Daniyal Final

INTERNSHIP REPORT
A report submitted in partial fulfillment for the award of degree of

B.Sc. (Hons.) Human Nutrition and Dietetics
Submitted by
(DANIYAL TAHIR)
Session: 2019-2023
Supervisor: Ms Safa Akram
DEPARTMENT OF HUMAN NUTRITION AND DIETETICS(HND)
AFRO ASIAN INSTITUE, LAHORE
AFFILIATED WITH GCUF, FAISLABAD

AFRO ASIAN INSTITUTE, LAHORE
DEPARTEMENT OF HUMAN NUTRITION AND DIETETICS (HND)
SUPERVISORY COMMITTEE
We, the Supervisory Committee, certify that the contents and the form of report submitted by
DANIYAL TAHIR (Regd. No:2019-GCUF-059192 ) was found satisfactory and we
recommend it for the evaluation from the examination committee for the award of the degree
BS (Hons.) Human Nutrition and Dietetics.
Ms Safa Akram
Supervisor ____________________
Ms Sania Khalid
Member ____________________
Ms Maryam Ashraf
Member ____________________
1
AFRO ASIAN INSTITUTE, LAHORE
DEPARTEMENT OF HUMAN NUTRITION AND DIETETICS (HND)
UNDERTAKING
I, DANIYAL TAHIR (Regd. No:2019-GCUF-059192.), declare that the contents of this
Internship Report have not been taken from any other work. I also undertake that I was
responsible for any plagiarism in this report.
_______________
2
DEDICATED TO
MY PARENTS
&
MY TEACHERS
3
ACKNOWLEDGEMENT
In the name of ALLAH, the Most Gracious and the Most Merciful. All praises to ALLAH
and his blessing for the completion of this report. I thank to ALLAH almighty for all the
opportunities, trials and strength that have been showered on me to complete the report.
My humblest gratitude to the holy Prophet Hazrat Muhammad (Peace be upon him) whose
way of life has been a continuous guidance for me.
First of all my deepest gratitude goes to my Parents and all of my Family Members. It would
not be possible to write this report without the support from them.
I would like to sincerely thank to my supervisor Miss Safa Akram and all members for their
guidance, understanding, patience and most importantly, they has provided positive
encouragement and a warm spirit to finish this report. It has been a great pleasure and honor
to have them as my supervisor.
I experienced so much during this process, not only from the academic aspect but also from
the clinical field. I am also grateful for those great people and professionals who guide me
through this internship period.
May Allah shower his countless blessings on the above cited personalities.
4
TABLE OF CONTENTS
Chapter No. Topic Page No.

01 Introduction of Nutrition
1
Anthropometric
2
measurements
02 Gastro Ward 3
Constipation 3
Celiac Disease 8
Ulcerative Colitis 13
GERD 18
Peptic ulcer 23
Lactose intolerance 28
03 Orthopedic Ward 33
Osteoarthritis 33
Bone fracture 39
Rheumatoid arthritis 45
Osteoporosis 51
04 Pulmonary Ward 57
Chronic Bronchitis 57
Tuberculosis 65
Asthma 78
Pneumonia 77
05 Cardiac ward 82
Heart Failure 82
Hypertension 88
5
CHD 94
06 Surgery Ward 99
Cholecystectomy 99
Appendectomy 107
Hernia 114
07 Gynae Ward 121
Cesarean 124
Gestational Diabetes Mellitus 126
Anemia 128
08 Pediatrics Ward 131
Hyperthyroidism 134
Typhoid fever 135
09 Medical Unit 136
Diabetes 136
Hepatitis 141
Cirrhosis 147
NAFLD 150
Cholelithasis 152
10 References 153
6
List of abbrevations:
Sr. No. Abbreviation Full Form

01 RD Registered Dietitian
02 BMI Body Mass Index
03 IBW Ideal Body Weight
04 BMR Basal Metabolic Rate
05 SBP Systolic Blood Pressure
06 DBP Diastolic Blood Pressure
07 LDL Low Density Lipoprotein
08 HDL High Density Lipoprotein
09 VLDL Very Low Density Lipoprotein
10 DASH Dietary Approaches To Stop Hypertension
11 CVD Cardio Vascular Disease
12 CHD Coronary Heart Disease
13 IHD Ischemic Heart Disease
14 PUFA Poly Unsaturated Fatty Acid
15 MUFA Mono Unsaturated Fatty Acid
16 HF Heart Failure
17 FPG Fasting Plasma Glucose
18 GTI Gastro Intestinal Track
19 CAP 4 Community Acquired Pneumonia
20 GERD Gastro Esophageal Reflex Disease
21 COPD7 Chronic Obstructive Pulmonary Disease
22 DHA Decosa Hexanoicnoic Acid
23 EPA Ecosa Pentanoic Acid
24 AKI 1 Acute Kidney Injury
7
CHAPTER NO: 1
INTRODUCTION
1.1 Nutrition
Nutrition is a process of obtaining and providing the food necessary for health & growth.
1.2 Nutrients
Nutrients are the substances that provide the nourishment essential for the maintenance of life
and growth. There are two types of nutrients:
1.2.1 Macronutrient
· Carbohydrates
· Protein
· Fat
1.2.2 Micronutrients
· Vitamins
·Minerals
1.3 Food
Any nutritious substance that can eat or drink by animals and humans or absorbed by plants
to maintain life and growth.
1.4 Nutritional Status
The condition of the body that is affected by the diet. The level of the nutrients in the body
and ability of nutrients to maintain normal metabolic integrity.
1.5 Nutritional Assessment
It is the detailed investigation to identify and quantify the nutritional problems. This can be
performed by Registered Dietitian (RD).
1.6 Tools of Assessment

 Anthropometric assessment
 Biochemical assessment
 Clinical assessment
 Dietary assessment
1.6.1 Anthropometric measurement
 Height
 Weight
 Body mass index (BMI)
 Formula for measuring BMI is:
Weight in kg/height in m2=BMI in kg/m2
 Ideal body weight (IBW)
For males
106lbs for 5 feet +6lb for each inch
For females
100lb for 5 feet + 5lb for each inch
Waist to hip ratio
Use to identify adiposity, also known as gluteal ratio
W/H=0.7(normal ratio)
1.7 Harris Benedict Equation (energy calculation)

Equation for males
66.5+13.75× (weight in kg) +5 × (height in cm) – 6.78×age
Equation for female
655.1+ 9.6 × (weight in kg) + 1.9 × (height in cm) – 4.7 × age
-1-
Chapter No.2
GASTRO WARD
During the first week of internship the rotation was placed at gastro ward.
(1)
2.1Case study:
32 years old Sabiha Nawaz is hospitalized due to complain of constipation from few days,
her height is 5’2 inches and current weight is 50kg. Her BMI is about 26.8 kg/m2 and TEE is
2234 kcal/day.
2.1.1Constipation:
A condition in which stool becomes hard, dry, and difficult to pass, and bowel movements
don’t happen very often. Other symptoms may include painful bowel movements, and feeling
bloated, uncomfortable, and sluggish.
2.1.2Medical nutrition therapy:
Primary nutrition therapy for constipation in otherwise healthy . Dietary Reference Intakes
(DRI) recommend consumption of 14 g dietary fiber per 1000 kcal.
Objective:
High fiber and semi-solid diet is given .
Dietary guidelines:
 Increase dietary fiber: Adequate fiber intake is essential for promoting regular bowel
movements. Include high-fiber foods in your diet such as fruits, vegetables, whole
grains, legumes, and nuts. Gradually increase your fiber intake and ensure you drink
enough fluids to prevent fiber from causing further constipation.
 Adequate fluid intake: Drink plenty of fluids, particularly water, throughout the day.
Sufficient hydration softens the stool and helps with its passage. Aim for at least 8
cups (64 ounces) of water per day, or more if you’re physically active or in a warm
climate.
 Regular physical activity: Engage in regular exercise or physical activity as it helps
stimulate the muscles in your digestive system and promotes bowel movements. Aim
for at least 150 minutes of moderate-intensity aerobic activity each week, along with
strength training exercises.
 Probiotics: Consider incorporating probiotics into your diet. Probiotics are beneficial
bacteria that help promote a healthy gut environment. They can be found in certain
yogurts, fermented foods, or taken as supplements. Consult with a healthcare
professional for guidance on choosing the right probiotic for you.
 Evaluate medications and supplements: Some medications and supplements can
contribute to constipation. Review your medications with a healthcare professional to
identify any potential culprits. They may be able to recommend alternatives or
adjustments to help alleviate constipation.
-2-
 Elimination patterns: Establish a regular bathroom routine by setting aside time each
day for bowel movements. Responding promptly to the urge to have a bowel
movement can help prevent stool from becoming dry and difficult to pass.
2.1.3Table of food choices:

Food Groups Food Allowed Food Restricted
Milk and Milk products Skim ,1% or 2% low fat Whole milk ( 4%),chocolate
milk, low fat and fat free milk
yogurt
Vegetables All other vegetables Fried or creamy style
vegetables, tomatoes
Fruits Apples, berries, melons, Citrus such as oranges,
bananas, peaches, pears grapefruits, pineapple
Breads and Grains All those made with low fat Any prepared with low milk
content and high fat
Meat and meat products Low fat meat, chicken, fish, Cold cuts , sausage, bacon,
turkey, fatty meat, chicken fat/skin
Fats and oils None or small amount All animals and vegetables
oils
Beverages Decaffeinated, non-mint Alcohol , coffee ( regular or
herbal tea, juices ( except decaf), carbonated
citrus ) , water beverages, tea , mint tea
Calculation:
• Patient name: Sabiha Nawaz
• Age: 32 years
• Height: 5’2 inches
• Weight: 66 kg
Anthropometric Measurements:
Height: 5’4 multiply first 5 feet with12 and
BMI: then add additional inches.
Formula= Weight kg x 100
Height m2  5x12= 60
 60+2=62
= 66kg x 100
(1.57)² Multiply it with 2.54 for converting in cm
= 66 x 100  64x2.54=157.48cm
2..46 Converting it into m
 157.48
= 26.8
100
 BMI= 26.8kg/m2 (patient has over =1.57m
weight)
-3-
IBW:
Height 5’2 for first 5 feet is 100 and multiply additional inches with +5
 100+5x2
 100+10
 110 Lbs.
Converting it into kg
=110
2.2
= 50kg
IBW=55kg
IBW%:
Formula = Actual weight x 100  Actual weight= 66kg

IBW  IBW= 50 kg
= 66 x 100
50
= 1.32 x 100
= 132%
IBW% = 132%
Energy Calculation:
BEE:
Formula for Female BEE= 665+ (9.6x weight kg) + (1.8xheight cm) – (4.7xage years)
BEE= 665+ (9.6x 50 kg) + (1.8x 157.48 cm) – (4.7x 32 years)
BEE= 665+ 480+ 283.46- 150.4
BEE= 1278 kcal
BEE= 1278 kcal
TEE:
Formula= BEE x Activity factor x Stress factor BEE= 1278 kcal
= 1278 x 1.1 x 1.3 A.F= 1.1
=1827.5 kcal S.F=1.3
TEE= 1828 kcal
AMDRS:
• Carbohydrates= 52% Calories= 1828 kcal
• Protein=18%
• Fats= 30%
-4-
CARBOHYDRATE:
= % x calories
100
= 52 x 1828 kcal
100
= 0.52 x 1828 kcal
= 950 kcal
= 950 as 1 gram of carb= 4kcal
4
Carbohydrate= 237 grams
PROTIEN:
= % x calories
100
= 18 x 1828
100
= 0.18 x 1828
= 328 kcal
= 328 as 1 gram of protein= 4kcal
4
Protein = 82 grams
FAT:
= % x calories
100
= 30 x 1828
100
= 0.3 x 1828
= 548 kcal
= 548
9 as 1 gram of fat= 9kcal
Fats= 60 grams
EXCHANGES:
Food Exchange Carbohydrate Protein Fats
Milk 3 36g 24g 15g
Vegetable 3 15g 6g -
Fruit 3 45g - -
Total - 96g 30g 15g
Starch= Total- Consumed Carbs= 237
= 237g- 96g
= 141g
-5-
•As 1 exchange of carbs = 15g
= 141
15
Carbohydrate= 09 exchanges
Starch 9 135g 18g 09g
Total - 18+30= 16+10= 36g
48g
- -
Protein= Total- Consumed Protein= 82g
= 82g- 48g
= 40g
•As 1 exchange of protein= 7g
= 50
7
Protein= 6 exchanges

Lean Meat 6 - 42g 12g
Total - -
- -
Fats= Total- Consumed Fat= 60g

= 60g-36g
= 24g
•As 1 exchange of fat= 5g
= 24
5
Fat= 5 exchanges
Food Exchange Carbohydrate Protein Fat
Fat 5 - - 25g
Total - - -
- -
-6-
2.1.4DIET PLAN:
Breakfast:
•2slice + 1 egg
Snack:
•2 banana
•1 apple
Lunch:
•1 cup lentil
•1 cup rice
•1 cup raita with vegetable
Snack:
•1 cup salad with ½ cup beans
Dinner:
•1½cup vegetable(cooked)
•1 chapatti(6inch)
•2oz steamed chicken
Bedtime:
 1glass milk with ispaghole
-7-
(2)
2.2Case Study:
Asif Masood, 44 yrs. Hospitalized due to celiac disease. He had a pain and complain for
fatigue bloating. His current weight is 64kg and height is 5’8’’. His BMI is 21.6kg /m2 and
TEE is 2168 Kcal/day.
2.2.1Celiac disease:
Celiac disease is a chronic digestive and immune disorder that damages the small intestine.
The disease is triggered by eating foods containing gluten. The disease can cause long-lasting
digestive problems and keep your body from getting all the nutrients it needs. The disease
may become apparent when an infant begins eating gluten-containing cereals.
2.2.2Medical Nutrition Therapy of celiac:
 Elimination of gluten peptides from the diet is the only treatment for CD presently.
The diet omits all dietary wheat, rye, and Barley, which are the major sources of the
prolamin fractions.
 Nutrition management includes restoration and maintenance of fluids, electrolytes,
macronutrients, and micronutrients, and introduction of a diet that is appropriate for
the extent of malabsorption (see Diarrhea earlier in this chapter).
 Along with other nutrients, B12 and folate supplementation may be needed if
deficiency is identified. Nutritional deficiency increases susceptibility to infectious
agents, further aggravating the condition.
Objective:
 Gluten free diet

 Electrolyte and fluid replacement
 Management of other co-morbid conditions
Dietary guidelines:
 Delete gluten sources (wheat, rye, barley) from diet
 Vitamin and mineral supplementation
 Substitute with corn, potato, rice, soybean, tapioca, and other non-gluten flours
 Calcium and vitamin D administration
 Read food labels carefully for hidden gluten containing ingredients
 Supplementation with ω-3 fatty acid
-8-
Milk and Milk products Skim ,1% or 2% low fat milk, Whole milk ( 4%),chocolate
low fat and fat free yogurt milk
Fats and oils None or small amount All animals and vegetables oils
Beverages Decaffeinated, non-mint herbal Alcohol , coffee ( regular or
tea, juices ( except citrus ) , decaf), carbonated beverages,
water tea , mint tea
Calculation:
• Patient name: Asif Masood
• Age: 44 years
• Weight: 64 kg
BMI:
Formula= Weight kg
Height m2
= 64/1.722
=21.64kg/m2 (Normal)
IBW:
Height 5’i for first 5 feet is 106 and multiply additional inches with +6
• 106+6x8
• 106+48
• 154 Lbs.
=154
2.2
= 70kg
IBW=70kg
-9-
IBW%:
Formula = Actual weight x 100
IBW
= 64 x 100
70
= 0.91x 100
= 91%
IBW% = 91%
Energy Calculation:
BEE:
Formula for male BEE= 66.5+ (13.8 x weight kg) + (5.0 x height cm) - (6.8 x age years)
BEE= 66.5+ (13.8 x 64kg) + (5.0 x 173 cm) – (6.8 x 44 years)
BEE= 66.5+ 883.2+ 865- 299.2
BEE= 1814.7- 299.2
BEE= 1515.5 kcal
BEE= 1516 kcal
TEE:
= 1516 x 1.1 x 1.3 A.F= 1.1
=2167.88 kcal S.F=1.3
TEE= 2168 kcal
AMDRS:
• Carbohydrates= 54% Calories= 2168
kcal
• Protein=18%
• Fats= 28%
CARBOHYDRATE:
= % x calories
100
= 54 x 2168 kcal
100
= 0.54 x 2168 kcal
= 1171 kcal
4
PROTIEN:
= % x calories
100
- 10 -
= 18 x 2168
100
= 0.18 x 2168
= 390 kcal
4
Protein = 98 grams
FAT:
= % x calories
100
= 28 x 2168
100
= 0.28 x 2168
= 607 kcal
= 607
Fats= 67 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 89g 22g 10g
= 293g- 89g
= 204g
= 204
15
Total - 22+28= 14+10= 24g
50g
- -
= 98g- 50g
= 48g
= 48
7
- 11 -
Total - -
- -

= 67g-38g
= 29g
= 29
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - -
- -
2.2.4DIET PLAN:
Breakfast:
•2 eggs
•1cup apple juice
Snack:
•1 cup salad
•6 Almonds
Lunch:
•2 millet flour (bajra) chapatti
•1 cup cooked vegetable
•3 oz chicken
Snack:
•1cup smashed potatoes
•1 cup unflavoured yogurt
Dinner:
•1½cup lentils
•2cup brown rice
Bedtime:
 1 cup milk
- 12 -
(3)
2.3Case Study:
53 years old Mrs. IFRAH is hospitalized due to vomiting, nausea, abdominal pain and
complain of ulcerative colitis. Her current weight is 53kg and her height is 5 feet 4 inches.
Her BMI is 21kg/m2 and TEE is 1782kcal/day.
2.3.1Ulcerative colitis
 Ulcerative colitis is a chronic inflammatory bowel disease (IBD) in which abnormal
reactions of the immune system cause inflammation and ulcers on the inner lining of
your large intestine. Ulcerative colitis can develop at any age, but the disease is more
likely to develop in people between the ages of 15 and 30.
 Ulcerative colitis is characterized by abscesses, fistulas, fibrosis, submucosal
thickening, localized strictures, narrowed segments of bowel, and partial or complete
obstruction of the intestinal lumen.
2.3.2Medical Nutrition Therapy

Diet rich in fruit and vegetables, rich in n-3 fatty acids, and low in n-6 fatty acids is
associated with a decreased risk of developing ulcerative
Objective:
low fiber fruits and vegetables, high sugar diet help to treat ulcerative colitis
Basic Principle:
Consumed low fiber diet, high sugar diet, drink adequate amount of fluids
Dietary Guidelines:
 low fiber fruits like bananas, honeydew melon, and cooked fruits.
 cooked, non-cruciferous vegetables like asparagus, potatoes, and cucumbers.
 lean protein sources like chicken, eggs, and tofu.
 omega-3 fatty acids, including fish.
 sugar-free or unsweetened applesauce.

