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: leading center of excellence in clinical
nutrition specialist program in 2025
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
Infection Center Ward, August 11th 2022

*dr. Husmiani
dr. Christine Rogahang
dr. Zarvia Utami Sucipto Rasikun
dr. Primalia Rosyidah
 Patient Identity
Mr. M, 69 y.o. (Male)
.

MR number 988844
Date of birth February 10th, 1953
Admission Date August 03 ,2022 rd

Consultation Date August 08th,2022

Medical diagnosis
Medical Clinical Nutritionist Diagnosis: Severe Protein Energy Malnutrition (SGA Score C)
Pulmonologist Diagnosis : Lung tumor (T4N2M0) + Cancer pain
Neurologist Diagnosis : Loss of consciousness lateralization dextra et causa suspected Space Occupying Lession
dd/ Brain metastases
 Subjective
(History taking)

Main Complaint Since 3 days ago due to decreased consciousness. NGT was
Unable to eat and drink via oral History taking inserted. History about decreased of oral intake since 1 month ago
due to chest pain and getting worse since 1 week ago due to
Nausea & Vomiting shortness of breath.

No history Swallowing Disorders

No History
Headache
No History
Epigastric and Abdominal pain
Fever and Seizure No History
There were history of fever 3 days ago and seizure 5 days
ago.
Weight loss
Cough and Shortness of Breath There was unintentional weight loss since 1 month
There were cough 1 month ago and shortness of breath 1 ago ± 5 kg (8.4%) from Initial Body Weight 59 kg.
week ago.
 Subjective
(History taking)

Defecation Urination
Last defecation was 3 days ago He urinated via diapers, frequency
2 times, yellowish

Fluid Balance
Input : Natrium chloride 0.9% 1500 cc; drugs 150 cc
Output: Urine 1200 cc; IWL 535 cc;
Fluid Balance : - 85 cc/24 Hours
 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
1 month
5 days ago
ago

He complained of chest pain. He He was referred to the

was brought by his family to emergency room at Wahidin
Polewali hospital and Sudirohusodo Hospital. And
hospitalized for 7 days. He was treated at infection center until
diagnosed infection in his lung. now.
 01 Job and Occupation
He is a entrepreneur.

Smoking
Psychosocial history 02
He is active smoker for 50 years
ago, 1-2 packs/day

03 Drugs and alcohol

No history
Dietary History
Typical intake and usual amount of food : (before admitted to the hospital)
Intake:
Via oral
Quantity:
He ate regularly 3 times/day, 3 portion of porridge with variety of side dishes and vegetables
Quality:
He likes to eat fried food

 1 month ago, he ate 3 times/day,½ portion of porridge with ½ portion of side dishes and vegetables
 5 days ago, he ate 3 times/day, ½ portion of porridge with ¼ portion of side vegetables
 Neither food allergies nor lactose intolerance
Intake & Fluid Analysis
Last intake Energy (kcal) Protein (g) Carbohydrate (g) Fat (g)

Intake before sick 1150 kcal 55 g 196 g 15 g

1 month ago 575 kcal 27.5 g 98 g 7.5 g

5 days ago 368.75 kcal 8.75 g 83.75 g 0g

24 food recall 160 kcal 5.3 g 31.5 g 1.5 gr

• Input : Natrium chloride 1500 cc; drugs 150 cc

• Output : Urine 1200 cc; IWL 535 cc
• Fluid Balance : - 85 cc/ 24 Hours
 OBJECTIVE
SEVERE ILLNESS
GCS E3M4V2

Vital signs Anthropometry

01 02
Blood pressure : 140/70 mmHg Body Length : 168 cm
Pulse : 84 beats/minute Ideal Body Weight : 61 kg
Respiratory rate : 20 times/minute MUAC : 23 cm
Temperature : 37.4°C Estimated MUAC BW : 53.5 kg

03 Functional Status :
ECOG Score IV
Handgrip Strength: can’t be evaluated
 Physical examination
HEAD AND NECK
Conjunctiva was anemic, Sclera was not icteric,
Oxygen support was inserted via canul nasal, Nasogastric tube
was inserted.
No enlargement of lymph nodes and thyroid gland.

