Patient Identity 3

Mrs. S, 53 y.o. (Female)

MR number 1027273
Date of birth July 15th,1970
Admission Date June 20th,2023
Consultation Date July 7th, 2023
MEDICAL
DIAGNOSIS
Medical Nutrition Diagnosis: Severe Protein Energy Malnutrition (ICD X E.43) + Severe Hypoalbuminemia(ICD X E.88.09)
Cardiology Diagnosis : Congestive Heart Failure NYHA III + Chronic Coronary Syndrome Clinical Type II + Hypertensive
Heart Disease + Suspect Infected DLC
Nephrology and Hypertension Acute pulmonary edema + Chronic Kidney Disease G5D + Diabetes Mellitus type 2 +
Suspected Urinary Tract Infection
 Subjective
(History taking)
Main Complaint
History taking Since yesterday due to loss of consciousness.
Unable to eat via oral
NGT was not inserted. There was history of
decreased oral intake since 9 months ago due to
Nausea & Vomiting
shortness of breath, swelling of the legs,
There were history of nausea and vomiting
nausea, intermittent left chest pain and
since yesterday. He vomited once and
weakness that worsened since yesterday.
contained churned food and fluid.
Swallowing Disorder
Headache
No history
No History
Epigastric and Abdominal pain
Fever and Seizure No History
No history
Weight loss
Cough and Shortness of Breath There was unintentional weight loss since 9
There was history of shortness of breath months ± 17.5 kg (29.1%) from initial body
since 9 months ago. weight 60 kg
 Subjective
(History taking)

Defecation Urination
Via diapers, 1x, last night, hard Via catheter 100 cc/ 24 hours ,
consistency, brownish color yellowish
 Patient Family
Cerebrovascular Disease
Cerebrovascular Disease
No History No History

Cardiovascular Disease, DM Cardiovascular Disease, DM

He was diagnosed with Coronary Heart Disease since 9
months ago but he did not underwent any procedure due to
His brother had DM
decreased renal function
Kidney and Urinary Disease
He was diagnosed with Hypertension since 10 years No history
ago that irregularly treated with amlodipine 10 mg
Hyperuricemia, Hypercholesterolemia
He was diagnosed with DM since 20 years ago that regularly
treated with insulin, but stopped since 6 months ago because No history
of frequent hypoglycemia
Others
Kidney and Urinary Disease No history
He was diagnosed with Chronic Kidney Disease since October
2022 and had regular of hemodialysis 3 times a week
(Tuesday, Thursday, Saturday) at PCC.

Hyperuricemia, Hypercholesterolemia
No History

Others
No History
 History of Present Illness
He complained of shortness of breath, swelling of the legs, nausea, intermittent left
9 months chest pain and weakness. He was admitted to a hospital in Papua and advised to
ago undergo a PCI procedure, but it could not be carried out due to decreased kidney
function and refused to do a hemodialysis procedure

2 months The patient was referred for a cimino procedure. Since there was a problem with
ago cimino in 2 months, he was advised to perform a DLC repair procedure.

2 weeks ago He was admitted to hospital for re-insertion of DLC in his right jugular vein .

He complained of shivering and inconsequentially speech. He treated with

3 days ago antipyretic by his family.

He experienced loss of consciousness, so family brought him to Emergency

Yesterday Department for further treatment and treated until present.
 10

01
Job and Occupation
He is an entrepreneur

Psychosocial history 02
Smoking
He was an active smoker since young age, 10
cigarettes/ day. But he stopped since 2 years
ago

03 Drugs and alcohol

No history
 Dietary History
Typical intake and usual amount of food: (before admitted to the hospital)
Intake:
Via oral
Quantity:
He ate regularly 3 times/day, 1 portion of white rice with a variety of side dishes, vegetable and some cake and
fried food
Quality:
He likes to eat fried food

