PLACEMENT WARD: NEPHROLOGY

 Kidney Stones
 Acute Kidney Disease

1. Kidney stones
Definition:
Kidney stones (also called renal calculi, nephrolithiasis or urolithiasis) are hard deposits
made of minerals and salt that form inside your kidneys.

Etiology:
Diet, excess body weight and some medical conditions.

Pathophysiology:
Kidney stone formation is a complex process that consists of saturation; super saturation;
nucleation; crystal growth or aggregation; crystal retention; and stone formation in the
presence of promoters, inhibitors, and complexes in urine.

Signs and symptoms:

Severe pain, Fever, Nausea, Vomiting and Blood in urine.

Major complication:
Severe infections including septicemia (blood poisoning), Renal scarring and damage to the
kidneys, resulting in permanent renal failure.

MNT:
Follow a healthy diet plan that has mostly vegetables and fruits, whole grains, and low-fat
dairy products. Limit sugar-sweetened foods and drinks, especially those that have high
fructose corn syrup.

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 2. Acute kidney injury

Definition:

Acute kidney injury (AKI), formerly acute renal failure (ARF), is characterized by a sudden
reduction in glomerular filtration rate (GFR).

Etiology:
Inadequate renal perfusion (Pre-renal), Diseases within the renal parenchyma (intrinsic),
Urinary tract obstruction (post-renal).
Pathophysiology:
Acute kidney injury (AKI, is characterized by a sudden reduction in glomerular filtration rate
(GFR), the amount of filtrate per unit in the nephrons, and altered ability of the kidney to
excrete the daily production of metabolic waste.
Sign and Symptoms:
 Too little urine leaving the body
 Fatigue or tiredness
 Swelling in legs
 Shortness of breath
Major Complications
High levels of potassium in the blood – in severe cases, this can lead to muscle weakness,
paralysis and heart rhythm problems. Fluid in the lungs (pulmonary edema) acidic blood
(metabolic acidosis) – which can cause nausea, vomiting and drowsiness.
MNT:
 Limit foods that are high in potassium.
 Limit milk and dairy products to 8 oz. per day.
 Choose fresh fruits and vegetables.
 Avoid salt substitutes & seasonings with potassium.
 Read labels on packaged foods & avoid potassium chloride.
 Pay close attention to serving size.

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 Case No: 01

Introduction:

Shamim Bibi is a 25-year-old female admitted to hospital with an active complaint of severe
ribs pain, vomiting, fever. She is complaining about blood in urine and facing trouble
urinating. She is diagnosed with kidney stones (calcium phosphate). She has no significant
family history.

Patient Profile:

Weight: 60 Kg Height: 5’1’’ BMI: 25 Kg/m2 (Overweight)

Goals:

 To achieve IBW of 47.7 Kg

 Gain optimal nutritional status
 To combat infections and enhance immunity
 To prevent dehydration without overloading kidneys
 Correction and prevention of vitamins and minerals deficiencies
 To balance serum electrolytes in normal range
 To improve appetite; enhance acceptability and digestibility

Energy Requirements:

 TEE: 1203 kcal (Must Consume)

 Energy Consumption: 922 kcal (24-hrs Dietary Recall)

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 Nutritional Diagnosis MNT Intervention
Assessment
Active complaints TEE= 1203Kcal/day Provision of low Na,
Name: Shamim K, and P in a day to
Severe pain in ribs, Macronutrients balance serum
Age: 25Y Ht: 5’1” vomiting, fever, blood electrolytes in a
in urine, unable to CHO 50%
normal range; that
Wt: 60kg, urinate Pro 20%
are necessary for
Fat 30%
BMI:25kg/m2 osmotic balance and
Current diagnosis: Micronutrients homeostasis.
IBW: 48kg Kidney stones Nutrients such as
Biochemical Data vit.A, vit E, vit.C, vit
Drug Nutrient B9, vit B12 and iron Antioxidant rich diet
Interactions
Test Result containing Vitamin
name Diet order C, E and A that is
Mod kcal, CHO, low required for the
Hb 10.5 (low) Aleve: stomach upset, protein, Mod fat, prevention of
dizziness, nausea, Low Na, K and P oxidative damage.
S.Cr 25 (high) heartburn diet, High
S.urea 180(low) Antioxidant diet
Metalozone: Reduce Food Group Provision of a
blood potassium and Exchanges nutritionally
magnesium levels
Clinical Signs & Milk 1 balanced diet
Nutrition Diagnosis containing foods
Symptoms
Fruits 3 from all 5 foods
Lips/Mouth: dry, groups daily, for the
Tongue: white, Limited food Vege 3 correction of
acceptance (NI-2.9) micronutrients
Appetite: suppressed, Meat 9 deficiency, which
Taste: altered, Inadequate vitamins
and minerals intake Starch 11 ultimately boosts
such as iron, zinc, immunity.
Skin: pale Hair: hair
fall vitamin B12 (NI-5.9.1), Fats 5
(NI-5.10.1)
Foods Allowed
24 -Hrs Dietary
Recall Altered nutrition Whole grains,
related lab values such cereals, fresh fruits
Breakfast: white as Hb=10.5g/dl (NC- & juices, vegetables,
bread 2 slices+ butter+ 2.2) low-fat milk, meat,
1 boiled egg+ 1 cup nuts
tea Foods Not Allowed

Lunch: 1 chapatti+ Sugary foods,

potato + spinach curry Bakery Items, Cold
drinks, sweet potato,
Dinner: 1 chapatti+ ½ peanuts, spinach,
cup chicken curry beets, strawberry

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 Case No: 02
Introduction:
Ali Sher a 16-year-old boy, was admitted in hospital with active complaint of hemoptysis,
hematuria, shortness of breath, cough, abdominal pain, peri-orbital and pedal edema. The
Doctor diagnosed Post Infection Acute Kidney Injury leading to chronic kidney disease. The
Doctor put the patient on Hemodialysis. He has no previous medical and surgical history. He
has a family history of Hypertension.

Patient Profile:

Weight: 53 Kg Height: 6ft BMI: 15.8 Kg/m2 (Underweight)

Goals:

 To achieve IBW of 77 Kg
 Correction and prevention of micronutrient deficiencies
 To reduce the risk of infections
 To balance serum electrolytes in normal range
 To improve appetite; enhance acceptability and digestibility

Energy Requirements:

 TEE: 2500 Kcal/day (Must Consume)

 Consumption: 1400 Kcal/day (24-hrs Dietary Recall)

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 Nutrition Assessment Diagnosis MNT Intervention

Name: Ali sher, Active Complaints TEE= 2500Kcal Provision of Oxalate-

free fruits and
Age: 16Y Ht: 6’ SOB, generalized Macronutrients vegetables to
body swelling, promote kidney
Wt: 53kg, hematuria, CHO 51%
health.
hemoptysis with
BMI:15.8kg/m2 Pro 18%
cough, chest pain
IBW: 77.6kg Fat 31%
Current diagnosis Provide small and
Biochemical Data Acute kidney injury Micronutrients frequent meals at
leads to CKD5 regular intervals (5-6
Test Result (hemodialysis). Vit. A, vit E, meals/day) to
improve appetite and
Hb 9 (low) Drug-Nutrient vit. C, vit B9, vit B12 enhance digestibility.
Interaction
S.Cr 7.6(high) Diet Order
Vify: Vit B12, iron,
S.urea 161(high) Ca, mg Mod CHO, Mod- Antioxidant rich diet
high protein, Mod containing Vitamin
Septran: Vit B9, Vit fat, Low Na, K and C, E and A that is
B2 P diet required for the
Clinical Signs &
prevention of
Symptoms Cyclomide: Vit B9, Food Group
oxidative damage.
Vit B6, Vit B12, iron Exchanges
Hyd.st: dehydrated,
Lips: Dry Tanzo: Vit B7, Vit K Milk 1
Tongue: White Nutrition Fruits 3
Diagnosis
Appetite: Suppressed Vege 3
Unintended weight
Skin: Pale loss (NC-3.2) Meat 9

Malnutrition (NI- Starch 11

5.2)
24-hrs Dietary Recall Fats 5
Inadequate vitamin
Breakfast: ½ cup Foods Allowed
B12 intake (NI-
tea+6,7 pc fruit cake
5.9.1) DASH diet, Apple,
watermelon, papaya,
peaches, broccoli,
Lunch: 1 chapati+1/2 carrots, cucumbers,
cup potato, egg salan whole grains,
chicken & nuts.
Foods Not Allowed
Sugary foods,
Bakery Items, Cold
drinks, sweet potato,
peanuts

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 PLACEMENT WARD: CARDIOLOGY

 Ischemic Heart Disease

 Acute Myocardial Infarction
1. Ischemic Heart Disease

Definition:
Ischemic heart disease refers to heart weakening caused by reduced blood flow to your heart.
Etiology:
Myocardial ischemia occurs when blood flow to the heart muscle (myocardium) is obstructed
by a partial or complete blockage of a coronary artery by a buildup of plaques
(atherosclerosis).
Pathophysiology:
ASCVD involves the accumulation of plaque within the walls of the arteries. It starts with
injury to the endothelial cells with an associated inflammatory response. Once in the tissue,
monocytes evolve into macro phages that ingest oxidized cholesterol and become foam cells
and then fatty streaks in these vessels resulting in blocked blood flow.
Signs & Symptoms:
 Chest discomfort.  Pressure
 Aching
 Heaviness
 Burning
 Tightness
Major Complications:
 Heart failure  Chest pain
 Abnormal heartbeat  Heart attack

MNT:

The Mediterranean Diet includes greater number of servings of fruits and vegetables (mostly
fresh) with an emphasis on root vegetables and greens, whole grains, fatty fish (rich in
omega-3 fatty acids), lower amounts of red meat and with an emphasis on lean meats, lower
fat dairy products, abundant nuts and legumes, and use of olive oil, canola oil, nut oil, or
margarine blended with rapeseed oil or flaxseed.

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 2. Myocardial Infarction

Definition:

Myocardial infarction (MI), colloquially known as "heart attack," is caused by decreased or

complete cessation of blood flow to a portion of the myocardium.

Etiology:

 Smoking
 Abnormal lipid profile
 Diabetes Mellitus

Pathophysiology:

The acute occlusion of one or multiple large epicardial coronary arteries for more than 20 to
40 minutes can lead to acute myocardial infarction.

Signs & Symptoms:

 Chest pain or discomfort

 Shortness of breath

 Pain in the jaw, neck, back, arm, or shoulder

 Feeling nauseous

Major Complications:

 Arrhythmias
 Heart block
 Hypotension
 Congestive heart failure

MNT:

The Mediterranean diet consists of greater number of servings of fruits and vegetables
(mostly fresh) with an emphasis on root vegetables and greens, whole grains, fatty fish, lower
amounts of red meat and with an emphasis on lean meats, lower fat dairy products, abundant

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nuts and legumes, and use of olive oil, canola oil, nut oil, or margarine blended with rapeseed
oil or flaxseed oil.