- 13 -
Calculation:
 Patient name: Ifrah

 Age: 25 years
 Height: 5’4 inches
 Weight: 53 kg
BMI:
Formula= Weight kg x 100 Height: 5’4 multiply first 5 feet with12 and
Height m2 then add additional inches.
= 53kg x 100  5x12= 60
(1.63)²  60+4=65
= 50 x 100 Multiply it with 2.54 for converting in cm

2.56  64x2.54=162.56cm
= 21 Converting it into m
 162.56
 BMI= 21kg/m2 (patient 100
has normal weight)
=1.6m
IBW:
 100+5x4
 100+20
 120 Lbs.
=120
2.2
- 14 -
= 55kg
IBW=55kg
IBW%:
IBW  IBW= 55 kg
= 53 x 100
55
= 0.963 x 100
= 96.3%
IBW% = 96%
Energy Calculation:
BEE:
Formula for Female BEE= 665+ (9.6x weight kg) + (1.8xheight cm) - (4.7xage years)
BEE= 665+ (9.6x 53 kg) + (1.8x 163 cm) – (4.7x 25 years)
BEE= 665+ 508.8+ 293.4- 117.5
BEE= 1467.2- 117.5
BEE= 1349.7 kcal
BEE= 1350 kcal
TEE:
= 1350 x 1.1 x 1.2 A.F= 1.1
=1782 kcal S.F= 1.2
TEE= 1782 kcal
AMDRS:
 Carbohydrates= 52% Calories= 1782 kcal
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1782 kcal
100
= 0.52 x 1782 kcal
= 927 kcal
4
- 15 -
PROTIEN:
= % x calories
100
= 18 x 1782
100
= 0.18 x 1782
= 321 kcal
4
Protein = 80 grams
FAT:
= % x calories
100
= 30 x 1782
100
= 0.3 x 1782
= 535 kcal
= 535
Fats= 59 grams
EXCHANGES:
Milk 2 24g 16g 4g
Fruit 3 45g - -
Total - 84g 22g 4g
Starch= Total- Consumed Carbs= 232g

= 232g- 84g
= 148g
 As 1 exchange of carbs = 15g
= 148
15
Total - 150+84 = 234g 22+20= 42g 10+4= 14g
- -
= 80g- 42g
- 16 -
= 38g
 As 1 exchange of protein= 7g
= 38
7
Total - - 42+35= 87g 10+14g= 24g
- -

= 59g-24g
= 35g
 As 1 exchange of fat= 5g
= 35
5
Fat= 7 exchanges
Fat 7 - - 35g
Total - - - 24+35= 59g
- -
2.3.4DIET PLAN:
Breakfast:
 2 slices of bread
 1 cup banana shake.
 2 boiled eggs
Snack:
 1 apple
Lunch:
 1 chapatti (home made)
 1 cup lentils
 1 cup salad
Snack:
 Steamed fish (1oz)
Dinner:
 2 chapatti (home made)
 ½ cup cooked vegetable
 1cup raita
Bed time:
 2 biscuits
- 17 -
(4)
2.4Case Study:
34 years old Mr. Shoaib Mansoor is hospitalized due to a disease name GERD
(gastroesophageal reflux disease), he is having abdominal pain and heartburn and acidity, his
height is 5’8 inches and current weight is 91 kg. His BMI is about 31 kg/m2 and TEE is 2399
kcal/day.
2.4.1GERD:
GERD occurs when stomach acid repeatedly flows back into a tube connecting to your mouth
and stomach. This acid reflux can irritate the lining of your esophagus.Many people
experience acid reflux from time to time.
2.4.2Medical Nutrition Therapy of GERD:

Fibrous foods makes patient feel full so you are less likely to overeat which may contribute to
heart burn.so, load up on healthy fibre from these foods: Whole grains such as oatmeal and
brown rice. Root vegetables such as sweet potatoes, carrots and beets.
Objective:
The goals of managing GERD are to address the resolution of symptoms and prevent
complications such as esophagitis , BE and oesophageal adenocarcinoma.
Basic Principle:
High protein, low carbs and low fat diet.
Dietary Guidelines:
 Avoid Trigger Foods: Certain foods and beverages can trigger or worsen GERD
symptoms. Common triggers include fatty and fried foods, spicy foods, citrus fruits
and juices, tomatoes, onions, chocolate, coffee, alcohol, and carbonated beverages.
Identify your personal trigger foods and limit or avoid them as much as possible.
 Portion Control: Overeating and large meals can contribute to GERD symptoms. Opt
for smaller, more frequent meals throughout the day rather than large meals.
 Maintain a Healthy Weight: Excess weight can put pressure on the abdomen and
increase the risk of GERD symptoms. Aim for a healthy weight through a balanced
diet and regular physical activity.
 Elevate the Head of the Bed: Raising the head of your bed by 6 to 8 inches can help
prevent stomach acid from flowing back into the esophagus while you sleep. This can
be achieved by using bed risers or placing a wedge-shaped pillow under the head of
the mattress.
 Eat Slowly and Mindfully: Chew your food thoroughly and take your time while
eating. Eating too quickly can contribute to GERD symptoms.
 Avoid Eating Close to Bedtime: Allow at least 2 to 3 hours between your last meal or
snack and bedtime. This helps ensure that your stomach is relatively empty when you
lie down, reducing the likelihood of acid reflux.
 Stay Hydrated: Drink plenty of water throughout the day. However, avoid excessive
fluid intake during meals, as it can contribute to reflux symptoms.
- 18 -
 Limit or avoid mint, citrus, tomatoes, and/or carbonated beverages according to
individual tolerance. These foods may cause further irritation to damaged oesophageal
mucosa but have not been found to cause reflux themselves.
 Smoking and excessive alcohol consumption can adversely affect health.
 So cessation of smoking is recommended, which contributes to the overall health of
the person.
Calculation:
• Patient name: Shoaib Mansoor
• Age: 34 years
• Weight: 91 kg
BMI:
Formula= Weight kg
Height m2
= 91/1.722
=31kg/m2 (OBESE)
IBW:
• 106+8x6
• 106+48
• 154 Lbs.
- 19 -
=136
2.2
= 70kg
IBW=70kg
IBW%:
IBW
= 91 x 100
70
= 1.3 x 100
= 130%
IBW% = 130%
Energy Calculation:
BEE:
BEE= 66.5+ 966+ 865- 231.2
BEE= 1897.5- 231.2
BEE= 1666.3 kcal
BEE= 1666.3 kcal
TEE:
= 1666 x 1.1 x 1.2 A.F= 1.1
=2199 kcal S.F=1.2
TEE= 2199 kcal
AMDRS:
• Carbohydrates= 52% Calories= 2199
kcal
• Protein=18%
• Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 2199 kcal
100
= 0.52 x 2199 kcal
= 1143 kcal
4
- 20 -
PROTIEN:
= % x calories
100
= 18 x 2199
100
= 0.18 x 2199
= 396 kcal
4
Protein = 99 grams
FAT:
= % x calories
100
= 30 x 2199
100
= 0.3 x 2199
= 658 kcal
= 658
Fats= 73 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 30g - -
Total - 69g 22g 10g

= 286g- 69g
= 217g
= 217
15
Total - 28+22= 14+10= 34g
50g
- -
= 99g- 50g
- 21 -
= 49g
= 49
7
Total - - 34+16=50
- -
= 73g-50g
= 23g
= 23
5
Fat= 4 exchanges
Fat 4 - - 20g
Total - - -
- -
2.4.4DIET PLAN:
Breakfast:
•1 cup tea
•3slice + 1 egg
Snack:
•2 peaches + grapes (17oz)
Lunch:
•1 cup lentil
•2 home made chapatti
•1 cup yogurt
Snack:
•5 piece chicken wings
Dinner:
•1½cup vegetable(cooked)
•2 chapatti(Home-made)
•½ cup raita
Bedtime:
 1small banana
 3 biscuits
- 22 -
(5)
2.5Case Study:
36 years old Haseeb Ali is hospitalized due to epigastric pain ,burning sensation in abdomen,
and complain of peptic ulcer. His current weight is 59kg and his height is 5 feet 11 inches.
His BMI is 18.67 kg/m2 and TEE is 2571kcal/day.
2.5.1Peptic ulcer:
A peptic ulcer is an open sore or raw area in the lining of the stomach or intestine.
There are two types of peptic ulcers:
 Gastric ulcer: occurs in the stomach.

 Duodenal ulcer: occurs in the first part of the small intestine.
2.5.2Medical Nutrition Therapy:

 Adequate protein intake is essential.
 Do not consume alcohol in large amount.
 Do not consume spicy foods, they cause secretion in stomach.
 Do not consume tea in peptic ulcer.
 Increase consumption of fermented foods (yogurt, cabbage)
 Consume non-spicy soft foods that are easy to digest.
Objective:
Vitamin c, balanced diet, low fat, zinc is used to treat peptic ulcer.
Basic Principle:
Consumed vitamin c low fat diet in peptic ulcer.
Dietary Guidelines:
 Decrease consumption of Alcohol.
 Spices particularly red and black pepper when inflamed.
 Coffee & caffeine.
 Increase consumption of omega 3 and omega 6 fatty acids

- 23 -
Calculation:
 Patient name: Haseeb Ali

 Age: 36 years
 Weight: 59 kg
BMI:
Formula= Weight kg x 100 Height: 5’11 multiply first 5 feet with12 and
= 59kg x 100  5x12= 60
(1.80)²  60+11=71
= 59 x 100 Multiply it with 2.54 for converting in cm

3.16  71x2.54=180.34cm
 180.34
 BMI= 18.67kg/m2 (patient 100
has under weight)
=1.8m
IBW:
 106+11x6
 106+66
 172 Lbs.
=172
2.2
= 78kg
IBW=78kg
- 24 -
IBW%:
IBW  IBW= 78 kg
= 59 x 100
78
= 0.70 x 100
= 70%
IBW% = 70%
Energy Calculation:
BEE:
BEE= 66.5+ 1076.4+ 900- 238
BEE= 1798 kcal
TEE:
= 1798 x 1.1 x 1.3 A.F= 1.1
=2571 kcal S.F= 1.3
TEE= 2571 kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 2571 kcal
100
= 0.52 x 2571 kcal
= 1362.3 kcal
= 1362.3 as 1 gram of carb= 4kcal
4
PROTIEN:
= % x calories
100
= 18 x 2571
100
= 0.18 x 2571
= 462.78 kcal
- 25 -
= 462.78 as 1 gram of protein= 4kcal
4
Protein = 116 grams
FAT:
= % x calories
100
= 30 x 2571
100
= 0.3 x 2571
= 745.59 kcal
= 745.59
Fats= 83 grams
EXCHANGES:
Milk 3 36g 16g 2g
Fruit 3 45g - -
Total - 101g 24g 2g

= 341g- 101g
= 240g
= 240
15

Starch 16 240 32 16
Total - 240+101 = 341g 32+24= 56g 16+2= 18g
- -

= 116g- 56g
= 62g
= 62
7
- 26 -
Total - - 56+56= 112g 18+16g= 34g
- -

= 83g-34g
= 49g
= 49
5
Fat= 10 exchanges
Fat 10 - - 50g
Total - - - 34+50= 84g
- -
2.5.4DIET PLAN:
Breakfast:
 3 bread slices
 1 cup tea with 1tbsp of sugar
 2 egg whole
Snack:
 1 cup banana shake with 1tbsp sugar
Lunch:
 2 chapatti (home-made)
 1 cup lentils
 1 cup salad
Snack:
 1 ½ cup salad
 1 apple
Dinner:
 Chicken sandwich (3 slice bread+ 4oz chicken)
Bed time:
 1 cup milk
 6 biscuits
- 27 -
(6)
2.6Case Study:
Mr, Soban Sheikh aged 23 is hospitalized due to incidence of disease named lactose
intolerance. He is having abdominal pain after consumption of any lactose containing
product. Patient is also experiencing bloating and diarrhea. His height is 5’10 inches and
current weight is 67 kg. His BMI is about 21kg/m2 and TEE is 2277kcal/day.
2.6.1Lactose intolerance:
 Lactose intolerance, also called lactase deficiency or hypolactasia, is

the inability to digest and metabolize lactose, a sugar found in milk.
 Lactose intolerance is not an allergy because it is not an immune response but caused
by lactase deficiency.
 Lactose intolerance is a condition characterized by the inability to digest lactose, a
sugar found in milk and dairy products, due to insufficient levels of lactase enzyme
2.6.2Medical nutrition therapy for lactose intolerance:
 Avoiding lactose-containing products

 Alternative products such as Plant- based milks and derivatives are
inherently lactose free: soy milk, rice milk, almond milk, hazelnut milk, oat milk,
hemp milk, peanut milk.

yogurt
oils
- 28 -
Calculation:
•Patient name: Soban Sheikh
•Age: 23 years
•Height: 5’10 inches
•Weight: 67 kg
BMI:
BMI: Height: 5’10 multiply first 5 feet with12 and
Formula= Weight kg then add additional inches.
Height m2
 5x12= 60
= 67kg  60+10=70
(1.8)(1.8) Multiply it with 2.54 for converting in cm
= 67
 70x2.54=178cm
3.24 Converting it into m
= 21  178
100
 BMI= 21kg/m2 (patient is
=1.8m
normal weight )
IBW:
 106+6x10
 106+60
 166 Lbs.
=166
2.2
= 75kg
IBW=75 kg
IBW%:
IBW
 Actual weight= 67 kg
= 67 x 100
 IBW= 75 kg
75
= 0.89 x 100
= 89%
IBW% = 89%
- 29 -
1.4.2 Energy Calculation:
BEE:
BEE= 66.5+ (13.8 x 67 kg) + (5.0 x 178 cm) – (6.8 x 23 years)
BEE= 66.5+ 925+ 890- 156
BEE= 1882- 156
BEE= 1726 kcal
BEE= 1726 kcal
TEE:
= 1726 x 1.1 x 1.2 A.F= 1.1
=2278 kcal S.F= 1.2
TEE= 2278 kcal
AMDRS:
• Carbohydrates= 52% Calories=2278 kcal
• Protein=18%
• Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 2278 kcal
100
= 0.52 x 2278 kcal
= 1184 kcal
4
PROTIEN:
= % x calories
100
= 18 x 2278
100
= 0.18 x 2278
= 410 kcal
4
Protein = 103 grams
- 30 -
FAT:
= % x calories
100
= 30 x 2278
100
= 0.3 x 2278
= 683 kcal
= 683
Fats= 75 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g

= 296g- 84g
= 212g
= 212
15

Total - 210+84 = 294g 28+22= 50g 14+10= 24g
- -

= 103g- 50g
= 53g
= 53
7
Total - - 56+50= 106g 16+24g= 40g
- -
- 31 -
= 75g-40g
= 35g
• As 1 exchange of fat= 5g
= 35
5
Fat= 7 exchanges
Fat 7 - - 35g
Total - - - 35+40= 75g
- -
2.6.4DIET PLAN:
Breakfast:
 1 cup oatmeal (1 cup cooked + 1 cup lactose free milk + 1 apple peeled).
 1 boiled egg
Snack:
 Mango smoothie ( 1 cup mango + 1 cup lactose free milk)
Lunch:
 1 cup brown rice
 1 cup lentils
 1 cup vegetable salad
Snack:
 1 cup brown pasta ( 1 cup mixed vegetable + 2 piece chicken boiled)
 Hand full of almonds
Dinner:
 1 whole grain flour chapatti
 1 cup kidney beans
 1 cup salted vegetable salad
Bed time:
 1 sandwich (2 brown bread slices + 1 boiled chicken piece + 1 tbsp. mayo).
- 32 -
Chapter No.3
ORTHOPEDIC WARD
During the second week of internship the rotation was placed at orthopedic ward.
(1)
3.1Case Study:
Mr. Umer Ayub 58 year’s male is hospitalized due to osteoarthritis in both knees. X-rays
showed severe osteoarthritis in both knees followed by pain, stiffness of joints. Calcium
deficiency and lack of physical activity is also observed. His height is 5 feet 6 inches and his
current weight is 70kg. His BMI is about 24.67kg/m2 and TEE is 1951kcal.
3.1.1Osteo-Arthritis:
 It is commonly known as degenerative arthritis or degenerative joints disease that
involves the loss of habitually of weight bearing joints.
 This cartilage normally allow bones to smoothly glide over each other that cause
pain stiffness, swelling, inflammation, loss of motion and changes in joint shape.
 Thumb, knees, hip, ankles and spines joints are most likely to be affected.
3.1.2Medical Nutrition Therapy of OA:
For the treatment of OA, nutrient rich diet, anti-inflammatory diet and calcium rich diet is
recommended.
Objective:
Anti-inflammatory diet, calcium rich and nutrient rich diet is prepared for maintaining or
losing body weight, reducing inflammation and pain, and to attain symptomatic relief.
Basic Principle:
High nutrient, anti-inflammatory, calcium rich diet
Dietary recommendation of OA:
Weight Management:
 In overweight or obese patients OA mostly like to occur.
 Weight change is an important measure in severity of OA.
 Weight lose can bring improvement in OA disease activity.
Anti-Inflammatory diet:
 Anti-inflammatory diet is recommended to reduce inflammation within joints.
 Diet should be full of fruits and vegetables of all bright and dark colors, especially
berries, oranges and yellow fruits and dark green vegetables like broccoli but
should avoid vegetables like potato.
 Diet should be full of whole grain carbs and should avoid processed and white bread
and rice.
 Low in saturated and Tran’s fats.
 High in Mono-unsaturated fatty acids like olive oil and nuts, high in Omega 3.
 Low in Omega 6.
- 33 -
Protein:
 Protein requirement are normal.
 Well-nourished individuals have don’t any increased requirements.
Vitamins, Minerals and Antioxidants:
 Vitamin E along with Omega-3 fatty acids help in reduction of inflammation.
 Diet rich with calcium, vitamin D, vitamin E, zinc and vitamin B.
 Intake of folate, vitamin B6 and vitamin B12.
Exercise:
 Normal exercise of 10-15 minutes is recommended.
oils
herbal tea, juices ( except decaf), carbonated beverages,
citrus ) , water tea , mint tea
Calculation:
 Patient name: Khalid Akhtar

