CLINICAL NUTRITION 202310

FINAL CLINICAL CASES

MULTIDISCIPLINARY TEAMS

In groups of 5-6 people: 2-3 physicians (at least one student from any other group in
the medical school generation) and 3 other teammates from other disciplines
(colleagues from bioethics, law school, rehabilitation, nurses, nutritionists,
psychology, chemist, etc.) discuss and answer one of the 3 cases available.
Follow the order of the questions. You can make videos, video calls, podcasts,
interviews, to establish that you asked someone else for their advice to approach the
questions from the case. You have to discuss the answers, not just ask the solution to
someone else.
Due date: May 18, 2023. Write your complete names and IDs.

CASE 1

49-year-old man (weight 73 kg, height 179 cm) with chronic kidney disease for 22
years, in treatment with hemodialysis 3 days per week (GFR = 10.3 mL/min/ 1.72m2).

He had a bowel obstruction 2 months ago, requiring surgery for lysis of adhesions.
Since then, he has been eating 50% of his usual intake, for the past three weeks he eats
less than 30% of what is recommended, losing 8 kilos in that time. He started with
nausea, vomiting, bloating and abdominal pain at the same time of evolution.

Past medical history: Hepatitis C virus infection 16 years ago, treated with pegylated
interferon and ribavirin, currently not active. Open cholecystectomy 7 years ago due
to chronic cholecystitis. Open appendectomy 3 years ago due to acute appendicitis

He is retired, but works in sales to complete their income, although now he can hardly
leave his house.

He is diagnosed once again with bowel pseudo obstruction, it was decided to give him
conservative management including fasting and decompression with a nasogastric
tube. The bowel obstruction resolved gradually in one week.

Clinical & laboratory findings: BP 130/70 mmHg HR 76 x’ RR 16 x’ T 37.20C

Serum creatinine 10.4 mg/dl

Urinary creatinine 54 mg/dl

Urinary creatinine 24 hours 1.13g/24 hours

Urinary volume in 24 hours 2103 mL/24 hours

Loss of subcutaneous fat (+) Muscular atrophy (++) Ankle edema (+++)
 1. Screen the patient. Perform and explain the screening tool that you chose and
why.

2. Assess the patient. Make the complete nutritional diagnosis. Which nutritional
assessment tool would be the most useful?

Other laboratory findings include the following:

Blood glucose 83 mg/dL, albumin 2.6 g/dL, Urinary Ureic Nitrogen 16 grams,
cholesterol 70 mg/dl.

3. According to the KDIGO guidelines, for nutrition in patients with chronic

kidney disease, serum albumin and cholesterol are valid tools of nutritional
status in maintenance dialysis patients. How do you classify this patient
nutritionally?

4. While the patient suffered the pseudo obstruction, what would have been your
recommendation? Would you have given enteral or parenteral nutrition?

5. Which one is the preferred nutritional access (temporal, permanent) for this
patient and why?

6. What is the degree of progression of the chronic kidney disease in the KDIGO
classification and what is the expected Glomerular Filtration Rate according to
the CKD-EPI formula? Why is this information important in clinical nutrition?

7. Make energy and macronutrient calculations. (Consider the comorbidities and

labs of the patient).

8. Which are the electrolyte imbalances that this patient is expected to have when
we start the nutritional treatment and why? Could these imbalances have a
nutritional and / or medical impact on the patient?

9. Does the patient need rehabilitation therapy? What kind?

10. Because of the years of evolution and diagnosis of chronic kidney disease, is
the patient a candidate for the withdrawal of the nutritional support?
(Bioethical analysis)
CASE 2:

A 66 year old man with T3N2M0 supraglottic laryngeal cancer is undergoing

chemoradiation: 35 radiotherapy sessions (7 weeks, 5 days per week), combined with
weekly cisplatin. He is now in his 15th week of treatment.