Case No: 01

Introduction:

Sikandar is a 75-year-old male, admitted to hospital with active complaints of abdominal pain
and SOB. He is diagnosed with Ischemic heart disease, CKD, and pulmonary tuberculosis.

Patient Profile:

Weight: 55 Kg Height: 5’7” BMI: 18.9 Kgm-2 (Normal)

Goals:

 Provision of Balanced diet

 Provision of dense nutrient foods
 Gain optimal nutrition status
 Provision of antioxidant diet to prevent atheroma formation and further complications
 Providing sufficient knowledge through nutritional education to make food healthier

Energy Requirements:

 TEE: 1590 Kcal/ day (Must Consume)

 Consumption: 190 Kcal (24-hrs Dietary Recall)

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 Anthropometric Diagnosis MNT Intervention
Measurements
Active complaints: TEE=1590kcal Provision of sodium
Name: Sikandar and phosphorus free
SOB, Abd. Pain Macronutrients food sources to help
Age: 75yrs Ht: 5’7” reduce load on
Current diagnosis: CHO 50%
kidneys.
Wt: 55kg IBW: 67kg
IHD, CKD, Protein 25%
Biochemical Data pulmonary TB
Fat 25%
Provision of low-fat
Test Result
Micronutrients and high fiber to
Hb 9.8-low Drug Nutrient prevent the risk of
Interaction Zinc, vitamin A, heart attack.
CRP 8.8-high Biotin, B-12,
Loprin: Calcium, vitamin D,
S.Cr 160-high Indigestion, VIT C, E. Small and frequent
breathing
ESR 20-high Diet order nutrient dense meals
difficulty
providing well-
BUN 12.5-high Lipiget: Mod. Carbs, protein balanced diet that
dizziness, nausea and fat, Antioxidant fulfills nutritional
rich diet, High requirement and
Clinical sign & Nezkil: Diarrhea, potassium and low Weight maintenance
symptoms headache sodium at IBW.

Hyd. status: Exchanges

dehydrated Cereals 8
Lips: Dry, cracked Nutritional Meat 8
Taste: altered Diagnosis
Fats 1
Skin: Dry Inadequate oral
Eyes: Pale intake (NI-2.1) Vegetable 4
Nails: Spooned Fruit 3

Inadequate fiber Milk 1

24- hrs Dietary intake (FH-1.5.4)
Recall Food Allowed

Breakfast: 1 bread Whole grains, fruits

slice+ 1 cup tea Inadequate & juices, vegetables,
mineral intake low fat dairy
Lunch: 2 plums
(NI-6.10.1) Foods not Allowed
Dinner: ____
Canned, processed,
frozen food products,
ghee, butter,
saturated fats, gravies
high in fat and salt

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 Case No: 02

Introduction:

M. Azam is a 63-year-old male admitted to hospital with active complaints of SOB, Profuse
sweating and peripheral edema. The diagnosis made by physicians is acute myocardial
infarction and Hypertension with insignificant medical and significant family history of
hypertension.

Patient Profile:

Weight: 56 Kg Height: 5’8’’ BMI: 25 Kg/m-2 (Overweight)

Goals:

 Provision of an adequate amount of calories

 Management of hypertension by regulation of high blood pressure.
 Gain optimal nutritional status
 Control the levels of cholesterol
 Provision of anti-inflammatory and antioxidant rich diet for the prevention of
atheroma formation and further complication

Energy Requirements:

 TEE:1860 Kcal/ day (Must Consume)

 Consumption: 350 Kcal (24-hrs Dietary Recall)

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 Anthropometric Diagnosis MNT Intervention
Measurements
Active complaints TEE=1860kcal Mediterranean diet: it is
Name: M. Azam cardio protective diet
SOB, Peripheral Macronutrients which provides healthy
Age:63y Ht:5’8” edema, profuse foods (Nuts, seeds, oils,
sweating CHO 58%
whole grain foods,
Wt:56kg IBW:60kg
Protein 18% fiber within defined
Current diagnosis
Biochemical Data portion sizes).
Acute myocardial Fat 23%
Test Result infarction,
Hypertension Micronutrients
Hb 9-low Small and frequent
Iron, vitamin A, nutrient dense meals
Family history
Chol. 196 = B12, Calcium, which provide desired
Hypertension vitamin D amount of energy to
LDH 1954- preserve health status.
high Drug nutrient Diet order:
interaction
Troponin 0.35-high Mod. Carbs, protein
Cefast: and fat, Antioxidant
SGPT 1539- Hypernatremia in rich diet, High
high blood potassium and low
sodium, DASH diet
Deplat: Nose
bleeding, gum Exchanges
Clinical sign &
symptoms bleeding
Cereals 10
Hyd. status: Lasix: Numbness,
tingling, headache Meat 4
dehydrated
Megavastin: Fats 1.5
Lips: Dry, cracked
flatulence weakness, Vegetable 4
Taste: altered constipation
Teeth: Dental Caries Fruit 4
Skin: Dry, Eyes: Pale Milk 3
Nails: Spooned Nutritional
Diagnosis Food Allowed
Limited acceptance Whole grains, fruits
Dietary History of good(NI-2.9) & juices,
Breakfast: ½ cup vegetables, low fat
Inadequate oral dairy, lean meat
dalya intake (NI-2.1)
Lunch: Roti ½ with Foods not Allowed
Inadequate fiber
turnip salan ½ cup intake (NI-5.8.5) Canned, processed,
Dinner: Plums 3-4 frozen food
Inadequate fiber products, ghee,
and apricots ½ cup intake(NI-5.8.5 butter, saturated
fats

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 PLACEMENT WARD: PULMONOLOGY

 COPD
 Pulmonary TB

1. Chronic Obstructive Pulmonary Disease

Definition:
Chronic obstructive pulmonary disease (COPD) is the name for a group of lung conditions
that cause breathing difficulties.

Pathophysiology:
COPD is a term that encompasses chronic bronchitis (a long-term condition of COPD in
which inflamed bronchi lead to mucus, cough and difficulty breathing) and emphysema (a
form of long-term lung disease characterized by the destruction of lung parenchyma with lack
of elastic recoil).

Etiology:
Smoking is the main cause of COPD.

Sign & Symptoms:



 Increasing breathlessness  Frequent chest infections

 A persistent chesty cough with  Persistent wheezing
phlegm that does not go away

Major Complication:
Complications of COPD can become life threatening beyond just shortness of breath and
limitations of activities to include pneumonia, heart disease, hypertension, cardiac
arrhythmias, and congestive heart failure.

MNT:
 Choose complex carbohydrates, such as whole-grain bread and pasta, fresh fruits
and vegetables.
 Limit simple carbohydrates, including table sugar, candy, cake and regular soft
drinks.

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  Eat 20 to 30 grams of fiber each day, from items such as bread, pasta, nuts, seeds,
fruits and vegetables.
2. Pulmonary TB

Definition:
Pulmonary TB is a bacterial infection of the lungs that can cause a range of symptoms,
including chest pain, breathlessness, and severe coughing.
Etiology:
Pulmonary TB is caused by the bacterium Mycobacterium tuberculosis (M tuberculosis).
Pathophysiology:
When an infectious TB patient coughs, the cough droplets contain tuberculous bacilli. Small
particles penetrate deep into the lungs. Each of these tiny droplets may carry 1 to 5 bacilli,
which are enough to establish infection.
Signs & Symptoms:
 Weight loss  Tiredness and fatigue
 Night sweats  Loss of appetite
 High temperature  Swelling in the neck
Major Complications:
 Spinal pain  Liver or kidney problems
 Joint damage  Heart disorder
MNT:
 Add superior quality protein.
 Adding whole grain cereals, pulses and sprouted legumes help to meet the demands of
dietary fiber.
 Load up with a rich array of fruits and vegetables heaped with antioxidants and
vitamins A, C, and E.
 Include green leafy vegetables twice or thrice a week to enrich iron content in the diet.
 Prefer a healthy source of unsaturated fats from nuts and seeds. Include oil such as
olive oil, coconut oil, and ground nut oil.

14
15
 Case No: 01

Introduction:
Rehan is 80 years old male admitted to the hospital with an active complaint of Acute
exacerbation of COPD (24–48-hour coughing),constipation from last 3 days, anemia, SOB
from 7 days and is currently diagnosed with COPD with a significant family history of DM,
HTN.
Patient Profile:
Weight: 59 Kg Height: 5’9” BMI: 19.2 Kg/m2 (Normal)
Goals:
 Maintain optimal nutritional status.
 To achieve IBW of 72.2kg.
 Treat symptoms interfering with food intake: cough, SOB and pain.
 Increase the food acceptance and oral intake.
 Correction and prevention of vitamins and minerals deficiencies.
 The prevention of weight loss.
 Prevention of the loss of lean body mass.
Energy Requirements:
 TEE: 1592.9 Kcal/day (Must Consume)
 Consumption: 590 Kcal/day (24-hrs Dietary Recall)

16
 Nutritional Diagnosis MNT Intervention
Asse;ssment
Active complaints TEE= 1592Kcal/day Provision of iron
Name: Rehan rich diet to fulfill
Acute exacerbation of Macronutrients RDA (8mg/day);
Age: 80 years Ht: 5’9” COPD, constipation, to correct
anemia, SOB CHO 40%
deficiency and
Wt: 59 kg BMI: 19.2
Protein 20% treat iron
kg/m2 IBW: 72.2 kg Current diagnosis
deficiency anemia.
Biochemical Data COPD (Chronic Fats 40%
Bronchitis)
Test Result Micronutrients
Antioxidant rich
nam Previous medical
Nutrients such as diet of Vitamin C,
e history
iron, zinc, folate, vitamin E and
Hb 7.8(low) Vitamin A; that is
DM and HTN vitamin B12,
Pco2 59 (high) Selenium, Vitamin C required for the
Drug and nutrient prevention of
interaction Diet Order oxidative damage.

Isoniazid: Doesn’t High kcal, Mod.