 Age: 58 years
 Weight: 70 kg
- 34 -
BMI:
Formula= Weight kg Height: 5’5 multiply first 5 feet with12 and
= 70kg  5x12= 60
(1.68)(1.68)  60+6=66
= 70 Multiply it with 2.54 for converting in cm
2.82  66x2.54=167.67cm
= 24.67 Converting it into m
 168
 BMI= 24.67kg/m2 (patient
100
weight is normal )
=1.68m
IBW:
 106+6x6
 106+36
 136 Lbs.
=136
2.2
= 65kg
IBW=65kg
IBW%:
Formula = Actual weight x 100  Actual weight= 70 kg

IBW  IBW= 65 kg
= 70 x 100
65
=1.07 x 100
= 107%
IBW% = 107%
Energy Calculation:
BEE:
Formula for male BEE= 66.5+ (13.8x weight kg) + (5.0xheight cm) - (6.8xage years)
BEE= 66.5+ (13.8x 70 kg) + (5.0x 168 cm) – (6.8x 58 years)
BEE= 66.5+ 966 + 840 – 394.4
BEE= 1872.5- 394.4
BEE= 1478.1 kcal
- 35 -
BEE= 1478 kcal
TEE:
Formula= BEE x Activity factor x Stress factor BEE= 1478kcal
= 1478 x 1.1 x 1.2 A.F= 1.1
= 1950.96 kcal S.F= 1.2
TEE= 1951 kcal
AMDRS:
 Carbohydrates= 52% Calories=1951 kcal
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1951 kcal
100
= 0.52 x 1951 kcal
= 1015 kcal
= 1015
4 as 1 gram of carb= 4kcal
PROTIEN:
= % x calories
100
= 18 x 1951
100
= 0.18 x 1951
= 351 kcal

4
Protein = 88 grams
FAT:
= % x calories
100
= 30 x 1951
100
= 0.3 x 1951
- 36 -
= 585 kcal
= 585

Fats= 65 grams
EXCHANGES:
Milk 3 36g 24g 15g
Fruit 3 45g - -
Total - 96g 30g 15g
= 254g- 96g
= 158g
= 158
15

Total - 165+96 = 261g 22+30= 52g 11+15= 26g
- -

= 88g- 52g
= 36g
= 36
7
Total - - 35+52= 87g 10+26g= 36g
- -

= 65g-36g
= 29g
= 29
5
Fat= 6 exchanges
- 37 -
Fat 6 - - 30g
Total - - - 30+36= 69g
- -
3.1.4DIET PLAN:
Breakfast:
 1 cup oatmeal (1 cup reduced fat milk + 3 strawberry +½cup oats)
Snack:
 1 banana
 6 cashews
Lunch:
 1 cup vegetable (cooked)
 2 chappati ( home made)
 ½ cup raita
Snack:
 1 cup tea
 3 biscuits
Dinner:
 5oz grilled chicken (with 1tbsp oil)
 2 cup rice
 ½ cup raita
 ½ cup salad
Snack:
 12 almonds
- 38 -
(2)3.2Case Study:
24 year old Mr. Qasim Ashraf is hospitalized due to fracture of left upper arm and pain in his
left arm, his height is 5’7 inches and current weight is 54 kg. His BMI is about 18.68 kg/m2
and TEE is 2400 kcal/day.
3.2.1Fracture:
A fracture is a broken bone, the same as a crack or a break. A bone may be completely
fractured or partially fractured.
3.2.2Medical Nutrition Therapy of Fracture:
For the treatment of fracture high protein and anti-inflammatory diet is recommended.
Objective:
High protein, anti-inflammatory and calcium rich diet is prepared to fasten the process of
healing, to prevent bone and tissue death and to reduce the inflammation.
Basic Principle:
High calorie, high protein, calcium rich, normal carbs and normal fat diet.
Dietary Guidelines:
Calcium and Vitamin D:
 An adequate calcium dietary intake, the principal component of bone, can
significantly reduce the loss of bone and is necessary to replenish the compulsory
daily calcium losses.
 Adults should get between 1,000 and 1,200 milligrams of calcium each day for
bone fracture.
 Milk and other dairy products are the best source of calcium but also significant
amounts are contained in foods such as green leafy vegetables (e.g., spinach),
broccoli, almonds, legumes, and seafood.
 Calcium in combination with vitamin D in dietary supplements is found to reduce
the incidence of fractures.
 It play an important role in protecting your bones, both by helping your body
absorb calcium and by supporting muscles needed to avoid falls.
 Up to 5000u Vitamin D3 daily during periods of bone healing is recommended.
 Foods that can contain high amounts of vitamin D are eggs, liver, fish, and
breakfast cereals.
Smoking and Alcohol:
 Smoking and excessive alcohol consumption can adversely affect bone health.
- 39 -
 So cessation of smoking is recommended, which contributes to the overall health
of the person.
 Regarding alcohol restriction, less than two servings of alcohol per day for men
and one for women may enhance bone health.
Omega-3 fatty acids:
 Include sources of omega-3 fatty acids in your diet to help reduce inflammation
and support the healing process. Good sources include fatty fish (salmon,
mackerel), walnuts, flaxseeds, and chia seeds
 Fish with dark flesh, such as salmon, are a rich source of omega-3 fatty acids and
vitamin D and are recommended as a safe way to increase the intake of vitamin D
and reduce the risk of fracture up to 33%.
Protein:
 You should aim to eat 1 to 1.2 grams of protein per kilogram body weight.
 Protein is needed to heal wounds, repair broken bones, build healthy blood cells,
keep your immune system strong, and support muscle protein growth and
strength.
Micronutrients:
 Vitamin C is needed to make a protein called collagen and for repairing tendons,
ligaments, bones and skin. Citrus fruits are high in vitamin C, but don’t overlook
other sources of vitamin C such as strawberries, kiwifruit, baked potatoes,
broccoli, and bell peppers.
 We recommend 500mg of vitamin C daily in both phase 1 and phase 2 of healing.
 Zinc is a mineral found mostly in animal foods such as meat, fish, poultry, and
dairy foods.
 Zinc is also found in whole grain breads and cereals, legumes (dried beans and
peas), and nuts
yogurt
- 40 -
oils
Calculation:
 Patient name: Qasim Ashraf

 Age: 24 years
 Weight: 54 kg
BMI:
= 54kg  5x12= 60
(1.7)(1.7)  60+7=67
2.89  6572.54=170cm
= 18.68 Converting it into m
 170
 BMI= 18.68kg/m2 (patient
100
has under weight)
=1.7m
IBW:
 106+6x7
 106+42
 148 Lbs.
=148
2.2
= 67kg
IBW= 67kg
- 41 -
IBW%:

IBW
= 54 x 100
67
= 0.81 x 100
= 81%
IBW% = 81%
Energy Calculation:
BEE:
BEE= 66.5+ 924.6+ 850- 163.2
BEE= 1841- 163.2
BEE= 1677.9 kcal
BEE= 1678 kcal
TEE:
= 1678 x 1.1 x 1.3 A.F= 1.1
= 2399.54kcal S.F= 1.3
TEE= 2400 kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 2400 kcal
100
= 0.52 x 2400 kcal
= 1248 kcal
4
PROTIEN:
= % x calories
100
- 42 -
= 18 x 2400
100
= 0.18 x 2400
= 432 kcal
4
Protein = 108 grams
FAT:
= % x calories
100
= 30 x 2400
100
= 0.3 x 2400
= 720 kcal
= 720
Fats= 80 grams
EXCHANGES:
Milk 3 36g 24g 15g
Fruit 3 45g - -
Total - 96g 30g 15g

= 312g- 96g
= 216g
= 216
15
Total - 210+96 = 306g 30+28= 58g 15+12= 27g
- -

= 108g- 58g
= 50g
- 43 -
= 50
7
Total - - 58+49= 107g 27+14g= 41g
- -

= 80g-41g
= 39g
= 39
5
Fat= 8 exchanges
Fat 8 - - 40g
Total - - - 40+39= 79g
- -
3.2.4DIET PLAN:
Breakfast:
 3slices of bread
 1 fried Eggs ( 1 tbsp oil)
 1 cup tea (1 cup reduced fat milk + 1 tbsp sugar )
Snack:
 Banana shake (3 small banana+1cup low fat milk+ 1tbsp sugar )
Lunch:
 1 chapatti (12 inches of whole grain flour)
 1 piece grilled fish (3oz + 1tbsp oil)
 1 cup salad
Snack:
 1 cup whole grain pasta (½ cup mixed vegetable)
 1 tsp oil
Dinner:
 1 steamed chicken (3 oz)
 1 cup vegetable rice (1cup rice+ ½ cup vegetable + 1 tsp)
Bed time:
 1 Cup milk (with 1 tbap honey)
- 44 -
(3)
3.3Case Study:
21 years old Mr. Saleem Anjum hospitalized due to diagnosis of Rheumatoid arthritis. Patient
is also suffering from pain, stiffness and inflammation within joints. His height is 5feet
3inches and his current weight is 52kg. His BMI is about 20kgm2 and his TEE is 1904kcal.
3.3.1Rheumatoid Arthritis:
Rheumatoid Arthritis is an autoimmune chronic disorder that affects the interstitial tissues,
blood vessels, cartilage, bones, tendons as well as synovial fluid membrane that line joint
surfaces. It cause inflammation in synovial membrane causing damage in cartilage.
3.3.2Medical Nutrition Therapy of RA:
For the treatment of RA gluten free, nutrient rich diet, anti-inflammatory diet and calcium
rich diet is recommended.
Objective:
Anti-inflammatory diet, gluten free, calcium rich and nutrient rich diet is prepared for
maintaining or losing body weight, reducing inflammation and pain, and to attain
symptomatic relief.
Basic Principle:
High nutrient, anti-inflammatory, calcium rich diet.
Dietary recommendation of RA:

Weight Management:
 In overweight or obese patients RA mostly like to occur.
 Weight change is an important measure in severity of RA.
 Weight lose can bring improvement in RA disease activity.
Gluten-free diet:
 A vegan, gluten-free diet diet causes improvement in RA symptoms because of the
reduction of immune reactivity to food antigens.
 Whole grain bread, brown rice and unrefined grains are recommended.
Fasting:
 Intermittent fasting during the acute phase of RA may provide some pain relief,
however after the normal diet is resumed, inflammation returns unless the fasting
period is followed by a vegetarian diet.
 Combination of fasting and vegetarian diet is beneficial for treatment of RA.
Anti-Inflammatory diet:
 Anti-inflammatory diet is recommended to reduce inflammation within joints.
 Diet should be full of fruits and vegetables of all bright and dark colors, especially
berries, oranges and yellow fruits and dark green vegetables like broccoli but
should avoid vegetables like potato.
 Diet should be full of whole grain carbs and should avoid processed and white bread
and rice.
 Low in saturated and Tran’s fats.
- 45 -
 High in Mono-unsaturated fatty acids like olive oil and nuts, high in Omega 3.
 Low in Omega 6.
Energy:
 People with RA should consume nutrient-rich diets and incorporate physical activity
throughout the day to boost their total energy expenditure.
 This helps them improve their physical activity, quality and maintain a healthy life.
Protein:
 Protein requirement for individuals who are poorly nourished or who are in the
inflammatory process of disease are 1.2 to 1.5g protein/kg body weight.
 Well-nourished individuals have don’t any increased requirements.
Fats:
 Fats should contribute less than 30% of the total energy intake for the purpose of
healthy eating and weight management.
Vitamins, Minerals and Antioxidants:
 Vitamin E along with Omega-3 fatty acids help in reduction of inflammation.
 Diet rich with calcium, vitamin D, vitamin E, zinc and vitamin B.
 Intake of folate, vitamin B6 and vitamin B12.
yogurt
oils
Calculation:
 Patient name: Saleem Anjum

 Age: 21 years
 Height: 5’83inches
 Weight: 52 kg
- 46 -
BMI:
Height: 5’3multiply first 5 feet with12 and then
Formula= Weight kg
add additional inches.
Height m2
= 52kg  5x12= 60
 60+3=64
(1.6)(1.6)
Multiply it with 2.54 for converting in cm
= 52
2.56  63x2.54=160cm
Converting it into m
= 20  160
 BMI= 20kg/m2 (patient is 100
normal weight ) =1.6m
IBW:
 106+6x3
 106+18
 124 Lbs.
=124
2.2
= 56kg
IBW=56kg
IBW%:
IBW
= 52 x 100
56
= 0.92 x 100
= 92%
IBW% = 92%
Energy Calculation:
BEE:
- 47 -
BEE= 66.5+ 718 + 800 - 142
BEE= 1585- 142
BEE= 1585 kcal
BEE= 1585 kcal
TEE:
Formula= BEE x Activity factor x Stress factor you BEE= 1585 kcal
= 1485 x 1.1 x 1.2 A.F= 1.1
=1904 kcal S.F= 1.2
TEE= 1904 kcal
AMDRS:
 Protein=18%
 Fats= 28%
CARBOHYDRATE:
= % x calories
100
= 54 x 1904 kcal
100
= 0.54 x 1904 kcal
= 1028 kcal
= 1028
PROTIEN:
= % x calories
100
= 18 x 1904
100
= 0.18 x 1904
= 343 kcal
4
Protein = 86 grams
FAT:
= % x calories
100
= 28 x 1904
100
- 48 -
= 0.28 x 1904
= 533 kcal
= 533
Fats= 59 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g

= 257g- 84g
= 173g
= 173
15

Total - 180+84 = 264g 24+22= 46g 12+10= 22g
- -
= 86g- 46g
= 40g
= 40
7
Total - - 42+46= 88g 12+22g= 34g
- -

= 59g-34g
= 25g
= 25
5
- 49 -
Fat= 5 exchanges

Fat 5 - - 25g
Total - - - 25+34= 59g
- -
3.3.4DIET PLAN:
Breakfast:
 1 cup oatmeal (1 cup reduced fat milk +
2 bananas + 1 tbsp honey )
Snack:
 12 almonds
Lunch:
 ½ cup lentils ( 1tbsp) oil
 cup vegetable salad
Snack:
 1 cup tea +1 tbsp sugar
 3 biscuits
Dinner:
 5 oz grilled fish
 2 chappati ( home-made)
 1 cup salad
Snack:
 17 graps
- 50 -
(4)
3.4Case Study:
Miss Shafaq Nazeer, 60 years old lady is hospitalized due to incidence of osteoporosis. She
has family history of osteoporosis by her mother. X-rays scan showed severe osteoporosis in
her knees followed by pain and stiffness. Her height is 5 feet 3 inches and weight is 60kg.
Her BMI is about 23kg/m2 and TEE is 1646kcal.
3.4.1Osteoporosis:
Osteoporosis is a bone disease that develops when bone mineral density and bone mass
decreases, or when the structure and strength of bone changes. It can occur both in old age
people and in young people but rarely.
There are 2 types of osteoporosis:
 Primary osteoporosis
 Secondary osteoporosis
Primary Osteoporosis:
 It occur as a result of natural aging process.
 BMD declines both with age and with the loss of estrogen after menopause.
 For women, primary osteoporosis is more likely 10 to 15 years after menopause.
 In men around 65 to 80 years.
Secondary Osteoporosis:
 It occur when an identifiable drug or disease process cause loss of bone tissue.
3.4.2Medical Nutrition Therapy of Osteoporosis:

For management of osteoporosis moderate intake of protein, carbohydrate .And calcium,
vitamin-D rich and anti-inflammatory diet is recommended.
Objective:
Moderate amount of protein, carbs and fat .And high intake of Vitamin D, calcium And
Phosphate helps to stop and prevent osteoporosis.
BasicPrinciple:
Moderate amount of protein, carbs and fat, high intake of Vitamin D and calcium.
Dietary recommendation of Osteoporosis:
Adequate calcium and vitamin D:

 Calcium (1000 mg/day) and vitamin D (800 to 1000 units/day) typically are
recommended as supplements for patients being treated with one of the bone drugs.
 These amounts are considered safe and sufficient for bone formation.
Sodium:
 A high sodium intake may contribute to osteoporosis because of increased calcium

excretion.
- 51 -
Energy:
 Energy intake does not have a direct effect on bone; rather, inadequate energy
intake leading to low body weight, or too many calories leading to overweight have
effects on bone.
 Being underweight is considered a risk factor for osteoporosis, whereas being
overweight may be protective.
Protein:
 Adequate protein intake, with adequate calcium intake, is needed for optimal bone
health.
 Dietary protein may increase acid load and thereby increase urinary calcium
excretion, protein also may improve calcium absorption and increase growth
factors, which also could improve bone health.

yogurt
oils
Calculation:
 Patient name: Shafaq Nazeer

 Age: 60 years
 Weight: 60 kg
- 52 -
BMI:
= 60kg  5x12= 60
(1.6)(1.6)  60+3=63
2.56  63x2.54=165cm
 165
 BMI= 23kg/m2 (patient
100
has normalweight )
=1.6m
IBW:
 100+5x3
 100+15
 115 Lbs.
=115
2.2
= 52kg
IBW=52kg
IBW%:

IBW
= 60 x 100
52
= 1.15 x 100
= 115%
IBW% = 115%
Energy Calculation:
BEE:
Formula for female BEE= 665+ (9.6x weight kg) + (1.8xheight cm) - (4.7xage years)
BEE= 665+ 576 + 288 - 282
BEE= 1529- 282
BEE= 1247 kcal
BEE= 1247 kcal
- 53 -
TEE:
= 1247 x 1.1 x 1.2 A.F= 1.1
= 1646.04 kcal S.F= 1.2
TEE= 1646 kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1646 kcal
100
= 0.52 x 1646 kcal
= 856 kcal
= 856
PROTIEN:
= % x calories
100
= 18 x 1646
100
= 0.18 x 1646
= 296 kcal
4
Protein = 74 grams
FAT:
= % x calories
100
= 30 x 1646
100
= 0.3 x 1646
= 494 kcal
= 491

