Patient Identity

Ms. A, 48 y.o. (Female)

MR number
.
993503
Date of birth July 23th, 1974
Admission Date November 09th, 2022
Consultation Date November 10th, 2022

Medical diagnosis
Medical Nutrition Diagnosis: Moderate Protein Energy Malnutrition (E44)
Orthopedics Diagnosis : Low Back Pain due to Intradural Extra Medullary as Level A5
Vertebral Lumbal I-II , lumbal II-III
EMD : Struma multinodular suspect malignancy
 Subjective
(History taking)
since 3 months ago due to lower back pain that
Chief Complaint has been getting worse since 5 days ago due to
severe back pain
Decreased of oral intake
Nasogastric Tube
Headache No History
No history
Swallowing Disorders
Nausea & Vomiting No history
No History Epigastric Pain
No History
Fever and Seizure
No history
Weight loss
Cough and Shortness of Breath There was history of unintentional weight loss
No history approximately ± 4 kg ( 8.3 % of initial weight, 48
kg) since 3 months ago
 Subjective
(History taking)

Defecation Urination
Last defecation was 4 days ago via Via Toilet, 3 times/day, yellowish
Toilet, normal concistency color, seems to be normal
yellowish color
 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
(Hypothiroid)
No history
There was lump on the neck since 20 years ago,
never checked and never treated,just found out as
hypothyroid
 History of PRESENT Illness

2 years • She complains of intermittent low back pain, there was history of slipped
ago and fall in sit position but only taking pain killer medicine

• the pain was worsened and went to primary health care. She then referred
3 months for MRI examination. She diagnosed with spine tumor and nerve
ago impingement. She referred to orthopedics polyclinic , routine control and
physiotherapy. There was plan for surgery but waiting for schedule

• She brought to ED because the pain worsened since 5 days before

yesterday admitted to hospital and being treated at L4 Orthopedics and planned for
surgery but waiting for the schedule and consulted to Endocrine colleagues
for hypothyroid management
 01 Occupation and Habit
She is housewife

Smoking
Psychosocial history 02
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
Quantity:
She eats regularly 3 times/day, 1 cups of white rice with 1 medium chunck of varied of animal side dishes,and 1
small bowl of vegetables, 1 portion of fruit
Quality:
She likes almost every food

 3 months ago, she ate ¾ cup of white rice with ¾ medium chunk of varied of animal side dishes and ¾ small bowl of
vegetables
 5 day ago, she ate ¼ cup of white rice with ¼ medium chunk of varied of animal side dishes and ¼ small bowl of
vegetables
 24 hours, She eat once a day, ¼ cup of rice, with ¼ medium chunk of varied of animal and vegetable side dishes and ¼
small bowl of vegetables, 1 piece of bread
 Neither food allergies nor lactose intolerance
Intake Analysis
Last intake Energy (kcal) Protein (g) Carbohydrate(g) Fat (g)

Intake before sick

1785 (105 %) 73.59 331.85 27.18

3 month ago 1300 (76.47%) 54.25 231 17.38

5 days ago 462.50 (27.21%) 19.25 81 6.63

24 hours 201.25(11.83%) 7.75 (15.40%) 29 (57.64%) 5.88

(26.27%)
 OBJECTIVE
MODERATE ILLNESS
GCS E4M6V5

Vital signs Anthropometry

01 02
Blood pressure : 129/87 mmHg Actual Body Weight : 44 kg
Pulse : 60 beats/minute Body Height : 145 cm
Respiratory rate : 18 times/minute IBM : 22.4 Kg/M²
Temperature : 36.5 °C IBW : 45 kg
MUAC : 24.5 cm
Estimated MUAC BW : 42.89 kg

Functional Status :
03
Handgrip Strength: 7.0 Kg (weak)
 Physical examination
HEAD AND NECK
Conjunctiva was not anemic, Sclera was not icteric
Oxygen support was not supported, Nasogastric tube was not inserted
There was enlargement of lymph nodes estimated mass size 10 x 10 cm

CHEST
Inspection : Symmetric ,there was no loss of subcutaneous fat
Palpation : No tenderness
Percussion : Sonor
Auscultation : Vesicular breathing sound. There was No Rhonchi
and wheezing, Regular heart sounds and no
murmurs
ABDOMEN
Inspection : Flat Appearance.
Auscultation : Normal Bowel Sound
Palpation : Hepar not palpable and lien not palpable
Percussion : Tympanic
 Physical examination
EXTREMITY
There was minimal wasting in all exterimities
There was no edema
 16

MEDICATION FROM OTHER DIVISION

Orthopedic (November 11st, 2022)
 IVFD RL 20 dpm / 24 hours / Intravenous
 Ranitidin 50 mg/ 12 hours / Intravenous
 Ketorolac 30 mg/24 hours/ Intravenous
 Gabapentin 300mg/ 24 hours / Intravenous
 LABORATORY FINDINGS

