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
Infection Centre, October 5th, 2023

dr.Inggrid Gloria Mangiwa

dr. Mulyanti Sulastri
dr. Utami Handayani *
dr. Jennifer
dr. Yusrawati
dr. Regina Tuwongkesong
dr. Nelci R Maniagasi
dr. Sri Windari Syafriani
dr. Sukuria Usman
 Patient Identity
1

Mr. A, 50 y.o. (Male)

MR number
.
01.04.56.07
Date of birth July 7th, 1973
Admission Date September 14th, 2023
Consultation Date October 2nd , 2023

Medical diagnosis
Medical Nutrition Diagnosis : Severe Protein Energy Malnutrition (E43)
EMD Diagnosis : Type 2 Diabetes Mellitus + Neck Abscess + Left Lung Tumor+
Multiple Nodular Lymphadenopathy
2
 Subjective
(History taking)

Main Complaint Since 2 months ago due to decreased appetite

History taking
Decreased of oral intake because of swelling and pain in the left neck. It has
worsened in the last 2 weeks due to progressive
Nausea & Vomiting neck swelling and pain.
No history.
Swallowing Disorder
Headache No history
No history

Fever and Seizure Epigastric and Abdominal pain

No history No history

Cough and Shortness of Breath Weight loss

No history There was history of unintentional weight loss of 7.1
kg from body weight of 58 kg (12.2 %) in 2 months
 4

Subjective
(History taking)

Defecation Urination
Via toilet, this morning, once a day, Via urinary pot, 1500 ml/ 24hours,
normal consistency, yellowish. yellowish
 Patient Family
Cerebrovascular Disease Cerebrovascular Disease
No history No History

Cardiovascular Disease, Cardiovascular Disease, DM

No history. No history

Kidney and Urinary Diseases Kidney and Urinary Disease

No History No history

Hyperuricemia, Hypercholesterolemia Hyperuricemia, Hypercholesterolemia

No History No history

Endocrinology Diabetes Mellitus

Diabetes Mellitus was diagnosed since 2 weeks ago and was No history
given Levemir 0-0-14 and Novorapid 6-6-6 from Endocrinology
Polyclinic of Wahidin Sudirohusodo Hospital Others
No history
Others
No history
 History of PRESENT Illness

He complained of a marble-sized abscess on the left neck that was painful.

2 months He was treated at public health center and was given analgesics but did not
getting better. He was referred to the emergency room of Sinjai Hospital.
ago

He complained of progressive enlargement and pain in the neck lump. He

was taken to the emergency room of Sinjai Hospital and treated for 1 day.
2 weeks
He was diagnosed with suspected left perihilar central nodular pneumonia
ago dd/ lung mass then referred to Wahidin Sudirohusodo Hospital and treated
in IC until now for planning debridement
 7

Occupation and Habit

01
unemployed

Smoking
02 Patient denies consuming cigarettes

Psychosocial history 03 Drugs and alcohol

Patient denies consuming drugs and
alcohol.
 8
Dietary History
Typical intake and usual amount of food (before He admitted to the hospital)
Intake:
Via oral
Quantity:
He ate regulary 3 times/day, 3 portion of white rice with 1 large chunk of varied animal side dishes, 1 large
chunk of derived plant side dishes, 1 medium portion of vegetables, and 2 portion of cakes or cookies per
day.
Quality:
He actually ate rice too much and likes sweet food

• 2 months ago, He ate 3 times/day 3/4 portion of white rice with 1 medium chunk of varied animal side
dishes, 1/2 medium chunk of derived plant side dishes, 2 x 1/2 small bowl of vegetables.
• 2 weeks ago, He ate 3 times/day, 1/2 portion of porridge with 1 medium chunk of varied animal
side dishes, 1 medium chunk of derived plant side dishes, 1 small bowl of vegetables.
• 24 hours ago, He ate regularly 3 times/day 3 tablespoons of porridge with ¼ portion of animal side
dishes and 1/3 portion of vegetables, 2 x ¼ portion of plant side dish,1 ½ portion of fruit per day.
• Neither food allergies nor lactose intolerance
 9

