Case No .3 Date:16.5.

2024

1.Personal data:
• Name of the patient : Bijoy Kumar Sarkar
• Name of Consultant : Dr. Rajdeep Choudhury
• Age : 66
• Sex : Male
• Address : Garbeta
• Type of patient : High fever
• Patient’s ID No. : UHID-1031
• Bed No. :561-A
• Socioeconomic condition : Medium

2. Assessment of Nutritional Status:

A. Clinical assessment
(As per ICMR Score Card Method)
I. General
• Appearance : Poor
II. Mouth
a) Lips
• Condition : Normal
b) Tongue
• Colour : Pale but coated
c) Buccal mucosa
• Condition : Normal
d) Gums
• Condition : Normal
e) Teeth
• Fluorosis : Absent
• Caries : Absent
 I. Hair
• Condition : Normal
II. Skin
a) General
• Appearance : Normal
• Elasticity : Normal
b) Regional
• Face : Normal
• Perineum : Normal
• Extremities : Normal
III. Adipose tissue
• Quantity : Deficient
IV. Oedema
• Distribution : Absent
V. Bones
• Condition : Normal
VI. Heart
• Size : Normal
VII. Alimentary system
• Appetite : Anorexia
• Stool : Normal evacuation

3.Assessment of Health status:

Blood pressure (mm Hg) Pulse rate Respiratory rate(per min) Body temp (F0)
(beats/min)
140/80 80 20 1010
4.Assessment of Diet History:
4.1 24 hour recall method (in hospital or home diet)

Time Food stuffs Amount

Morning (6:00 AM) Biscuit 2 Pieces

Break fast (8:00 AM) Suji 1K

Rice 1K
Lunch (12:00 PM) Dal 1K
Mixed veg. curry 1.5 K

Afternoon (3:00 PM) Biscuit 2 Pieces

Evening (6:00 PM) Potato curry with Bengal gram 1K

Wheat whole 2 Pieces

Dinner (8:30 PM) Fried potato 1 Serving
Mixed veg. curry 1.5 K
 4.2 Analysis of nutrient intake

Amount Energy Carbohydr Protein Fat Vit-A Vit-C Fe Ca

Food stuff
(gm) (Kcal) ate (gm) (gm) (gm) (mcg) (mg) (mg) (mg)

Biscuit 40 140 25.32 0.32 0.40 00 00 00 00

Suji 50 174 37.4 5.20 0.40 00 00 0.80 8
Wheat
50 170.50 34.70 6.05 0.85 14.50 00 2.45 29
whole
Rice 100 340 79 6.4 0.40 00 00 1 9
Lentil 30 102.90 17.70 7.53 0.10 81 00 2.27 20.70
Papya 100 27 5.70 0.70 0.20 00 12 0.90 28
Brinjal 50 12 2 0.70 0.15 37 6 0.19 9
Pumpkin
100 57 7.90 4.60 0.80 00 00 00 3.92
leaves
Potato 150 145.50 33.90 2.40 0.15 36 25.50 0.72 15
Onion 50 25 5.55 0.60 0.05 00 5.50 0.30 23.45
Green chilly 10 2.90 0.30 0.29 0.06 17.50 11.10 0.44 3
Bengal
10 36 6.09 1.71 0.53 18.90 18.60 0.46 20.20
gram
Sugar 10 39.80 19.04 0.01 00 00 00 0.02 1.20
Oil 15 135 00 00 15 00 00 00 00
Total 1407.60 265.50 36.51 19.20 204.90 78.70 9.55 553.55

4.3 Current medication

Medication name Dosage
PAN-40 40 mg
clavam 1.2 gm
Neomal 100 ml
Rantac 50 mg
 5. Preparation of Diet Chart according to patient’s condition:
1. Diet chart preparation

Amount Energy Carbohydr Protein Fat Thiami Vit-B2 Ca

Food stuff n
(gm) (Kcal) ate (gm) (gm) (gm) (mg) (mg)
(mcg)
Rice 100 346 79 6.4 0.4 0.21 0.05 9
Puffed rice 50 162.5 36.8 3.75 0.5 0.105 0.005 11.5
Wheat flour 50 170.5 34.7 6.05 0.85 0.245 0.085 24
Carrot 100 48 10.6 0.9 0.2 0.04 0.02 80
Potato 100 97 22.6 1.6 0.1 0.10 0.01 10
Papaya 100 27 5.7 0.7 0.2 0.01 0.01 28
Pumkin 100 25 4.6 1.4 0.1 0.06 0.04 10
Apple 100 59 13.4 0.2 0.5 _ _ 10
Grapes 100 71 16.5 0.5 0.3 _ _ 20
Egg 75 129.75 _ 9.975 9.975 0.10 0.40 45
Milk 200 134 8.8 6.4 8.2 0.10 0.4 240
Oil 5 45 _ _ 5 _ _ _

Jaggery 10 38.3 9.5 0.04 0.01 0 0 8

Fowl 50 54.5 _ 12.95 0.3 _ 0.14 12.5

Total 1405.55 242.2 50.865 26.185 0.997 1.6 508

 2. Menu planning

Household
6 Time Menu Food stuff(gm) Amount measurement

Early morning
(6:30am) Fruits Apple 100 1 pieces

Breakfast
(9:00am) Milk Cow’s milk 50 1/2 big glass

Puffed rice 50 1 katori

Lunch Rice Parboiled rice 100 1 serving
(12:30pm) Chicken
Fowl 50 1 bowl
curry
Vegs Papaya 10 1 piece
mix pumkin

Mid afternoon
(4:00pm) Fruits Grapes 100 1 katori

Evening Milk Milk 100 1 glass

(6:00pm) jaggery 10
Dinner Bread Whole wheat flour 50 2 picecs
(9:30pm)
Veg.fry Carrot and potato 15 2 pieces
Egg curry Egg 75 1 piece
Bed time
(10:30pm) Milk Milk 50 1/2 glass
6.Provide proper guideline
6.1 Replanishelectrolytesby adding
food rich in potassium &sodium
such of bananas, orange juice or
both.
6.2Drink planty of clear liquid
everyday until the patient recover.

6.3 Add semisolids & low fiber foods

gradually as the patient’s bowl
movement return to normal.
6.4 Add ground flax meal to the
patient’s diet to maintained healthy 7
regular bowl movement.
6.5 Add mainly healthy saturated fats such
as organic extra virgin coconut oil to the
patient’s diet to promote digestive
regularity.