 9 months ago, He ate 3 times a day ½ portion of white rice with ½ portion of medium chunk of varied of animal-
derived side dishes, and ½ small bowl of vegetables, 1 portion of fruit, and , 2 measuring spoons of Nephrisol D
 2 month ago, he ate 3 times a day 10 tablespoons of white rice with 1 portion of medium chunk of varied of animal-
derived side dishes, and 1 small bowl of vegetables, 1 portion of fruit, and 2 measuring spoons of Nephrisol D
 2 weeks ago he ate 3 times a day ½ portion white rice with 1 medium chunk of varied of animal-derived side
dishes, 1 small bowl of vegetables, 2 measuring spoons of Nephrisol D
 3 ago, he ate 3 times a day ½ portion of porridge with ¼ medium chunk of varied of animal-derived side dishes, 1/3
portion of vegetables
 24 hours, He ate 8 tablespoons of plain porridge
 No food allergy nor lactose intolerance
 Intake & Fluid Analysis
Last intake Energy (kcal) Protein (g) Carbohydrate(g) Fat (g)

Intake Before sick 1475 kcal (92.1%) 59 g (16%) 272 g (73.7%) 15 g (9.1%)

9 months ago 1171.8 kcal (73.2%) 61.25 g (20.9%) 371,25 g (63.2) 18.75 g (14.4%)

2 months ago 1086 kcal (67.8%) 50.5 g (18.6%) 191.5 g (70.5%) 12 g (9.9%)

2 weeks ago 867.5 kcal (54.2) 45.5 g (21.1) 141.5 g (65.2%) 12 g (12.4%)

3 days ago 468.5 kcal (29.2%) 17.99 g (15.3%) 90.2 g (77%) 3.75 g (7.2Z%)

24 hours 140 kcal (8.75%) 3.2 g (9.14%) 32 g (91.43%) 0 g (0%)

• Input : Oral 100 cc; medication 400 cc = 500 cc / 24 hours

• Output : Urine 50 cc; vomit 50 cc; defecation 100 cc; IWL 637.5 cc = 837.5 cc/24 hours
• Fluid Balance : - 337 cc/24 hours
 OBJECTIVE
Severe ILLNESS
GCS E3M5V3

Anthropometry
Vital signs
01 02
Body Height : 152 cm
Blood pressure : 116/63 mmHg
IBW : 52 kg
Pulse : 105 beats/minute
MUAC : 21.5 cm
Respiratory rate : 24 times/minute
Estimated BW : 42.5 kg
MAP : 80 mmHg
Temperature : 37°C
Sp02 : 99% via nasal cannula 3
liter per minute

03 Functional Status :
Handgrip Strength: can not be evaluated
 Physical examination
HEAD AND NECK
• Conjunctiva was anemic, and sclera was not icteric.
• Oxygen was supported via nasal cannula 3 litre per minute
nasogastric tube was not inserted
• There was no enlargement of lymph nodes, no enlargement of
the thyroid gland.

CHEST
• Inspection : Symmetric, there was loss of subcutaneous fat
• Palpation : No tenderness
• Percussion : Sonor
• Auscultation : Vesicular breathing sound, there was rhonchi in both lungs
and no wheezing. There was regular heart sounds and no murmurs
 Physical examination
ABDOMEN
Inspection : Flat appearance
Auscultation : Normal Bowel Sound
Palpation : No tenderness, liver and spleen were not palpable
Percussion : Tympanic

EXTREMITY
There was edema at lower extremities
There was wasting at all extremities
LABORATORY FINDINGS
Laboratory July 7th,2023 July 8th,2023 Normal Value

WBC 23.100 4,0 - 10,0 x 103/μL

HB 8.2 12.0-16.0 g/dl

MCV 91 80 – 100 μm3

MCH 29 27.0 – 32.0 pg

MCHC 32 32.0-36.0 g/dl
PLT 149000 150-400 x 103 /μL

NLR 47.45 < 3.13

TLC 462 1.5 - 4 x 103/μL

RBG 264 166 < 140 mg/dl

LABORATORY FINDINGS
Laboratory July 7th,2023 Normal Value
Urea 111 10-50 mg/dl

Creatinine 2.99 P < 1,1, L<1,3 mg/dl

PT 12.8 10-14 seconds

INR 1.20 0.8 - 1.1 seconds
APTT 30.5 22 - 30 seconds
AST 112 <38 U/L
ALT 59 <41 U/L
Sodium 129 136-145 mmol/L

