Case study

DEMOGRAPHIC DATA

A. Patients Details

1. Name: X
2. Age: 70 years
3. Gender: Male
4. Occupation: Farmer

B. Hospital

1. Name of hospital: Pondicherry Institute of Medical Sciences

2. Date of admission: 04-06-2022
3. No. of. days hospital stay: Not yet discharged
3. Ward: ENT Ward [Division – NEURO]
4. Period of assessment: 29-06-2022 – 05-07-2022

MEDICAL HISTORY

A. Present complaints

Patient brought to casualty with alleged history of Renal Tubular Acidosis with
 Sustained injury to the head and left eye
 Ear and nasal bleed, Stiffness of body

B. Past medical history

Hypertension x 10 years and is on medication

C. Family history

No significant history related to health

D. Social history

Alcohol/Tobacco -- No usage, Medications – No illegal drug use

E. Final medical diagnosis

 Multiple cerebral contusion

 Left Sub Arachnoid Haemorrhage
 Left Frontal bone fractures
 Renal Tubular Acidosis
  Hyponatremia
MEDICATIONS – DOSAGE – MECHANISM OF ACTION

MEDICATION DOSAGE ACTION

It is used to treat seizures.

Modulates synaptic
T. LEVETIRACETAM 500 mg neurotransmitter release
through binding to synaptic
vesicle protein SV₂ A in the
brain
It is a proton pump -
Inhibitor. It works by
T. PAN 40 mg reducing the stomach
acids.
Vitamin and mineral
C. BECADEXAMIN 1 Cap supplementation

It is an angiotensin receptor and

T. TELMISARTAN + calcium channel blocker used to
AMOLDIPINE 40 mg + 5 mg treat High Blood pressure.

It is an antipsychotic and
CHLORPROMAZINE 25 mg neuroleptic drug

Mineral supplementation
Inj. Ca GLUCONATE 10 ml for high blood potassium
and low calcium
It is used to treat
hyponatremia by reducing water
T. TOLVAPTAN 15 mg reabsorption and producing
aquaresis without sodium loss

ANTHROPOMETRIC MEASUREMENT

Height in supine position – 160 Cms

Ideal body weight – 60 Kgs
EVALUATION
NORMAL
PARAMETERS VALUE 29-06-2022 30-06-2022 01-07-2022 02-07-2022 03-07-2022

Oxygen
(SpO²) % 97-100 97 99 98 97 99
Body
temperature [F] 98.6 96 97 98 98 98

Pulse Rate
[Bpm] 60-100 94 94 95 95 94

Blood pressure
mm/hg 120/80 130/80 130/80 130/80 130/80 130/80

BIOCHEMICAL EVALUATION

PARAMETERS 29-06-2022 30-06-2022 01-07-2022 02-07-2022 NORMAL RANGE

Haemoglobin 13.9 12.2 11.8 9.4 13.2-16.2 g/dl

Platelets 328 338 440 468 150-450x10c U/L
Urea 33 34 35 35 15-40 mg/dl
Ser.Creatinine 0.7 0.7 0.7 0.7 0.7-1.4 mg/dl
Sodium 115 116 128 134 135-145 mmol/l
Potassium 3.6 3.9 3.8 3.7 3.5-5.0 mmol/l
Chlorides 98 99 99 99 95-108 mEq/l

CLINICAL EVALUATION
 SKIN: Light discolouration
 HEENT: Scalp normal, pupils are reactive to light, dry mouth.
 NECK: Resistance to movement due to trauma in head
 CHEST: Normal
 ABDOMEN: Normal without distension
 EXTREMETIES: No oedema
 NEUROLOGICAL: Regaining reflexes

DIETARY HISTORY
 Inclusion of all five basic food groups regularly
 Patient includes non-vegetarian at least thrice a week. Avoids red meat
 No allergies to any specific food
  Does not consume Junk foods
 Avoids outside foods

HOSPITAL RECALL
Patient was started with RT feed on 10-06-2022
10-06-2022: 4th Hourly naso gastric bolus feed
12-06-2022: 2nd Hourly naso gastric bolus feed
Patient was progressed to 2nd hourly bolus feed due to energy requirement

DIET DETAILS AND CHART

DAY 1 And DAY 2

29-06-2022 – 30-06-2022
3rd Hourly naso gastric bolus feed
Energy Required: 1600 Kcals
Protein Required: 97 g

DAY 3, 4 And 5
01-07-2022, 02-07-2022 And 03-07-2022
2nd Hourly naso gastric bolus feed
Energy Required: 1800 Kcals
Protein Required: 120 g
NUTRITIONAL THERAPY
A. Nutritional Requirements

Energy requirements:
2100 kcals @ 35 kcals/kg body weight

Protein requirements:
95 g @ 1.5 g/kg body weight

Fat requirements:
30% of total calories

Sodium requirements:
85 mmol/L

Potassium requirements:
1 mmol/L

Fluid requirements:
2.5-3 litre/day

B. Details of diet Prescribed

2nd Hourly naso gastric bolus feed

Energy Required: 2100 Kcals
Protein Required: 95 g
Fluid Required: 2.5 Litre

 Additional Free water @ 50ml/feed

 Additional Salt 8gms / day

C. Goals of nutritional management and intervention

 To provide adequate energy and protein requirements to prevent catabolism

 A diet excessive in sodium is provided to prevent and correct hyponatremia
 A normal potassium diet is provided to meet the requirements
 Slowly and steadily reintroducing the patient to oral feed from polymeric formulas
SUMMARY
70-year-old male was brought to casualty with alleged history of Renal Tubular Acidosis
and sustained injury to head with Nasal and Ear bleeding. vitals were stabilized and Hemodynamic
stability was attained and was introduced to 4th hourly Naso-gastric bolus feed and was progressed to
2nd hourly feed as the energy requirement was not met then. Patient did not tolerate oral feed,
therefore is being continued on 2nd hourly Naso-gastric bolus feed, also hyponatremia was corrected
with dietary salt and medication. For Further requirements, patient is recommended standard
polymeric formula and later can be progressed to normal oral diet gradually step by step.