Since his first chemotherapy he has been very nauseous, a symptom that is now
controlled by metoclopramide. He now has a fungal infection in the throat, for which
he receives clotrimazol. He also has pain while swallowing even liquids due to
mucositis, for which he is taking tramadol and acetaminophen. Moreover, he is
experiencing changes in taste.

His weight before disease (6 months ago) was 69.5 kg, height 1.79 m. His current
weight is 60 kg, BMI=18.7 kg/m2. He is not able to do his work fully; his activity
level has considerably decreased. He now takes a small breakfast (1 portion of yogurt
with sugar), a small lunch (cream soup, scrambled eggs), and a small dinner (cream
soup, small soft sausage, and Greek yogurt as dessert). In addition, he is taking half a
bottle of oral nutritional supplements (ONS; energy and protein rich; 300 kcal, 20 g
protein per bottle) per day, because he doesn't like them. Total fluid intake (including
coffee, the two yogurts, water and ONS) is about 1200 ml per day.

Labs: Total cholesterol 145 mg/dL, albumin 2.8 g/dL, prealbumin 9 mg/dL, WBC
1500, Neutrophils 200, lymphocytes 800, Hemoglobin 9 g/dL, hematocrit 32%.
Fat free mass index: 13 kg/m2

1- Is the patient at risk of undernutrition? Screen the patient. Explain the screening
tool that you selected.

2- His PG-SGA Short Form score is 16. What does this mean?

3- How would you rate the nutritional status of this patient? Assess the patient.
Explain assessment tools that you used.

4- Define 3 nutritional goals.

5- What would be your current nutritional treatment strategy? (enteral versus

parenteral nutrition, access)

6- Calculate energy and macronutrient requirements.

7- Would you recommend any specific nutrients to prevent chemotoxicity?

8- Are drug-nutrient interactions expected? What micronutrients will be deficient with

the chemotherapy he is receiving?

9- Is the patient a candidate for rehabilitation sessions?

10- The patient is telling us that he wants to stop all the treatments and that he doesn't
want to live anymore. Is he a candidate to withdraw the nutritional treatment?
CASE 3

Recently widowed 96-year-old woman (weight 58 kg, height, 165 cm, calf
circumference 26 cm) presented to the ER 24 hours after she was found on the
bathroom floor by the cleaning lady (she lives alone). She presents with right-side
weakness of her body, facial droop, and slurred speech. Computed tomography of the
head revealed left middle cerebral artery infarction and intraventricular hemorrhage.
Due to her Glasgow coma scale (6), she had to be intubated and sent to the ICU.

Her medical history includes chronic obstructive pulmonary disease (COPD),

diabetes, hypertension, hyperlipidemia. The drugs she takes daily are metformin,
atorvastatin, amlodipine, ciprofibrate, and sertraline.

Initial labs include albumin 2.4 g/dL, prealbumin 10 mg/dL, indirect calorimetry 1390
kcal/day, glucose 180 mg/dL.

1- Screen the patient. Explain the screening tool that you chose and why.

2- Assess the patient. What other assessment tools would be useful?

3- Would you start enteral or parenteral nutrition? Explain.

4- What is the preferred nutritional access and why?

Laboratory data includes blood glucose, 300 mg/dL, albumin, 1.8 g/dL, glycosylated
hemoglobin 7%, BUN 45, creatinine 1.5 g/dL, CPK 250 UI/L, triglycerides 180
mg/dL.

5- Make energy and macronutrient calculations.

6- Insulin is initiated. What are the drug- nutrient, drug-drug interactions to be

expected? How would you prevent them?

Because of her history of COPD, the patient cannot be extubated from mechanical
ventilation. It has been 35 days since her admission.

7- What are the rehabilitation seances the patient needs when she is bedridden and in
a coma state?

8- What is the patient ́s neurological diagnosis after a month in a coma?

9- Is the patient a candidate for the withdrawal of the hydro nutritional support?
(Principalis analysis).

10- Who has the legal authority to decide the medical therapies the patient should or
should not receive if the coma state persists longer than 3 months?