Intake & Fluid Analysis

Carbohydrate
Intake Energy (kcal) Protein (g) Fat (g)
(g)
Before sick 2137 kcal 74.6 g 425.4 g 17.8 g

2 months ago 943 kcal 44.5 g 165.5 g 10.5 g

2 weeks ago 887.5 kcal 28.21 g 136 g 15 g

400 kcal 16 g 71 g 5g
24 hours
(21.05%) (16%) (71%) (11.25 %)

• Input : 1000 ml (oral liquid + nutrition + medication) + 500 ml (IVFD NaCl

0.9%)
• Output : Urine 1500ml; Defecation 100ml; IWL 558 ml
• Fluid Balance : - 658 ml / 24 hours
 10

OBJECTIVE
MODERATE ILLNESS
GCS E4M6V5

Vital signs
01 02 Anthropometry
Blood pressure : 150/80 mmHg Body Height : 162 cm
MAP : 103.3 mmHg Ideal Body Weight : 55.8 Kg
Pulse : 98 beats/minute MUAC : 24 cm
Respiratory rate : 20 times/minute Estimated MUAC BW : 50.9 Kg
Temperature : 36.6 0C
SpO2 : 98% without modality

03 Functional Status
Handgrip Strength : 25.6 Kg (right),
 Physical examination
HEAD AND NECK
Normocephalic, conjunctiva was not anemic, sclera was not
icteric, NGT was not inserted. Oxygen was not supported.
There was no enlargement of thyroid gland and lymph nodes.
There is a mass with a size of about 16 x 11 cm with a reddish
color compared to the surrounding skin. There was wounds
appear and crusts. There was tenderness. The borderlines are
difficult to evaluate because they are covered with a bandage.

CHEST
Inspection : Symmetrical, there was loss of subcutaneous fat
Palpation : No tenderness.
Percussion : Sonor.
Auscultation : vesicular breathing sounds, there was no rhonchi, no
wheezing. Regular heart sound, no murmur.

ABDOMEN
Inspection : Flat appearance
Palpation : No tenderness. Liver and Spleen were not palpable, no ascites
Percussion : Tympanic
Auscultation : Normal Bowel Sound
 Physical examination

EXTREMITY
There was warm acral, no edema, CRT<2
seconds. There was wasting in all extremities.
LABORATORY FINDINGS
Laboratory October 2nd , 2023 Normal Value

WBC 11.200 4,0 - 10,0 x 103/μL

PLT 347.000 150-400 x 103 /μL

HGB 11.8 12.0 -16.0 gr/dl

MCV 83 80 – 100 μm3
MCH 28 27.0 – 32.0 pg
MCHC 33 32.0-36.0 g/dl
Neut 80 52,0 - 75,0 %
Lymph 10.9 20,0 - 40,0 %
TLC 1220.8 20-40 x 103/μL
NLR 7.3 <3
 LABORATORY FINDINGS
Laboratory September 27th, 2023 September 30th, 2023 Normal Value
<38 U/L
AST - 35

ALT - 15 <41 U/L

Albumin 2.4 - 3.5 – 5.0 gr/dL

CRP - 81.9 < 5 mg/l

Procalcitonin - 0.28 < 0,05 ng/ml

Sodium - 133 136– 145 mmol/

Potassium - 3.5 3.5 – 5.1 mmol/l
Chloride - 101 97 - 111 mmol/l
 RADIOLOGIC FINDINGS

CT Neck without contrast (September 19th, 2023)

- Soft tissue mass involving musculus regio nuchae to regio colli antero lateral
sinistra with air density around it suspected abscess

CT Thorax with contrast (September 15th, 2023)

