Vision

A leading center of excellence in clinical nutrition

specialist program in 2025

Missions

Clinical Nutrition Specialist Program will provide a

comprehensive clinical training program 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
Surgery Ward, November 21th 2022

dr. Indrawaty Alimuddin

dr. Tien Muliawati
dr. Ruwiyatul Aliyah*
dr. Christine Rogahang
dr. Utami Handayani
dr. Kaslan
dr. Meylisa
 Patient Identity
Mr. H, 34 y.o. (Male)
MR number
.
976844
Date of birth October 9th, 1988
Admission Date November 15th, 2022
Consultation Date November 16th, 2022

Medical diagnosis
Medical Nutrition Diagnosis: Moderate Protein Energy Malnutrition (E44)
Digestive Diagnosis : Obstructive Jaundice et causa Stone Common Bile Duct
 Subjective since 5 months ago due to abdominal pain,
(History taking) nausea and vomiting, worsened in the last 2
weeks due to continuous vomiting with
Chief Complaint frequency more than 5 times, contained fluid
Decreased of oral intake and food left over
Nasogastric Tube
Headache No History
No history
Swallowing Disorders
Nausea & Vomiting No history
There was nausea since 2 weeks ago, but no
vomitting at this time. Last vomitting was 7 days ago
Abdominal Pain
There is upper right abdominal pain since 2
Fever and Seizure
weeks ago
No history
Weight loss
Cough and Shortness of Breath There was history of unintentional weight loss
No history approximately 7 kg ( 7.5 % of initial weight, 95
kg) since 5 months ago
 Subjective
(History taking)

Defecation Urination
Last defecation was 2 days ago, soft Via toilet, 2 times/day, seems to be
consistency, gray color normal
 Patient Family
Cerebrovascular disease Cerebrovascular disease
No history
No History
Cardiovascular disease, DM Cardiovascular disease, DM
No history No History

Kidney and urinary disease Kidney and urinary disease

No History No history

Hyperuricemia, hypercholesterolemia Hyperuricemia, hypercholesterolemia

No history No history

Others Others
No History) No history
 History of PRESENT Illness
• Patient complained upper right abdominal pain accompanied with nausea
and vomiting brought to Kolonedale Hospital, there he treated for 4 days
5 months with a diagnose chronic cholelithiasis and cholelithiasis of cystic duct, then
ago referred to Wahidin Sudirohusodo Hospital for further treatment. At Wahidin
Hospital he treated for 3 weeks diagnosed with obstructive jaundice et
causa distal CBD stone, undergone laparotomy exploration procedure of
CBD. And outpatient at polyclinic for several times.

• patient complained continuous abdominal pain, then brought to morowali

2 weeks hospital, there he treated for 1 week then referred to pelamonia hospital but
ago only treated for 1 day, with diagnose obstructive jaundice et causa suspect
CBD stone

• referred to Wahidin hospital for further treatment and treated at L4 urology

yesterday
until now.
 01 Occupation and Habit
He is Private Employee

Smoking
Psychosocial history 02
No History

03 Drugs and alcohol

No History
Intake Analysis
Last intake Energy (kcal) Protein (g) Carbohydrate(g) Fat (g)

24 hours 96.75 kcal 1.15 (8.5%) 21.1 (87.24%) 0.7 (6.51%)

(4.39%)
 OBJECTIVE
MODERATE ILLNESS
GCS E4M6V5

Vital signs Anthropometry

01 02
Blood pressure : 90/60 mmHg Body Height : 165 cm
Pulse : 68 beats/minute Acutal Body Weight : 88 kg
Respiratory rate : 16 times/minute Ideal Body Weight : 58,5kg
Temperature : 36.4°C MUAC : 32 cm
MAP : 70 mmHg BMI : 32,32
Estimated MUAC BW : 71,17 kg