Clinical sign & take with tyramine CHO, High protein,
symptoms rich food High fat, low Na diet
& DASH diet
Lips/Mouth: Peel Rifampicin: Interact
and dry Hyd. Status: with I, Ca, Zn Food Group
Dehydration Exchanges
Lasix: Interact with
Teeth/Gum:Bleedin Fruits 4
sodium (fermentable
g
meat, banana)
Veges 3
Skin: Pale and dry
Milk 2
Eyes: pale
Nutrition diagnosis
Cereals 4
Nails: White
Inadequate oral
intake (NI-2.1) Meat 7

Increase nutrients Fat 6

24- hrs. Dietary
Recall needs (NI-5.l) Foods Allowed
Breakfast: 2-3 Disordered Eating Whole wheat,
biscuits+1cup milk Patterns (NB-1.5) oranges, cherries
seasonal fruit juice,
Lunch: 1 cup of
meat and poultry,
broth+ breast 2pc
mushrooms.
Dinner: 1 cup of
Foods Not Allowed
broth+1 roti
Refine products
(white flour, rice or
sugars) Coffee .

17
 Case No: 02

Introduction:

Mr. Falak Sher is a 46-year-old man admitted to hospital with active complaints of fever,
chills with dry as well as productive cough often (whitish). He has had an on/off fever since
last 2-3 months. He is diagnosed with pulmonary tuberculosis. He has no significant family
history.

Patient Profile:

Weight: 55 Kg Height: 5’7’’ BMI: 19.03 Kg/m2 (Normal)

Goals:
 Provision of an adequate amount of calories
 Regulation of blood pressure regularly
 Weight maintenance at desirable body weight
 Provision of a nutritionally balanced diet
 Providing sufficient knowledge through nutritional education to manage diet and
disease related issues
Energy Requirements:

 TEE: 1979 Kcal/day (Must Consume)

 Consumption: 849 Kcal (24- hrs Dietary Recall)

18
 Nutritional Diagnosis MNT Intervention
Assessment
Active complaints TEE: 1979 kcal Micronutrients rich
Name: Falak Sher diet- iron (organ
Fever, chills, Macronutrients meat, spinach, beet
Age: 46years Ht: 5’7” productive cough root, pomegranate),
CHO 55%
potassium (banana,
Wt: 55kg BMI: 19.03kg/m2 Current diagnosis
Proteins 25% guava), B12(meat
IBW: 67 kg Pulmonary sources, soil
tuberculosis Fats 20% vegetable), fat
Biochemical Data soluble vitamins (A,
Micronutrients D, E).
Test Result
Drug-Nutrient Iron, vitamin B12, Small Nutrient
Hb 13.2 Calcium, vitamin D,
Interaction dense meals having
CRP 55.9(high zinc, B-Vit, Vit A, C, optimal amount of
) Provase: bloating, E energy provided at
ESR 10(high) anorexia specific intervals of
Diet Order
Rocophin: nausea, 2-3 hours.
vomiting High kcal, Mod.
Clinical Signs & CHO, High protein,
Symptoms Myteka: respiratory High fat, low Na diet
infection, fever & DASH diet.
Hydration status:
dehydrated Food Group
Exchanges
Lips: cracked Teeth/gum: Nutritional
glossitis, bleeding Diagnosis Fruits 3
Nails: pale Eyes: pale Inadequate Oral Veges 3
Intake (NI-2.1)
Skin: flaky Milk 3
Inadequate Protein
Intake(NI-52.1) Cereals 11
24-hrs Dietary Recall Inadequate vitamin Meat 3
Breakfast: 1 cup tea+ A, C, D, E, B12 Fat 3
Intake (NI-54.1)
1 slice bread+ 1 egg boiled. Foods Allowed
Lunch:1chapati+½cupmutt Whole grains, fruits
on and fresh juices,
vegetables, lean
Snack: ½ chapatti+
meat, nuts & seeds
½ cup eggplant curry
Foods not Allowed
Canned, processed,
Dinner: ------ frozen food products,
ghee, butter, gravies
high in fat and salt.

19
 PLACEMENT WARD: ENDOCRINOLOGY

 Diabetes mellitus
 Hypothyroidism
1. Diabetes Mellitus

Definition:
Diabetes mellitus is a group of diseases characterized by high blood glucose concentrations
resulting from defects in insulin secretion, insulin action, or both.
Etiology:
The exact cause of most types of diabetes is unknown. In all cases, sugar builds up in the
bloodstream. This is because the pancreas doesn't produce enough insulin.
Pathophysiology:
T2DM is characterized by a combination of insulin resistance and beta-cell failure.
Endogenous insulin levels may be normal, depressed, or elevated, but they are inadequate to
overcome concomitant insulin resistance (decreased tissue sensitivity or responsiveness to
insulin.) As a result, hyperglycemia ensues.
Sign & Symptoms:
 Frequent urination
 Excessive thirst
 Unexplained weight loss
 Extreme hunger
Major Complication:
 Eye problems (retinopathy)
 Kidney problems (nephropathy)
 Nerve damage (neuropathy)
MNT:
 Use one or more vegetables, legumes, lentils, rice, bread, grams, wholegrain cereals,
fresh fruits as the basis of your meals.
 Have small servings of protein rich foods such as fish, seafood, eggs, lean meat,
skinless, chicken, low-fat cheese, low fat yoghurt, low-fat milk, nuts etc.
 Minimize fats, sugars, salt, and alcohol.
2. Hypothyroidism

20
Introduction:
Hypothyroidism is a common condition where the thyroid doesn't create and release enough
thyroid hormone into your bloodstream.
Etiology:
Hashimoto's disease, an autoimmune disorder, is the most common cause of hypothyroidism.
Pathophysiology:
The enlarged, chronically inflamed thyroid gland becomes nonfunctional, with reactive parts
of the gland deteriorating after several years.
Sign and symptoms:
 Tiredness
 Being sensitive to cold
 Weight gain

Major complication:
Over time, untreated hypothyroidism can cause several health problems, such as obesity, joint
pain, infertility and heart disease.
MNT:
 Taking leafy greens, whole grains, nuts, seed, and zinc-rich legumes.
 Cruciferous vegetables, such as broccoli and cabbage, are full of fiber and other
nutrients.
 Consume low fat meat, milk and dairy products.
 Stay hydrated.

21
 Case No: 01

Introduction:

Mr. Shakeel is a 50 year old man with an active complaint of elevated blood sugar level. He
has a previous medical history of diabetes mellitus.

Patient Profile:

Weight: 70 Kg Height: 5’6’’ BMI: 25 Kg/m2 (Overweight)

Goals:

 To achieve IBW of 64.5 Kg

 To gain optimal nutritional status
 To control blood sugar and blood pressure
 Correction and prevention of vitamins and minerals deficiencies
 To improve appetite; enhance acceptability and digestibility

Energy Requirements:

 TEE: 1593 Kcal (Must Consume)

 Energy Consumption: 1160 Kcal/day (24-hrs Dietary Recall)

22
Nutritional Diagnosis MNT Intervention
Assessment
Active complaints TEE=1593Kcal Provide small and
Name: Shakeel Vomiting, frequent meals at
abdominal Macronutrients regular intervals (5-6
Age: 50 yrs. Ht: 5’6’’ discomfort meals/day), to
CHO 55%
improve appetite and
Wt: 70 kg BMI: 25 Current Diagnosis Pro 25%
enhance acceptability
kg/m2 IBW: 64.5 kg Fat 20%
& digestibility.
Hyperglycemia, Diet order
Biochemical Data Hypertension High antioxidant diet
Mod kcal, CHO, containing Vitamin C,
Test Result Previous Medical protein, fat, Low GI,
name E and A; such as
History High fiber. guava, oranges, nuts,
Bil 9 DM type 2 Micronutrient oils, carrot and other
citrus fruits to fulfill
Na 136 Family History Vit. A, E, C, B9, RDA; which prevents
B12and iron, zinc, oxidative stress.
FBGL 144 DM type 2 chromium
Drug-Nutrient- Food Group
Interaction Exchanges
Clinical signs &
symptoms Lipiget: Nausea, Milk 3
Digestive
Hyd. Sta: Problem Fruits 4
dehydrated
Vege 5
Nitromust:
Lips/Mouth: dry Blurred vision, Meat 3
Tongue: magenta Chest pain Starch 7
Humulin: Leg Fats 2
Gums: bleeding
cramps, Increased
Bowel: constipated thirst
Foods Allowed
Whole grains, Green
24 hrs. dietary Nutrition leafy vegetable, Low
recall Diagnosis glycemic foods, Plant
based protein.
Breakfast: 2 bread Limited food
slices, 1 cup tea acceptance (NI- Foods not Allowed
2.9)
Snack: 2 apples Processed and refined
Inadequate cereals, Sugary foods,
Lunch:2 chapatti, 1 vitamins and High glycemic foods
cup chicken curry minerals intake
such as iron, zinc,
Dinner: 2 chapatti, 1
vitamin B12
cup lentils
(NI-5.9.1)
(5.10.1)

23
 Case No: 02

Introduction:

Abeeha Fatima is 23 years old female admitted in hospital with active complaints of
Insomnia, aggressive behavior and dysphagia. The physicians make diagnosis is
Hypothyroidism and depression. Family history is not significant.

Patient Profile:

Weight: 52 Kg Height: 5’2’’ BMI: 21 Kg/m2 (Normal)

Goals:

 Correction and prevention of vitamins and minerals deficiencies

 Encourage antioxidant rich diet
 To improve appetite; enhance acceptability and digestibility
 To control TSH Level (0.4-4ml U/L) Gain optimal nutritional status
 Encourage nutrient dense balanced diet
 To balance hemoglobin in normal range (12-14 g/dl)

Energy Requirements:

 TEE: 1591 kcal ( Must Consume)

 Consumption: 1380 kcal (24- hrs. Dietary Recall)

24
Nutritional Diagnosis MNT Intervention
Assessment
Active complaints TEE: 1591 kcal Encourage provision
Name: Abeeha Fatima of nutrient dense
Insomnia, aggressive Macronutrient balanced diet
Age: 23yrs Ht: 5’2’’ behavior, dysphagia.
CHO 50%
Wt: 52kg IBW: 50kg Current Diagnosis
Pro 20% Provide small and
TEE:1591kcal/day Hypothyroidism, frequent meals at
Depression Fat 30%
regular intervals (5-
Biochemical Data
Micronutrient 6 meals/day), to
Drug- Nutrient
Test Result improve appetite
Interaction
Vit. A, E, C, B9, B12, and enhance
Hb 6.08(low) Thyroxin: weight Iron and Selenium, acceptability &
gain/ loss Ca, Vit. D rich food digestibility.
TSH 17.48(high)
Diet Order
RBGL 4.8
Citanew: Nausea, Low kcal, Mod High antioxidant
Headache complex CHO, Mod diet containing
protein, Mod fat, Vitamin C, E and A;
Clinical signs &
Low GI diet., high such as guava,
symptoms
antioxidant rich oranges, nuts, oils,
Gablin: Dizziness, carrot and other
Hyd.st: Dehydration weight gain Food Group citrus fruits to fulfill
Lips/Mouth: dry, Exchanges RDA; which
prevents from
Cracked Tongue: red Milk 3
Nuberol Forte: Dry oxidative stress.
Skin: pigmented, dry mouth, stomach Fruits 4
upset
Nails: spoon shaped Vege 5