- Sinistra pulmonary mass with multiple bilateral pulmonary nodular lesions
and lymphadenopathy level 1L, 2L, 4R, 4L, and 7 (T4N3Mx)
- Bilateral pneumonia
- Bilateral pleural effusion
 MEDICATION FROM OTHER DIVISION
Internal Endocrine Subdivision (October, 2nd 2023)
Therapy Plan:
- 1700kcal DM diet
- Levemir 0-0-8 (postponed)
- novorapid 4-4-4 (postponed)
- albumin 25% 100 cc/24hours/intravenous

Monitoring Plan
- Monitor general condition and vital signs
- Checking fasting blood glucose in morning time
- Target of random blood glucose : 140-180mg/dl
- Target of fasting blood glucose 80-130 mg/dl
 ASSESSMENT
METABOLIC STATUS
October 2nd, 2023
Leucocytosis 11.200
Normochromic normocytic anaemia 11.8
Mild depletion of immune system 1220.8
Increased NLR 7.3

September 30th, 2023

Mild hyponatremia 133
Elevated CRP 81.9
Increased procalcitonin 0.28

September 27th, 2023

Severe hypoalbuminemia 2.4

GI - TRACT STATUS : Functional

HYDRATION STATUS : Normovolemic
FUNCTIONAL STATUS : Handgrip Strength: 25.6 kg (right)
 DIAGNOSIS & PROGNOSIS

Medical Nutrition Diagnosis : Severe Protein Energy Malnutrition (E43)

EMD Diagnosis : Type 2 Diabetes Mellitus + Neck Abscess + Left lung
Tumor+ Multiple Nodular Lymphadenopathy

Prognosis
 Vitam : Dubia
 Functionam : Dubia
 Sanactionam : Dubia
 Planning

 Basal energy expenditure : 1233.83 kcal

 Total energy expenditure : 1924.7 ~ 1900 kcal (1.2/1.3)
 Macronutrient Composition
• Protein: 1.5 g/kg MUAC BW/day = 76.35 g (16 %)
• Carbohydrate: 50% = 237.5 g
• Fat: 34 %= 71 g

 Fluid requirement 30 ml/kg MUAC BW /24 hours ~ 1700 ml/24 hours

 Correction of hypoalbuminemia with target of 3.5 gr/dl

 Correction of hyponatremia with target of 140 mmol/L (deficit 213.78 mEq + daily requirement 101.8
mEq, total requirement 315.58 mEq )
 Nutritional medical therapy was given based on high risk of refeeding syndrome 10 kcal/kg MUAC
BW/day = 509 kcal (26.7%TEE) via enteral
INSTRUCTION
 regular blenderized food 3 x 50 cc (246.675 kcal)
 ONS peptisol 150 kcal
 VCO 80 kcal

 Correction of hyponatremia with daily sodium intake

 Supplementation via enteral

- Zinc 20 mg/12 hours
- Vitamin B complex 2 tab/8 hours
- Thiamin 100 mg/ 8 hours

 Monitoring and evaluation:

- Daily intake
- Gastrointestinal tolerance
- Fluid Balance
- hemodynamics and vital signs

 Nutrition education:
- Nutritional intake according to schedule
- nasogastric tube and urine catheter insertion