Functional Status
03
Handgrip Strength: 11,1 kg
 Physical examination
HEAD AND NECK
Conjunctiva was not anemic, Sclera was icteric.
Oxygen was not supported
Nasogastric tube was not inserted
There was 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. No Rhonchi and
wheezing, regular heart sounds and no murmurs
ABDOMEN
Inspection : flat appearance
Auscultation : Normal Bowel Sound
Palpation : No tenderness
Percussion : Tympanic
 Physical examination
EXTREMITY
There was no wasting and edema at all extremities
 16

MEDICATION FROM OTHER DIVISION

Digestive (November 16th, 2022)

 IVFD NaCl 0,9% 20tpm

 Ceftriaxone 1gr/ 24 hours / Intravenous
 Ranitidin 50 mg/ 12 hours / Intravenous
 Metronidazole 1g/8 hours/ Intravenous
 LABORATORY FINDINGS
November
Laboratory Normal Value
14h, 2022
Fasting Plasma 102 <110 mg/dl
Glucose
Random Blood 118 <140 mg/dl
Glucose
AST 58 <38 U/L
ALT 65 <41 U/L
Total Bilirubin 48,55 <1,1 mg/dl
Direct Bilirubin 36,66 <0,30 mg/dl
Ureum 25 10- 50 mg/dl
Creatinine 0.59 M:(<1.3) ; F:(<1.1)
mg/dL
Sodium 128,8 135 – 145 mmol/L
Potassium 3,78 3.5 – 5.0 mmol/L
Chloride 102.8 97 – 111 mmol/L
PT 13 10-14 second
INR 1,04 0,8 – 1,1 second
APTT 36,3 22-30 second
Total Cholesterol 144 <200 mg/dl
HDL 30 M : 55, F : 65 mg/dl
LDL 54,9 <130
 RADIOLOGIC FINDINGS
USG Abdomen (November 7th 2022) ( Kolonodale Hospital )

 Hepatosplenomegaly
 Fatty liver
 Assesment
Metabolical status
November 14th, 2022
• Hyperbilirubinemia 48.5/ 36.6
• Hyponatremia 128, ESO 26.5
• Prolonged Coagulation Time 13/104/36.3

GI- Tract status Functional

HYDRATION STATUS Normovolemic
Functional Status Handgrip Strength: 11,1 kg
 22

Diagnosis & Prognosis

Medical Nutrition Diagnosis: Moderate Protein Energy Malnutrition (E44)
Digestive Diagnosis : Obstructive Jaundice et causa Stone Common Bile Duct

Prognosis
Vitam: Dubia ad bonam
Functionam: Dubia ad bonam
Sanactionam: Dubia ad bonam
 23
Planning
Basal Energy Expenditure : 1420 Kcal
Total Energy Expenditure : 2200 Kcal (1.2/1.3)

Macronutrient Composition:
• Protein 1.8 g/kgIBW/day : 105 g (17.6%)
• Carbohydrate 55% : 302 g
• Fat 26% : 63 g

Medical Nutrition Therapy is given equivalent to 40% TEE = 880 Kcal via enteral:
- Liver Blenderized food 380 Kcal
- ONS Hepatosol 300 Kcal
- Fruit Juice 100 Kcal

Fluid requirements 2000 cc/24 hours

Correction of Hyponatremia with sodium intake & NaCl 0.9%/ 1000 ml/ 24 hours (Total Deficit 528 + daily
Requirement 176 = 704 mEq) target 138 mmol/L
 24
Planning
• Supplementation via enteral :
 B. Complex 2 tabs/8 hours
 Zinc 20mg/ 24 hours

• Monitoring and evaluation

 Haemodynamic
 Daily intake
 Gastrointestinal tolerance

• Nutritional education:
 Follow the meal according to the schedule
 Insert NGT if there is no contraindications

• Lab : Hematological routine, Albumin, Lipid Profile, HbA1C, UUN

• Agree to join multidisciplinary care
FOLLOW UP
 Subjective Objective Assessment Planning