Potassium 3.4 3,5-5,1 mmol/L

Chloride 98 97-111 mmol/L

LABORATORY FINDINGS

Laboratory July 8th,2023 Normal Value

PH 7.414 7.35 - 7.45

PO2 186.4 80.0 - 100.0 mmHg

PCO2 27.1 35.0 - 45.0 mmHg

SO2 99.9 95 - 98 %

HCO3 17.5 22 - 26 mmol/

BE -7.3 - 2 s/d + 2 mmol/l

ctO2 14.2 15.8-22.3

ctCO2 18.3 23-27
 RADIOLOGIC FINDINGS
Thorax PA (July 08th, 2023)
- Cardiomegaly with signs of pulmonary edema
- Left pleural effusion

USG Whole Abdomen (March, 30th 2023)

- Cholelith
- Right renal cyst
- Left pleural effusion
 ECHOCARDIOGRAPHY FINDINGS
Echocardiography Bedside (July, 7th 2023)

- Severely Abnormal LV Systolic Function, EF 21.6% (Biplane)

- Decreased RV Systolic Function, TAPSE 1.1 Cm
- Moderate Tricuspid Regurgitation
- Mild Mitral Regurgitation
- Mild Pulmonal Regurgitation
- Akinetic And Hypokinetic Segmental
- All Chambers Dilatation
- Erap 15 Mmhg (2.2/1.8)
 Echo hemodynamic
Jun 19th,2023

LVOT VTI 9.9 cm

LVOT CO 3.8 l/m
LVOT SV 39.1
mle RAP 15 mmHg
SVR 987 dynes/sec/cm5
 MEDICATION FROM OTHER DIVISION
Cardiology (July 8th, 2023) Nephrology and Hypertension (July 8th, 2023)

 IVFD sodium chloride 0.9 % 500 cc/24 hours/intravenous  Hemodialysis 3 times a week (Tuesday, Thursday
 Furosemide 40 mg/24 hours/Intravenous Saturday) --> Sodium Profiling plan
 Ceftriaxone 2 g / 24 hours /Intravenous (Day 2)
 Spironolactone 25 mg/ 24 hours /Oral
 Clopidogrel 75 mg/24 hours/oral
 Nitrokaf 2.5 mg/12 hours /oral
 Atorvastatin 20 mg/24 hours /oral
 Paracetamol 1 g/ Intravenous (Extra)
 ASSESSMENT
nutritional status Severe Protein Energy Malnutrition

Metabolic status
July 8th, 2023
Hyperglycemia 166  264
Blood Gas Analysis Respiratory Alkalosis Compensated

July 7th, 2023

Leukocytosis 23.100
Normocytic normochromic anemia 8.2
Thrombocytopenia 149,000
Increased of NLR 47.45
Severe Depletion of immune system 462
Decreased of renal function ur/cr 111/2.99 eGFR 20
Elevated transaminase enzymes 112/59
Moderate hyponatremia 129 ESO 291.1
Mild hypokalemia 3.4

GI- Tract status Functional

Hydration status Hypervolemic

Functional status Can not be evaluated

 DIAGNOSIS & PROGNOSIS

Medical Nutrition Diagnosis: Severe Protein Energy Malnutrition (ICD X E.43) + Severe
Hypoalbuminemia(ICD X E.88.09)
Cardiology Diagnosis : Congestive Heart Failure NYHA III + Chronic Coronary Syndrome Clinical
Type II + Hypertensive Heart Disease + Suspect Infected DLC
Nephrology and Hypertension Acute pulmonary edema + Chronic Kidney Disease G5D + Diabetes
Mellitus type 2 + Suspected Urinary Tract Infection

Prognosis
Vitam: Dubia
Functionam: Dubia
Sanactionam: Dubia
Energy requirements Planning
• Basal Energy Expenditure : 1014.35 kcal
• Total Energy Expenditure : 1582.38 ~ 1600 kcal (1.2/1.3)

