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,
PELAMONIA HOSPITAL
November 24th 2022

dr. Jeffry*
dr. Maya Rosmaria Puspita
 3
Patient Identity
.Mrs. M, 42 y.o. (Female)
MR number 715442
Date of birth October 21st,1980
Admission Date November 21st,2022
Consultation Date November 22nd,2022

Medical diagnosis

Medical Nutrition Diagnosis: Severe Protein Energy Malnutrition (SGA score C)

Oncologist Diagnosis : Papillary Carsinoma Thyroid + Cancer Pain
 4

Subjective
Since 2 months ago due to swallowing pain, nape pain
Main Complaint and headache. It had been getting worse since 2 weeks
Decrease of oral intake ago due to worsening swallowing pain and worsening
headache.

Nausea & Vomiting Swallowing Pain

There swallowing pain since 2 months ago
There was nausea occasionally. No history of
vomiting. Nasogastric Tube
No history
Fever and Seizure
No History Epigastric and Abdominal Pain
No History

Cough and Shortness of Breath Weight Loss

No History There was unintentional weight loss since 2 months ago, ±
6,1 kg (12.4%) from initial body weight 47 kg
 5
Subjective
(History taking)

Defecation Urination
Last defecation was last night, soft Via Chamber pot, yellowish
consistency, brownish
 6

Patient Family
Cerebrovascular disease
Cerebrovascular disease
No History
No History
Cardiovascular disease,
Hypertension, DM
Cardiovascular disease,
Hypertension, 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
Thyroidectomy 1 year ago
 7
History of PRESENT Illness

2 months 2 weeks 5 days 2 days ago

ago ago ago

She was complained

She was complained She referred to
headache and nape
worsening headache and emergency room at
pain. She went to She was hospitalized for 3
worsening nape pain. She Pelamonia Hospital and
Wahidin days at RSUD KH Hayung
went to outpatient of RSUD treated in surgery ward
Sudirohusodo
KH Hayung. until now
Hospital’s outpatient.
 8

01 Job and Occupation

House wife

Psychosocial history 02 Smoking

No History

03 Drugs and alcohol

No History
Dietary History 9

Typical intake and usual amount of food: (before admitted to the hospital)
Intake:
Via oral
She eats regularly 3 times/day, 1 portion of white rice with a variety of side dishes and vegetable
Quality:
She likes to eat grilled fish, instant noodle, and fruit 4-5 times/week

 2 months ago, She ate 3 times/day,½- ¾ portion of white rice, with ½- ¾ portion of side dishes and vegetable,
½- ¾ portion of fruit
 1 month ago, She ate 3 times/day, ¼ - ½ portion of white rice or porridge, with ¼ - ½ side dishes and
vegetable, ¼ - ½ portion of fruit
 2 weeks ago, She ate 3 times/day, 5 tablespoons white rice or porridge,a few of side dishes and vegetable
 24 hours, she ate 3 times /day, 5 tablespoons white rice or porridge, ,a few of side dishes, 3 portion of fruit
Intake Analysis
10

Last intake Energy (kcal) Protein (g) Carbohydrate(g) Lipid (g)

24 hours 421.71 kcal (20.%) 15.3 g (23.4%) 83 g (67.5%) 3 g (7.4%)

Fluid balance : difficult to evaluated

 11

OBJECTIVE
Moderate ILLNESS
Compos Mentis, GCS E4M6V5

Vital signs Anthropometry

01 02
Blood pressure : 116/77 mmHg Body Length : 157 cm
Pulse : 84 beats/minute Ideal Body Weight : 51.3 kg
Respiratory rate : 20 times/minute Estimated MUAC BW : 40.9
MAP : 90 mmhg MUAC : 20.5 cm
Temperature : 36.5 °C

03 Functional Status : 04 Handgrip Strength : 10.2 kg

ECOG Score II
 Physical examination 14

HEAD AND NECK

Conjunctiva was anemic, Sclera was not icteric
Oxygen was not supported
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 was no rhonchi
and wheezing, regular heart sound and no murmur

ABDOMEN
Inspection : Flat Appearance
Auscultation : Normal Bowel Sound
Palpation : No tenderness
Percussion : Tympanic
 15

Physical examination
EXTREMITY
There was minimal wasting and no oedema at all extremities
 16

MEDICATION FROM OTHER DIVISION

Oncologist (November 22th, 2022)
 IVFD RL 20 gtt/minute/ intravenous
 MST 1 tablet/12 Hours/oral
 Ranitidine 1 ampoule/ 8 hours/ intravenous
 Neurobion 1 ampoule/ 24 hours/ intravenous
 LABORATORY FINDINGS
November
Laboratory Normal Value
21st, 2022
WBC 17.48 4,0 - 10,0 x 103/μL
TLC 1083.7 1.5 - 4 x 103/μL
PLT 540 150-400 x 103 /μL
HGB 9.4 12.0 -16.0 gr/dl
MCV 75.1 80 – 100 μm3
MCH 24.2 27.0 – 32.0 pg
MCHC 32.2 32.0-36.0 g/dl
Neutrofil 87.5 52.0-75.0%
Lymfosit 6.2 20.0-40.0%
NLR 14.11 < 3.13
 Assesment
Metabolical status

November 21st, 2022

• Hypochromic Microcytic Anemia 9.4
• Increased of NLR 14.5
• Thrombocytosis 540.00
• Leukocytosis 17.480