Fats= 55 grams
- 54 -
EXCHANGES:
Milk 3 36g 24g 15g
Fruit 3 45g - -
Total - 96g 30g 15g
= 214g- 96g
= 118g
= 118
15
Total - 120+96 = 216g 16+30= 46g 8+15= 23g
- -
= 74g- 46g
= 28g
= 28
7
Total - - 28+46= 74g 8+23g= 31g
- -
= 55g-31g
= 24g
= 24
5
Fat= 5 exchanges
Fat 5 - - 25g
Total - - - 25+31= 56g
- -
- 55 -
3.3.4DIET PLAN:
Breakfast:
 1 cup reduced fat milk
 1 whole egg
 1 whole wheat flour chapatti
Snack:
 2 apple
Lunch:
 1 whole wheat flour chapatti
 1 piece baked chicken (1 tbsp oil
 1 cup cooked vegetable
Snack:
 2-3 whole wheat biscuits
 1 peach
Dinner:
 2 piece grilled fish (6oz) (2 tbsp oil)
 1 cup vegetable salad
 1 cup raita
Bed time:
 1 cup reduced fat milk
- 56 -
Chapter No.4
PULMO WARD
During the third week of internship the rotation was placed at pulmo ward.
(1)
4.1Case Study:
Miss Zainab Saleem, 25 years old lady is hospitalized due to Chronic bronchitis. Having
difficulty in breathing and productic cough, chest tightness and weight loas in past few days .
Her height is 5 feet 4 inches and weight is 53kg. Her BMI is about 21kg/m2 and TEE is
1782kcal.
4.1.1Chronic Bronchitis
 Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD)

characterized by inflammation and narrowing of the bronchial tubes, which carry air
to and from the lungs. It is a long-term condition that causes persistent coughing and
excessive mucus production in the airways.
 The primary cause of chronic bronchitis is long-term exposure to irritants, most
commonly cigarette smoke. Other respiratory irritants, such as air pollution, chemical
fumes, and dust, can also contribute to the development of chronic bronchitis. The
repeated exposure to these irritants leads to chronic inflammation and damage to the
bronchial tubes, resulting in a range of symptoms.
 The main symptom of chronic bronchitis is a persistent cough that lasts for at least
three months in two consecutive years. This cough is often productive, meaning it
produces mucus or phlegm. Other symptoms may include shortness of breath,
wheezing, chest tightness, and frequent respiratory infections. Over time, the
persistent inflammation and mucus production can lead to a narrowing of the airways,
making it increasingly difficult to breathe.
4.1.2Medical Nutrition Therapy
 Medical Nutrition Therapy for chronic bronchitis are

 Use anti-oxidents
 Maintain body weight
 Use calcium, vitamin c and potassium supplement
 Use omega 3 fatty acid.
Objective:
Low carb, high protein and fat diet
- 57 -
Basic Principle:
Consumed energy dense diet with low carbs.
Dietary Guidelines:
Balanced Diet:
 It is important to follow a well-balanced diet that includes a variety of nutrient-rich

foods.
 This should include a mix of fruits, vegetables, whole grains, lean proteins, and
healthy fats.
Adequate Calories:
 In cases where individuals with chronic bronchitis experience unintentional weight

loss or have increased energy needs due to the increased work of breathing.
 it is important to ensure an adequate calorie intake to maintain a healthy weight and
provide energy.
Protein Intake:
 Protein is essential for tissue repair and immune function.

 Sufficient protein of 1.2 to 1.5 g/kg of dry body weight is necessary to maintain or
restore lung and muscle strength, as well as To promote immune function.
 A balanced ratio of protein (15% To 20% of calories)
Omega-3 Fatty Acids:
 Omega-3 fatty acids, found in fatty fish (such as salmon and mackerel), flaxseeds,
chia seeds, and walnuts, have anti-inflammatory properties and may help reduce
inflammation in the airways.
Antioxidants:
 Foods rich in antioxidants, such as fruits and vegetables (especially brightly colored
ones), help protect the body's cells from damage caused by inflammation and
oxidative stress.
 Include a variety of colorful fruits and vegetables in the diet.
Fluid Intake:
 Staying well-hydrated is important for maintaining optimal lung function and thinning
mucus secretions, making them easier to cough up.
 Aim to drink adequate fluids throughout the day, primarily water.
- 58 -
Avoid Trigger Foods:
 Some individuals with chronic bronchitis may have food sensitivities or allergies that
can worsen respiratory symptoms.
 Identifying and avoiding specific trigger foods can help manage symptoms.
Small, Frequent Meals:
 Eating smaller, more frequent meals throughout the day can help alleviate feelings of
fullness and discomfort caused by increased pressure from the diaphragm.
 This can also help maintain energy levels and nutrient intake.

yogurt
oils
Calculation:
Patient name: Zainab Saleem
Age: 25 years
Height: 5’4 inches
Weight: 53 kg
- 59 -
BMI:
Height: 5’4 multiply first 5 feet with12 and
Formula= Weight kg
then add additional inches.
Height m2 5x12= 60
= 53kg
60+4=65
(1.63)²
= 53
64x2.54=162.56cm
2.56
Converting it into m
= 21
162.56
BMI= 21kg/m2
(patient has 100
normal weight)
IBW:
 100+5x4
 100+20
 120 Lbs.
=120
2.2
IBW=55kg
IBW%:
IBW
= 53 x 100
55
= 0.963 x 100
= 96.3%
IBW% = 96%
- 60 -
Energy Calculation:
BEE:
Formula for Female BEE= 665+ (9.6x weight kg) + (1.8xheight cm) - (4.7xage years)
BEE= 665+ 508.8+ 293.4- 117.5
BEE= 1467.2- 117.5
BEE= 1349.7 kcal
BEE= 1350 kcal
TEE:
= 1350 x 1.1 x 1.2 A.F= 1.1
=1782 kcal S.F= 1.2

TEE= 1782 kcal
AMDRS:
Carbohydrates= 48% Calories= 1782 kcal
Protein=18%
Fats= 34%
CARBOHYDRATE:
= % x calories
100
= 48 x 1782 kcal
100
= 0.48 x 1782 kcal
= 855 kcal
4
- 61 -
PROTIEN:
= % x calories
100
= 18 x 1782
100
= 0.18 x 1782
= 321 kcal
4
Protein = 80 grams
FAT:
= % x calories
100
= 34 x 1782
100
= 0.34 x 1782
= 606 kcal
= 606
Fats= 68 grams
EXCHANGES:
Milk 2 24g 16g 4g
Fruit 3 45g - -
Total - 84g 22g 4g

= 214g- 84g
= 130g
- 62 -
As 1 exchange of carbs = 15g
= 130
15

Total - 135+84 = 219g 22+18= 40g 9+4= 13g
- -

= 80g- 40g
= 40g
As 1 exchange of protein= 7g
= 40
7

Total - - 42+40= 82g 10+13g= 23g
- -

= 68g-23g
= 48g
As 1 exchange of fat= 5g
= 45
5
Fat= 9 exchanges
Fat 9 - - 45g
- 63 -
Total - - - 23+45= 68g
- -
4.1.4DIET PLAN:
Pre breakfast:
 1 cup Apple juice( 2apple)
Breakfast:
 slices of bread
 1 boiled eggs
 1 cup tea
Snack:
 1 banana + 6 cashews
Lunch:
 1 chapatti (home made)
 1 cup lentils
 1 cup salad
Snack:
 6 almonds
Dinner:
 1½ chappati (home made)
 1 cup cooked veges
 1 steamed chicken (3oz)
Bed time:
 1 cup milk
- 64 -
4.2Case Study:
Mr.M.Tanzeel, 44 yrs. Hospitalized due to Tuberculosis. He had a blood cough , chest
pain and losing weight . His current weight is 64kg and height is 5’8’’. His BMI is 21.6kg
/m2 and TEE is 2364.96 Kcal/day.
4.2.1Tuberculosis:
Tuberculosis (TB) is a contagious infectious disease caused by the bacterium Mycobacterium
tuberculosis. It primarily affects the lungs but can also affect other parts of the body, such as
the kidneys, spine, and brain. TB is transmitted through the air when an infected individual
coughs, sneezes, or speaks, releasing tiny droplets containing the bacteria into the air.
4.2.2Medical Nutrition Therapy of Tuberculosis:
Nutrition management of tuberculosis is done by:
 Weight management.
 Protein is vital in preventing muscle tissue wastage and an in-Take of 15% of energy
needs or 1.2 to 1.5 g/kg ideal body Weight, approximately 75 to 100 g per day, is
recommended.
 Low carbohydrate diet.
Objective:
 Weight management
 ow carbs, high protein diet.
Dietary guidelines:
Energy :
 Current energy recommendations are those for undernourished and catabolic patients,
35 to 40 kcal/kg of ideal body
 Weight. For patients with any concomitant infections such as HIV, energy
requirements increase by 20% to 30% to maintain Body weight.
Protein:
 Protein is vital in preventing muscle tissue wastage and an in-Take of 15% of energy
needs or 1.2 to 1.5 g/kg ideal body Weight, approximately 75 to 100 g per day, is
recommended.
Micronutrients:
- 65 -
 Certain micronutrients play a crucial role in supporting the immune system and
combating the infection.
 These include vitamin A, vitamin C, vitamin E, zinc, selenium, and iron.
 Encourage the consumption of foods rich in these nutrients, such as fruits, vegetables,
whole grains, nuts, seeds, and lean meats.
Hydration:
 Adequate hydration is essential to prevent dehydration and promote overall health.

Encourage individuals with TB to drink plenty of fluids, such as water, herbal teas,
and soups, throughout the day.
Avoid Alcohol and Smoking:
 Alcohol and smoking can weaken the immune system and hinder the body’s ability to
fight off TB infection.
 Encourage individuals to avoid alcohol and quit smoking for better treatment
outcomes.

yogurt
oils
Calculation:
Patient name: Asif Masood
Age: 44 years
Height: 5’8 inches
Weight: 64 kg
- 66 -
BMI:
Formula= Weight kg
Height m2
= 64/1.722
=21.64kg/m2 (Normal)
IBW:
Height 5’i for first 5 feet is 106 and multiply additional inches with +6
106+6x8
106+48
154 Lbs.
=154
2.2
= 70kg
IBW=70kg
IBW%:
IBW
= 64 x 100
70
= 0.91x 100
= 91%
IBW% = 91%
Energy Calculation:
BEE:
BEE= 66.5+ 883.2+ 865- 299.2
BEE= 1814.7- 299.2
BEE= 1515.5 kcal
- 67 -
BEE= 1516 kcal
TEE:
= 1516 x 1.1 x 1.3 A.F= 1.2
=2167.88kcal S.F=1.3
TEE= 2168 kcal
AMDRS:
Carbohydrates= 50% Calories= 2167 kcal
Protein=20%
Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 50 x 2167 kcal
100
= 0.50 x 2168 kcal
= 1084 kcal
4
PROTIEN:
= % x calories
100
= 20 x 2168
100
= 0.20 x 2168
= 434 kcal
Protein = 109 grams
FAT:
= % x calories
100
= 30 x 2168
100
= 0.30 x 2168
= 650 kcal
= 650
Fats= 72 grams
- 68 -
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g

= 271g- 84g
= 187g
As 1 exchange of carbs = 15g
= 187
15
Total - 22+24=46g 12+10= 22g
- -

= 109g- 46g
= 63g
As 1 exchange of protein= 7g
= 63
7
Total - -
- -
- 69 -
= 72g-40g
= 30g
As 1 exchange of fat= 5g
= 30
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - -
- -
4.2.4DIET PLAN:
Breakfast:
 1 cup oatmeal ( 1cup low fat milk + 1 banana)
Snack:
 1 apple juice + 3 almonds
Lunch:
 1 grilled chicken (4oz)
 1 cup vegetable ( cooked)
 chapatti (home made)
Snack:
 17 grapes + 1 peach
Dinner:
 1 grilled fish (4oz)
 2cup brown rice
 1 cup salad
Bedtime:
 1 cup milk
- 70 -
CASE: 3
4.3Case Study:
Miss, Saima aged 40 hospitalized due to asthma. She has a history of smoking.
Patient is suffering from severe chest pain, chest tightness followed by shortage of breath and
wheezing. Her height is 5’7 inches and weight is 52kg. Her BMI is about 17kg/m2 and TEE
is 1823kcal.
4.3.1Asthma:
 Asthma is a chronic disorder that affects the airways and characterized by bronchial
hyper-reactivity, reversible airflow obstruction, and airway remodeling.
Symptoms:
Asthmatic symptoms include:
 Periodic episodes of chest tightness

 Breathlessness
 Wheezing
Increased risk of asthma:
 Increased risk of asthma development also has, been linked to air pollution, tobacco
smoke exposure, and small size at birth, respiratory infection, and lower
socioeconomic status.
4.3.2Medical Nutrition Therapy of Asthma:
 For treatment of asthma moderate intake of protein, calcium, vitamin C and anti-
inflammatory diet is, recommended
Objective:
 A diet rich in antioxidants and monounsaturated fats and Supplementation of
vitamin C and zinc also have, been reported to improve asthma symptoms and lung
function.
Basic Principle:
 Moderate amount of protein, carbs and fat, good intake of Vitamin C and calcium.
Dietary Guidelines:
 Modulation of antioxidant intake with nutritional supplementation has a beneficial

effect on the severity and progression of asthma.
 A diet rich in antioxidants and monounsaturated fats seems to have a protective effect
on childhood asthma by counteracting oxidative stress.
 Omega-3 polyunsaturated fatty acid (PUFA) fish oil was, supplemented throughout
childhood and wheezing was reduce.
 Supplementation of vitamin C and zinc also have been reported to improve asthma
symptoms and lung function
 High doses of vitamin D supplementation were not shown to have any protective effect
Gastro-esophageal reflux disease (GERD) and food allergens:
- 71 -
 Gastro-esophageal reflux disease (GERD) and food allergens are the two most
common dietary triggers for asthma.
 A critical component of medical nutrition therapy for asthmatic patients is a diet free
of known irritants such as spicy foods, caffeine, chocolate, and acidic foods
 Limiting the intake of high fat foods and portion control can prevent gastric
secretions, which exacerbate GERD.
4.3.3Table Food choices for Asthma:
Food Groups Foods Allowed Foods Restricted
Bread, Cereals and Grains Whole grain bread, brown White bread, white rice,
rice, oatmeal, Chapatti, Bakery items, white flour
whole grain flour
Milk and Milk products Milk, cheese, yogurt without Milk, cheese and yogurt with
cream if tolerable added cream and fats
Meat (red/ white and eggs) Fish, lean meat, red meat and Processed meat and all meats
eggs. that made in high quantity of
oil, fat cuts.
Lentils/daals All lentils cooked in low oil All fried lentils
Vegetables (green Spinach, Green leafy Tomatoes, potatoes and deep
leafy/starchy) vegetables, broccoli cooked fried vegetables.
in low amount of oil
Fruits All fruits None
Dried fruits/ nuts and seeds All kind of fruits, nuts and Fried and salted nuts and
seeds seeds
Fats and oils Olive oil, sunflower oil, Butter, ghee, margarine,
canola oil cooking oil and fried foods
Desserts and Sweets All types of desserts and All types of desserts with
sweets high fats and added sugar
like kheer and halwa
Fluids and Drinks Water, fresh juices, tea, Coffee, Beverages with
green tea and lassi added sugar, soft drinks and
alcohol
Calculation:
 Patient name: Saima fazal
 Age: 40 years
 Weight: 52 kg
- 72 -
BMI:
52kg  5x12= 60
(1.7)(1.7)  60+7=67
2.89  67x2.54=170cm
 170
underweight ) 100
=1.7m
IBW:
 100+5x7
 100+35
 135 Lbs.
=135
2.2
61kg
IBW=61kg
IBW%:
IBW  IBW= 61 kg
= 52 x 100
61
= 0.8 x 100
= 80%
IBW% = 80%
Energy Calculation:
BEE:
BEE= 665+ 598 + 306 - 188  Weight: 61kg
BEE= 1569- 188  Height: 170cm
BEE= 1381 kcal  Age: 40 years
BEE= 1381 kcal
- 73 -
TEE:
= 1381 x 1.1 x 1.2 A.F= 1.1
= 1823 kcal S.F= 1.2
TEE= 1823kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1823 kcal
100
= 0.52 x 1823 kcal
= 912 kcal
4
PROTIEN:
= % x calories
100
= 18 x 1823
100
= 0.18 x 1823
= 328 kcal
4
Protein = 82 grams
FAT:
= % x calories
100
= 30 x 1823
100
= 0.3 x 1823
= 547
= 547/9 as 1 gram of fat= 9kcal
Fats= 61 grams
- 74 -
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 3 45g - -
Total - 84g 22g 10g
= 228g- 84g
= 144g
= 144
15
Total - 150+84 = 234g 20+22= 42g 10+10= 20g
- -

82g- 42g
40g
= 40
6
Total - - 42+42= 84g 12+20g= 32g
- -

61g-32g
29g
= 29
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - - 30+32= 62g
- -
- 75 -
4.3.4DIET PLAN:
Breakfast: Exchanges
 Beet root + carrot juice ( 1 beet root + 2 carrots) Milk: 2
Snack:
Fruit: 3
 1-cup sweet potato + 1 cup vegetable and beans salad.
Lunch: Vegetable: 3
 Pulao ( 1 cup brown rice + 2 chicken pieces ) Starch: 10
 1 cup raita
Protein: 6
Snack:
 Banana smoothie ( 2 bananas + 1 cup low fat milk) Fat: 6
 12 cherries
Dinner:
 1 whole grain chapatti
 1 cup chicken curry ( 2 pieces of chicken)
Snack:
 6 almonds.
- 76 -
CASE: 4
4.4Case Study:
Miss Bushra aged 60 years old woman is, hospitalized due to pneumonia. Her height is 5’3
inches and current weight is 68kg. Her BMI is about 17 kg/m2 and TEE is 1620 kcal/day
4.4.1PNEUMONIA:
An inflammatory condition of the lungs that causes chest pain, fever, cough, and dyspnea is
called pneumonia. In the clinical setting, there are various kinds of pneumonias, such as:
 Community-acquired pneumonia, which may be viral or bacterial; hospital-

acquired pneumonia;
 Pneumonia in an immune compromised host;
 Ventilator-associated pneumonia (VAP);
 Aspiration pneumonia.
 Three clinical syndromes exist within the category of aspiration pneumonia:
 Chemical pneumonitis resulting from aspiration of acid
 Bacterial infection
 Airway obstruction.
4.4.2Medical Nutrition Therapy of Pneumonia:
Parenteral and Enteral Nutrition (SCCM/ASPEN) guidelines, nutritional interventions for

preventing aspiration pneumonia and managing it when it exists in the patient in the acute
care setting are the following:
 Direct tube feedings into the small bowel rather than the stomach
 Implement continuous feedings rather than bolus feedings recommended
 Elevate the head of the patient’s bed to 45 degrees
 Use prokinetic agents
 Minimize use of sedatives
 Optimize oral hygiene
 Use naloxone to improve gut motility
4.4.3 Table Food choices for Asthma:
Food Groups Foods Allowed Foods Restricted