 Laboratory: UUN, Random Blood Glucose, urea, creatinine, and magnesium

 Agree to join multidisciplinary care

FOLLOW UP
LABORATORY FINDINGS

Laboratory October 3rd, 2023 Normal Value

Random blood glucose 117 < 200 mg/dL

Ureum 25 10- 50 mg/dl

Creatinine 0.60 M:(<1.3) ; F:(<1.1) mg/dl

magnesium 1.04 1.5 – 2.3 mg/dL

 Subjective Objective Assessment Planning
Patient was refused General Condition: Moderate Illness appearance Metabolic Status :  Basal energy expenditure : 1233.83 kcal
the Nasogastric GCS 15 (GCS E4M6V5) October 3rd 2023  Total energy expenditure : 1924.7 ~ 1900 kcal (1.2/1.3)
tube and Urine -moderate hypomagnesemia 1.04  Macronutrient Composition
• Protein: 1.5 g/kg MUAC BW/day = 76.35 g (16 %)
catheter insertion . Food Recall 24 hours : Carbohydrate: 50% = 237.5 g
•
Nutrition intake via Energy : 350 kcal (18.4%) October 2nd 2023 : • Fat: 34 %= 71 g
oral. There was pain Protein : 7.5 g (8.57%) Leucocytosis 11,200
in swallowing and Karbohidrat : 79.5 g (90.86%) Normochromic normocytic anaemia  Fluid requirement 30 ml/kgBW/24 hours ~ 1700 ml/24
back pain. Lemak : 0 g (0%) 11.8 hours
There were no Mild depletion of immune system  correction of hypoalbuminemia with target of 3.5 gr/dl
nausea, vomiting, Vital sign: 1220.8  correction of hyponatremia with target of 140 mmol/L
fever, and Blood pressure : 140/80 mmHg Increased of NLR 7.3 (deficit 213.78 mEq + daily requirement 101.8 mEq, total
swallowing MAP. : 100 mmHg Mild hypoalbuminemia 3.0 < 2.4 requirement 315.58 mEq )
 Correction of hypomagnesemia with target 25.45
difficulties. Pulse : 82 x/minute mmol/L
Respiratory rate : 20 x/minute September 30 2023 :
th
 Nutritional medical therapy was given based on
Defecation: 1x, via Temperature : 36.8°C Mild hyponatremia 133 high risk of refeeding syndrome 10 kcal/kg
toilet yesterday, SpO2 : 98% without modality Elevated of CRP 81.9 MUAC BW/day = 509 kcal (26.7%TEE) via oral
normal consistency, Increased of procalcitonin 0.28  regular blenderized food 3 x 50 cc (246.675
yellowish Anthropometry kcal)
Body Height : 162cm  ONS peptisol 150 kcal
Urination : via urine Ideal Body Weight: 55.8 kg  VCO 80 kcal
chamber, 1000 MUAC : 24 cm  Correction of hypoalbuminemia with daily intake
cc/24 hours Estimated MUAC BW : 50.9kg Medical Nutrition Diagnosis :  Correction of hyponatremia with daily sodium intake
Severe Protein Energy  Correction of hypomagnesemia with daily intake and
BC: 1500 cc - (100 Physical Examination Malnutrition (E43) antacid syrup
+ 1000 + 763.5) = - HEAD AND NECK EMD Diagnosis : Type 2 Diabetes  Supplementation via oral
363.5 cc/24hours Normocephalic, conjunctiva was not anemic, sclera was not icteric, NGT was not inserted. Oxygen was Mellitus + Neck Abscess + Left - Zinc 20 mg/12 hours
lung Tumor+ Multiple Nodular - Vitamin B complex 2 tab/8 hours
not supported. - Thiamin 100 mg/ 8 hours
There was no enlargement of thyroid gland and lymph nodes. Lymphadenopathy - Antacid syrup 3 x 2 tablespoons
In Left Neck Area :  Monitoring and evaluation:
There was a mass with a size of about 16 x 11 cm with a reddish color compared to the surrounding skin. - Daily intake
The borderline was difficult to evaluate because it was covered with a gauze - Gastrointestinal tolerance
1st day - Fluid Balance
Follow Up, - hemodynamics and vital signs
October 3rd, 2023 CHEST
Inspection : Symmetrical, there was loss of subcutaneous fat  Nutrition education:
Palpation : No tenderness. - Nutritional intake according to schedule
Percussion : Sonor.
Auscultation : vesicular breathing sounds, there was no rhonchi, no wheezing. Regular heart sound, no  Laboratory: waiting for UUN result
murmur.  Agree to join multidisciplinary care