GI- Tract status Functional

HYDRATION STATUS Normovolemic
 22

Diagnosis & Prognosis

Medical Nutrition Diagnosis: Severe Protein Energy Malnutrition (SGA Score C)

Oncologist Diagnosis : Papillary Carsinoma Thyroid + Cancer Pain

Prognosis
Vitam: Dubia ad bonam
Functionam: Dubia ad bonam
Sanactionam: Dubia ad bonam
 23
Planning
Basal Energy Expenditure : 1140.3 Kcal
Total Energy Expenditure : 1800 Kcal (AF/SF 1.2/1.3)

Macronutrient Composition:
• Protein 1.5 g/kgBW/day : 76.9 g (17.1%)
• Carbohydrate 50% : 225 g
• Fat 32.9% : 65.8 g

Medical Nutrition therapy is given 40% TEE (720 kcal) via oral :

Oral :
• Soft Standart food 287.5 kcal
• ONS Entrasol platinum 3 x 125 kcal
• Fruit Juice 50 kcal
• VCO 80 kcal

Fluid requirements 1800 cc/24 hours

 24
Planning
• Supplementation via oral :
 Zinc 20 mg/24 hours/ oral
 Neurobion 1 Amp/24 jam/Intravenous
 Vitamin C 500 mg/24 jam/ oral

• Monitoring and evaluation

 Vital Sign
 Daily intake
 Gastrointestinal tolerance

• Nutritional education:
 Follow the meal according to the schedule

• Lab : Urea, Creatinine, Albumin, electrolyte

• Agree to join multidisciplinary care
 25

FOLLOW UP
 LABORATORY FINDINGS

November
Laboratory Normal Value
22nd, 2022
Albumin 2.5 3.5 – 5 g/dl
Ureum 35 10 – 50 mg/dl

Creatinin 0.74 0.6 – 1.2 mg/dl

eGFR 100.24
Random Blood Glucose 115 70-200 mg/dl
Sodium 134.1 136-145 mmol/L
Pottasium 3.13 3.5 -5.1 mmol/L
Chloride 104.0 96-106 mmol/L
 Subjective Objective Assessment Planning

Headache, nape General Condition : Severe Illness, GCS E4M6V5 Metabolic status : Basal Energy Expenditure : 1140.3 Kcal
pain was Total Energy Expenditure : 1800 Kcal (AF/SF 1.2/1.3)
decreasing. Difficult Food Recall 24 hours via oral :
to swallow was Energy : 421.71 kcal (20.3%) November 22th 2022 Macronutrient Composition:
decreased. There Protein : 15.3 gr (23.4%) • Protein 1.5 g/kgBW/day : 76.9 g (17.1%)
wasn’t nausea and Carbohydrate : 83 gr (67.5 %) • Mild Hypoalbuminemia 2.5
vomiting. There Fat : 3 gr (7.4 %) • Mild hyponatremia 134.1 eso 280.4 • Carbohydrate 50% : 225 g
wasn’t fever.
Vital sign : • Mild Hypokalemia 3.13 • Fat 32.9% : 65.8 g
Blood pressure : 106/77 mmHg • November 4st, 2022
Pulse : 88 beats/minute • Hypochromic Microcytic Anemia 9.4 • Medical Nutrition therapy is given 50% TEE (900 kcal), via oral :
Respiratory rate : 20 times/minute
Temperature : 36.5°C • Increased of NLR 14.5
• Oral :
• Thrombocytosis 540.00 • Soft Standart food 575 kcal
Defecation Anthropometry:
Last defecation last Body Length : 157 cm • Leukocytosis 17.480 • ONS Entrasol platinum 3 x 93.75 kcal
night, soft Ideal Body Weight : 51.3 kg
consistency, • White egg extra 2x37,5 kcal
brownish MUAC : 20.5 cm
Medical Nutrition Diagnosis: Severe Protein
Estimated MUAC BW : 40.9 kg Energy Malnutrition (SGA C) • Juice 50 kcal
Urination
Via potty, normal, Oncologist Diagnosis : Papillary carsinoma • Vco 40 kcal
yellowish Thyroid + Cancer Pain
Physical Examination:
HEAD AND NECK Fluid requirements 1800 cc/24 hours
Conjunctiva was anemic, Sclera was not icteric
Oxygen was not supported • Correction of hypoalbuminemia with protein intyaje 1,5 g/bw and
Nasogastric tube was not inserted Vipalbumin 2 caps/8hours
1st day No enlargement of lymph nodes and thyroid gland
• Correction of hyponatremia with daily inytake and Nacl 0,9 500ml/24
Follow Up hours(def 114.7 + 91.8 : 226.5,meq target 140mmol/l)
CHEST
(November 23rd ,
Inspection : Symmetric ,there was no loss of Correction of hypokalemia with high kalium intake and KSR
2022) •
subcutaneous fat. 600mg/12hours for 3 days(def 10.4+ 40.9: 51.4 meq target 4mmol/l)
Palpation : No tenderness
Percussion : Sonor • Supplementation via oral :
Auscultation : Vesicular breathing sound. No Rhonchi, no
wheezing  Zinc 20 mg/24 hours
ABDOMEN  Neurobion 1 Amp/24 jam/IV
IInspection : Flat Appereance
Auscultation : Normal Bowel Sound  Vitamin C 500 mg/24 jam
Palpation : No tenderness
Percussion : Tympanic  Ksr 600mg/12hours
 Curcuma 400mg/8hours
EXTREMITY
There was no oedem and wasting at all extremiries  Vip Albumin 2 caps/8hours
SGA
Thank you