Eyes: rough, pale Meat 3

Nutrition
Hair: brittle Diagnosis Starch 6

Imbalance of Fat 2
nutrients(NI-5.5)
24-hrs dietary recall Foods Allowed
Altered GI function
Breakfast: 1 paratha, (NC-1.4) Carrots, Peppers,
1 egg fried, 1 cup tea Apple, spinach,
Inadequate Fiber Grapes, Citrus fruits
Lunch: 1 chapatti, ½ intake (NI-5.8.5)
cup (potato, spinach) Foods Not Allowed

Snack: 1 cup tea Cruciferous

vegetables, gluten
Dinner: 1 chapatti, grains and seeds,
½ cup chicken curry soy-based products

25
 PLACEMENT WARD: GASTROENTEROLOGY

 Diarrhea
 Gastritis
1. Diarrhea

Definition:
Diarrhea is the condition of having at least three loose, liquid, or watery bowel movements
each day.
Etiology:
Exposure to pathogenic bacteria, such as E. coli or parasites through contaminated food or
water, leads to diarrhea.
Pathophysiology:
Diarrhea may be related to inflammatory disease; infections with fungal, bacterial, or viral
agents; medications; overconsumption of sugars or other osmotic substances; an allergic
response to a food, or insufficient or damaged mucosal absorptive surface.
Sign and symptoms:
The main symptom of diarrhea is passing loose, watery stool three or more times a day.
People with diarrhea may also have one or more of the following symptoms:

 Cramping  Pain in the abdomen

 Nausea  Light-headedness
Major complication:
If your diarrhea fails to improve and resolve completely, you can be at risk of complications
(dehydration, electrolyte imbalance, and kidney failure and organ damage).
MNT:
A diet known as BRAT may also quickly relieve diarrhea. BRAT stands for bananas, rice,
applesauce, and toast. This diet is effective due to the bland nature of these foods, and the fact
that they're starchy, low-fiber foods. These foods have a binding effect in the digestive tract
to make stools bulkier.

26
 2. Gastritis
Definition:
The membranes lining the stomach wall protect it from acid and germs. If this protective
lining is irritated or damaged, it can become inflamed. Long-lasting inflammations can
further damage the stomach lining and lead to stomach (gastric) ulcers. Inflammation of the
stomach lining is called gastritis.
Etiology:
Gastritis can be caused by irritation due to excessive alcohol use, chronic vomiting, stress, or
the use of certain medications such as aspirin or other anti-inflammatory drugs. It may also be
caused by any of the following: Helicobacter pylori.
Pathophysiology:
Gastritis occurs when mucosa of stomach lining gets damaged, causing inflammation, which
results in decreased mucosa and thus causing atrophy.
Sign and symptoms:
 Gnawing or burning ache or pain (indigestion) in your upper abdomen that may
become either worse or better with eating
 Nausea
 Vomiting
 A feeling of fullness in your upper abdomen after eating

Major complication:
Left untreated, gastritis may lead to stomach ulcers and stomach bleeding.
MNT:
 High fiber foods, such as whole grains, fruits, vegetables, and beans.
 Low fat foods, such as fish, lean meats, and vegetables.
 Foods with low acidity, including vegetables and beans.
 Noncarbonated drinks.
 Caffeine-free drinks.
 Small amounts of chili pepper or its pungent ingredient, capsicum, may increase
mucosal protection by increasing production of mucus.

27
 Case No: 01

Introduction:

Ms. Rafia is a 60-year-old female admitted to hospital with active complaints of nausea,
abdominal pain and loose stools. She has no previous medical history.

Patient Profile:

Weight: 75 Kg Height: 5’4’’ BMI: 28.4 Kg/m2 (Overweight)

Goals:

 Correction and prevention of micronutrient deficiencies

 To improve appetite; enhance acceptability and digestibility
 To improve the quality of life
 Correction and prevention of vitamins and minerals deficiencies

Energy Requirements:

 TEE: 1325 Kcal (Must Consume)

 Energy Consumption: No food since the last 24 hours

28
Nutritional Assessment Diagnosis MNT Intervention

Name: Rafia Age: 60Y Active complaint TEE=1325 Kcal/day

Ht:5’4’’ Wt:75kg, Loose stools, nausea, Macronutrients Provision of small
BMI:28.4kg/m2 Abd. Pain and more frequent
IBW:54.5kg CHO 55% meals to prevent
Current diagnosis gastric problems
Protein 25%
Biochemical Data Diarrhea, Acute and vomiting(7-8
Hb 12.0 = gastric enteritis Fat 25% meals per day)
Bil 16 =
Previous medical Micronutrient
Na 139 = history Nutrient such as Vit Provision of
HTN balanced diet to
A, Vit E, Vit C, Vit
maintain optimal
B9, Vit B12, iron
Drug-Nutrient health such as milk
Clinical Signs& rich foods.
Interaction (3), fruits (6), and
Symptoms Diet order vegies (7).
Buscopan: dry Mod Energy, carbs,
Hyd.st: dehydrated,
mouth, fast heart protein, fats, Na+
Lips/Mouth: Dry, rate K+, Zinc, B9, B3,
Appetite: altered, Anti-inflammatory,
Flagyl: Headache, BRAT diet
Skin: flaky, depression Food Group
Exchanges
Bowel: loose stools, Novidat: nausea, Fruits 3
Nails: pale nail beds vomiting
Teeth: bleeding Veges 3

Nutrition diagnosis Milk 3

24 Hours Dietary Inadequate fluid Cereal 6
Recall intake (NI-3.1)
Meat 3
No food since the last
24 hours Inadequate fiber Fat 1
intake (NI-53.5)
Foods Allowed
Poor nutrition Whole grains, Fresh
quality of life (NB- fruits, vegetable skim
2.5) milk, lean meat, eggs,
chicken and fish.
Unroasted nut
Foods not Allowed
White chapatti,
White flour
processed & refined
grains like cereals
Bakery items

29
 Case No: 02

Introduction:

Shama bibi is 33 years old female admitted to the hospital with active complaints of nausea,
vomiting, upper abdominal pain, and low-grade fever, headache and diagnosed with acute
gastritis.

Patient Profile:

Weight: 50 Kg Height: 5’3” BMI: 19 Kg/m2 (Normal)

Goals:

 Correction of nutritional deficiencies

 To improve appetite; enhance acceptability and digestibility
 To improve the quality of life
 To normalize BMI in normal range (18.5-24.9kg/m2)
 To gain optimal nutritional status

Energy Requirements:

 TEE: 1625 Kcal/day (Must Consume)

 Consumption: 450 Kcal/day (24-hrs Dietary Recall)

30
Nutritional Diagnosis MNT Intervention
Assessment
Active complaints TEE= 1770Kcal/day Provide small and
Name: Shama frequent meals at
Age: 33Y Ht:5’3” Nausea, vomiting, Macronutrient regular intervals (5-6
upper abdominal pain, meals/day), to
Wt: 50kg
and low-grade fever, CHO 53% improve appetite that
BMI: 19kg/m2,
headache decreases gastro-
IBW: 53kg Pro 17%
Biochemical Data esophageal reflex.
Current diagnosis
Fat 30%
Provision of iron rich
Test Result Acute gastritis
Micronutrient diet to fulfill RDA
Drug-Nutrient such as whole grains,
Hb 11(low) Vit A, E, C, B9,
Interaction meat, pulses etc; to
BUN 46(in) B12and iron, zinc rich correct deficiency
Vify: Vit B12, Iron, foods. and treat iron
S.Cr 1.1(in) Ca, Mg deficiency anemia.
Diet order
Omeprazole: Iron,
Ca, Mg, Na Mod kcal, CHO,
Clinical Signs &
protein, fat and anti-
Symptoms
Cimetidine: inflammatory diet.
Hyd. st: dehydrated
Grapefruit juice
Lips/Mouth: dry Food groups
Tongue: Red Exchanges
Magenta Skin: pale,
Nails: pale, Eyes: Nutrition Milk 2
pale diagnosis
Fruits 3
Limited food
24 hrs dietary recall Vege 3
acceptance (NI-2.9)
Breakfast: ½ cup of
oatmeal Meat 6

Snack: apple Inadequate energy Starch 10

intake (NI-1.2)
Fats 6
Lunch: porridge +
milk Foods Allowed
Malnutrition (NI-
Dinner: 1 cup Whole grains, Green
5.2)
oatmeal leafy vegetable, Low
Inadequate vitamins glycemic foods, Plant
& minerals intake based protein.
such as iron, zinc,
Foods not Allowed
vitamin B12 (NI-
5.9.1) (NI-5.10.1) Processed and refined
cereals, Sugary foods,
High glycemic foods.

31
 PLACEMENT WARD: GENERAL OPD

 Obesity
1. Obesity
Definition:
An abnormal or excessive accumulation of body fat that presents a risk to health.
Etiology:
Obesity is a multifactorial disease, caused by a myriad of genetic, cultural, and
social factors.
Pathophysiology:
Pathophysiology involves an imbalance between energy intake and energy
expenditure.
Sign & Symptoms:
 Excess body fat  Snoring
 SOB  Trouble sleeping
 Sweating more than usual
Major Complications:
 Diabetes Mellitus  Hyperlipidemia
 Hypertension  Osteoarthritis
 Digestive problems
MNT:

 Reduce daily sodium intake.

 Consume less than 300 mg per day of dietary cholesterol.
 Increase vegetables and fruit intake.
 Include at least half of all grains as whole grains.
 Increase intake of fat-free or low-fat milk and milk products.

32
 Case No: 01

Introduction:

Komal is a 27-year-old female admitted to hospital with active complaints of chest pain and
heaviness radiating to back and arm. She is diagnosed with obesity and angina. She has no
significant previous medical and family history.

Patient Profile:

Height: 5’3’’ Weight: 80 Kg BMI: 31.25 Kg/m2 (Obese-1)

Goals:

 To achieve IBW of 52.3 Kg

 To gain optimal nutritional status
 Correction and prevention of vitamins and minerals deficiencies
 To control blood sugar and blood pressure
 Complete diet monitoring regarding fiber and fat intake

Energy Requirements:

 TEE: 1468 Kcal ( Must Consume)

 Energy Consumption: 900 Kcal (24-hrs Dietary Recall)

Nutritional Diagnosis MNT Intervention

Assessment
Active complaints TEE= 1468Kcal/day Provision of low
Name: Komal calorie diet to maintain
Chest pain, pain Macronutrients to maintain ideal body
Age: 27yrs Ht:5’3’’ radiating to back weight 52.3kg.
and arm CHO 50%
Wt: 80 kg BMI: 31.25 Pro 30% Provision of low Na+2
Current Fat 20% intake of Na+
IBW: 52.3kg Diagnosis Micronutrient 1500mg/day to
TEE: 1468kcal maintain normal B.P
Angina, Obesity Nutrients such as vit.A, 120/ 80 mmhg.
Biochemical Data Vit E, vit.C, Vit B9, Vit
Drug-Nutrient- B12and iron, zinc, Provision of high fiber
Interaction chromium
Test Result diet of 100g/day to
Loprin: Diet Order lower cholesterol level
Hb. 11.9
Heartburn, of 200mg/dl.