ABDOMEN
Inspection : Flat appearance
Palpation : No tenderness. Liver and Spleen were not palpable, no ascites
Percussion : Tympanic
Auscultation : Normal Bowel Sound
EXTREMITY
There was warm acral, no edema, CRT<2 seconds. There was wasting in all extremities.
 Subjective Objective Assessment Planning
Patient was refused General Condition: Moderate Illness appearance Metabolic Status :  Basal energy expenditure : 1233.83 kcal
the Nasogastric GCS 15 (GCS E4M6V5) October 3rd, 2023  Total energy expenditure : 1924.7 ~ 1900 kcal (1.2/1.3)
tube and Urine -moderate hypomagnesemia  Macronutrient Composition
• Protein: 1.5 g/kg MUAC BW/day = 76.35 g (16 %)
catheter insertion . Food Recall 24 hours 0 kcal 1.04 Carbohydrate: 50% = 237.5 g
•
The patient was • Fat: 34 %= 71 g
instructed to fast by Vital sign: October 2nd 2023 :  Fluid requirement 30 ml/kgBW/24 hours ~ 1700 ml/24
surgeon for his Blood pressure : 145/80 mmHg Leucocytosis 11,200 hours
surgery. Pulse : 83 x/minute Normochromic normocytic  correction of hypoalbuminemia with target of 3.5 gr/dl
There was pain in Respiratory rate : 19 x/minute anaemia 11.8  correction of hyponatremia with target of 140 mmol/L
swallowing and Temperature : 36.8°C Mild depletion of immune (deficit 213.78 mEq + daily requirement 101.8 mEq, total
back pain. SpO2 : 98% without modality system 1220.8 requirement 315.58 mEq )
There were no Increased of NLR 7.3  Correction of hypomagnesemia with target 25.45 mmol
nausea, vomiting, Mild hypoalbuminemia 3.0 <
 Nutritional medical therapy was given based on
fever, and Physical Examination 2.4 high risk of refeeding syndrome 10 kcal/kg MUAC
swallowing HEAD AND NECK BW/day = 509 kcal (26.7%TEE) via oral
difficulties. there Normocephalic, conjunctiva was not anemic, sclera was not icteric, NGT was not inserted. Oxygen was not September 30th 2023 :
 regular blenderized food 3 x 50 cc (246.675
were post operative supported. Mild hyponatremia 133 kcal)
pain in his neck There was no enlargement of thyroid gland and lymph nodes. Elevated of CRP 81.9
 ONS peptisol 150 kcal
Increased of procalcitonin 0.28
 VCO 80 kcal
There was wound that covered by gauze in his left neck area  Correction of hypoalbuminemia with daily intake
Defecation: 1x, via  Correction of hyponatremia with daily sodium intake
toilet , 2 days ago,  Correction of hypomagnesemia with daily magnesium
normal consistency, CHEST intake and antacid syrup
yellowish Inspection : Symmetrical, there was loss of subcutaneous fat  Supplementation via oral
Palpation : No tenderness. Medical Nutrition - Zinc 20 mg/12 hours
Urination : via urine Percussion : Sonor. Diagnosis : Severe Protein - Vitamin B complex 2 tab/8 hours
chamber, 800 cc/24 Energy Malnutrition (E43) - Thiamin 100 mg/ 8 hours
Auscultation : vesicular breathing sounds, there was no rhonchi, no wheezing. Regular heart sound, no - Antacid syrup 3 x 2 tablespoons
hours murmur. EMD Diagnosis : Type 2
Diabetes Mellitus + Neck  Monitoring and evaluation:
BC: 1200 cc - (800 ABDOMEN Abscess + Left lung Tumor+ - Daily intake
+ 763.5) = -363.5 Inspection : Flat appearance Multiple Nodular
- Gastrointestinal tolerance
cc/24hours Palpation : No tenderness. Liver and Spleen were not palpable, no ascites Lymphadenopathy
- Fluid Balance
Percussion : Tympanic Surgeon Diagnosis : POD 1
- hemodynamics and vital signs
Auscultation : Normal Bowel Sound debridement in left neck
region  Nutrition education:
EXTREMITY - Nutritional intake according to schedule
There was warm acral, no edema, CRT<2 seconds. There was wasting in all extremities.
2nd day  Laboratory: waiting for UUN result
Follow Up,
October 4th, 2023  Agree to join multidisciplinary care
SGA
Thank you