Clinical Nutrition (CTN A)

NAME:
SECTION:
CASE 1: UPPER GIT (Gastritis, Ulcer)
DQ is a 75 y/o woman who comes to your clinic with a 1 year history severe burning in her throat and regurgitation.
She wakes up at least once a night with heartburn. She has been self-medicating with over-the-counter ranitidine
75mg at bedtime for the last 6 months with no improvement. Her past medical history is significant for anxiety,
hypothyroidism, hypertension and diabetes. Her weight is 86 kg and her height is 54 (163 cm). She smokes 2 packs
of cigarettes per day. Drug allergies include lisinopril (angioedema)
MEDICAL HISTORY, PHYSICAL EXAMINATION AND DIAGNOSTIC TESTS
PMH: T2DM since age 45 (well controlled); hypertension for 20 years (well controlled)
FH: noncontributory
SH: worked as a teacher in an elementary school; lives at home with husband and teenage daughter
MEDS: Metformin 500 mg orally twice daily; hydrochlorothiazide 12.5 mg orally once daily; amlodipine 10 mg orally
once daily, levothyroxine 0.025 mg once daily, and lorazepam 0.5 mg at bedtime
ROS: (+) heartburn, regurgitation; (-) chest pain, nausea, vomiting, diarrhea, weight loss, change in appetite,
shortness of breath or cough, difficulty or painful swallowing
VS : BP: 128/76 mmHg, P: 79 bpm, RR: 16 breaths/min, T: 37C (98.6F)
CV: RRR, normal S1, S2; no murmurs, rubs or gallops
Abd: soft, nontender; (+) bowel sounds, (-) hepatosplenomegaly, heme (-) stool
Laboratory results:
HbA1: 7%
HDL: 25mg/dL
Trigly: 180mg/dL

Total cholesterol: 214mg/dL

LDL: 90mg/dL
Tyroxine total: 5 mcg/dL

SALIENT FEATURES:

Severe burning in throat and regurgitation

Wakes up atleast once a night with heartburn

Wt 86 kg, Ht 54 (BMI: 32.4 obese)

Smokes 2 packs of cigarette per day

(+) heartburn and regurgitation

PMH: anxiety, hypothyroidism, T2DM since 45 y/o

(well controlled), HTN for 20 years (well controlled
HbA1c 7% (increased)
HDL 25 mg/dL (decreased)
Trigly 180 mg/dL (increased)
Total cholesterol 214 mg/dL (increased)

PRINCIPLES:
COMPUTATION:
A. Ideal Body Weight
Female: IBW = 45.5 kg + 2.3 kg for each inch over feet
*Patients height = 54 (163cm)
IBW = 45.5 kg + (2.3 kg x 4)
= 45.5 kg + 9.2 kg
= 54.7 kg
B. Adjusted Body Weight
ABW = IBW + 0.25 (actual weight IBW)
= 54.7 kg + 0.25 (86 kg 54.7 kg)
= 54.7 kg + 0.25 (31.3 kg)
= 54. 7 kg + 7.83 kg
= 62.53 kg or 63 kg

C. Basal Metabolic Rate

Female: BMR = 0.9 kcal/kg/hr x 24 hours
= 0.9 x 63 x 24
= 1,361 kcal or 1,400 kcal

D. Total Caloric Requirement

TCR = BMR x Activity Factor x Injury Factor
*Activity Factor = 1.3 (very light)
*Injury Factor = 1.3 (normal/non-stressed)
TCR = 1,400 kcal x 1.3 x 1.3
= 2,366 kcal or 2,400 kcal

Distribution of CHO, CHON and Fats

CHO (60%)

2,400 kcal x .60 = 1,440/4 = 360g

CHON (15%)

2,400 kcal x .15 = 360/4 = 90g

FATS (25%)

2,400 kcal x .25 = 600/9 = 66.7g or 67g

Diet RX: 2,400 kcal (CHO: 360g, CHON: 90g, FATS: 67g)