33
ESR 25(high) Change in Mod. Complex Carbs,
amount of urine Proteins, Low fat, High
CRP 14(high) fiber, Low sugar and
Eziday: Fatigue, salt
dry mouth
Food Group
Clinical Signs & Nitromust: Exchanges
Symptoms Blurred vision,
Chest pain Milk 3
Lips/Mouth: dry,
Fruits 3
Tongue: swollen Azomax: Black Vege 3
Skin: dry Nails: stools, chest Meat 2
brittle Hair: thin pain Starch 6
Teeth: bleeding
Eyes: pale Fats 2

Nutrition
Diagnosis Foods Allowed
24 hrs. dietary
Obesity (NC- Whole grains & cereals
recall
3.3) Fresh Fruits and
Breakfast: 1 cup vegetable Lean meat
tea, 1 paratha, 1 cup Excessive egg, oils Seeds, chia
curry potato Carbohydrate seed, flex seed
Intake (NI-53.2)
Lunch: 1 bowl of Foods not Allowed
vermicelli Inadequate fiber
intake (NI-53.6) Avoid refined flour and
Dinner: 6 biscuits+ cereals
250 ml juice
Avoid refined grains
Avoid Packed juices
and canned fruits and
vegetables

PLACEMENT WARD: PEDIATRICS

 Malnutrition
1. Malnutrition

Introduction:
The World Health Organization (WHO) defines malnutrition as the cellular imbalance
between the supply of nutrients and energy and body’s demand to ensure growth,
maintenance and specific functions.
Classification of Malnutrition:

34
  Under nutrition: It is defined as insufficient food intake combined with repeated
occurrence of infectious diseases.
 Moderate Acute Malnutrition: It is defined as weight for height Z-score <-2 but>-3
 Severe Acute Malnutrition:
 MUAC <11.5CM
 Weight for height Z-score<-3
 Bilateral pitting edema
Signs of Severe Malnutrition:
 Severe wasting
 Edema
 Dermataosis
 Eye signs
Feeding Formulas: F- 75 is a starter to use during initial management, beginning as soon
as possible and continuing for 2-7 days until the child is stabilized. It is low in protein and
sodium and high in carbohydrates. As the child is stabilized on F-75, F-100 is used as ‘catch-
up’ to rebuild wasted tissues. It contains more calories and protein.

Case No: 01

Introduction:

Sabiha 8 month’s baby girl was admitted to hospital with active complaint of fever, vomiting,
diarrhea and reluctant to feed and edema on her hands and feet. The Doctor diagnosed her
with SAM (severely acute malnourished) and watery diarrhea. She has no previous medical
or surgical history.

Patient Profile:

Weight: 06 Kg Height: (62cm) MAC: 10 cm (SAM)

35
Goals:

 To gain optimal nutritional status and IBW of 8.5 Kg

 To minimize further unintentional weight loss
 To achieve an appropriate growth rate via catch up growth
 To improve nutritional quality of life
 To provide nutrition education regarding breast feeding and complementary feeding
to parents.

Energy Requirements:

 EER: 694 Kcal/day (Must Consume)

 Consumption: 292.5 Kcal/day (24-hrs Dietary Recall)

36
 Nutritional Diagnosis MNT Intervention
Assessment Active Complaints Provision of starter
Feeds Calculation
Name: Sabiha formula milk (F-
Vomiting, Diarrhea Stabilization Phase:(F-75) 75) in appropriate
Age: 8 months Fever Reluctant to quantities and
feed Da Freq Feeds small, frequent
Ht: 62 cm Wt: 06 kg y feedings to enhance
Current Diagnosis
IBW: 8.5 kg digestibility and
1 12 54ml/2h fulfill energy
Severely acute
EER: 694 kcal malnourished, 2 8 81ml/3h needs.
Diarrhea
Biochemical Data
3 6 108ml/4h
Drug nutrient Addition of catch -
Test Result
Interaction Transition Phase: (F-100)
up formula (F-100)
Hb 7.4(low) after stabilization,
Cipro: 4 6 108ml/4h
Electrolytes to increase growth
HCT 24(low)
imbalances Rehabilitation phase: (F- rate and maintain
TLC 137(high) 100) nutritional status.
Tanzo: Allergic
reactions 5 6 162ml/4h
Addition of
Clinical Signs & Micronutrients complementary
Symptoms Vit A, D, E, K, C, Ca, Iron, feeding by
Zn, omega3&6, Vit B- introduction soft
Hyd. Sta: foods gradually
dehydrated Nutritional complex.
Diagnosis To accomplish the
Tongue: Inflamed Dietary Guidelines
daily caloric
Inadequate
In stabilization center demands, include
Nails: Pale energy intake
(SC) start feeding with RUTF (ready to
(NI-1.2)
Skin: Edema F-75 formula milk with 2 use therapeutic
Sub-optimal hours interval foods
Eyes: Pale growth rate (NC-
3.5) If no vomiting and
diarrhea change to 3-
Malnutrition hourly feeds.
Diet History
(NI-5.2)
After a day on 3-hourly
Feeding route:
Diet Order feeds; change to 4-hourly
Oral
feeds on next day.
Mother milk, F-75,
Feed: F-75(50 ml)
F-100, RUTF If tolerated; change to F-
mother feed (3
100 for 4-hourly for 2-3
times)
weeks.
Frequency:
(8feedings/day)

37
 PLACEMENT WARD: SURGERY

 Ileostomy
 Appendectomy

1. Ileostomy
Definition:
An ileostomy is a surgically created opening from the distal small bowel (most often the
terminal ileum) to the skin when the entire colon, rectum, and anus are removed or bypassed.
Etiology:
One of the most common reasons for an ileostomy is inflammatory bowel disease (IBD). The
two types of inflammatory bowel disease are Crohn's disease and ulcerative colitis.
Pathophysiology:
Loss of the fluid absorptive capacity of the colon results in increased fluid and electrolyte
losses, which causes a state of relative fluid depletion.
Signs & Symptoms:
 Continuous nausea and vomiting
 Cramps and nausea
 Laceration from clothing
 Stoma separation from skin
Major Complications:
Irritation and inflammation of the skin around the stoma. Narrowing of the stoma (stoma
stricture) a section of the bowel pushing through the opening in the skin (stoma prolapse) an
internal part of the body, such as an organ, pushing through a weakness in the muscle or
surrounding tissue wall (parastomal hernia).
MNT:
It's best to eat mostly bland, low-fiber foods for the first few weeks after your surgery. Bland
foods are cooked, easy-to-digest foods that aren't spicy, heavy, or fried. Eating bland foods
will help you avoid uncomfortable symptoms, such as: Diarrhea (loose or watery bowel
movements.

38
 2. Appendectomy
Definition:
Appendicitis is an inflammation of the appendix, a finger shaped poouch that projects from
your colon on the lower right side of your abdomen.
Etiology:
Appendicitis may be caused by various infections such as viruses, bacteria, or parasites in
your digestive tract.
Pathophysiology:
The pathophysiology of appendicitis likely stems from obstruction of the appendiceal orifice.
This obstruction may be caused by lymphoid hyperplasia, infections etc. Bacterial
overgrowth occurs in the obstructed appendix, once significant inflammation and necrosis
occur, the appendix is at risk of perforation, leading to a localized abscess and sometimes
frank peritonitis.
Signs & Symptoms:
 Sudden pain that begins on the right side of the lower abdomen
 Nausea and vomiting
 Loss of appetite
Major Complications:
The main problem with appendicitis is the risk of a burst appendix.
MNT:
 Inclusion of fibrous foods in the diet.
 Eat only easy to digest foods for the first few days
 Get back to normal diet after a few days
 Foods rich in Zinc such as dry fruits, eggs, whole grains

39
 CASE NO: 01

Introduction:

Rehan 32 year old male admitted to hospital with active complaint of fever, generalized
abdominal pain, severe constipation. Doctor performed exploratory laparotomy and
laparoscopy ileostomy 6 days back.

Patient Profile:

Weight: 70 Kg Height: 5’11” BMI: 21.5 Kg/m2 (Normal)

Goals:

 To reduce oxidative stress, inflammation and pain sensations

 To reduce the incidence of shut down mechanism & catabolism of the body
 To correct the micronutrients deficiencies
 To reduce the risk of bloating and abdominal pressure
 To improve digestibility and bioavailability of essential nutrients

Energy Requirements:

 TEE: 2100 Kcal/day (Must Consume)

 Consumption: 470 Kcal/day (24-hrs Dietary Recall)

40
 Anthropometric Medical Diagnosis MNT Intervention
Measurements
Active Complaints TEE:2100Kcal/day Provide small and
Name: Rehan frequent meals at
Fever and constipation No Macronutrients regular intervals (5-
Age: 32 years stool passed from 5 days, 6 meals/day) to
Generalized abdominal CHO 50%
improve appetite
Ht: 5’11’’ pain
Protein 20% and enhance
ABW: 70 kg digestibility.
Current Diagnosis
Fats 30%
IBW: 75 kg Exp. Laparotomy,
Ileostomy Micronutrients
BMI: 21.5kg/m2 High antioxidant
Iron, vitamin C, E, A, diet containing
Biochemical Data Drug Nutrient
D, zinc, Ca, Mg Vitamin C vitamin
Interaction
E and Vitamin A
Test Result Diet Order such as guava, nuts,
Vify: reduce absorption
Hb 11(low) of Vit B12, Mg oils, carrot and
Mod Kcal, Mod CHO,
citrus fruits to
High protein, Mod fat,
HCT 37(low) Cefast: reduce fulfill RDA which
low fiber diet for 6-8
absorption of iron, Ca, prevents from
weeks
Temp 100 Mg and B-complex oxidative stress.
Food Groups
Tramal: lack of energy
Exchanges
Clinical sign & Provision of a
Fruits 4 blended diet to
symptoms
Nutrition Diagnosis normalize GIT
Veges 5
Lips: Dry function, bowel
Skin: Dry, Malnutrition (NI-3.1) frequency and gut
Milk 3
Nails: Pale health.
Altered GI-function
Eyes: Pale Cereals 9
Mouth: Dry (NI-1.4)
Taste: altered Meat 6
Inadequate energy Provision of
intake (NI-1.2) Fat 5 nutrient dense
foods to improve
24 hrs. dietary Foods Allowed optimal nutritional
recall status and prevent
Diet rich in omega-3
anemia.
Breakfast: (flaxseeds, chia seeds,
biscuits 2 and 1 almonds, walnut, olive
cup tea with sugar. oil), Iron and vitamin C
rich.
Lunch: 1 cup
apple juice. Foods Not Allowed

Dinner: bread slice 1 Refined grains, odor

and ½ cup chicken producing foods
broth with 2 pieces. (beans, cruciferous
vegetables), obstructive
foods.