Intake via oral, ngt General Condition :MODERATE ILLNESS GCS E4M6V5 November 14th, 2022 Basal Energy Expenditure : 1420 Kcal
was not inserted. Vital sign :
There were nausea Blood pressure : 120/80 mmHg • Hyperbilirubinemia 48.5/ Total Energy Expenditure : 2200 Kcal (1.2/1.3)
Pulse : 90 beats/minute
and Vomiting 2 times,
Respiratory rate : 20 times/minute
36.6
contained liquid and Temperature : 37.1°C
food leftover. There • Moderate Hyponatremia 128,
was epigastric pain, Macronutrient Composition:
Anhtropometry ESO 265
patient fasted due to
Body Length : 165 cm • Protein 1.8 g/kgIBW/day : 105 g (19%)
MRI procedure • Prolonged Coagulation Time
Ideal Body Weight : 58.5 kg 13/104/36.3 • Carbohydrate 55% : 302 g
Defecation was Estimated MUAC BW : 71.17 kg
yesterday, seem to be • Fat 26% : 63 g
normal MUAC : 32 cm
Medical Nutrition Diagnosis:
IBM : 32.32 Moderate Protein Energy
Urination : Via Toilet,
seems to be normal Malnutrition (E44)
Food Recall 24 hours via Oral Medical Nutrition Therapy is given equivalent to
Energy : 209 Kcal (9.5%) Digestive Diagnosis : 40% TEE = 880 Kcal via oral:
Protein : 3.8 gr (3.8%) Obstructive jaundice et causa
Carbohydrate : 45.2 gr (86%)
Stone CBD - Low Fat soft standard food with chopped side dishes
Fat : 1.4 gr (6%) 575 kcal
1st day
Follow Up Physical Examination:
HEAD AND NECK
- ONS Hepatosol 300 Kcal
(November 17th,
2022) - Fruit Juice 100 Kcal
Conjunctiva was not anemic, Sclera was icteric
Oxygen was not supported
Nasogastric tube was not inserted - Egg whites 112.5 kcal
There was no enlargement of lymph nodes and thyroid gland
Fluid requirements 2000 cc/24 hours
CHEST
Inspection : Symmetric, There was loss of subcutaneous fat Correction of hyponatremia with sodium intake & NaCl
Palpation : No tenderness 0.9%/ 1000 ml/ 24 hours (Total Deficit 528 + daily
Percussion : Sonor Requirement 176 = 704 mEq) target 138 mmol/L
Auscultation : Vesicular breathing sound.There was no rhonchi and
wheezing, regular heart sounds and no murmurs
Supplementation via Oral :
ABDOMEN -Zinc 20mg/24jam/oral
Inspection : Flat Appearance - B comp 2 tab/8 hours
Auscultation : Normal Bowel Sound
Palpation : No Tenderness
Percussion : Tympanic Monitoring and evaluation
-Haemodynamic
EXTREMITY -Daily intake
There was not wasting and edema in all extremities -Gastrointestinal tolerance

Nutritional education:
Follow the meal according to the schedule & Waiting for
Routine Hematology , Albumin, Profile Lipid , HbA1c,
 LABORATORY FINDINGS

November
Laboratory Normal Value
17th, 2022
WBC 10.06 4,0 - 10,0 x 103/μL
TLC 1.166 1.5 - 4 x 103/μL
PLT 145.000 150-400 x 103 /μL
HGB 13.9 12.0 -16.0 gr/dl
MCV 94 80 – 100 μm3
MCH 33 27.0 – 32.0 pg
MCHC 35 32.0-36.0 g/dl
Neutrofil 80.3 52.0-75.0%
Lymfosit 11.0 20.0-40.0%
HbA1c 4.2 4-6%
Albumin 4.2 3.5-5.0 gr/dl
Total Cholestrol 123 200 mg/dL