Bread, Cereals and Grains Whole grain bread, brown White bread, white rice,
rice, oatmeal, Chapatti, Bakery items, white flour
whole grain flour
Milk and Milk products Milk, cheese, yogurt without Milk, cheese and yogurt with
- 77 -
cream if tolerable added cream and fats
Meat (red/ white and eggs) Fish, lean meat, red meat and Processed meat and all meats
eggs. that made in high quantity of
oil, fat cuts.
Lentils/daals All lentils cooked in low oil All fried lentils
Vegetables (green Spinach, Green leafy Tomatoes, potatoes and deep
leafy/starchy) vegetables, broccoli cooked fried vegetables.
in low amount of oil
Fruits All fruits None
Dried fruits/ nuts and seeds All kind of fruits, nuts and Fried and salted nuts and
seeds seeds
Fats and oils Olive oil, sunflower oil, Butter, ghee, margarine,
canola oil cooking oil and fried foods
Desserts and Sweets All types of desserts and All types of desserts with
sweets high fats and added sugar
like kheer and halwa
Fluids and Drinks Water, fresh juices, tea, Coffee, Beverages with
green tea and lassi added sugar, soft drinks and
alcohol
Calculation:
 Patient name: Bushra bibi
 Age: 68 years
 Weight: 44 kg
BMI:
44kg  5x12= 60
(1.6)(1.6)  60+3=63
2.56  63x2.54=160cm
 160
underweight ) 100
=1.6m
IBW:
- 78 -
 100+5x3
 100+15
 115 Lbs.
=115/2.2
=52 kg
IBW=52 kg
IBW%:
IBW  IBW= 52 kg
= 44 x 100
52
= 0.84 x 100
= 84%
IBW% = 84%
Energy Calculation:
BEE:
BEE= 665+ 499 + 288 - 320  Weight: 52kg
BEE= 1452- 320  Height: 160cm
BEE= 1132 kcal  Age: 68 years
BEE= 1132 kcal
TEE:
= 1132 x 1.1 x 1.3 A.F= 1.1
= 1619 kcal S.F= 1.3
TEE= 1619 kcal
AMDRS:
 Carbohydrates= 52% Calories=1619 kcal
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1619 kcal
100
= 0.52 x 1619 kcal
= 842 kcal
4
- 79 -
PROTIEN:
= % x calories
100
= 18 x 1619
100
= 0.18 x 1619
= 291 kcal
4
Protein = 73 grams
FAT:
= % x calories
100
= 30 x 1619
100
= 0.3 x 1619
= 486
= 486

Fats= 54 grams
EXCHANGES:
Milk 2 24g 16g 10g
Fruit 4 60g - -
Total - 99g 22g 10g
= 210g- 99g
= 111g
= 111
15
Total - 105+99 = 204g 21+22= 43g 7+10= 17g
- -
73g- 43g
- 80 -
30g
= 30
7
Total - - 28+43= 71g 12+17g= 29g
- -
54 g-29g
25g
= 25
5
Fat= 5 exchanges
Fat 5 - - 25g
Total - - - 25+29= 54g
- -
4.4.4DIET Plan: (2hrs for Pneumonia patient)

8:00: EXCHANGES:
 Shake (1 cup milk+ 2 Banana Blended )
Milk: 2
10:00
 1-cup lentils soup. Fruit: 4
12:00
 Juice ( 1 beet root + 2 carrot blended ) Vegetable: 3
2:00 Starch: 7
 1 cup rice drink Meat: 4
4:00 Fat: 5
 1 cup lemonade
6:00
 1 cup chicken soup (2oz)
8:00
 1 cup pineapple juice
10:00
 1 cup milk+ 3 almonds ( blended)
- 81 -
Chapter no 5:
Cardiovascular Ward:
During the fourth week of internship the rotation was placed at cardio ward.
(1)
5.1Case Study:
39 years old female Mrs.Khansa is hospitalized due to heart failure, chest pain. Her current
weight is 56kg and height is 5 feet 2 inches. Her BMI is 23kg/m2 and TEE is 1863 kcal.
5.1.1Heart Failure:
Heart failure formerly called congestive HF; the heart cannot provide adequate blood flow to
the rest of the body.
Symptoms:
 Fatigue
 Dyspnea (SOB)
 Fluid Retention
5.1.2Medical Nutrition therapy:
 Consume a diet low in saturated and trans-fat.
 Restrict sodium diet.
 Increase use of whole grains, fruits, vegetables.
 Lose or maintain appropriate weight.
 Use magnesium supplementation.
 Use thiamine supplementation.
 Increase physical activity.
 Avoid Alcohol and tobacco.
Objective:
Diet low in saturated and Trans – fat, magnesium, thiamine, recommended.
Basic Principles:
Complex carbs, moderate protein is recommended.
Dietary Guidelines:
 Diet low in saturated fat and trans-fat
 Restrict sodium diet
 Increase use of whole grains, fruits vegetables.
- 82 -
 Magnesium supplementation
 Thiamine supplementation.
 Increase physical activity

yogurt
oils
Calculation:
 Patient name: Khansa
 Age: 39 years
 Weight: 56 kg
BMI: Height: 5’5 multiply first 5 feet with12 and
Formula= Weight kg then add additional inches.
Height m2  5x12= 60
 60+2=62
= 56kg Multiply it with 2.54 for converting in cm
(1.57)(1.57)
= 56  62x2.54=157.48cm
= 22.76  157.48
 BMI= 23kg/m2 (patient is 100
normal weight ) =1.57m
- 83 -
IBW:
 100+5x2
 100+10
 110 Lbs.
=110
2.2
IBW=50kg
IBW%
IBW  IBW= 50 kg
= 56 x 100
50
= 112%
IBW% = 112%
Energy Calculation:
BEE:
BEE= 665+ (9.6x 56 kg) + (1.8x 157.48 cm) – (4.7x 39 years)
BEE= 665+ 537.6+ 283.46- 183.3
BEE= 1486.06- 183.3
BEE= 1302.76 kcal
BEE= 1303 kcal
TEE:
= 1303x 1.1 x 1.3 A.F= 1.1
= 1863.29kcal S.F= 1.3
TEE= 1863 kcal
AMDRS:
 Protein=18%
 Fats= 28%
CARBOHYDRATE:
= % x calories
100
= 54 x 1863 kcal
100
=0.54x1863
- 84 -
= 1006.02 kcal
= 1006
PROTIEN:
= % x calories
100
= 18 x 1863
100
=0.18 x 1863
= 335.34kcal
4
Protein = 84 grams
FAT:
= % x calories
100
= 28 x 1863
100
=0.28 x 1863
= 521.63 kcal
= 522

Fats= 58 grams
EXCHANGES:
Milk 1 12g 8g 2g
(low fat)
Fruit 3 45g - -
Total - 72g 14g 2g

= 252g- 72g
= 180g
= 180
15
- 85 -
Total - 180+72 = 252g 14+36= 50g 12+2= 14g
- -

= 84g- 50g
= 34g
= 34
7
Total - - 35+50= 85g 10+14g= 24g
- -

= 58g-24g
= 34g
= 34
5
Fat= 7 exchanges
Fat 7 - - 35g
Total - - - 24+35= 59g
- -
- 86 -
5.1.4DIET PLAN:
Breakfast:
 1 cup cooked oatmeal
 ½ cup low fat milk
Snack:
 Beans salad 2 cups
 (1/2 cup lobia +1/4 cup channa+1 cucumber+1/4 cup cabbage+1/4 pea+1/4 carrots)
Lunch:
• 1 chapatti ( 12 inches)
• 1 cup cooked carrots with potatoes
• ½ cup raita
Snack time:
 Fruit chat (add 2 banana and one apple)
Dinner:
 1 chapatti(12 inch)
 1 cup cooked green lentils
Snack time
 Steamed fish (1+1/2 oz.)
- 87 -
(2)
5.2Case study:
57 years old Mrs.Shajra is hospitalized due to hypertension, Heart attack. Her current weight
is 57kg and height is 5 feet 5 inches. Her BMI is 22kg/m2 and her TEE is 1775 kcal.
Diagnosis:
The Patient blood pressure reading for several weeks had consistently shown a reading of
160/100mmHg, which is in the high range.
5.2.1Hypertension:
 Hypertension is persistently high arterial blood pressure, the force exerted per unit
area on the walls of arteries.
 It is often called silent killer.
Types:
 Systolic Blood Pressure:

The systolic blood pressure, the upper reading in a blood pressure measurement, is the force
exerted on the walls of blood vessels as the heart contracts and pushes blood out of its
chambers.
 Diastolic Blood Pressure:

The lower reading known as diastolic blood pressure, measures the force as the heart relaxes
between contractions.
 Use protein in normal range.

 Less than 50% carbs.
 Sodium less than 2300mg if patient has issue with sodium.
 Use food without salt and sugar.
 Avoid High glycemic foods in hypertension because they increase blood glucose
level.
 Use complex carbs such as bread, chapati, fruits and veggies.
- 88 -
Objective:
Use low sodium, moderate protein, omega 3 and omega 6 fatty acids potassium, magnesium,
calcium diet.
Basic Principles:
DASH (dietary Approaches to control hypertension) is used to treat hypertension.
Dietary guidelines:
 Sodium Intake:
Consume less than 2300mg sodium per day, because it is associated with even greater
reduction in blood pressure.
 Weight Management:
Optimal body weight should be achieved and maintained to reduce blood pressure. increase
the amount of aerobic or dynamic resistance physical activity to a minimum of 90 to 150
minutes per week is recommended as an adjunct therapy of hypertension management.
 Alcohol:
Alcohol consumption should be limited to no more than two drinks daily in men. Excessive
alcohol consumption is associated with left ventricular function.
 DASH DIET:
The Dash diet is used for preventing and controlling high blood pressure.
 Potassium:
Consume a diet rich in potassium, may lower blood pressure. The recommended intake of
potassium for adults is 4.7g/day. Potassium rich fruits and vegetables include green leafy
vegetables, fruits, and roots vegetables.
 Calcium and magnesium:

Increase intake of calcium and magnesium may have blood pressure benefits.

- 89 -
oils
Calculation:
 Patient name: Shajra
 Age: 57 years
 Weight: 57 kg
BMI:
Height m2
 5x12= 60
= 57kg  60+5=65
(1.6)(1.6)
=57
 65x2.54=165cm
= 22.26  165
100
 BMI= 22kg/m2 (patient has
=1.6m
normal weight)
IBW:
 100+5x5
 100+25
 125 Lbs.
- 90 -
=125
2.2
= 57kg
IBW= 57kg
IBW%:
Formula = Actual weight x 100  Actual weight=57 kg
IBW  IBW= 57 kg
= 57 x 100
57
= 100%
IBW% = 100%
Energy Calculation:
BEE:
Formula for male BEE= 665+ (9.6x weight kg) + (1.8xheight cm) - (4.7xage years)
BEE=665+547.2+297-267.9
BEE=1509.2-267.9  Weight: 57kg
BEE= 1241.3 kcal  Height: 165 cm
BEE= 1241kcal  Age: 57 years
TEE:
Formula= BEE x Activity factor x Stress factor BEE= 1241kcal
= 1241x 1.1 x 1.3 A.F= 1.1
= 1774.63kcal S.F= 1.3
TEE= 1775 kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 1775 kcal
100
= 0.52 x 1775 kcal
= 923 kcal
4
- 91 -
PROTIEN:
= % x calories
100
= 18 x 1775
100
= 0.18 x 1775
= 319.7 kcal
= 319.7 as 1 gram of protein= 4kcal
4
Protein = 80 grams
FAT:
= % x calories
100
= 30 x 1775
100
= 0.3 x 1775
= 532 kcal
= 532
Fats= 59 grams
EXCHANGES:
Milk 2 24g 16g 6g
Fruit 3 45g - -
Total - 84g 22g 6g
Starch= Total- Consumed Carbs= 231g = 231g- 84g
= 147g
= 147
15
Total - 150+84 = 234g 22+20= 42g 10+6= 16g
- -

= 80g- 42g
- 92 -
= 38g
= 38
7
Total - - 42+42= 77g 10+16g= 26g
- -
= 59g-26g
= 33g
= 33
5
Fat= 6 exchanges
Fat 6 - - 30g
Total - - - 30+26= 56g
- -
5.2.4DIET PLAN:
Breakfast:
 1 cup oatmeal with 1 cup milk(skim less than 1% fat)
Snack:
 Fruit salad (2 pears and 8 pieces of strawberry)
Lunch:
 1 cup boiled bran rice
 ½ piece cooked lentils
 1 cup salad (cucumber, cabbage, tomatoes, onion)
Snack:
 6-7 almonds
Dinner:
 1 chapatti (12 inch) whole grain flour)
 1 cup cooked carrots +1/2 cup medium potatoes
 Steamed fish 4oz.
Snack:
 1 cup boiled low fat milk
(3)
- 93 -
5.3Case Study :
29 years old Mr.Asim is hospitalized due to coronary heart disease, shortness of breath, and
radiation in left arm. His current weight is 68kg, height is 5 feet 9 inches. His BMI is
22.2kg/m2, TEE is 2367 kcal.
5.3.1Coronary heart disease:

Coronary heart disease refers to a condition where is a significant narrowing or blockage in
the coronary arteries that supply blood to the heart.
5.3.2Medical Nutrition therapy:

 Consume a dietary pattern that emphasize intake of vegetables, fruits, and whole
grains.
 Low fat dairy products, poultry, fish, legumes, oils and nuts recommended.
 Limit the intake of sweets, sugar-sweetened beverages and red meats.
 Reduce percent of calories from saturated fat.
 Reduce percent of calories from trans-fat.
 Physical activity for 40 minutes per day.
 (Mediterranean diet) serving of fruits and vegetables (mostly fish) root vegetables and
greens, whole grains, fatty fish (rich in omega-3 fatty acids).
Objective:
Healthy protein, calcium, vitamin D, potassium, recommended.
Basic principles:
Mediterranean diet and vegan diet are recommended.
Dietary guidelines:
 Mediterranean diet pattern
 Weight reduction if needed
 Increase dietary fiber to 25-30g/day or more.
 Add omega-3 fatty acids from food sources.
 Add fruits and vegetables.

- 94 -
oils
Calculation:
 Patient name: Mr. Atif
 Age: 29 years
 Weight: 68 kg
BMI:
Height m2
 5x12= 60
= 68kg  60+9=69
(1.75)(1.75)
= 68
 69x2.54=175cm
= 22.22  175
100
 BMI=22.22kg/m2 (patient
=1.75m
has underweight)
IBW:
 106+6x9
 106+54
 160 Lbs.
=160
2.2
= 72kg
IBW= 72kg
IBW%:
- 95 -  IBW= 72 kg
IBW
= 68 x 100
72
= 94%
IBW% = 94%
Energy Calculation:
BEE:
BEE= 66.5+ 938.4+ 875- 197.2
BEE= 1879.9-197.2  Weight: 68kg
BEE=1682.7  Height: 175 cm
BEE= 1683kcal  Age: 29 years
TEE:
= 1683x 1.1 x 1.2 A.F= 1.1
= 2221.56kcal S.F= 1.2
TEE= 2222 kcal
AMDRS:
 Protein=18%
 Fats= 30%
CARBOHYDRATE:
= % x calories
100
= 52 x 2222 kcal
100
= 0.52 x 2222 kcal
= 1155.44 kcal
4
PROTIEN:
= % x calories
100
= 18 x 2222
100
- 96 -
= 0.18 x 2222
= 399.96 kcal
4
Protein = 100 grams
FAT:
= % x calories
100
= 30 x 2222
100
= 0.3 x 2222
= 666.6 kcal
= 667
Fats= 74 grams
EXCHANGES:
Milk 2 24g 16g 6g
Fruit 3 45g - -
Total - 84g 22g 6g
= 289g- 84g
= 205g
= 205
15
Total - 210+84 = 294g 22+42= 64g 6+14= 20g
- -

= 100g- 64g
= 36g
= 36
7
- 97 -
Total - - 35+64= 99g 15+20g= 35g
- -

= 74g-35g
= 39g
= 39
5
Fat= 8 exchanges
Fat 8 - - 40g
Total - - - 38+40= 78g
- -
5.3.4DIET PLAN:
Breakfast:
 2 bran bread
 2 fried egg (egg white + 1tsp oil)
 1tsp oil
Snack:
 1 apple
 6-7 almonds
Lunch:
 2 cup rice
 1 cup lentils
 1 cup raita with vegetable added
Snack:
 1 sandwich (2 oz. chicken 2 bread slice)
Dinner:
 1 chapatti
 ½ cup green beans
 1 cup vegetable cooked
Bedtime:
 1 cup yoghurt with 2 banana
- 98 -
Chapter No.6:
Surgical Ward
During the fifth week of internship, the rotation was placed at Surgical Ward
6.1Case Study:37 years old MR.Wahab is hospitalized due to cholecystitis. He had a

history of gallstones and acute cholecystitis. His gallbladder was inflamed and surgery was,
advised. Later on after surgery patient’s GCS factor is 9. Patient is on EN and PCT tube is
placed. His current weight is 80kg and height is 5 feet 7 inches. His BMI is 28kg/m2 and her
TEE is 2097 kcal.
6.1.1Cholecystectomy:
“Cholecystectomy is surgical removal of the gallbladder, especially if the stones are
numerous, large, or calcified”
 Gallstones are more prevalent in low-fiber, high-fat, westernized diets.