41
 CASE NO: 02

Introduction:

Rubina Shaheen, 35 years old, was admitted to hospital with active complaints of lower
abdominal pain, pain in RIF, constipation. She diagnosed herself as Appendicitis and planned
for appendectomy with previous surgical history of cholecystectomy and significant family
history of DM.

Patient Profile:

Weight: 50 Kg Height: 5’3” BMI: 20 Kg/m2 (Normal)

Goals:

 To preserve optimal nutritional status and achieve an IBW of 52kg

 To treat normal bowel movements
 To restore micronutrient deficiency
 To improve appetite; enhance acceptability and digestibility
 To provide nutritional education regarding healthy food consumption

Energy Requirements:

 TEE:1681Kcal/day (Must Consume)

 Consumption: NPO (24-hrs Dietary Recall)

42
 Anthropometric Diagnosis MNT Intervention
Measurements
Active Complaints TEE: 1681Kcal/day Provision of high
Name: Rubina fiber to fulfill RDA
Lower abdominal pain Macronutrients of 38g/day.
Age: 35 years Insoluble fiber adds
Pain in RIF CHO 53%
bulk to fecal
Ht: 5’8’’ ABW: 50kg
constipation Proteins 20% material, which
IBW:52 kg facilitate its passage
BMI: 20kg/m2 Current Diagnosis Fats 27% and resolve
constipation.
Biochemical Data Appendicitis Planned Micronutrients
for appendectomy Provision of
Test Result Zinc, Vit A C, E, B complex
Previous Medical complex, fiber carbohydrates
Hb 15(normal) History such as whole
Diet Order
Cholecystectomy grains due to
S.Cr 2.2(high) more fiber content
Mod Kcal, Mod
Drug nutrient Complex CHO, Mod it regulates
BUN 45(high)
interaction protein, Low fat, High cholesterol
fiber diet metabolism.
Cefast: interact with
calcium iron and Food Groups Provision of amino
Clinical Signs &
magnesium Exchanges acids L-Arginine
Symptoms
absorption and L- glutamine
Hydration status: Fruits 3 recovery and
dehydrated Epival: irritability, reduce
nausea Veges 4 inflammation.
Lips: dry Tongue:
Milk 2
magenta red
Nutrition diagnosis Cereals 9
Taste: altered
Appetite: Meat 5
Suppressed Fat 4
Increase nutrient needs
Nails: Pale, (NC-5.1)
Foods Allowed
mottled
Unintended weight loss
(NC-3.2) Whole grain cereals,
Eyes: Pale wheat, oats and
conjunctiva porridge. Lean meat,
Undesirable food
choices (NB-1.7) Egg, milk, yogurt, olive
oil, Flaxseed, chia seed.
Turmeric
Foods Restricted
Refined grains,
processed foods, Fast
food, carbonated
beverages.

43
 PLACEMENT WARD: NEUROLOGY

 Epilepsy
1. Epilepsy

Definition:
Epilepsy is a chronic condition characterized by unprovoked, recurring seizures.
Etiology:
Seizures are caused by abnormal electrical activity of a group of neurons which causes an
imbalance of nerve-signaling chemicals called neurotransmitters.
Pathophysiology:
A clinical workup usually reveals no anatomic abnormalities, and the cause of the seizure
may remain unknown (idiopathic).
Signs & Symptoms:
 Jerking movements of arms and legs
 Staring
 Loss of consciousness
 Breathing Problems
Complications:
 Losses in visual memory
 Difficulty learning
 Permanent brain damage (stroke or other damage)
MNT:
 Most of the diet is composed of fresh meats, eggs, cheese, fish, heavy whipping
cream, butter, oils, nuts, and seeds.
 Vegetables and fruits are added in small amounts, within the current diet prescription.

44
 Case No: 01

Introduction:

Maryam is an 18-year-old female admitted in hospital with active complaints of severe

headache, seizures and more than 30 episodes of blanking out phase in 1 day. The Doctor
diagnosed her with absence seizures of epilepsy and generalized body weakness. She has a
previous history of epileptic fits from childhood. She has also a family history of epilepsy in
her father.

Patient Profile:

Weight: 50 Kg Height: 5’4” BMI: 19 Kg/m2 (Normal)

Goals:

 To gain optimal nutritional status and achieve IBW of 55kg

 Preserve the lean body mass.
 Increase the protein and fat intake to reduce fits frequency by induce ketosis
 Correction and prevention of vitamins and minerals deficiencies
 To improve appetite; enhance acceptability and digestibility

Energy Requirements:

 TEE: 1614 Kcal/day (Must Consume)

 Consumption: 669 Kcal/day (24-hrs Dietary Recall)

45
 Nutritional Diagnosis MNT Intervention
Assessment
Active complaints TEE= 1614Kcal/day Provision of energy
Name: Maryam dense and nutrient
Severe headache, Macronutrients dense foods to prevent
Age: 18Y Ht: 5’4”, Seizures, Loss of weight loss and gain
Wt: 50kg, BMI: consciousness CHO 30%
ideal body weight
19kg/m2, IBW: 55kg Pro 20%
(55kg).
Current diagnosis Fat 50%
Biochemical Data Micronutrients
Epilepsy
Test Result Vit. D, Calcium, Increase consumption
Previous Medical iron, Zn, omega-3, B of vitamin B
Hb 10.1 (low) Condition complex complexes, especially
HCT 35 (low) Epilepsy from thiamine, folate and
Diet order vitamin B3, B6 & B12
childhood
MCHC 32.8(low) Mod. calorie, low because their
Drug Nutrient CHO, high protein, deficiency may cause
Interactions high fat, ketogenic memory loss and
diet neurological damages.
Clinical Signs & Phenobarbitl: These helps with DNA
Symptoms drowsiness, bone Food Group
repair.
weakness Exchanges
Lips/Mouth: dry,
Tongue: white, Phenytoin: Fruits 2
Appetite:suppressed, reduce absorption
Taste: bitter, Skin: Veges 4
of conjugated
pale, dry,Eyes: Pale folate Milk 2

Cereals 3
24 hrs. dietary
Meat 7
recall Nutrition Diagnosis
Fat 9
Breakfast: 1/2 roti Inadequate energy
with 2 chicken intake (NI-1.2) Foods Allowed
cutluts
Flaxseeds, chia
Inadequate oral seeds, almonds,
Lunch: 1 apple, 1 intake (NI-1.1)
banana and 1 cup walnuts, olive oil etc
milk Malnutrition (NI- Turmeric, garlic,
5.2) meat, fish, green
Dinner: 1 cup tea,
2-3 biscuits. Inadequate fluid leafy vegetables
intake (NI-5.8.5) Foods Not Allowed
Refined grains
(white flour and
rice). Omega 6 fatty
acid (corn oil,
sunflower oil).

46
 PLACEMENT WARD: GYNECOLOGY

 Pregnancy with Complication

 Menstrual Problem
1. Amniotic Fluid Leakage During Pregnancy
Definition:
Amniotic fluid is a clear, slightly yellowish liquid that surrounds the unborn baby (fetus)
during pregnancy. It is contained in the amniotic sac.
Etiology:
 Birth defects  Preeclampsia
 Poor fetal growth  Diabetes
 Rupture of the membranes
Pathophysiology:
Amniotic fluid leaks occur when a hole or tear is present in the amniotic sac. Ruptures
usually signify the start of labor.
Signs & Symptoms:
 Wet underwear, but the fluid is odorless, colorless.
 Decreased movement of the baby in the uterus, when there has already been a major
loss of fluid.
Complications:
 Miscarriage
 Physical deformities
 Premature Birth

MNT:
 Hydration is very helpful for upping amniotic fluid levels
 Foods with water – Watermelon, Cucumber, Lauki, (Squash/Gourd family of
veggies), Buttermilk, lemon/lime water with pink salt to improve electrolytes.

47
 2. Premature Menopause

Definition:
Premature menopause, or premature ovarian insufficiency (POI), is defined as being
menopause that happens before the age of 40.
Etiology:
 Chemotherapy or radiation to treat cancer
 Surgery that removes your ovaries
Pathophysiology:
The pituitary gland produces the follicle-stimulating hormone (FSH) and luteinizing hormone
(LH) and influences the synthesis of testosterone and progesterone in the ovaries throughout
normal menopause. Estradiol and progesterone levels decrease due to depletion of the ovarian
reserve, while FSH and LH levels increase.
Signs & Symptoms:
 Hot flashes
 More frequent urinary tract infections (UTIs)
 Dry skin, dry eyes or dry mouth
 Breast tenderness

Complications:
 Osteoporosis
 Heart disease
 Depression
MNT:
 Eat and drink two to four servings of dairy products and calcium-rich foods a day.
 Eat at least three servings of iron-rich foods a day. Iron is found in lean red meat, poultry,
fish, eggs, leafy green vegetables, nuts, and enriched grain products.
 Help yourself to foods high in fiber, such as whole-grain breads, cereals, pasta, rice, fresh
fruits, and vegetables
 Have at least 1 1/2 cups of fruit and 2 cups of vegetables each day.

48
 Case No: 01

Introduction:

Sawera Imran is 21 years old female admitted to gynecology ward with active complaint of
decreased amniotic fluid due to leakage from vagina, this is her first pregnancy, she has
single fetus lying transverse. She has no significant previous medical and family history.

Patient Profile:

Weight: 65 Kg Height: 5’2’’ BMI: 26.2 Kg/m2 (Overweight)

Goals:

 To preserve optimal nutritional status.