Macronutrient Composition:
• Protein : 0.8 g/kgIBW/day = 34 g (8.5%)
• Carbohydrate : 50 % = 200 g
• Fat : 41.5 % = 73.7 g

Medical nutrition therapy was given 30 % of TEE (330 kcal) via enteral feeding

Correction of hyponatremia with a target of 136 mmol/L (sodium deficit 178.5 meq +
daily requirement 85 meq, total requirement 263.5 meq)

Correction of hypokalemia with a target of 4 mmol/L (potassium deficit 7.65 meq + daily
requirement 42.5, total requirement 50.15 meq)
Via Enteral :
Blenderized food with low protein 3 x 50 cc (260.7 kcal) Planning
ONS Nephrisol 3x1.5 measuring spoon (292.5 kcal)

Fluid requirement 1000cc + Urine Production = 1100 cc/24 hours

Correction of hyponatremia with daily sodium intake and maintenance 0.9% 500 cc/ 24 hours for 3 days
Correction of hypokalemia with daily potassium intake

Supplementation via Enteral :

- Zinc 20mg/24hours
- B Complex 2 tablets/8 hours

Monitoring and evaluation

- Hemodynamics : nutrition postponed if MAP < 65 mmHg
- Daily intake
- Gastrointestinal tolerance : nutrition postponed if residue > 500 ml/6 hours or black residue
- fluid balance

Nutrition education
- nutrition on schedule
- NGT Insertion

Laboratory : albumin, lipid profile

Agree to join multidisciplinary care
SGA
FOLLOW UP
LABORATORY FINDINGS
Laboratory July 10th,2023 Normal Value
WBC 23.600 4,0 - 10,0 x 103/μL

HB 8.4 12.0-16.0 g/dl

MCV 87 80 – 100 μm3

MCH 29 27.0 – 32.0 pg

MCHC 34 32.0-36.0 g/dl

PLT 116000 150-400 x 103 /μL

NLR 7.1 < 3.13

TLC 2784.8 1.5 - 4 x 103/μL

Urea 198 10-50 mg/dl

Creatinine 3.06 P < 1,1, L<1,3 mg/dl

Total Bilirubin 5.46 Dewasa < 1.0 mg/dl

Direct Bilirubin 4.74 Dewasa <0.3 mg/dl

Procalcitonin >100 < 0,05 ng/ml

 LABORATORY FINDINGS
Laboratory July 9th , 2023 July 10th,2023 Normal Value

Urea 198 10 - 50 mg/dl

Creatinine 3.06 P < 1,1, L<1,3 mg/dl

Albumin 2.5 3,5 - 5 g/dl

RBG 116 131 < 140 mg/dl

Total Cholesterol 129 < 200 mg/dl

HDL Cholesterol 12 L (>55); P(>65) mg/dl

LDL Cholesterol 34 < 130 mg/dl

Triglycerides 357 < 200 mg/dl

LED 122 (L < 10 , P <20)