 Consumption of large amounts of animal protein and animal fat, especially saturated fat,
and a lack of dietary fiber, promote gallstone development
 Individuals consuming refined carbohydrates have a 60% greater risk for developing
gallstones, compared with those who consumed the most fiber, in particular insoluble
fiber
 Plant-based diets may reduce the risk of cholelithiasis.
 Vegetarian diets are high in fiber and low in fat, consisting primarily of unsaturated fat.
 vitamin C, which is generally high in vegetarian diets, affects the rate-limiting step in the
catabolism of cholesterol to bile acids and inversely is related to the risk of gallstones in
women.
 Weight cycling (repeatedly losing and regaining weight), fasting, and very-low-calorie
diets increase the likelihood of cholelithiasis
 Physical activity reduces the risk of cholecystitis.
 Corrects energy and nutrient deficiencies and excesses in the diet
 Educates the patient on a personalized diet that provides optimal levels of nutrients,
monitors growth in children, and watches for food-drug interactions.
 Vitamin and minerals supplements
 Consume diet rich in antioxidants
- 99 -
 Small frequent meals that are nutritionally dense
 The patient eats the main meal when energy level is at its highest
 Adequate calories, protein, vitamins, and minerals to maintain a desirable weight - a BMI
of 20 to 24 kg/m2
 Availability of foods that require less preparation and can be heated easily in a microwave
oven
 Limitation of alcohol to fewer than 2 drinks/day (30 g alcohol)
 A period of rest before mealtime
 Treat the reversible causes of anorexia such as early satiety
 Evaluate the rate and severity of weight loss
 Treat the symptoms interfering with food intake: nausea and vomiting, dyspnea,
mucositis, constipation, and pain
 Provide nutritional support
Objective:
 A high-fiber, low-fat, plant-based diet to prevent gallbladder contractions
Basic Principle:
 A high-fiber, low-fat, plant-based diet to prevent gallbladder contractions
Dietary Guideline
 Consumption of large amounts of animal protein and animal fat, especially saturated fat,
and a lack of dietary fiber, promote gallstone development
 Individuals consuming refined carbohydrates have a 60% greater risk for developing
gallstones, compared with those who consumed the most fiber, in particular insoluble
fiber
 Plant-based diets may reduce the risk of cholelithiasis.
 Vegetarian diets are high in fiber and low in fat, consisting primarily of unsaturated fat.
Calculation:
Patient name: Wahab Age: 37yrs
Height:5’7 Weight: 80kg
Gender: Male.
- 100 -
BMI:
 Height: 5’5 multiply first 5 feet with12 and
Formula= Weight (kg)
Height (m2) 5x12+7=67
 Multiply it with 2.54 for converting in cm
=80
(1.7)(1.7) 67x2.54=170.18cm
 Converting it into m
= 80 =170.18
2.89 100
= 1.7 m
= 27.68
 BMI= 28 kg/m2 (patient is
overweight body weight)
IBW: For Male:

106lb for first 5feet +6lb for additional
=106+6x7
= 148Lbs.
=148
2.2
IBW = 67 kg.
IBW%:
IBW
= 80 x 100
67
IBW% = 119%
Energy Calculation:
BEE:
Formula for male:
BEE= 66.5+ (13.8x weight kg) + (5.0xheight cm) - (6.8xage years)
BEE= 66.5+ (13.8x 67) + (5.0x 170cm) – (6.8x 37years)
- 101 -
BEE=66.5+924.5+850-251.6
BEE= 1589 kcal
TEE:
Formula= BEE x Activity factor x Stress factor.
= 1589 x 1.1 x 1.2
= 2097.48kcal
TEE= 2097kcal.
AMDRS:
 Carbohydrates= 57%
 Protein=20%
 Fats= 23%
CARBOHYDRATE:
= % x calories
100
= 57 x2097 kcal
100
= 1195 kcal
= 1195
4 1 gram of carbohydrate = 4kcal
PROTIEN:
= % x calories
100
= 20 x 2097
100
= 419kcal
1 gram of protein= 4kcal
= 419
4
Protein = 105 grams
- 102 -
FAT:
= % x calories
100
= 23 x 2097
100
= 482 kcal
= 482 1 gram of fat= 9kcal
9
Fats= 54 grams
EXCHANGES:

Milk 2 24g 16g 6g
Fruit 3 45g - -
Total - 84g 22g 6g

= 298g- 84g
= 214g
= 214
15
Total - 22+28= 6+14= 20g
50g
- -

= 105g- 50g
= 55g
= 55
7
- 103 -
Total - -
- -

= 54g-36g
= 18g
= 18
5
Fat= 4 exchanges
Fat 4 - - 20g
Total - - -
- -
Fluid Requirement:
= 1500+25 x60
Weight = 80kg
= 1500 + 1500 1500ml for first 20 kg and 25ml for additional kg
= 3000ml = 80-20
=60kg
As 1 glass = 250ml
= 3000/250
= 12 glasses.
6.1.3 DIET Plan:

Clear Liquid: (1 hourly diet plan)
Timing Feed ML
8:00 AM Water 30ml
9:00 AM Herbal green tea 70ml
10:00 AM ORS 180ml
11:00 AM Broth 200ml
12:00 PM Glucose 250ml
- 104 -
1:00 PM Water 250ml
2:00 PM Water with lemon 250ml
4:00 PM Green tea 250ml
5:00 PM ORS 250ml
7:00 PM Broth 250ml
8:00 PM ORS 250ml
9:00 PM Water 250ml
Total ML 2980 ML
Liquid diet: (2 hourly diet plan)
TIME SERVING DIET

6:00 AM 1 cup Corn soup
8:00 AM 1 cup Shake(1 cup milk +1
mango)
10:00 AM 1 cup 2oz chicken broth
12:00 AM 1.5 cup Lentils soup
2:00 PM 1 cup Carrot juice (2 carrots)
4:00 PM 1 cup Rice drink
6:00 PM 1 cup Corn soup
8:00 PM 1 cup Lentils soup
12:00 PM 1 cup Shake ( 1 cup milk+1
banana)
2:00 AM 1 cup Lentil soup
4:00 AM 1 cup Juice ( 1 apple +1 carrot)
- 105 -
Semi Solid: EXCHANGES:
8:00 Milk: 2
 Cooked oats ( 1cup milk + 1 bananas + 1cup oats) Fruit: 3

10:00
Vegetable: 3
 Juice ( 2 carrot + 2 beetroot)
Starch: 14
12:00 Protein: 8
 1 cup lentils soup Fat: 4
2:00
 1 cup yakhni ( 3 slice bran bread soaked with 2oz chicken)
4:00
 1 cup apple juice
6:00
 1 cup veg + chicken soup (2oz chicken + ½ cup veg)
8:00
 1 cup rice blended with 1 cup milk
- 106 -
6.2 Case Study:
50 years old MR.Anees is, hospitalized due to hernia. He had a history of abdomen muscle
weakness. His hernia surgery was, advised. Later on after surgery patient’s GCS factor is 9.
Patient is on EN and NG tube is, placed. His current weight is 63kg and height is 5 feet 5
inches. His BMI is 23kg/m2 and her TEE is 1850 kcal.
6.2.1Appendectomy:
“A surgical operation to remove the appendix (a tube-shaped sac attached to and opening
into the lower end of the large intestine in humans and some other mammals)”
 If your appendectomy was done laparoscopic ally, limit your activity for three to five day
you had an open appendectomy, limit your activity for 10 to 14 days.
 Place a pillow over your abdomen and apply pressure before you cough, laugh or move to
help reduce pain.
of 20 to 24 kg/m2
oven
- 107 -
Objective:
 A high-fiber, low-fat, vitamin A and Vitamin D rich diet help to prevent appendectomy
Basic Principle:
 A high-fiber, low-fat, vitamin A and Vitamin D rich diet help to prevent appendectomy
Dietary Guideline
 If your appendectomy was done laparoscopic ally, limit your activity for three to five day
you had an open appendectomy, limit your activity for 10 to 14 days.
 Place a pillow over your abdomen and apply pressure before you cough, laugh or move to
help reduce pain.
 Vitamin and minerals supplements.
Calculation:
Patient name: ANEES Age: 50yrs

Height:5’5 Weight: 63kg
Gender: Male.
BMI:

Height (m2)  Height: 5’5 multiply first 5 feet with12 and
=63
5x12+5=65
(1.65)(1.65)
= 85
2.7 65x2.54=165cm
 Converting it into m
= 22.9 =165
 BMI=23 kg/m2 (patient has 100
normalbody weight) = 1.65 m
- 108 -
IBW: For Male:
106lb for first 5feet +6lb for additional
=106+6x5
= 136Lbs.
=136
2.2
IBW = 62 kg.
IBW%:

IBW
= 63 x 100
62
IBW% = 101%
Energy Calculation:
BEE:
Formula for male:
BEE= 66.5+ (13.8x weight kg) + (5.0xheight cm) - (6.8xage years)
BEE= 66.5+ (13.8x 63) + (5.0x 165cm) – (6.8x 50years)
BEE=66.5+869.4+825-340
BEE= 1421 kcal
TEE:
Formula= BEE x Activity factor x Stress factor.
= 1421 x 1.1 x 1.2
TEE= 1876kcal.
AMDRS:
 Protein=20%
 Fats= 23%
- 109 -
CARBOHYDRATE:
= % x calories
100
= 57 x1876 kcal
100
= 1069.32 kcal
= 1069
PROTIEN:
= % x calories
100
= 20 x 1876
100
= 375kcal
1 gram of protein= 4kcal
= 375
4
Protein = 94 grams
FAT:
= % x calories
100
= 23 x 1876
100
= 431.48 kcal
= 497 1 gram of fat= 9kcal
9
Fats= 48 grams
EXCHANGES:
Milk 3 36g 24g 9g
Fruit 3 45g - -
Total - 96g 30g 9g
= 267g- 96g
- 110 -
= 171g
= 17
15
Total - 22+30= 9+11= 20g
52g
- -

= 94g- 52g
= 42g
= 42
7
Total - -
- -

= 48g-32g
= 16g
= 16
5
Fat= 3 exchanges
Fat 3 - - 15g
Total - - -
- -
Fluid Requirement: Weight = 85kg

1500ml for first 20 kg and 25ml for
= 1500+25 x65
additional kg
= 1500 + 1625 = 85-20
=65kg
- 111 -
= 3125ml
As 1 glass = 250ml
= 3125/250
= 12 glasses.
DIET Plan:
Timing Feed ML
8:00 AM Water 30ml
9:00 AM Herbal green tea 70ml
10:00 AM ORS 180ml
11:00 AM Broth 200ml
1:00 PM Water 250ml
5:00 PM ORS 250ml
7:00 PM Broth 250ml
8:00 PM ORS 250ml
9:00 PM Water 250ml
Total ML
- 112 -
Liquid diet: (2 hourly diet plan)
TIME SERVING DIET

6:00 AM 1 cup Corn soup
8:00 AM 1 cup Shake(1 cup milk +1 mango)
10:00 AM 1 cup 2oz chicken broth
12:00 AM 1.5 cup Lentils soup
2:00 PM 1 cup Carrot juice (2 carrots)
4:00 PM 1 cup Rice drink
12:00 PM 1 cup Shake ( 1 cup milk+1 banana)
2:00 AM 1 cup Lentil soup
4:00 AM 1 cup Juice ( 1 apple +1 carrot)
8:00 Milk: 2
 Cooked oats ( 1cup milk + 1 bananas + 1cup oats) Fruit: 3

10:00
Vegetable: 3
 Juice ( 2 carrot + 2 beetroot)
Starch: 14
12:00 Protein: 8
 1 cup lentils soup Fat: 3
2:00
 1 cup yakhni ( 3 slice bran bread soaked with 2oz chicken)
4:00
 1 cup apple juice
6:00
 1 cup veg + chicken soup (2oz chicken + ½ cup veg)
8:00
 1 cup rice blended with 1 cup milk

10:00
 1 cup lentil soup
- 113 -
6.3 Case Study:
50 years old MRS.RAZIA is, hospitalized due to hernia. He had a history of abdomen muscle
weakness. His hernia surgery was, advised. Later on after surgery patient’s GCS factor is 9.
Patient is on EN and NG tube is, placed. His current weight is 82kg and height is 5 feet 3
inches. His BMI is 32kg/m2 and her TEE is 1850 kcal.
6.3.1 Hernia:
A condition in which part of an organ is displaced and protrudes through the wall of the
cavity containing it (often involving the intestine at a weak point in the abdominal wall):
6.3.2 Medical Nutrition Therapy:

of 20 to 24 kg/m2
oven
 Emphasize high-fiber foods
 If you're diagnosed with a hiatal hernia, you should avoid high-acid foods. Also avoid
foods that are fatty, oily, and rich, as well as processed foods with preservatives.
 Eat foods high in probiotics, such as fermented foods, and consider taking probiotic
supplements to promote healthy digestion.
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 Avoid excessive hunger, which increases stomach acid.
 Avoid eating large meals.
Objective:
 A high-fiber, low-fat, moderate protein help to prevent hernia
Basic Principle:
 A high-fiber, low-fat, moderate protein help to prevent hernia
Dietary Guideline
 Eat frequent meals and snacks in small portions.

 Drink plenty of fluids (particularly water) each day.
 Keep a food diary to identify your triggers.
 Chew your food thoroughly, eat slowly, and drink lots of water during meals to promote
proper digestion.
 Do not eat before exercising.
 Eat foods high in probiotics, such as fermented foods, and consider taking probiotic
supplements to promote healthy digestion.
 Avoid excessive hunger, which increases stomach acid.
 Avoid eating large meals.
Calculation:
Patient name: RAZIA Age: 50 years
Height: 5’3’’ inches Weight:82 kg
Gender: Female
BMI:  Height: 5’ multiply first 3 feet with12 and

Height (m2) 5x12+3=63
= 82 kg
(1.6)(1.6)
63x2.54=160cm
= 82  Converting it into m
2.5 =160
100
= 32
=1.6m
 BMI= 32kg/m2 (obese)
- 115 -
IBW:
For female:
100 lb for first 5 feet + 5lb for additional.
=100+5x3
=115 lbs.
Converting lb into kg
=115
2.2
=52 kg
IBW = 52kg.
IBW%:

IBW  Actual weight= 82kg
 IBW= 52 kg
= 82 x 100
52
=132%
Energy Calculation:
BEE for Female:

BEE=655+ (9.6x8x weight kg) + (1.8xheight cm) - (4.7xage years)
BEE=655+9.6x60+4.7x50-4.7x50
BEE=1294 kcal.
TEE= BEE x activity factor x stress factor
= 1294 x 1.1 x 1.3
= 1850 kcal/day.
AMDRS:
 Protein=18%
 Fats= 27%
CARBOHYDRATE:
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= % x calories
100
= 55 x1850 kcal
100
= 1017kcal
= 1017
Carbohydrate= 254grams
PROTIEN:
= % x calories
100
= 18 x 1850kcal
100
= 333kcal 1 gram of protein= 4kcal
= 333
4
Protein = 83grams.
FAT:
= % x calories
100
= 27 x 1850kcal
100
= 499 kcal
= 499 1 gram of fat= 9kcal 9
Fats= 55grams
EXCHANGES:
Milk 2 24g 16g 6g
Fruit 3 45g - -
Total - 84g 22g 6g

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= 254g- 84g
= 170g
= 170
15

Total - 22+22= 6+11= 17g
44g
- -

= 83g- 44g
= 39g
= 39
7

Total - -
- -

= 55g-32g
= 23g
= 23
5
Fat= 4 exchanges

Fat 4 - - 20g
Total - - -
- -
Fluid Requirement:
 Weight = 78kg
- 118 -
 1500ml for first 20 kg and 25ml
for additional kg
= 82-20
= 1500+25 x 62
= 1500 + 1550
= 3050ml
As 1 glass = 250ml
= 3050
250
Fluid requirement = 12 glasses.
DIET Plan:
Timing Feed ML
8:00 AM Water 30ml
9:00 AM Water with glucose 50ml
10:00 AM Water 130ml
11:00 AM Water with honey 170ml
12:00 PM ORS 180ml
2:00 PM Water 210ml
3:00 PM ORS 220ml
5:00 PM Water with honey 230ml
6:00 PM ORS 230ml
7:00 PM Water 250ml
8:00 PM Water with glucose 250ml
9:00 PM ORS 250ml
10:00 PM Water 250ml
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Liquid Diet Plan:
TIME SERVING Diet

8:00 AM 1 cup 2 carrot+ 2 beetroot
10:00 AM ½ cup Veg soup
2:00 PM 1 cup Milk + mashed
biscuits (2-3)
4:00 PM 1 cup Chicken soup (2oz)
8:00 PM 1 cup Shake (3 banana + 2
tbsp honey + 1 cup
milk)
10:00 PM ½ cup Lentil soup

8:00 Milk: 2
 1 cup cooked oatmeal (1 cup milk + 1 banana blended)
10:00 Fruit: 3
 1 cup juice (2 carrot + 2 beetroot)
Vegetable: 3
12:00
Starch: 10
2:00 Protein: 5
 1 cup yakhni ( 1oz ) + 2 slice bran bread. Fat: 4
4:00
 Smoothie (1 apple + 1 carrot)
6:00
8:00
 1 cup peach juice.
10:00
 1 cup milk + 2-3 biscuits.
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Chapter No.7
GYNAE WARD:
During the fifth week of internship, the rotation placed at Gynae ward.
Nutrients Requirements during Pregnancy:
Nutrients Recommendations
Carbohydrates RDI is slightly high during pregnancy to maintain the
blood glucose level and choose complex
carbohydrates more preferably than simple.
Protein RDA is 0.8 g/kg current weight/day for first half
RDA is 1.1 g/kg/day for second half of the pregnancy
Fat There are no specific recommendations for fat. Its
amount depends on
total caloric intake for proper weight gain.
Recommendations of omega-6
and omega-3 are slightly increased
Fiber DRI is 14 g/day/1000 kcals
Energy DRI increases about 340 kcal/day for second
trimester, and 452 kcal/day
for third trimester
Vitamin
Vitamin B6 Standard dose is about 25 mg three times a day which
is not dangerous
Folic acid According to the centers for disease control and
prevention the recommendations are 400 mcg/day for
all women of childbearing age expecting pregnancy
Vitamin B12 Vitamin B12 is found in high amount in animal food
sources, their sufficient intake can easily meet the
vitamin B12 requirements
Vitamin C DRI of vitamin C is increased during pregnancy and
its good sources like 7FM citrus fruits should be
- 121 -
encouraged
Vitamin A Supplementation is not necessary and is often limited
to 5000 IU/day
Vitamin D The requirements are not increased during pregnancy
and 600 IU/day is sufficient
Vitamin E The requirements are not increased during pregnancy
Vitamin K The requirements are not increased during pregnancy
Minerals
Calcium The requirements are not increased but some women
having low calcium status when entering into the
pregnancy so require encouraged calcium- rich-foods
intake
Copper Requirements are increased slightly during pregnancy
Fluoride The requirements are not increased during pregnancy
Iodine Women should receive 150 mcg/day during
pregnancy and lactation in the form of potassium
iodide
Iron RDA of iron nearly doubles during pregnancy
Magnesium Recommendation slightly increases during pregnancy
Phosphorus The requirements are not increased during pregnancy
Selenium DRA slightly increases during pregnancy
Sodium Sodium intake should not be restricted below 2300
mg/day
Zinc Requirement slightly increase during pregnancy
Exercise At least 30 minutes of moderate intensity exercise

most days of week
Nutrients Requirements during Lactation:

Nutrients Recommendations
Carbohydrates The RDA of carbohydrates is based on to provide
sufficient energy by diet for the production of milk
and to maintain the energy level
- 122 -
Protein RDA is 1.1 g/kg/day of woman's body weight
Fat There are no specific recommendations for fat. Its
amount depends on the amount of energy required by
the mother for the production of milk.
Recommendations of specific omega-6 and omega-3
are low than
pregnancy
Energy DRI of energy is about 330 kcal greater per day for
first six month of lactation, and 400 kcal greater per
day for second six month of lactation
Vitamin
Vitamin D The requirements are not increased during lactation
and 600 IU/day is sufficient
Minerals
Calcium The lactating women are encouraged to intake
calcium-rich-foods to meet
their DRA
Iodine The requirements are nearly double to non-pregnant
values
Sodium There is no specific recommendations and restrictions
for breastfeeding mothers
Zinc Requirements during lactation are more than the
pregnancy
Fluids Drink to thirst but not in excess
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7.1 CASE
7.1.1 Cesarean:
Cesarean section, C-section, or Cesarean birth is the surgical delivery of a baby through a cut
(incision) made in the mother's abdomen and uterus. Health care providers use it when they
believe it is safer for the mother, the baby, or both. The incision made in the skin may be up-
and-down (vertical).
7.1.2 Medical Nutrition Therapy for Cesarean:
Objective:
The main purpose of the diet design for mother after the C-section delivery is to provide food
that helps the mother to digest food easily and aid the bowel movements without straining the
wound on abdomen and meets the nutritional requirements.
Basic Principle:
High in protein, high energy, high in major vitamins and minerals especially vitamin C and
iron respectively and plenty of fluids.
Dietary Guidelines:
 Protein rich foods help in healing process contribute to the growth of new tissues
and maintain the muscles post-surgery.
 Vitamin C speeds up the healing process and fights against the infections.
 Lots of blood is lost during C-section delivery, which may deplete the iron level of
the body and leave you exhausted and fatigued. Intake iron rich foods after the C-
section delivery because iron is required for the hemoglobin and to fulfill the blood
that lost during delivery.
Iron is important for the proper functioning of immune system.
 After the C-section, females should eat nutritious and easily digestible foods like
soups, broth, cottage cheese and yogurt.
 After C-section delivery mothers often experience increased gas and constipation,
they should avoid foods that cause the constipation and gas problems. Avoid fried
foods, carbonated drinks these produce gas and avoid processed foods like pasta,
breads etc. these are hard to digest and cause constipation.
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 Intake fibrous foods to avoid constipation also fatty acids from flaxseeds and
primrose oil can help.
 Intake lots of yogurt to restore the intestinal bacterial balance.
 Drink plenty of water to avoid dehydration and avoid constipation.
 Hydration improve the bowel movement and increase the rate of recovery.
 Intake 8 to 10 glasses of water and other fluids like low fat milk, herbal teas, non-
citrus and unsweetened fruit juices and coconut water.
 Drinking plenty of water is also necessary during breast-feeding which can leave
you thirsty.
 To increase the breast milk production, drink calcium fortified juices, milk and low
fat yogurt.
 Get sufficient vitamins especially vitamin C and E from food sources and
supplements that help the body to heal faster and fight against infections.
 Resume your normal diet when you do not feel pain during bowel movements and
digest foods easily.
- 125 -
7.2 CASE
7.2.1 Gestational Diabetes:
Gestational diabetes occurs when your body cannot make enough insulin during your
pregnancy. Insulin is a hormone made by your pancreas that acts like a key, to let blood sugar
into the cells in your body, for use as energy.
7.2.2 Medical Nutrition Therapy of GDM:
Basic Principle:
The MNT for GDM is primary a carbohydrate-controlled meal plan but it also provides
sufficient amount of necessary nutrients for maternal and fetus growth, gives adequate
amount of energy for required weight gain, maintains the normal blood glucose level and also
prevent the ketosis.
Dietary Guidelines:
 Carbohydrates requirement of a day of pregnant women should be divided into

three small or medium meals and two to four snacks
 The minimum amount of carbohydrates for pregnant woman are 175g/day.
 Evening snacks are important to prevent the ketosis in nighttime due to the low
blood glucose level.
 CHO are in high amount not much tolerated in morning or breakfast than other
meal due to cortisol and growth hormone so initial meal plan may have about 30g
of CHO in breakfast
 Caloric restriction for pregnant women should be, done with caution, moderate
caloric restriction is, recommended to slow down the weight gain in the obese or
overweight pregnant women with GDM.
 Small restriction of calories helps to slow down the maternal weight gain in
pregnant women with GDM without affecting the fetus normal growth.
 Less than 1700 to 1800 calories are not advice in pregnancy.
 Exercise helps in decreasing the insulin resistance and maintain the blood glucose
level, combination of exercise with appropriate diet gives maximum benefits, exact
exercise is unknown but fast walking after meal is, recommended.
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 Breastfeeding reduces the risk of T2DM after pregnancy in those women having
GDM or preexisting diabetes during pregnancy.
 Overweight and obese women with GDM recommend to, reduce weight after
delivery, which reduces the risk of recurrent GDM and T2DM in future.
- 127 -
7.3 CASE
7.3.1Anemia: Iron Deficiency Anemia (IDA) occurs due to the long-term iron deficiency
in the body or we can also say that anemia is the end stage of long-term iron deprivation. It is,
characterized by the small sized (microcytic) erythrocytes production and low level of
circulating hemoglobin.
Causes:
 Inadequate dietary intake

 Inadequate absorption due to celiac diseases, intestinal resection and drug
interference
 Inadequate utilization like in gastrointestinal diseases
 Increased iron demand like in pregnancy
 Increased excretion of iron due to blood loss in injury, heavy menses and
hemorrhage
 Increased utilization of body's iron stores
Symptoms:
Early Iron Deficiency:
 Abnormal cognitive development in children

 Growth abnormalities
 Epithelial disorders
 Reduce gastric activity
 Low immunity
 Restless leg syndrome
 Alter neurotransmitter (dopamine)
Late Iron Deficiency (Anemia)
Anemia affects various body systems, which are:
 Impaired muscle function like decreased work performance and exercise tolerance
 Neurological disturbance
 Fatigue
- 128 -
 Anorexia
 Pica
 Pagophagia (ice eating)
Complications
If the iron deficiency anemia remains untreated then the complications arise which are:
 Glossitis
 Gastritis
 Achlorhydria
 Koilonychias
 Cardiac failure.
Medical Management:
 The basic aim of the treatment should be to identify the underlying cause of the
anemia.
 Ferrous is the more absorbable form of the iron in body than the ferric, oral
supplementation of the ferrous iron is the primary treatment of the anemia.
 Iron best absorbs in empty stomach but it can cause gastric irritation like nausea,
vomiting, diarrhea and constipation so it is, recommended that to intake, the iron
supplements with meals but it affects its absorbability.
 Chelated iron is more absorbable than the non-chelated iron and it also not affected
by iron absorption inhibitors, which are calcium, phosphate, oxalate and phytate
7.3.2 Medical Nutrition Therapy of Iron Deficiency Anemia:
Objective
 The diet is, planned to maintain the iron level in the body. Diet should be consists
on iron rich sources meat, chicken and fish, also provide acidic medium, which
enhances the iron absorption.
- 129 -
Dietary Guidelines:
 With supplemental iron it is important to paid attention to sufficient intake of

absorbable dietary iron
 A good source of iron provides at least 10% of the recommended dietary
allowance of
 Iron.
 1.8 mg of iron requires to meet the daily needs of 80% to 90% adult women and
adolescents boys and girls
 Bioavailability is more important in the treatment and prevention of iron
deficiency than the total amount of dietary iron consumed
 Absorption of iron depends on the individual's iron stores, more the iron
deficiency greater the iron absorption
 Anemic person absorbs approximately 20% to 30% dietary iron as compared with
5% to 10% absorb by healthy person
 There are two forms of the iron present in the foods which are heme iron and non-
heme iron
 Heme iron which is about 15% is absorbed is organic and present in the meat, fish
and poultry. It is more absorbable than the non-heme iron
 Non-heme iron present in the meat, fish, poultry, egg, grains, vegetables and
fruits, its absorption rate is about 3% to 8%.
 Vitamin C enhances the iron absorption by binding the iron and forms the readily
absorbable complex
 Diet should contain the vitamin C rich sources which are citrus fruits, cabbage and
potatoes
 There are different types of iron absorption inhibitors that inhibit its absorption at
varying degrees. Whole grain cereals and soybeans have carbonates, phytates and
oxalates that binds the iron and decrease its bioavailability
 In coffee and tea, tannin is present that binds the iron in egg phosvitin binds the
iron.
- 130 -
Chapter No.8
PEDIATRIC WARD:
During the sixth week of internship, the rotation placed at Pediatric ward.
Infancy is the life stage start from the birth to the 2 years of life.
Table of Equation for Calculating Estimated Energy Requirements for
Infants:
Age In Months Calculations
0-3 (89 * Weight of infant kg]-100)+175
4-6 (89*Weight of infant [kg]-100)+56
7-12 (89*Weight of infant[kg]-100)+22
13-35 (89*Weight of infant [kg[kg]-100)+20
Protein:
Protein is required for the tissue replacement, deposition of the lean body mass and for
growth. Infants require a larger amount of amino, for infants all amino acids are essential
while for adults not all are essential and require in relatively low amounts. Histidine is
essential for infants but not for adults. Tyrosine, cysteine and taurine are may be essential for
premature infants.
Table for Protein dietary intake for Infants:
Age Gram/kg/day
0-6 1.52g/kg/day
6-12 1.2g/kg/day
Water:
The water requirement for infants can be determine by the loss of water through skin, lungs,
feces, urine, and small amount require for growth. DRI is about 0.7L/day for infants up to 6
month and from 6 to 12 months 0.8L/day.
- 131 -
Table for Maintenance of Fluid for Infants and Children:
Weight in Kg Fluid Requirements

0-10 100ml/kg
10000ml
11-20
10kg+50mlal for each kg more
than 10 kg
1500ml for 20kg+20mlml for each kg more

More than 20
than 20kg
Table for Nutritional Ranges for Healthy Child of Age 1-3 years:
Nutrients Percentages
CHO 45%-65%
Fat 30%-40%
Protein 5%-20%
Intake should be consists in these percentages for healthy child of age 4-18 years
Table for Nutritional Ranges for Healthy Child of Age 4-18 years:
Nutrients Percentages
CHO 45%-65%
Fat 25%-35%
Protein 10%-30%
Table for Protein dietary intake for Infants:
Age Gram/kg/day
1-3 1.05g/kg/day
4-8 0.95g/kg/day
9-13 0.95g/kg/day
- 132 -
Table for Maintenance of Fluid for Infants and Children:
Weight in Kg Fluid Requirements

0-10 100ml/kg
11-20 0ml for 10 kg+50mml for 10 kg + 50ml for

each kg more than 10 kg
More than 20 1500ml for 20kg+20nor 20kg + 20ml for

each kg more than 20kg
Table for Protein dietary reference intake:
Age Gram/kg/day
0-6 1.52g/kg/day
6-12 1.2g/kg/day
- 133 -
8.1 CASE: 1
8.1.1 Hypothyroidism:
Hypothyroidism, also called underactive thyroid, is, when the thyroid gland does not make
enough thyroid hormones to meet your body's needs. The thyroid is a small, butterfly-shaped
gland in the front of your neck.
8.1.2 Medical Nutrition Therapy of Iron Deficiency Anemia:
Dietary Guidelines:
Many nutrients are involved in the maintenance of the thyroid function specially the iodine
and the selenium, so in thyroid related problems iodine receives more attention.
Iodine
 It is the trace element in the body and its total amount in the body is about 10 to 15
mg and from this about 70% to 80% present in the thyroid gland for the synthesis
of thyroid hormones.
 Inadequate intake of iodine impairs the thyroid function and can cause the different
diseases
 Severe iodine deficiency during pregnancy increases the risk of spontaneous
abortion congenital abnormalities on fetus.
Goitrogens:
 Green leafy vegetables having the anti-thyroid effect, these inhibit the production of
thyroid hormones by producing the goitrin, which interfere in production.
 Soybean is an important protein source but it also shows goitrogenic properties in
the deficiency of iodine.
 Low iron status or anemia can cause low thyroid hormones production or
hypothyroidism
 Sufficient amount of iron is require for adequate production of the thyroxin.
- 134 -
8.2 CASE: 2
8.2 1Typhoid Fever:
Typhoid is an infectious disease with an acute fever of short duration and occurs only in
humans. Salmonella typhi causes typhoid. Feces and urine of the patients or carriers of the
contaminated with feces from patients or persons recovered from the disease. House flies
help.
Symptoms:
 Inflammation of the intestine

 Intestinal ulcers
 Hemorrhage and enlargement of spleen.
 Peyer’s patches of lymphatic tissue situated in the small intestine are a seat of
infection in typhoid fever.
 The patient may complain of diarrhea or constipation and severe stomach pain.
8.2.2Medical Nutrition Therapy of Typhoid fever:
Basic Principle:
A high calorie, high protein, high carbohydrate, high fluid, low fat, low fiber and bland diet
is, recommended for typhoid patients.
Dietary Guidelines:
 At first clear fluid diet is given followed by full fluid and soft diet
 Liquid diets may not meet high calorie and high protein requirements.
 Liquid diets are helpful in meeting water and electrolyte requirements。
 As the patient improves, a soft diet can be given。
 Because of intestinal inflammation, fiber and spices must be, eliminated in the diet.
- 135 -
Chapter no 9:
Medical Unit:
During the Seventh week of internship, the rotation was, placed at Medical Unit.
9.1 CASE:
9.1.1 Diabetes:A disease in which the body’s ability to produce or respond to

the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and
elevated levels of glucose in the blood. This disease occurs when the body does not make
enough insulin or does not use it the way it should.
Types:
 Prediabetes
 Types 1 Diabetes
 Type 2 Diabetes
 Gestational Diabetes
Prediabetes:
Individuals with a stage of impaired glucose homeostasis that includes impaired fasting
glucose (IFG) and impaired glucose tolerance (IGT) ae referred to as having prediabetes. IFG
(100-125mg/dl) and IGT (140-199 mg/dl) are, diagnosed as prediabetes.
Diabetes-Type 1:
 Type 1 diabetes mellitus (T1D) is an autoimmune disease that leads to the

destruction of insulin-producing pancreatic beta cells.
 Individuals with T1D require life-long insulin replacement with multiple daily
insulin injections daily, insulin pump therapy, or the use of an automated
insulin delivery system.
 It accounts for 5% of all diagnosed cases of diabetes.
Diabetes-Type 2
 If you have type 2 diabetes, cells do not respond normally to insulin; this is,
called insulin resistance.
- 136 -
 Your pancreas makes more insulin to try to get cells to respond.
 Eventually your pancreas cannot keep up, and your blood sugar rises, setting the
stage for prediabetes and type 2 diabetes.
 Type 2 diabetes is also, called type 2 diabetes mellitus and adult-onset diabetes.
 T2DM accounts for 90% to 95% of all diagnosed cases of diabetes.
Gestational Diabetes:
 Gestational diabetes mellitus (GDM) is a condition in which a hormone made by

the placenta prevents the body from using insulin effectively.
 Glucose builds up in the blood instead of being absorbed by the cells.
 Unlike type 1 diabetes, gestational diabetes is, not caused by a lack of insulin, but
by other hormones produced during pregnancy that can make insulin less
effective, a condition referred to as insulin resistance.
 Gestational diabetic symptoms disappear following delivery.
 Approximately 3 to 8 percent of all pregnant women in the United States are,
diagnosed with gestational diabetes.
Symptoms:
 Urinate (pee) a lot, often at night.

 Are very thirsty.
 Lose weight without trying.
 Are very hungry.
 Have blurry vision.
 Have numb or tingling hands or feet.
 Feel very tired.
 Have very dry skin.
- 137 -
9.1.2 Medical Nutrition Therapy:
For pre diabetes:
 MNT should be, individualized for each patient take into account a patient health
status, food preference, food security and house situation.
 Healthy eating Pattern.
 Regular Physical Activity.
 Healthy body weight.
 Moderate Alcohol intake.
 No smoking
 Mediterranean diet
 MUFAS (olive oil)
 Plant based diet.
 Moderate intake of fish and wine.
 High intake of fruits and vegetables.
 Low intake of red meat and whole fat dairy products.
 High intake of whole grain and dietary fibers.
 Low intake of carbonated drinks and fatty acids.
For Diabetes:
 Individualized approach and effective nutrition, self-management, education,

counselling and support.
 Monitoring glucose, A1C and lipids levels, and blood pressure, weight, and
quality of life issues.
 Physical activity.
 Planned Carbohydrate intake.
Objective:
 To promote and support healthful eating patterns, emphasizing a variety of

nutrient dense foods in appropriate portion sizes, to improve overall diet and
specifically toAttain individualized glucose, blood pressure and lipid goals.
- 138 -
 Achieve and maintain body weight goals.
 Delay or prevent complications of Diabetes
 To address individual nutrition needs based on personal and cultural
preference’s, health literacy and numeracy, access to healthful food choices,
willingness and ability to make behavioral changes.
 To maintain the pleasure of eating by providing positive messages about food
choices while limiting food choices only when indicated by scientific evidence.
 To provide the individual with diabetes with practical tools for day-to-day meal
planning rather than focusing on individual macronutrients, micronutrients or
single foods.
Dietary Guidelines:
Energy balance and weight:
For Children and Adolescents:
 Height and weight should be, monitored via appropriate height and weight growth
charts.
 Prevention of excessive weight gain while encouraging normal linear growth.
 Prevention of obesity.
 Healthy life styles.
For Adults:
 Reduced calorie intake can lead to reduction in A1C of 0.3% to 2.0% in adults
with T2DM.
 Weight lose interventions.
 Mediterranean-style diet.
Carbohydrate Intake:
 Approach of consuming low carbohydrate diet.
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 Insulin to Carbohydrate ratios to adjust insulin doses for variable carbohydrate
intake.
 Carbohydrate counting plan.
 Natural sources of carbohydrate than processed forms.
 Restriction of table sugar containing foods.
Fiber and Whole grain:
 Intervention involving fiber supplementation for T2DM can reduce fasting blood
glucose.
 40g/day of fiber is, recommended for the population with diabetes.
Nonnutritive Sweeteners:
 Reduced calorie sweeteners approved by the FDA include sugar alcohols

(erythritol, isomalt) when consumed within established dietary intake levels,
facilitate in the reduction of added sugar intake.
 It cause decrease in total energy intake.
 They reduced total calorie intake.
Protein intake:
 Protein should be 1 to 1.5g/kg body weight/day or 15% to 20% to total calories.
Fat intake:
 Monounsaturated fatty acids (MUFA) - rich foods as a component of the

Mediterranean-style eating patterns are associated with improved glycemic
control.
 Poly unsaturated fatty acids.
 Omega 3 fatty acids.
- 140 -
9.2 CASE:
9.2.1 Hepatitis:
Hepatitis means inflammation of the liver. The liver is a vital organ that processes nutrients,
filters the blood, and fights infections. When the liver is inflamed or damaged, its function
can be, affected.
Symptoms:
 Yellow skin or eyes.