 Balanced nutrient dense diet
 To treat constipation and normalize bowl frequency
 To maintain normal hydration status and soften the stool
 Maintain body weight accordingly trimester
 To improve appetite; enhance acceptability and digestibility

Energy Requirement:

 TEE: 1969 Kcal/ day (Must Consume)

 Consumption: 1059 Kcal (24-hrs Dietary Recall)

49
 Anthropometric Diagnosis MNT Intervention
Measurements
Active complaints TEE= 1969 kcal Provision of
Name: Sawera Imran Macronutrients plenty of water for
Amniotic fluid drinking to fulfill
Age:21 y Ht:5’2” leakage CHO 50% amniotic fluid
requirement.
Wt: 65kg IBW: 50 kg Current diagnosis Protein 25%
Biochemical Data Low levels of Fat 25%
amniotic fluid, Fetus Provision of high
Test Result lying transverse Micronutrients protein diet to
Hb 10.9-low Vit B3, B6, B9, B12, support synthesis
Drug nutrient
A, C, D, Iron, Zinc of maternal and
interaction
PLT 265 = fetal tissues.
Nootopil: Diet order
Neutro. 74
Headache, Mod. Carbs, High
Lymph. 20= protein and Mod. fat, Provision of
Diarrhea
High iron, folate, vitamins
Panama G: calcium, fluid rich supplementation
Vomiting, to fulfill body’s
Clinical sign & micronutrient
heartburn Food Group
symptoms requirement.
Exchanges
Hyd. status:
Cereals 9
dehydrated Nutritional
Diagnosis Meat 3
Skin: Dry
Bowel Frequency: Fats 3
Inadequate energy
constipation
intake (NI-1.4)
Vegetable 4
Increase nutrient
24 hrs. Dietary Recall needs (NC-5.1) Fruit 4
Breakfast: 1 Paratha, 1 Milk 3
egg, 1 cup tea Inadequate fluid
intake (NI-3.1) Food Allowed
Snack: 1 apple
Food and nutrition Whole grains, fruits
Lunch: 1 chapati, 1 related knowledge & juices, vegetables,
cup okra curry deficit (NB-1.1) low fat dairy,
broccoli, sweet
Snack: 1 cup tea
potatoes, rice, bread,
Dinner: ½ chapatti, ½ lean meat, eggs, nuts
cup okra curry
Foods not Allowed
Snack: 1 cup milk
Canned, processed,
frozen food products,
ghee, butter,
saturated fats,
gravies high in fat.

50
 Case No: 02

Introduction:

Ms. Narmeen, 24 years old, was admitted to hospital with active complaints of Pelvic pain
(periodic pain), headache, nausea, lethargic, generalized weakness. She diagnosed herself as
Premature menopause, ovarian shrinkage, and secondary amenorrhea. She has a history of
fibular fractures with family history of HTN.

Patient Profile:

Weight: 70kg Height: 5’1’’ BMI: 30 Kg/m2 (Obesity-1)

Goals:

 To gain optimal nutritional status and prevent complications

 To improve digestibility and absorption
 Correction and prevention of vitamins and minerals deficiencies
 Balanced Nutrient Dense diet
 To provide nutritional education regarding healthy food choices

Energy Requirements:

 TEE: 1544 Kcal/day (Must Consume)

 Consumption: 1085 Kcal/day (24-hrs Dietary Recall)

51
 Anthropometric Diagnosis MNT Intervention
Measurements
Active complaints TEE= 1544 kcal Provision of a
Name: Narmeen nutritionally
Pelvic pain, Macronutrients balanced diet
Age: 24 y Ht:5’1” headache, nausea containing foods
CHO 54%
from all 5 foods
Wt: 70 kg IBW: 47.7 kg Current diagnosis
Protein 18% groups on a daily
Biochemical Data Premature basis, for the
menopause, Fat 28% correction of
Test Result ovarian shrinkage micronutrients
Micronutrients deficiency.
Hb 8.9-low Nutritional
Vit A, E, D, C, Iron,
Diagnosis
SGOT 156-high zinc, calcium,
Impaired omega-3 Provision of high
Na 146.4-high antioxidant diet to
nutrient
Diet order prevent oxidative
utilization (NC-
2.1) stress.
Mod. Carbs, protein
Clinical sign & fat, High iron, Zn,
symptoms Increase nutrient
calcium, Vit D
needs (NI-5.1)
Provision of nutrient
Hyd. status: Exchanges dense foods to
dehydrated Skin: Dry, Inadequate fluid
intake (NI-3.1) improve nutritional
Pale LIPS/ Mouth: Cereals 8
status and prevent
Dry Nails: spooned Inadequate anemia.
Eyes: Pale Hair: Meat 3
energy intake
Rough (NI-1.2) Fats 4

Vegetable 4
Dietary History
Fruit 3
Breakfast: 1
chapati+1/2 cup pulses Milk 2

Snack: 1 cup tea Food Allowed

Lunch: 1 chapati+1/2 Lean meat, nuts,
cup chicken seeds, beans, green
leafy vegetables,
Dinner: boiled rice 2/3 whole grains, citrus
cup+1/ cup pulses fruits
Foods not Allowed
Refined grains,
iodized salt, dairy
foods, fried & baked
items, soy products.

52
 PLACEMENT WARD: ONCOLOGY

 Breast Cancer
1. Breast Cancer

Definition:
Breast cancer is a disease in which cells in the breast grow out of control.
Etiology:
 Age  Radiation exposure
 Smoking  Hormone replacement therapy
Pathophysiology:
Breast cancer is a malignant tumor that starts in the cells of the breast. Damage to DNA and
genetic mutations can lead to breast cancer experimentally linked to estrogen exposure. Some
individuals inherit defects in DNA and genes like the BRCA1, BRCA2 and P53 among
others.
Signs & Symptoms:
 New lump in the breast
 Thickening of the breast
 Redness or flaky skin
 Pulling in of the nipple
 Pain in any area of the breast.

Complications:
 Bone complications
 Lung complications
 Liver complications
MNT:
 Maintain a healthy body weight.
 Adequate dietary intakes of food-based macro- and micronutrients rich in β-carotene
and vitamins A, E, and C.
 Increase dietary quality with nutrient-dense foods.
 Reduce simple sugars and added fats.

53
 Case No: 01

Introduction:

Rukhshanda is a 42-year-old female admitted to hospital with active complaint of pain in

right side of chest and nausea. The doctor diagnosed her CA breast (carcinoma breast) with
multiple lumps in the right breast upper lateral quadrant and most probably fibro adenoma.
The surgeon performed lumpectomy and sent tissues for biopsy. She has a family history of
CA breasts in mother and aunts.

Patient Profile:

Weight: 68 kg Height: 5’2” BMI: 27 Kg/m2 (Overweight)

Goals:

 To reduce oxidative stress, inflammation and pain sensations

 To reduce the incidence of shut down mechanism & catabolism of the body
 To correct and prevent the micronutrients deficiencies
 To improve nutritional quality of life and gain optimal nutritional status
 To improve appetite, digestibility and bioavailability of essential nutrients

Energy Requirements:

 TEE: 1647Kcal/day (Must Consume)

 Consumption: 270Kcal/day (24-hrs Dietary Recall)

54
 Nutritional Diagnosis MNT Intervention
Assessment
Active complaints TEE= 1468Kcal/day Provision of
Name: Rukhshanda antioxidant rich diet
Age: 42 yrs. Upper right quadrant Macronutrients containing vitamin C,
Ht:5’2’’ Wt.: 68 kg chest pain, nausea E and A to reduce
CHO 52%
oxidative stress.
BMI: 27 kg/m2 Current Diagnosis Pro 18%
Fat 30%
CA Breast, Fibro- Provision of diet
IBW: 50 kg Micronutrient
adenoma containing omega-3
TEE: 1647 kcal Vit. A, E, C, D, B- and 6 fatty acids to
Drug-Nutrient- Complex, iron gain anti-
Biochemical Data Interaction inflammatory effect.
Diet Order
Test Result Augmentin: Ca, Provision of red,
Iron, Zn, Mg Mod. Complex Carbs, orange, yellow, purple
Hob. 12= Proteins, fat, High
Omeprazole: Vit and green fruits and
RBGL 90 = antioxidant diet vegetables for
B12, Iron, Ca
phytochemical to fight
Food Group
HCT 37(low) against different types
Exchanges
of cancer.
Nutrition Milk 2
Diagnosis
Clinical Signs & Fruits 4
Symptoms Food and nutrition Vege 4
related knowledge
Hyd.st: Meat 4
deficit ( NB-1.1)
dehydrated,
Lips/Mouth: dry, Starch 7
Inadequate oral
Tongue: intake (NI-2.1) Fats 4
Magenta- red
Skin: dry Nails: Unintentional
spoonedTeeth: weight loss (NC- Foods Allowed
bleeding gums 3.2)
Whole grains &
Inadequate cereals Fresh Fruits
vitamins intake and vegetable, Lean
(B6, B12, B9) meat egg, oils Seeds,
24 hrs. dietary chia seed, flex seed,
recall (NI-5.0.1) carrot, capsicum,
citrus fruits, guava
Breakfast: 1 Inadequate iron
apple intake (NI-5.10.1) Foods Not Allowed

Lunch: ½ chapatti White flour, refined

+ ½ cup eggplant rice, bakery items,
salan beverages, fatty meat,
junk food, spicy fried
Dinner: 1 apple food.

55
 PLACEMENT WARD: ICU

 Empyema Thoracic
1. Empyema Thoracic

Definition:
Thoracic empyema is an infectious process defined by frank pus in the pleural space.
Etiology:

A significant proportion of pleural space infection presents as complications in community-

or hospital-acquired pneumonia.

Pathophysiology:

Exudative stage-initial bacterial infection causes an acute inflammatory response between

pulmonary parenchyma and visceral pleura.

Fibrinopurulent and Loculated stage-In the absence of appropriate treatment, the effusion
can become complicated via deposition of fibrin clots and membranes resulting in isolated
collections of fluid in the pleural space.

Chronic Organizational stage-If not drained, fibroblasts coalesce to form a thick pleural
peel between the visceral and parietal pleura.

Signs & Symptoms:

 Chest pain
 Dry cough
 Excessive sweating

Complications:
Complications of empyema can be secondary to the underlying disease process, and patients
may succumb to worsening sepsis, septic shock, or death.
MNT:
Include complex carbohydrates, consume protein rich sources, monounsaturated and
polyunsaturated fats, fresh fruits and vegetables include minerals, vitamins and fiber that help
keep your body healthy and in shape.

56
 Case No: 01

Introduction:

Shanzay is 19 years old female admitted to ICU ward due to high fever. She is diagnosed
with Empyema Thoracic. She has no significant previous medical and family history.