HDL Cholestrol 7 M >55; F >65 mg/ dl

LDL Cholestrol 65 <130 mg / dl
Triglycerides 408 200 mg/ dl
NLR 7.3 < 3.13
 LABORATORY FINDINGS

November
Laboratory Normal Value
18th, 2022
UUN 8 12-20 gr/ 24 hours
 Subjective Objective Assessment Planning

Intake via oral, There General Condition :MODERATE ILLNESS GCS E4M6V5 November 14th, 2022 Basal Energy Expenditure : 1420 Kcal
was no nausea and Vital sign :
Vomiting. There was Blood pressure : 90/60 mmHg • Hyperbilirubinemia 48.5/ Total Energy Expenditure : 2200 Kcal (1.2/1.3)
Pulse : 68 beats/minute
intermittent
Respiratory rate : 16 times/minute
36.6
abdominal pain Temperature : 36.4°C
• Moderate Hyponatremia 128, Macronutrient Composition:
Anhtropometry ESO 265
Defecation was
Body Length : 165 cm • Protein 1.8 g/kgIBW/day : 105 g (19%)
yesterday, seem to be • Prolonged Coagulation Time
normal Ideal Body Weight : 58.5 kg 13/104/36.3 • Carbohydrate 55% : 302 g
Estimated MUAC BW : 71.17 kg
Urination : Via Toilet, • Fat 26% : 63 g
seems to be normal MUAC : 32 cm
November 17th, 2022
IBM : 32.32
-Leukocytosis 10,600
Food Recall 24 hours via Oral Medical Nutrition Therapy is given equivalent to
Energy : 779 Kcal (35%) - Increased NLR 7.3 50% TEE = 1100 Kcal via oral:
2nd day Protein : 29.4 gr (15%)
Follow Up Carbohydrate : 146.2 gr (75%) - Moderate Deplession of Imune - soft standard food with chopped side dishes ( hepar
(November 18th, Fat : 7.5 gr (8.6%) System 1166 diet) 575 kcal
2022)
Physical Examination:
HEAD AND NECK -Hypertriglycerides 408 - ONS Hepatosol 300 Kcal

Conjunctiva was not anemic, Sclera was icteric - Fruit Juice 100 Kcal
Oxygen was not supported
Nasogastric tube was not inserted Medical Nutrition Diagnosis: - Egg whites 112.5 kcal
There was no enlargement of lymph nodes and thyroid gland Moderate Protein Energy
Malnutrition (E44) Fluid requirements 2000 cc/24 hours
CHEST
Inspection : Symmetric, There was loss of subcutaneous fat Correction of hyponatremia with sodium intake & NaCl
Palpation : No tenderness
Digestive Diagnosis :
Obstructive Jaundice et causa 0.9%/ 1000 ml/ 24 hours (Total Deficit 528 + daily
Percussion : Sonor Requirement 176 = 704 mEq) target 138 mmol/L
Auscultation : Vesicular breathing sound.There was no rhonchi and Stone CBD & waiting for lab result
wheezing, regular heart sounds and no murmurs

ABDOMEN Supplementation via Oral :

Inspection : Flat Appearance -Zinc 20mg/24jam/oral
Auscultation : Normal Bowel Sound - B comp 2 tab/8 hours
Palpation : No Tenderness
Percussion : Tympanic
Monitoring and evaluation
EXTREMITY -Haemodynamic
There was not wasting and edema in all extremities -Daily intake
-Gastrointestinal tolerance

Nutritional education:
Follow the meal according to the schedule
 Subjective Objective Assessment Planning