November
Laboratory Normal Value
09th, 2022
WBC 10.0 4,0 - 10,0 x 103/μL
TLC 1770 1.5 - 4 x 103/μL
PLT 346.000 150-400 x 103 /μL
HGB 13.3 12.0 -16.0 gr/dl
MCV 80 80 – 100 μm3
MCH 27 27.0 – 32.0 pg
MCHC 34 32.0-36.0 g/dl
Neutrofil 75.6 52.0-75.0%
Lymfosit 17.7 20.0-40.0%
Random Plasma Glucose 119 < 200 mg/dl
Urea 22 10- 50 mg/dl
Creatinine 0.60 M:(<1.3) ; F:(<1.1) mg/dL

Sodium 142 135 – 145 mmol/L

Potassium 3.5 3.5 – 5.0 mmol/L
Chloride 106 97 – 111 mmol/L
NLR 4.27 < 3.13
 LABORATORY FINDINGS

October November
Laboratory Normal Value
31st, 2022 09th, 2022
FT4 0.85 0.93 – 1.71 ng/dl
TSHS <0.05 0.27 – 4.20 mlU/ml
AST 16 <38 U/L
ALT 0.60 <41 U/L
PT 10.8 10-14
INR 1.0 0.8-1.1
APTT 28.3 22-30
 RADIOLOGIC FINDINGS
Thorax Photo PA/AP (November 10th 2022)
- Normal cardio and pulmo
- Elevation of the right diaphragm
MRI Lumbosacral (September 27th 2022 )
- Extramedullar intradural mass as high as CV L1-L3 suggestive schwannoma differential diagnosis of
meningioma
- Bulging disc levels L3-L4, L4-L5 and L5-S1 pressing thecal sac
- MR Myelography : visible stenosis canalis spinal level L1-L3
MRI Servical (September 27th 2022 )
- Bulging disc levels C3-C4, C4-C5, C5-C6 and C6-C7 pressing thecal sac
- MR Myelography :does not appear cervical level spinal canalis stenosis
USG thyroid :
- Bilateral thyroid mass ( TIRADS 5 )
 Assesment
Metabolical status
November 09th, 2022
• Increased NLR 4.2
October 31st , 2022
• Decreased of FT4 0,85
• Decreased of TSHs < 0,05

GI- Tract status Functional

HYDRATION STATUS Normovolemic
Functional Status Handgrip Strength 7.0 kg
 22

Diagnosis & Prognosis

Medical Nutrition Diagnosis: Moderate Protein Energy Malnutrition (E44)
Orthopedics Diagnosis : Low Back Pain due to Intradural Extra Medullary as Level A5
Vertebral Lumbal I-II , lumbal II-III
EMD : Struma multinodular suspect malignancy

Prognosis
Vitam: Dubia ad bonam
Functionam: Dubia ad bonam
Sanactionam: Dubia ad bonam
 23
Planning
Basal Energy Expenditure : 1119 Kcal
Total Energy Expenditure : 1700 Kcal

Macronutrient Composition:
• Protein 1.5 g/kgBW/day : 66 g (15.7%)
• Carbohydrate 50% : 212 g
• Fat 30.5% : 65.1 g

Medical Nutrition therapy is given 40% TEE (680 Kcal) via oral :
- Standard food 331 Kcal
- ONS Peptisol 250 Kcal
- EVOO 160 Kcal

Fluid requirements 1700 cc/24 hours

 24
Planning
• Supplementation via oral :
 B. Complex 2 tabs/8 hours
 Zinc 20mg/ 24 hours
 Curcuma 400mg/8 hours

• Monitoring and evaluation

 Haemodynamic
 Daily intake
 Gastrointestinal tolerance

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

• Lab : UUN, Albumin

• Agree to join multidisciplinary care

FOLLOW UP
 LABORATORY FINDINGS

November
Laboratory Normal Value
10th, 2022
Albumin 4.7 3.5 – 5.0 gr/dl
PNI 55.85 > 45
 Subjective Objective Assessment Planning