 Objective Assessment Planning

Intake nutrition General Condition : Severe illness appearance Nutritional Status : SGA SCORE C Energy requirements
via enteral. NGT GCS 11 (E3M5V3) Metabolic Status : Basal Energy Expenditure : 1014.35 kcal
was inserted.He Total Energy Expenditure : 1582.38 = 1600 kcal (1.2/1.3)
Decreased of his Vital sign: 10/7/23
consciousness. Blood pressure : 116/63 mmHg on norepinephrine 0.1 mcg Macronutrient Composition:
MAP : 80 mmmHg Leukocytosis 23.600 < 23.100 Protein : 0.8 gr/ kgIBW/day = 34 gr (8.5%)
There were no Normochromic normocytic anemia 8.4 ← 8.2
•
nausea and Pulse : 102 x/minute thrombocytopenia 116.000 ← 149.000 • Carbohydrate : 50 % = 200gr
vomiting. there was Respiratory rate : 24 x/minute Increased NLR 7.1 ← 47.45 • Fat : 41.5 % = 73.7 gr
swelling at his Temperature : 37.8 °C Improved depletion of immune system 2784.8 ← 462
lower extremities. SpO2 : 99% vai nasal canula 3 lpm Decreased of renal function 198 /3.06 eGFR 16 ← 111/2.99 eGFR Medical nutrition therapy is given 30 % of TEE (330 kcal) via
There were fever 20 enteral
and shortness of Food Recall 24 hours via enteral : Mild hyponatremia 132 ESO 304.2 ← 129 ESO 291.1
breath Energy : 368.8 kcal (23.05 %) Improved hypokalemia 3.7 ← 3.4 Correction of hyponatremia with a target 136 mmol/L
Protein : 7.5 g (8.13%) Improved blood glucose 131 ← 166 ← 264
Defecation: Via Carbohydrate : 56.4 g (61.17%) Increased of LED 122 Correction of hypoalbuminemia with target 3.5 g/dL
Hyperbilirubinemia ; Total/direct 5.46/4.74
diapers, last Fat : 13.2 gr (32.21%) Increased of procalcitonin > 100
defecation 3 days Fluid requirements 1000 ml + urine production = 1100 ml/ 24
Hypertriglyceridemia 357
ago, hard Anthropometry Mild hypoalbuminemia 2.5 hours
consistency,
brownish Body Height : 152 cm Nutritional medical therapy is given 30% KET (330 kcal) via
IBW : 52 kg Gastro Intestinal Status : Functional enteral :
Urination : via MUAC : 21.5 cm
catheters 500 cc/24 MUAC BW : 42.5 kg Hydration Status : Hypervolume (overload)
- Low Protein blenderized food 3 x 50 cc (260.7 kcal)
hours yellowish - Nephrisol 3x1.5 measuring spoon (292.5 kcal)
Functional Status : ECOG III Correction of hyponatremia with diuretic
BC : 900 - (500 – Physical Examination:
637.5) = - 237.5 HEAD AND NECK
Conjunctiva was anemic, and sclera was not icteric. Correction of hypoalbuminemia with protein 0.8
cc/24 jam Medical Nutrition Diagnosis: Severe Protein Energy Malnutrition g/MUACBW/day dan extract Snakehead fish capsules 2 caps/ 8
There was oxygen support via nasal cannule 3 liter per minute (ICD X E.43) + Severe hypoalbuminemia hours
There was no enlargement of lymph nodes, no enlargement of the thyroid gland.
1st day CHEST Cardiology Diagnosis : Congestive Heart Failure NYHA III + Chronic
Coronary Syndrome Clinical Type II + Hypertensive Heart Disease + Supplementation via oral :
Follow Up July 10th Inspection : Symmetric, there was loss of subcutaneous fat
Suspect Infected DLC - Zinc 20 mg/24 hours
2023 Palpation : No tenderness
- Vitamin B comp 2 tab/8 hours
Percussion : Sonor
Nephrology and Hypertension Acute pulmonary edema + Chronic Monitoring & evaluation:
Auscultation : Vesicular breathing sound, there was rhonchi in both Kidney Disease G5D + Diabetes Mellitus type 2 + Suspected Urinary  Daily Intake
lungs and no wheezing. there was regular heart sounds and no murmurs Tract Infection  Gastrointestinal tolerance : delay nutrition if residue
> 500 ml/ 6 hours or residue black - fluid balance
ABDOMEN
 Fluid balance
Inspection : flat appearance
Hemodynamics : delay nutrition when MAP < 65 mm
Auscultation : Normal Bowel Sound Hg
Palpation : No tenderness, liver and spleen were not palpable,
Nutritional education :
Percussion : tympanic
nutrition according to the schedule
EXTREMITY
There was edema at lower extremities
There was wasting at all extremities Laboratory : -
 Objective Assessmenta Planning