 Not wanting to eat.
 Upset stomach.
 Throwing up.
 Stomach pain.
 Fever.
 Dark urine or light- colored stools.
 Diarrhea.
 Fever,
 Malaise,
 Loss of appetite
 diarrhea,
 Nausea,
 Abdominal discomfort
 Jaundice
 Chills
 Fever
Types:
 Hepatitis A
 Hepatitis B
 Hepatitis C
 Jaundice
- 141 -
Hepatitis A:
Overview. Hepatitis A is an inflammation of the liver caused by the hepatitis A virus (HAV).
The virus is, primarily spread when an uninfected (and unvaccinated) person ingests food or
water that is, contaminated with the faeces of an infected person. Hepatitis A is a contagious
liver infection caused by the hepatitis A virus.
Hepatitis B:
Hepatitis B is a vaccine-preventable liver infection caused by the hepatitis B virus (HBV).
Hepatitis B is, spread when blood, semen, or other body fluids from a person infected with
the virus enters the body of someone who is not infected.
Hepatitis C:
Hepatitis C is a liver infection caused by the hepatitis C virus (HCV). Hepatitis C is, spread
through contact with blood from an infected person. Today, most people become, infected
with the hepatitis C virus by sharing needles or other equipment used to prepare and inject
drugs.
Jaundice:
A condition in which the skin and the whites of the eyes become yellow, urine darkens, and
the color of stool becomes lighter than normal. Jaundice occurs when the liver is not working
properly or when a bile duct is blocked.
Causes of hepatitis
Type of
Common route of transmission
hepatitis
hepatitis A exposure to HAV in food or water
contact with HBV in body fluids, such as blood, vaginal secretions, or

hepatitis B
semen
contact with HCV in body fluids, such as blood, vaginal secretions, or

hepatitis C
semen
- 142 -
hepatitis D contact with blood containing HDV
hepatitis E exposure to HEV in food or water
9.2.2 Medical Nutrition Therapy of Hepatitis:
 For a patient with Hepatitis food choices are not limited to a few bland dishes.
There are plenty of healthy, tasty food options, which are both beneficial for the
liver and for the recovery process.
 Avoid alcohol and cigarettes for a healthy liver.
 Avoid taking vitamin supplements or over-the-counter drugs without consulting
your doctor.
 Do not skip meals when recovering from Hepatitis.
 Eat small meals.
 Drink lots of water.
 Take adequate rest.
Objective:
Dietary changes, Small frequent meals with adequate protein and energy to treat
malnourishment and for speeding up the recovery process.
Basic Principle:
1.0 to 1.2 grams of protein per kilograms of body weight. Low Sodium and low fat
diet. Less than 30% fat.
Dietary Guidelines for Hepatitis:
Whole grain:
 Whole grains are very beneficial to consume as part of a healthy Hepatitis diet.
 These can be in the form of bran, whole wheat bread or cereal, brown rice, whole
grain pasta or porridge.
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 Include other whole grains such as whole oats, wild rice, rye, oatmeal and corn.
Fruits and Vegetables:
 Fruits and vegetables should be a significant part of any diet to help in recovering
from a liver disease.
 They are full of essential nutrients and are easy to digest. As a bonus, they also
contain antioxidants, which can protect the liver cells from damage.
 However, it is, recommended that one go easy on starchy vegetables such as
potatoes when on a Hepatitis recovery diet.
 While canned or frozen fruits are fine, it is always a good idea to try to eat fresh and
seasonal produce when possible.
Fats and Oils:
 Olive oil, canola oil and flaxseed oil are all healthy fats that are, recommended as
part of a diet for patients with Hepatitis.
 Fat should be less than 30% for the patient’s with steatorrhea.
Protein:
 Healthy proteins in the form of low-fat milk and dairy products along with lean
meats, beans, eggs and soy products can also be a part of a healthy liver diet.
 1.0 to 1.2 grams of protein per kilograms of body weight.
Processed food items :
Processed food items are, best avoided when recovering from Hepatitis.
 Processed food items include processed ingredients that are harder on the liver and
relatively devoid of nutrients.
 Processed breads, cheese and almost all fast -food items also best avoided during
Hepatitis, as they can worsen recovery times.
- 144 -
Sugar intake :
 Sugar intake should be limited for a healthy liver.
 This includes all artificial sweeteners as well as fruits juices.
 Juices have high concentrations of sugar in them, which can be difficult for the liver
to digest when the body is under attack from the Hepatitis virus.
Hepatitis A
 Hepatitis A is a short-term illness and may not require treatment. However, if

symptoms cause a great deal of discomfort, bed rest may be necessary. In addition,
if you experience vomiting or diarrhea, your doctor may recommend a dietary
program to maintain your hydration and nutrition.
Vaccine for Hepatitis B:
 The Centers for Disease Control and Prevention (CDC) Trusted

Source recommends that all children and adults up to age 59 should receive the
hepatitis B vaccine.
 Infants should get their first hepatitis B vaccine within 24 hours of birth and
complete their doses by age 6 to 18 months.
 All unvaccinated children and adults through age 59 should receive the vaccine. In
addition, unvaccinated adults over the age 60 who are at risk of hepatitis B should
get the vaccine.
 Adults over age 60 who are not at risk of hepatitis B may also choose to get the
shot.
 Several types of the HBV vaccine are also safe to administer to pregnant women.
Jaundice:
There is no cure for yellow fever. Treatment involves managing symptoms and assisting your
immune system in fighting off the infection by:
- 145 -
 getting enough fluids, possibly through your veins
 getting oxygen
 maintaining a healthy blood pressure
 getting blood transfusions
 having dialysis if you experience kidney failure
 getting treatment for other infections that may develop
Hepatitis C:
 Antiviral medications can treat both acute and chronic forms of hepatitis C.
 Typically, people who develop chronic hepatitis C will use a combination of
antiviral drug therapies. They may also need further testing to determine the best
form of treatment.
 People who develop cirrhosis or liver disease due to chronic hepatitis C may be
candidates for a liver transplant.
Hepatitis D
 The WHO Trusted Source lists PEGylated interferon alpha as a treatment for
hepatitis D. However, this medication can have severe side effects. As a result, it is,
not recommended for people with cirrhosis liver damage, those with psychiatric
conditions, and people with autoimmune diseases.
9.2 CASE:
- 146 -
9.2.1Cirrhosis:
An advanced stage of liver disease in which extensive scarring replaces healthy liver tissue,
causing impaired liver function and liver failure. A cirrhotic liver is often shrunken and has
an irregular, nodular appearance. The physical changes in liver tissue may interfere with
blood flow, causing fluid to accumulate in blood vessels and body tissues. Advanced
cirrhosis can disrupt kidney and lung function.
Causes of Cirrhosis:
 Alcoholic liver disease

 Autoimmune hepatitis Bile duct obstructions
 Complications of gallbladder surgery
 Cystic fibrosis
 Diseases that cause bile duct injury
 Wilson’s disease (causes excessive liver copper)
 Steatohepatitis (fatty liver disease)
 Viral hepatitis
 Hepatitis B
 Hepatitis C
Symptoms:
 Tiredness and weakness.
 Loss of appetite.
 Weight loss and muscle wasting.
 Feeling sick (nausea) and vomiting.
 Tenderness or pain around the liver area.
 Yellowing of the skin and the whites of the eyes (jaundice).
Complications
It includes portal hypertension, gastroesophageal varices, ascites, and hepatic
encephalopathy.
 Portal hypertension:
- 147 -
Elevated blood pressure in the portal vein due to obstructed blood flow through the
liver
 Hepatic encephalopathy:
A condition in advanced liver disease characterized by altered neurological
functioning, including personality changes, reduced mental abilities, and
disturbances in motor function.
 Ascites:
An abnormal accumulation of fluid in the abdominal cavity.
 Gastroesophageal varices:
When blood flow through the portal vein is, impeded, the blood is, diverted to the
smaller blood vessels surrounding the liver.
These collaterals develop throughout the gastrointestinal (GI) tract and in regions
near the abdominal wall. As pressure builds, the collateral vessels become enlarged
and engorged, forming abnormally dilated vessels called varices.
9.2.2 Medical Nutrition Therapy for Liver Cirrhosis:

Energy:
 Energy needs may be approximately 20% above resting metabolic rate (RMR);
calculate or measure RMR and apply the stress factor 1.2.
 Energy requirements may be higher in patients with infection or malnutrition. Energy
requirements may be lower in patients who would benefit from weight loss.
Meal frequency:
 To improve food intake, patients should consume small meals 4 to 6 times daily
Protein:
 Provide 0.8 to 1.2 g protein per kilogram of dry body weight per day to maintain
nitrogen balance and prevent wasting.
Carbohydrate:
 No carbohydrate restrictions unless patient has insulin resistance or diabetes.
 For persons with insulin resistance or diabetes, provide up to 50% to 60% of
kilocalories from carbohydrates (mainly complex carbohydrates); carbohydrate intake
should be consistent from day to day and at each meal and snack.
Fat:
- 148 -
 No, fat restrictions unless fat malabsorption is present.
 If fat is malabsorbed, restrict fat to 30% of total kilocalories or as necessary to control
steatorrhea; use medium-chain triglycerides (MCT) to increase kilocalories.
Sodium and fluid:

 Restrict sodium as necessary to control ascites; 2000 mg sodium per day is adequate
restriction in most cases.
 If ascites is, accompanied by low serum sodium levels (less than 128 mEq/L), restrict
fluids to 1200 to 1500 mL per day. In severe cases (serum sodium less than 125
mEq/L), restrict fluids to 1000 to 1200 mL per day.
Vitamins and minerals:

 Ensure adequate intake from diet or supplements based on individual needs.
Enteral and Parenteral Nutrition Support:

 In patients who are unable to consume enough food, tube feedings may be infused
overnight as a supplement to oral intakes or may replace oral feedings entirely
 Although standard formulas are often appropriate, an energy-dense, moderate-protein,
low-electrolyte formula may be necessary for patients with ascites or fluid restrictions.
 To avoid excessive fluid delivery, patients with ascites typically require concentrated
parenteral solutions, which are, infused into central veins.
9.3 Case
- 149 -
9.3.1 NON-ALCOHOLIC FATTY LIVER DISEASE:
Non-alcoholic fatty liver disease is a spectrum of liver disease ranging from steatosis to
steatohepatitis and cirrhosis. It involves the accumulation of fat droplets in the hepatocytes
and can lead to fibrosis, cirrhosis and even hepatocellular carcinoma.
 The initial stage of NAFLD is characterized by the accumulation of fat in the liver.
 Non-alcoholic steohepatitis is associated with the hepatocyte injury with or without
fibrous tissue in the liver.
 NASH is develop into chronic liver disease and NASH cirrhosis.
Causes of non-alcoholic fatty liver disease:
 It include drugs inborn errors of metabolism and acquired metabolic disorders.

 It is directly associated with obesity, type 2 diabetes mellitus, dyslipidemia, and the
metabolic syndrome.
9.3.2 Medical Nutrition Therapy of NAFLD:
For the treatment of NAFLD weight reduction, insulin sensitizing drugs such as
thiazolidinedione’s and vitamin E.
Objective:
Eating lower glycemic index foods such as most fruits vegetables and whole grains.
High fiber plants like legumes and whole grains. Reduce intake of sugars or
beverages, refined carbohydrates and saturated fat.
Basic Principle:
High fiber plant, fruits, vegetables, and whole grains

Dietary Guidelines:
 Weight loss:
The treatment recommendations for NAFLD from the American Association for
the study of liver disease (AASLD) is first weight loss for obese. Rapid and
uncontrolled weight loss can be detrimental for patients. It is recommended to
avoid a very low caloric diet.
 Saturated fat:
- 150 -
Saturated fat should be avoided because they increase the risk of liver fat and
insulin resistant.
 Regular exercise:
A good diet and a regular exercise can reverse it. Losing 10% of your current
weight can dramatically decrease the amount of fat in the liver as well as reduce
the inflammation.
 Mediterranean diet:
The Mediterranean diet has a beneficial effect on NAFLD. This die is based on
the high intake of extra virgin olive oil, fruits, vegetables, nuts and cereals
moderate intake of fish and other meats, dairy products and low intake of eggs and
sweets.
9.4 Case
- 151 -
9.4.1 CHOLELIHIASIS:
The formation of gallstones is called cholelithasis. Virtually all gallstones from within the
gallbladder. In most cases gallstones are asymptomatic. Gallstones that pass from the
gallbladder into the common bile duct may remain there indefinitely without causing
symptoms or they may pass to the duodenum with or without symptoms.
 Choledocholethiasis develops when the stones slip into the bile ducts producing
the obstruction pain and cramps.
 If passage of bile into the duodenum is interrupted cholecystitis can develop.
 In the absence of bile in the intestines lipid absorption is impaired and without bile
pigments stools become light in the color (alcoholic).
 Most of the gallstones are un-pigmented cholesterol stones composed of
cholesterol bilirubin and calcium salts.
9.4.2 Medical Nutrition Therapy of cholelithasis:
For the treatment of cholelithasis low fiber and high fat diet is prevalent. Eat healthy
fats like olive oil, fish oil to help your gallbladder contract and empty on a regular
basis. Lean meat, poultry and fish are good sources also. Use low fat dairy products.
Objective:
Eat high fat low fiber diet. Consumption of animal protein animal fat and a lack of
dietary fiber may promote the gallstones development. Refined carbohydrates have a
60% of greater risk of gallstones.
Basic Principle:
Fruits, vegetables and whole grains or low fiber diet. Weight cycling, fasting very
low calorie diets may increase the risk of gallstones.
Dietary Guidelines:
 Weight loss:
The treatment recommendations for NAFLD from the American Association for
the study of liver disease (AASLD) is first weight loss for obese. Rapid and
uncontrolled weight loss can be detrimental for patients. It is recommended to
avoid a very low caloric diet.
- 152 -
 Saturated fat:
Saturated fat should be avoided because they increase the risk of liver fat and
insulin resistant.
 Regular exercise:
A good diet and a regular exercise can reverse it. Losing 10% of your current
weight can dramatically decrease the amount of fat in the liver as well as reduce
the inflammation.
 Mediterranean diet:
The Mediterranean diet has a beneficial effect on NAFLD. This die is based on
the high intake of extra virgin olive oil, fruits, vegetables, nuts and cereals
moderate intake of fish and other meats, dairy products and low intake of eggs and
sweets.
References :
- 153 -
 ROLFES, SR , PINNA. K.AND WHITNEY, E. 2008.
UNDERSTANDING NORMAL AND CLINICAL NU1'RITION_ 8th
ED. CENGAGE LEARNING, BELMONT, CA 9002-3098.USA 1192
PAGES
 ANIS R.A., LARIK,Z.,RIAZ,S., ALI,A.,ATHAR.N, AN'D SALEEM,
M. DIET MA1NUAL FOR PAKISTAN NUTRITION WING
MINISTRY OF HEALTH ISLAMABAD,JSB.PAKISTAN 13.5 PAGES
 FOOD AND NUTRITON CARE PROCESS (EDITON I2th)
- 154 -

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INTERNSHIP REPORT

A report submitted in partial fulfillment for the award of degree of

Supervisor: Ms Safa Akram

DEPARTMENT OF HUMAN NUTRITION AND DIETETICS(HND)

AFRO ASIAN INSTITUE, LAHORE

AFFILIATED WITH GCUF, FAISLABAD

Chapter No. Topic Page No.

Sr. No. Abbreviation Full Form

1.6 Tools of Assessment

1.7 Harris Benedict Equation (energy calculation)

2.1.3Table of food choices:

Formula = Actual weight x 100  Actual weight= 66kg

Food Exchange Carbohydrate Protein Fats

Fats= Total- Consumed Fat= 60g

 1glass milk with ispaghole

2.2.2Medical Nutrition Therapy of celiac:

 Gluten free diet

2.2.3Table of food choices:

Food Groups Food Allowed Food Restricted

Fats= Total- Consumed Fat= 67g

2.3.2Medical Nutrition Therapy

2.3.3Table of food choices:

 Patient name: Ifrah

= 50 x 100 Multiply it with 2.54 for converting in cm

Starch= Total- Consumed Carbs= 232g

Fats= Total- Consumed Fat= 59g

2.4.2Medical Nutrition Therapy of GERD:

Starch= Total- Consumed Carbs= 286

 Gastric ulcer: occurs in the stomach.

2.5.2Medical Nutrition Therapy:

2.5.3Table of food choices:

 Patient name: Haseeb Ali

= 59 x 100 Multiply it with 2.54 for converting in cm

Starch= Total- Consumed Carbs= 341g

Food Exchange Carbohydrate Protein Fats

Protein= Total- Consumed Protein= 116g

Fats= Total- Consumed Fat= 83g

 Lactose intolerance, also called lactase deficiency or hypolactasia, is

2.6.2Medical nutrition therapy for lactose intolerance:

 Avoiding lactose-containing products

2.6.3Table of food choices:

Starch= Total- Consumed Carbs= 296g

Food Exchange Carbohydrate Protein Fats

Protein= Total- Consumed Protein= 103g

3.1.3Table of food choices:

Food Groups Food Allowed Food Restricted

 Patient name: Khalid Akhtar

Formula = Actual weight x 100  Actual weight= 70 kg

= 351 as 1 gram of protein= 4kcal

9 as 1 gram of fat= 9kcal

Food Exchange Carbohydrate Protein Fats

Protein= Total- Consumed Protein= 88g

Fats= Total- Consumed Fat= 65g

3.2.2Medical Nutrition Therapy of Fracture:

3.2.3Table of food choices:

Food Groups Food Allowed Food Restricted

 Patient name: Qasim Ashraf

Formula = Actual weight x 100