Intake via oral, There General Condition :MODERATE ILLNESS GCS E4M6V5 November 09th, 2022 BEE : 1119 Kcal
was no nausea and Vital sign : TEE : 1700 Kcal (1.2/1.3)
Vomiting. There was Blood pressure : 130/80 mmHg • Increased NLR 4.2
low back pain Pulse : 70 beats/minute
Respiratory rate : 22 times/minute Macronutrient Composition:
Temperature : 36.5°C
October 31st , 2022 Protein 1.5 g/kgBW/day : 66 g (15.7%)
• Decreased of FT4 0,85 Carbohydrate 50% : 212 g
Anhtropometry
Defecation was 2 Fat 30.5% : 65.1 g
days ago Body Length : 145 cm • Decreased of TSHs < 0,05
Actual Body Weight : 44 kg Medical Nutrition therapy is given 60% TEE (1020 kcal),
Urination : Via toilet, Ideal Body Weight : 45 kg via oral :
seems to be normal -Standart food 662 Kcal
Estimated MUAC BW : 42.89 kg
-ONS Peptisol 250 kcal
MUAC : 24.5 cm Medical Nutrition Diagnosis: -EVOO 160 Kcal
IBM : 22.4 kg/M² Moderate Protein Energy
Malnutrition (E44) Fluid requirements 1700 cc/24 hours
1st day
Follow Up Food Recall 24 hours via Oral Orthopedics Diagnosis : Low
(November 11th, Energy : 842 Kcal (49%) Supplementation via oral :
Protein : 30.5 gr (14%) Back Pain due to Intradural -Zinc 20mg/24jam/oral
2022) Carbohydrate : 154 gr (73%) Extra Medullary as Level A5 - B comp 2 tab/8 hours
Fat : 11 gr (11.7%) Vertebral Lumbal I-II , lumbal II-III -Curcuma 400mg/8 hours
Physical Examination: EMD : Struma multinodular -Vitamin D 1000 IU/ 24 jam
HEAD AND NECK suspect malignancy
Conjunctiva was not anemic, Sclera was not icteric Monitoring and evaluation
Oxygen was not supported
Nasogastric tube was not inserted
-Haemodynamic
There was enlargement of lymph nodes estimated mass size 12 x 10 cm -Daily intake
-Gastrointestinal tolerance
CHEST
Inspection : Symmetric, There was loss of subcutaneous fat Nutritional education:
Palpation : No tenderness
Percussion : Sonor
Follow the meal according to the schedule
Auscultation : Vesicular breathing sound.There was rhonchi,
There was not wheezing, regular heart sounds and no murmurs Lab : Waiting for UUN, Albumin result
ABDOMEN
Inspection : Flate Appearance
Auscultation : Normal Bowel Sound
Palpation : Liver and spleen was not pappable
Percussion : Tympanic

EXTREMITY
There was wasting in all extremities
There was no edema
 Subjective Objective Assessment Planning

Intake via oral, There General Condition :MODERATE ILLNESS GCS E4M6V5 November 09th, 2022 BEE : 1119 Kcal
was no nausea and Vital sign : TEE : 1700 Kcal (1.2/1.3)
Vomiting. There was Blood pressure : 130/70 mmHg • Increased NLR 4.2
low back pain Pulse : 80 beats/minute Macronutrient Composition:
Respiratory rate : 22 times/minute October 31st , 2022 Protein 1.5 g/kgBW/day : 66 g (15.7%)
Temperature : 36.5°C
• Decreased of FT4 0,85 Carbohydrate 50% : 212 g
Defecation was Food Recall 24 hours via Oral Fat 30.5% : 65.1 g
yesterday Energy : 1075 Kcal (63%) • Decreased of TSHs < 0,05
Protein : 43.5 gr (16.2%) Medical Nutrition therapy is given 80% TEE (1360 kcal),
Urination : Via toilet, Carbohydrate : 160 gr (59%) via oral :
seems to be normal Fat : 28.5 gr (23%) -Standart food 662 Kcal
-ONS Peptisol 300 kcal
Physical Examination:
HEAD AND NECK
- Fruit Juice 100 Kcal
Conjunctiva was not anemic, Sclera was not icteric Medical Nutrition Diagnosis: -EVOO 240 Kcal
2nd day Oxygen was not supported Moderate Protein Energy
Follow Up Nasogastric tube was not inserted Malnutrition (E44) Fluid requirements 1700 cc/24 hours
(November 12th, There was enlargement of lymph nodes estimated mass size 12 x
2022) 10 cm Orthopedics Diagnosis : Low Supplementation via oral :
Back Pain due to Intradural -Zinc 20mg/24jam/oral
CHEST Extra Medullary as Level A5 - B comp 2 tab/8 hours
Inspection : Symmetric, There was loss of subcutaneous fat Vertebral Lumbal I-II , lumbal II-III -Curcuma 400mg/8 hours
Palpation : No tenderness
Percussion : Sonor
-Vitamin D 1000 IU/24 jam
EMD : Struma multinodular
Auscultation : Vesicular breathing sound.There was rhonchi, suspect malignancy
There was not wheezing, regular heart sounds and no Monitoring and evaluation
murmurs -Haemodynamic
-Daily intake
ABDOMEN -Gastrointestinal tolerance
Inspection : Flate Appearance
Auscultation : Normal Bowel Sound Nutritional education:
Palpation : Liver and spleen was not pappable Follow the meal according to the schedule
Percussion : Tympanic
Lab : Waiting for UUN result
EXTREMITY
There was wasting in all extremities
There was no edema
Thank you