CHEST
Inspection : Symmetric, there were loss of subcutaneous fat
Palpation : No tenderness
Percussion : Sonor
Auscultation : Vesicular breathing sound, there were
ronchi but no wheezing, regular heart sounds
 Physical examination
ABDOMEN
Inspection : Flat appearance
Auscultation : Normal Bowel Sound
Palpation : No tenderness
Percussion : Tympanic
EXTREMITY
There were wasting at all extremity but no
oedema
 MEDICATION FROM OTHER DIVISION

Pulmonology ( August 8th 2022):

 IVFD Natrium Chloride 0,9% 20 drips/ minute
 Ceftriaxone 2 gr / 24 hours / intravenous
 Azitromicyn 500 mg/ 24 hours/ oral
 Acetyl Cystein 200 mg/ 8 hours/oral
 MST 10 mg / 12 hours/ oral
 Omeprazole 40 mg/24 hours / intravenous
 Paracetamol 500 mg / 8 hours / oral

Neurology (August 8th, 2022):

 Citicolin 500 mg/12 jam / intravenous
 Mecobalamin 500 mcg / 12 hours / intravenous
 Laboratory
LABORATORY FINDINGS
August 7th, 2022 August 5 th, 2022 Normal –Value
HGB 8.9 - 12.0 -16.0 gr/dl
WBC 24500 - 4.0 – 10.0 x 103/μL

TLC 2205 - 1.5 - 4 x 103/μL

NLR 9.4 - 1-3
MCV 85 - 80 – 100 μm3
MCH 29 - 27.0 – 32.0 pg
MCHC 34 - 32.0-36.0 g/dl
PT - - 10 – 14 Sec
INR - - --
APTT - - 22.0 – 30.0 Sec
Random Blood Glucose - - <140 mg/dl
PLT 308000 - 150-400 x 103 /μL

Urea - - 10- 50 mg/dl

Creatinine - - M:(<1.3) ; F:(<1.1) mg/dl
ALT
- - <38 U/L

AST - - <41 U/L

Albumin 2.5 - 3.5 – 5.0gr/dl

Total Bilirubin - - <1.1 mg/dl

Direct Bilirubin - - <0.30 mg/dl
Sodium - 136 135 – 145 mmol/L
Potassium - 4.2 3.5 – 5.0 mmol/L
Chloride - 105 97 – 111 mmol/L
Procalcitonin 0.20 0.16 <0.05 ng/ ml
 RADIOLOGY FINDINGS
Radiology Thoraks PA/AP + Lateral (August 8th, 2022)
• Left lung mass
• Long active pulmonary tuberculosis, extensive lesions
• Dilatation, elongation et atherosclerosis aortae
• Elevation of the right diaphragm (intrahepatic process)
 Assesment
Metabolical status
August 7th, 2022
• Normochromic Normocytic Anemia 8.9
• Leukocytosis 24500
• Moderate hypoalbuminemia 2.5
• Increase of NLR 9.4
• Increased of procalcitonin 0.20

GI- Tract status Functional

HYDRATION STATUS Normovolemic
Functional Status ECOG IV
 Assessment
Medical Clinical Nutritionist Diagnosis: Severe Protein Energy Malnutrition (SGA Score C)
Pulmonologist Diagnosis : Lung tumor (T4N2M0) + Cancer pain
Neurologist Diagnosis : Loss of consciousness lateralization dextra et causa suspected Space Occupying Lession
dd/ Brain metastases

Prognosis
Vitam: Dubia ad Malam
Functionam: Dubia ad Malam
Sanactionam: Dubia ad Malam
Basal Energy Expenditure : 1170 Kcal Planning
Total Energy Expenditure : 1800 Kcal (1.2/1.3)

Macronutrient Composition:
• Protein 1.3 g/kg BW/day = 69.5 g (15.4 %)
• Carbohydrate 50% = 225 g
• Fat 35.6 % = 71.2 g

Medical nutrition therapy is given 40% TEE (720 Kcal) via enteral :
• Blenderized standard food 493 kcal
• Ons Peptisol 150 kcal
• VCO 80 kcal

Fluid requirements 1800 cc/ 24 hours

 Planning
• Correction of Hypoalbuminemia with protein intake 1.3 g/ kg BW / day.

