Laxadyne syrup 10cc/8hours/oral
• Ranitidine 50mg/12 hours/intravenous
• Ketorolac 30mg/12hours/intravenous
Metabolical status
June 10th, 2021
Impairment of Carbohydrate metabolism (6.4%)
June 9th, 2021
Normocytic normochromic anemia (11.1)
Thrombocytopenia (107000)
Moderate depletion of immune system (1012)
Impairment of kidney function (84/2.35)
Hyperkalemia (5.5)

GI- Tract status Functional

Assessment
Clinical Nutrition Diagnosis : Moderate Protein Energy Malnutrition (SGA Score B)
Neurology Diagnosis : Non Traumatic Intracerebral Hemorrhage + Hemiplegia affecting right non dominant
side + Dysarthria
Nephrology Diagnosis : Acute On CKD + Essential Hypertension + Type 2 Diabetes Mellitus
 

• BEE = 1163.8 kcal Planning

• TEE = 1815.5 1800 kcal (1.2/1.3)

Macronutrient Composition :
• Protein 0.8 g/kg IBW/day = 46.8 g/day (10.4%)
• Carbohydrate 50% = 225 g
• Fat 39.6% = 79.2 g

Nutritional therapy was given 50% of TEE (900 kcal) via enteral
• DM Blenderized food 447.15 kcal
• ONS Nephrisol 405 kcal
• Fluid requirements 1800 ml/24 hours Planning
• Correction of hyperkalemia with low potassium intake and kalitake 1 sachet/8hours/enteral (By Nephrologist)
• Suplementation via enteral :
- Zinc 20 mg/24 hours
- B Complex 2 tab/8 hours
- Curcuma 400 mg/8 hours
- Folic Acid 1 mg/24 hours

•Monitoring & evaluation :

- Daily intake
- Gastrointestinal tolerance

• Nutritional education : Insert Nasogastric tube, Follow the meal plan according to schedule

• Laboratory : Albumin, Total Protein

• Agree to join multidisciplinary care

FOLLOW UP
LABORATORY FINDINGS

Laboratory1 June 11st, 2021 Normal Value

Random Blood Glucose 150 140-200mg/dl
 RADIOLOGY FINDINGS
USG Abdomen (June 11st, 2021)
 Splenomegaly
 Cholecystitis
 Ascites
 Subjective Objective Assessment Planning
Nutritional General Condition : Moderate Illness, GCS E4M6V5 Metabolic Status : BEE = 1163.8 kcal
intake via oral Food Recall via oral and enteral: TEE = 1815.5 ~ 1800 kcal (1.2/1.3)
and enteral. No Energy: 437.5 + 202.13 = 639.63 kcal (36%) June 10th, 2021
residue. There Protein: 15 + 12.9 = 27.9 g (17%) Impairment of Carbohydrate metabolism Macronutrient Composition :
(6.4%) Protein 0.8g/kg IBW/day = 46.8 g/day (10.4%)
was no Carbohydrate: 86.25 + 19.73 = 105.98 g (66%) Carbohydrate 50% = 225 g
shortness of Fat: 3.5 + 7.65 = 11.15 g (16%) June 9th, 2021
Normocytic normochromic anemia (11.1) Fat 39.6% = 79.2 g
breath Thrombocytopenia (107000)
Anthropometry Moderate depletion of immune system Nutritional therapy was given 50% of TEE (900
Defecation: Body length : 165 cm (1012) kcal) via enteral
He defecated IBW : 58.5 kg Impairment of kidney function (84/2.35) DM Blenderized food 447.15 kcal
this morning, MUAC : 23 cm Hyperkalemia (5.5) ONS Nephrisol 405 kcal
seemed to be MUAC Body Weight : 51.15 kg
normal Handgrip Strength : 11.3 Fluid requirements : 1800 ml/24 hours
Gastrointestinal Status : Functional
Clinical Nutrition Diagnosis : Moderate Correction of hyperkalemia with low potassium
Urination: Vital sign : intake and kalitake 1 sachet/8hours/enteral (by
He urinated via Blood pressure : 160/83 mmHg Protein Energy Malnutrition (SGA Score B)
nephrologist)
diaper, changed Pulse : 92 bpm Neurology Diagnosis : Non Traumatic
twice per day. Respiratory rate: 20 x/ minute Intracerebral Hemorrhage + Hemiplegia Suplementation via enteral :
Then he Temperature : 36.5°C affecting right non dominant side + - Zinc 20 mg/24 hours
urinated via Dysarthria - B Complex 2 tab/8 hours
cathether - Curcuma 400 mg/8 hours
800cc/13hours Physical Examination: Nephrology Diagnosis : Acute On CKD +
HEAD AND NECK - Folic Acid 1 mg/24 hours
Essential Hypertension + Type 2 Diabetes
Conjunctiva was anemic, sclera was not icteric Mellitus Monitoring & evaluation :
Oxygen support was not applied - Daily intake
Nasogastric tube was inserted
1st day No enlargement of lymph nodes and thyroid gland
- Gastrointestinal tolerance