Intake nutrition General Condition : Severe illness appearance Nutritional Status : SGA SCORE C Energy requirements
via enteral . NGT GCS 12 (E3M5V4) Metabolic Status : Basal Energy Expenditure : 1014.35 kcal
was inserted. He Total Energy Expenditure : 1582.38 ~ 1600 kcal
decreased of his Vital sign: 10/7/23 (1.2/1.3)
consciousness. Blood pressure : 110/60 mmHg with norepinephrine 0.1 mcg
Leukocytosis 23.600 < 23.100
There were no Pulse : 108 x/minute Normochromic normocytic anemia 8.4 ← 8.2 Macronutrient Composition:
nausea and Respiratory rate : 24 x/minute thrombocytopenia 116.000 ← 149.000 • Protein : 0.8 g/kgIBW/day = 34 g (8.5%)
vomiting. There Temperature : 37.3 °C Increased NLR 7.1 ← 47.45 • Carbohydrate : 50 % = 200 g
were swelling of SpO2 : 99% via nasal cannule 3 lpm Improved depletion of immune system 2784.8 ← 462 • Fat : 41.5 % = 73.7 g
her leg, Decreased of renal function 198 /3.06 eGFR 16 ← 111/2.99 eGFR
shortness of Food Recall 24 hours via enteral : 20 Medical nutrition therapy was given 50 % of TEE (800
breath and fever Energy : 553.2 kcal ( 34.05% ) Mild hyponatremia 132 ESO 304.2 ← 129 ESO 291.1 kcal) via enteral
Protein : 11.25 g (8.13% ) Improved hypokalemia 3.7 ← 3.4
Defecation: Via Carbohydrate : 84.6 g (61.71%) Improved blood glucose 131 ← 166 ← 264 Correction of hyponatremia with a target of 140 mmol/L
Increased of LED 122
diapers, Fat : 19.8 g (32.21%) Hyperbilirubinemia ; Total/direct 5.46/4.74 Correction of hypoalbuminemia with target 3.5 gr/dL
yesterday, a Increased of procalcitonin > 100
time/day, hard Hypertriglyceridemia 357 Via Enteral :
consistency, Physical Examination: Mild hypoalbuminemia 2.5 Blenderized food Low protein 3 x 100 cc (521.4 kcal)
brownish HEAD AND NECK ONS Nefrisol 3x1.5 measuring spoon (292.5 kcal)
Conjunctiva was anemic, and sclera was not icteric. Gastro Intestinal Status : Functional
Urination : via There was oxygen support via nasal cannule 3 liter per minute Fluid requirement 1000cc + Urine Production = 1100 cc/24
There was no enlargement of lymph nodes, no enlargement of the thyroid gland. hours
catheter, 700 Hydration Status : Hypervolume (overload)
cc/24 hours, CHEST Correction of hyponatremia with diuretic
yellowish Inspection :Symmetric, there was loss of subcutaneous fat Functional Status : Can not be evaluated
Palpation : No tenderness Correction of hypoalbuminemia with protein 0.8
BC : 900 - (100+ Percussion : Sonor g/MUACBW/day dan extract Snakehead fish capsules 2 caps/ 8
700 + 637.5) = - Auscultation : Vesicular breathing sound, there was rhonchi in both Medical Nutrition Diagnosis: Severe Protein Energy hours
537.5 cc/24 jam lungs and no wheezing. there was regular heart sounds and no murmurs Malnutrition (ICD X E.43) + Severe hypoalbuminemia
Cardiology Diagnosis : Congestive Heart Failure NYHA III + Supplementation via Enteral :
ABDOMEN Chronic Coronary Syndrome Clinical Type II + - Zinc 20 mg/24h
2nd day Inspection : flat appearance Hypertensive Heart Disease + Suspect Infected DLC - B Complex 2 tablets/8 hours
Follow Up July Auscultation : Normal Bowel Sound Nephrology and Hypertension Acute pulmonary edema +
11th 2023 Palpation : No tenderness, liver and spleen were not palpable, Chronic Kidney Disease G5D + Diabetes Mellitus type 2 + Monitoring and evaluation
Percussion : tympanic Suspected Urinary Tract Infection - Hemodynamics : nutrition postponed if MAP < 65
EXTREMITY mmHg
There was edema at lower extremities - Daily intake
There was wasting at all extremities - Gastrointestinal tolerance : nutrition postponed if
residue > 500 ml/6 hours or black residue
- fluid balance

Nutrition education
- nutrition on schedule
Laboratory : -
THANK YOU