Intake via oral, There General Condition :MODERATE ILLNESS GCS E4M6V5 November 18th, 2022 Basal Energy Expenditure : 1420 Kcal
was no nausea and Vital sign :
Vomiting. There is Blood pressure : 100/60 mmHg -UUN 8 BN -7 Total Energy Expenditure : 2200 Kcal (1.2/1.3)
minimal abdominal Pulse : 68 beats/minute
Respiratory rate : 16 times/minute
pain Temperature : 36.5°C
- Mild Hyponatremia 131 <-128
November 17th, 2022 Macronutrient Composition:
Anhtropometry
Defecation was 2
Body Length : 165 cm - Leukocytosis 10,600 • Protein 1.8 g/kgIBW/day : 105 g (19%)
days ago, seem to be
normal Ideal Body Weight : 58.5 kg
• Carbohydrate 55% : 302 g
Estimated MUAC BW : 71.17 kg - Increased NLR 7.3
Urination : Via Toilet, • Fat 26% : 63 g
seems to be normal MUAC : 32 cm - Moderate Deplession of
IBM : 32.32 Immune System 1166

Food Recall 24 hours via Oral - -Hypertriglycerides 408 Medical Nutrition Therapy is given equivalent to
Energy : 1162 Kcal (52%) 70% TEE = 1540 Kcal via oral:
3rd day Protein : 52.5gr (18%) November 14th, 2022
Follow Up Carbohydrate : 204 gr (70%) - soft standard food with chopped side dishes ( hepar
(November 19th, Fat : 13.8 gr (10%) • Hyperbilirubinemia 48.5/ diet) 575 kcal
2022) 36.6
Physical Examination:
HEAD AND NECK
- ONS Hepatosol 300 Kcal
• Moderate Hyponatremia
Conjunctiva was not anemic, Sclera was icteric 128, ESO 265 - Fruit Juice 100 Kcal
Oxygen was not supported
Nasogastric tube was not inserted • Prolonged Coagulation - Egg whites 112.5 kcal
There was no enlargement of lymph nodes and thyroid gland Time 13/104/36.3
Fluid requirements 2000 cc/24 hours
CHEST
Inspection : Symmetric, There was loss of subcutaneous fat Correction of hyponatremia with sodium intake & NaCl
Palpation : No tenderness 0.9%/ 1000 ml/ 24 hours (Total Deficit 475 + daily
Percussion : Sonor Requirement 176 = 651 mEq) target 140 mmol/L
Auscultation : Vesicular breathing sound.There was no rhonchi and
wheezing, regular heart sounds and no murmurs
Medical Nutrition Diagnosis:
Moderate Protein Energy Supplementation via Oral :
ABDOMEN Malnutrition (E44) -Zinc 20mg/24jam/oral
Inspection : Flat Appearance - B comp 2 tab/8 hours
Auscultation : Normal Bowel Sound Digestive Diagnosis :
Palpation : No Tenderness Obstructive Jaundice et causa
Percussion : Tympanic Monitoring and evaluation
Stone CBD -Haemodynamic
EXTREMITY -Daily intake
There was not wasting and edema in all extremities -Gastrointestinal tolerance

Nutritional education:
Follow the meal according to the schedule
SGA
 Genetik, Jenis Obesitas, pola hidup,
Biosintesis kolesterol berlebihan
Kelamin, Usia merokok
Trombositope
nia Gangguan
hemostasis
Respon inflamasi
(IL-1,IL6,TNF α Batu CBD
Stres hormon
Hiperbilirubinemia Ikterus
meningkat

Deplesi Obst.ekstrahepatik
sedang system oleh CBD
vit B, vit C,
imun Leukositosis Kembali ke
zinc sirkulasi
Antibiotik
Aliran bil, garam Nyeri Mual dan
Hiperkatabolik empedu / hasil perut muntah
Peningkatan NLR
eksresi hepatic
tersumbat

Asupan makan Koreksi dengan

Hiponatemia
Glukoneogenesis menurun asupan dan NaCl
Proteolisis Penurunan BB 0,9%
Hipertrigliserida
Lipolisis

Terapi nutrisi 1800 kkal

Protein 1.8gr/kgBBI,
Malnutrisi
Karbohidrat55%, Lemak
25-27 %
Thank you