Follow Up CHEST Nutritional education : Follow the meal plan

Symmetric, there was loss of subcutaneous fat, no tenderness, sonor, according to schedule
(June 11th, Vesicular breathing sound, no rhonchi and wheezing
2021) ABDOMEN Laboratory : waiting for the newest laboratory
Flat appearance, Normal bowel sound, No tenderness, Tympanic result : Albumin, Total Protein
EXTREMITY
There was wasting at the lower extremities
There was no edema at all extremities
LABORATORY FINDINGS

Laboratory1 June 12nd, 2021 Normal Value

Fasting Blood Glucose 151 110 mg/dl
 LABORATORY FINDINGS
URINALYSIS Laboratory June 11th, 2021 Normal Value
Colour Dark yellow Light yellow
pH 6,0 4.5 - 8.0
Spesific gravity >1.030 1.005 - 1.035
Protein ++/100 Negatif
Glucose Negatif Negatif
Bilirubine Negatif Negatif
Urobilinogen Normal Normal
Keton Negatif Negatif
Nitrit Negatif Negatif
Blood +++ / 200 Negatif
Leukocyte +++ / 500 Negatif
Vit. C 0 Negatif
Leukocyte sediment 74 < 5 lpb
Eritrocyte Sediment 198 < 5 lpb
Thorax Sediment Negatif lpk
Crystal Sediment Negatif lpk
Epithelial cell sediment 55 lpk
Others Sediment Bacteria= 1, WBCC=2, MUCOSA=46 ul
 Subjective Objective Assessment Planning
Nutritional General Condition : Moderate Illness, GCS E4M6V5 Metabolic Status : BEE = 1163.8 kcal
intake via Food Recall via enteral: TEE = 1815.5 ~ 1800 kcal (1.2/1.3)
enteral. No Energy: 852.15 kcal (47.3%) June 12nd, 2021
residue. There Protein: 20.85 g (9.7%) Fasting blood glucose 151, Macronutrient Composition :
Proteinuria, hematuria, leukocyturia Protein 1 g/kg IBW/day = 58,5 g/day (13%)
were no Carbohydrate: 108.6 (50%) Carbohydrate 50% = 225 g
shortness of Fat: 36.3 g (38,3%) June 10th, 2021
Impairment of Carbohydrate metabolism Fat 37% = 74 g
breath, fever,
and cough. Vital sign : (6.4%)
June 9th, 2021 Nutritional therapy was given 70% of TEE (1260
Blood pressure : 145/80 mmHg Normocytic normochromic anemia (11.1) kcal) via enteral:
Defecation: Pulse : 72 bpm Thrombocytopenia (107000) DM Blenderized food 670.73 kcal
Last defecation Respiratory rate: 20 x/ minute Moderate depletion of immune system ONS Entramix 585 kcal
was yesterday, Temperature : 36.8°C (1012.6)
seemed to be Impairment of kidney function (84/2.35) Fluid requirements 1800 cc/24 hours
normal Physical Examination: Hyperkalemia (5.5)
Correction of hyperkalemia with low potassium
HEAD AND NECK intake and kalitake 1 sachet/8hours/enteral (by
Urination: Conjunctiva was anemic, sclera was not icteric Gastrointestinal Status : Functional nephrologist)
He urinated via Oxygen support was not applied
via cathether Nasogastric tube was inserted Clinical Nutrition Diagnosis : Moderate Suplementation via enteral :
1600cc/24 No enlargement of lymph nodes and thyroid gland Protein Energy Malnutrition (SGA Score B) - Zinc 20 mg/24 hours
hours CHEST - B Complex 2 tab/8 hours
Neurology Diagnosis : Non Traumatic
Symmetric, there was loss of subcutaneous fat, no tenderness, sonor, Intracerebral Hemorrhage + Hemiplegia - Curcuma 400 mg/8 hours
Vesicular breathing sound, no rhonchi and wheezing affecting right non dominant side + - Folic Acid 1 mg/24 hours
ABDOMEN Dysarthria
Monitoring & evaluation :
Flat appearance, Normal bowel sound, No tenderness, Tympanic
2 day
nd
EXTREMITY
Nephrology Diagnosis : Acute On CKD +
Essential Hypertension + Type 2 Diabetes
- Daily intake
- Gastrointestinal tolerance
There was wasting at the lower extremities
Follow Up There was no edema at all extremities
Mellitus
Nutritional education : Follow the meal plan
(June 12th, according to the schedule
2021)
Laboratory : waiting for the newest laboratory
result: Albumin, total protein
SGA