• Supplementation:
• Zinc 20 mg/ 24 hours/ enteral
• Vitamin B complex 2 tabs/ 8 hours/ enteral
• Curcuma 400 mg/ 8 hours/ enteral

• Monitoring & evaluation:

• Hemodynamic, MAP < 65 mmHg  nutrition postponed
• Gastrointestinal tolerance, if residue > 250 cc/4 hours or blackies  nutrition postponed
• Fluid Balance
• Daily intake

• Nutritional education: Follow the meal according to the schedule

• Laboratory : Random blood glucose, Ur/Cr, UUN, PT/INR/APTT

• Agree to join multidisciplinary care

FOLLOW UP
 Subjective Objective Assessment Planning
Nutrition via General Condition : Severe Illness, GCS E2M4V1 on vascon Metabolic Status Energy requirements : 25 kcal/kg BW/day : 1300 Kcal
enteral, no August 7 , 2022
th
residue Food Recall 24 hours via enteral : Macronutrient Composition:
Energy : 328.9 kcal (18.27%) • Normochromic Normocytic Anemia 8.9
• Leukocytosis 24500 • Protein 0.8 g/kg BW/day = 42.8 g (13 %)
Protein : 17 gr (20.6 %)
There was Carbohydrate : 42 gr (51 %) • Moderate hypoalbuminemia 2.5 • Carbohydrate 45% = 145.25 g
shortness of Fat : 10.1 gr (27.6%) • Increase of NLR 9.4 • Fat 42 % = 60.6 g
breath, fever. • Increased of procalcitonin 0.20
And no Vital sign : Medical nutrition  Nutrition Postponed
vomiting, Blood pressure : 80/55 mmHg on vascon Medical Clinical Nutritionist Diagnosis:
nausea and Pulse : 148 beats/minute Severe Protein Energy Malnutrition (SGA Fluid requirements 1300 cc/ 24 hours
cough. Respiratory rate : 46 times/minute Score C)
Temperature : 37.5°C • Correction of Hypoalbuminemia with protein intake 0.8 g/ kg
O2 support SpO2 : 92 % on NRM 15 Lpm Pulmonologist Diagnosis : Lung tumor BW / day.
via NRM MAP : 63 mmHg (T4N2M0) + Cancer pain
Neurologist Diagnosis : Loss of • Supplementation  Postponed
Defecation Body Length : 168 cm
Ideal Body Weight : 61 kg consciousness lateralization dextra et
Not for this causa suspected Space Occupying Lession • Monitoring & evaluation:
morning MUAC : 23 cm
Estimated MUAC BW : 53.5 kg dd/ Brain metastases • Hemodynamic, MAP < 65 mmHg  nutrition postponed
• Gastrointestinal tolerance, if residue > 250 cc/4 hours or
Physical Examination: blackies  nutrition postponed
Urination • Fluid Balance
HEAD AND NECK
1200 cc per • Daily intake
24 hours via Conjunctiva was anemic, Sclera was not icteric.
diapers Oxygen support was applied with NRM. NGT installed • Nutritional education: Follow the meal according to the schedule
No enlargement of lymph nodes and thyroid gland.
CHEST • Laboratory : wait the result random blood glucose, Ur/Cr,
BC: 1179 - Inspection : Symmetric
Palpation : No tenderness UUN, PT/INR/APTT
(300 + 150 + Percussion : Sonor
946) : - 217 Auscultation : Vesicular breathing sound. There were
rhonchi and no wheezing
1st day ABDOMEN
Follow Up Inspection : Flat Appearance
Auscultation : Normal Bowel Sound
(August, 9 Palpation : No tenderness
th , 2022) Percussion : Tympanic
EXTREMITY
There were wasting all extremity and no oedema
SGA
Thank you