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CASE 2: CARDIOVASCULAR (Hpn, MI)
P.H., a 68-year-old, 80-kg man, is being admitted to the ED after experiencing an episode of sustained chest pain while
mowing his yard. After waiting 1 hour, he called 911 and was transported to the ED. Physical examination reveals a
diaphoretic man who appears ashen. Heart rate and rhythm are regular, and no S3 or S4 sounds are present. Vital
signs include BP 180/110 mm Hg, heart rate 105 beats/minute, and respiratory rate 32 breaths/minute. P.H.s chest
pain radiates to his left arm and jaw, and he describes the pain as crushing and like an elephant sitting on my
chest. He rates it as a 10/10 in intensity. Thus far, his pain has not responded to five sublingual (SL) nitroglycerin
(NTG) tablets at home and three more in the ambulance. His ECG reveals a 3-mm ST segment elevation and Q waves
in leads I and V2 to V4. Based on his history and physical examination, P.H. is diagnosed with an anterior infarction.
Laboratory values include the following:
Sodium (Na), 141 mEq/L
Potassium (K), 3.9 mEq/L
Chloride (Cl), 100 mEq/L
CO2, 20 mEq/L
Blood urea nitrogen (BUN), 19 mg/dL
Serum creatinine (SCr), 1.2 mg/dL

Glucose, 149 mg/dL

Magnesium (Mg), 1.3 mEq/L
CK, 1200 U/L, with a 12% CK-MB fraction (normal, 0%5%)
Troponin I, 60 ng/mL (normal, <2)
Cholesterol, 259 mg/dL
Trigkycerides, 300 mg/dL

P.H. has a prior history of coronary artery disease (CAD). A previous cardiac catheterization 2 years ago revealed
lesions in his middle left anterior descending coronary artery (75% stenosis) and proximal left circumflex artery (30%
stenosis). His echocardiogram at the time showed an EF of 58%. These lesions were deemed suitable for medical
management. He also has a history of recurrent bouts of bronchitis associated with bronchospasm for 10 years,
diabetes mellitus treated with insulin for 18 years with a hemoglobin A1c of 6.8%, and stage 1 hypertension with blood
pressures usually 140/85 mm Hg. His father died of an MI at age 70. His mother and siblings are all alive and well. P.H.
has smoked one pack of cigarettes a day for 30 years, and he drinks approximately one six-pack of beer a week. He
has no history of IV drug use. On admission, P.H.s medications include insulin glargine 40 units daily; albuterol inhaler,
as needed (PRN); hydrochlorothiazide, 25 mg daily; NTG patch, 0.2 mg/hour; and NTG SL, 0.4 mg PRN for chest pain.
SALIENT FEATURES:
PRINCIPLES:
COMPUTATION:
24 HOUR DIET:
CASE 3: LOWER GIT (Gallstone/Cirrhosis)
LP, a 56-year old male, was admitted to the hospital because of nausea, vomiting and abdominal pain. He had a long
history of alcohol abuse, with multiple hospital admissions for alcoholic gastritis and alcohol withdrawal. Physical
examination revealed a cachectic male patient (weighting 55 kg) with clouded mentation who was not responsive to
questions about his name and place. Tense ascites and edema was noted, and liver was percussed at 9 cm below the
right costal margin. The spleen was not palpated, and no active bowel sounds were heard. Laboratory results on
admission included the following:
Na, 132 mEq/L
K 3.7 mEq/L
Cl, 98 mEq/L
Bicarbonate, 27 mEq/L
BUN, 24 mg/dL
SCr, 1.4 mg/dL
Hgb, 9.2 g/dL

AST, 520 IU
Hct, 24.1%
Alkaline phosphatase -218 IU
LDH - 305 IU
Total Bilirubin, 3.5 mg/dL
PT, 22 seconds (INR 1.8)

Two days after admission, he had an episode of hematemesis. He became mentally confused and at times
unresponsive to verbal command. An NGT was inserted and coffee ground materials were noted. Saline lavage was
done until fluid coming out of the NGT was clear.
On the third hospital day, the patient was still confused and this time asterixis and fetor hepaticus was noted. Followup lab exams were as follows:
Hgb 7.2 g/dL
BUN 36 mg/dL
Hct - 21.2%
SALIENT FEATURES:
PRINCIPLES:
COMPUTATION:

PT 22 sec (INR 1.8)

K 3.1 mEq/L
Guaiac (+) stool SCr 1.4 mg/dL

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