Patient Profile:

Weight: 50 Kg Height: 5’3’’ BMI: 19.5 Kg/m2 (Normal)

Goals:

 Provision of an adequate amount of calories

 Weight maintenance
 Gain optimal nutritional status
 Correct appetite and bowel frequency

Energy Requirements:

 TEE: 1509 kcal/ day (Must Consume)

 Consumption: NPO

57
 Anthropometric Diagnosis MNT Intervention
Measurements
Active complaints TEE: 1590kcal Provision of
Name: Shanzay optimal amount of
Fever Macronutrients energy by having
Age:19 y Ht:5’3” small and frequent
CHO 50%
nutrient dense
Wt:50kg IBW: 52kg
Current diagnosis Protein 30% meals 5-6/ day to
Biochemical Data fulfill body’s
Empyema Thoracic Fat 20% energy demands.
Test Result
Drug nutrient Micronutrients Provision of anti-
Hb 9.9-low interaction inflammatory diet
Vit C, A, D, E, and anti-oxidant
Alb 32-low Loprin: Iron, Zinc, Ca diet rich diet to
Indigestion, reduce infection
S.Cr 54.9-high breathing Diet order
and oxidative
difficulty stress.
ESR 43-high High energy,
Nezkil: Diarrhea, Moderate CHO,
Platelets 817-high Increasing soluble
headache Proteins, Fat, High
and insoluble fiber
Antioxidant diet
Meronum: in the diet by
Interact with Ca, I, Exchanges enhancing fruits
Clinical sign & and vegetables in
symptoms Mg
Cereals 8 diet to relieve
constipation.
Hydration status: Meat 10
dehydrated
Fats 2
Lips: Dry, cracked Nutritional
Diagnosis Vegetable 3
Taste: altered
Skin: Dry, Eyes: Inadequate oral Fruit 2
Pale intake (NI-2.1) Milk 2
Nails: Spooned
Increased nutrient Food Allowed
needs (NI-5.1)
Dietary History Brown rice, oats,
Altered GI- Rice flakes,
NPO function (NI-1.4) pomegranate,
papaya, apple,
sugarcane, pumpkin
Foods not Allowed
Canned, processed,
frozen food, ghee,
butter, saturated
fats, gravies high in
fat, salt, okra

58
 PLACEMENT WARD: GENERAL MEDICINE

 Typhoid Fever
 Malaria
1. Typhoid Fever

Definition:
Typhoid fever is a life-threatening infection caused by the bacterium Salmonella Typhi.
Pathophysiology:
Once consumed, typhoid bacteria cross the epithelial layer of the intestinal wall. They are
then quickly consumed by macrophages and transported to the aggregates of lymphoid tissue
in small intestine where the immune function of the gut is most concentrated.
Signs & Symptoms:
 Prolonged high fever
 Fatigue
 Headache
Complications:
The 2 most common complications in untreated typhoid fever are: internal bleeding in the
digestive system, splitting (perforation) of a section of the digestive system or bowel, which
spreads the infection to nearby tissue.
MNT:

 Drink plenty of water.

 Avoid high fiber foods.
 Consume protein rich diet.
 Consume soft foods.
 Include yoghurt, eggs, and milk in your diet.

2. Malaria

Definition:

59
Malaria is a non-contagious and cannot spread from one person to another; the disease is
transmitted through the bites of female Anopheles mosquito.
Etiology:
Malaria is caused by a single-celled parasite of the genus plasmodium. The parasite is

transmitted to humans most commonly through mosquito bites.

Pathophysiology:
Malarial infection begins when a person is bitten by an infected female anopheles mosquito
and Plasmodium (species) parasites in the form of sporozoites are injected into the
bloodstream. The sporozoites travel to the liver, multiplying asexually over the next 7–10
days.
Signs & Symptoms:
Fever, headache and chills are typically experienced, though these symptoms may be mild
and difficult to recognize as malaria.
Complications:
 Liver failure and jaundice
 Pulmonary edema
 Acute respiratory distress syndrome (ARDS)
MNT:
 Consume foods that give instant energy.
 A high protein with high carbohydrates diet is helpful in protein utilization for
anabolic and tissue building purposes.
 Fats intake should be moderate. The uses of dairy fats like butter, cream, fats in milk
products, etc. are helpful in digestion.
 Liberal fluid intake is desired to compensate for the fluid losses from the body. A
daily fluid intake of 3 to 3.5 liters is recommended.

Case No: 01

Introduction:

60
Mr. Aliyan Raza is a21 years old male admitted to hospital with active complaints of fever
since last 1 week, body pain, headache and watery eyes. He is diagnosed with Typhoid Fever.

Patient Profile:

Weight: 58 Kg Height: 5’6’’ BMI: 20 Kg/m2 (Normal)

Goals:

 Correction of nutritional deficiencies

 To improve appetite; enhance acceptability and digestibility
 To improve the quality of life
 To gain optimal nutritional status

Energy Requirement:

 TEE: 1971 Kcal/day (Must Consume)

 Consumption: 60 Kcal (24-hrs Dietary Recall)

Test
Anthropometric
Result Diagnosis MNT Intervention
Measurements
Hb(g/d L) 14= Active TEE=1971Kcal/day Provision of high
Name: M.Aliyan Raza, complaints caloric diet to
Lymph.
Age: 45(high)
21Y Ht:5’6’’ Fever, body Macronutrients maintain IBW to
Wt:58 kg, ache, CHO 55% achieve daily caloric
ESR BMI:20 45(high) headache, amount of 1971
kg/m2, watery eyes Protein 25% kcal/day.
ALT 55(high)
TEE:1971
Fats 25% Provision of high
kcal/day
Neutrophil 69.6= Current diagnosis
Typhoid fever protein diet to
Micronutrient preserve lean body
Biochemical
Vit. A, E, C, mass and to fight
Data Drug-Nutrient
Clinical Signs & B9, B12, infection by
Interaction
Symptoms Ca, iron rich providing daily
foods. protein of 123g.

61
Hyd.st: dehydrated, Ceftriaxone: Diet order Provision of small
High and frequent meals
Lips/Mouth: Dry, confusion, Energy, from all 5 groups to
drowsiness moderate fulfill nutritional
Appetite: altered,
carbs, requirement and
Skin: pale, protein, fats, prevent micronutrient
Ranitidine: Anti- deficiency.
Nails: brittle Headache, inflammator
constipation y,
Hair: rough, antioxidant
Teeth: bleeding rich
Ondanstron:
Eyes: watery, Exchanges
yellowish drowsiness, chills Food Servings
group

Nutrition Diagnosis Fruits 3

1.Inadequate fluid
Veges 3
24 hrs. Dietary intake( NI-3.1)
Recall 2.Inadequate oral Milk 3
intake (NI-2.1)
Snack: 3 plums 3.Inadequate vitamin Cereal 11
C intake( NI- 5.9.1)
Meat 8

Fat 2

Foods Allowed
Whole grains,
cereals, fresh fruits
and juices,
vegetables, low-fat
milk, meat, nuts
Foods not
Allowed
Avoid refined
flour
Avoid bakery
items
Avoid packaged
foods

Case No: 02

Introduction:

62
Mr. Najam is a 22-year-old man admitted to hospital with active complaints of fever and
SOB. He is diagnosed with Malaria. He has no previous medical or family history.

Patient Profile:

Weight: 58kg Height: 5’8’’ BMI: 20 Kg/m2 (Normal)

Goals:

 To achieve IBW of 47kg

 To gain optimal nutritional status
 To correct altered and suppressed appetite
 Correction and prevention of vitamins and minerals deficiencies
 To improve appetite; enhance acceptability and digestibility

Energy Requirement:

 TEE: 1913 Kcal/day (Must Consume)

 Consumption: 280 Kcal (24-hrs Dietary Recall)

Anthropometric Diagnosis MNT Intervention

Measurements
Active TEE: 1913kcal/day Provision of
Name: M. Najam, complaints nutritionally
Age: 22Y,Wt:5kg, Fever, body Macronutrients balanced diet
Ht:5’8’’ BMI:20kg/m2, pain, SOB containing foods
CHO 50%
IBW: 70kg Current from all 5 foods
TEE:1913 diagnosis Protein 30% groups for the
kcal/day Malaria correction and
Fats 20% prevention of
Biochemical Data micronutrients
Drug-Nutrient Micronutrient deficiency.
Test Result Interaction Vit. A, Vit
Name E, Vit k, High antioxidant
Meronum: bluish Vit B9, Vit diet containing
Hb(g/dl) 10.4(low) skin, dizziness Vitamin C, E and
B12,
Ca,iron rich A such as guava,
CRP 1126 Risek: Stomach
foods. oranges, nuts,
pain, blisters
ESR 46 Diet order oils, carrots and
Vancomycin: High other citrus fruits
black stools, Energy, to fulfill RDA
bleeding gums moderate which prevents
Clinical Signs & oxidative stress.
carbs, high

63
 Symptoms Neurobion: protein Provision of diet
nausea, vomiting moderate containing
Hyd.st: dehydrated, fats omega-3 and
Lips/Mouth: Dry, omega-6 fatty-
Appetite: altered, Exchanges acids to gain anti-
Skin: dry, Nails: Food Servings inflammatory
spooned, Hair: rough, Nutrition group effect.
Teeth: bleeding, Diagnosis
spongy Fruits 3
Inadequate protein-
energy intake (NI- Veges 3
24-hrs Dietary Recall 5.3)
Milk 2
Breakfast: 1 bread Inadequate
Cereals 10
slice+ ½ cup tea vitamins (A, D, E)
intake (NI-54.1) Meat 6
Snack: 2-3 plums
Involuntary weight Fat 2
Dinner: 2-3 tbsp. rice loss (NC-3.21)
(boiled) Foods Allowed
Whole grains, fresh
fruits, fresh juices,
vegetables, low-fat
milk, Meat Nuts,
Seeds
Foods Not Allowed
Spicy food, bakery
items, packaged
items, cold drinks

PLACEMENT WARD: ORTHOPEDICS

 Osteoporosis
 Osteomalacia
1. Osteoporosis

Definition:

64
Osteoporosis is a bone disease that develops when bone mineral density and bone mass
decreases or when the structure and strength of bone changes.

Etiology:

 Age, older than 60

 Amenorrhea in women
 Family history of osteoporosis
 Inadequate calcium or vitamin D intake

Pathophysiology:
Traditional pathophysiologic models frequently emphasize endocrine mechanisms, e.g.
estrogen deficiency and secondary hyperparathyroidism in elderly due to estrogen deficiency .

Complications:

Bone fracture, particularly in the spine or hip, are the most serious complications of
osteoporosis.

MNT:

It includes adequate calcium and vitamin D, and a balanced diet of low-fat dairy, fruits, and
vegetables. 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.

65
 2. Osteomalacia

Definition:
The abnormal loss of bone mineral and matrix leading to porous, fragile bone tissue with
enlarged spaces that is prone to fracture or deformity, common disease of aging in both men
and women.
Etiology:
 Decreased Vitamin D production
 Decreased Vitamin D absorption
 Altered Vitamin D Metabolism
Pathophysiology:
The synthesis of active vitamin D (calcitriol) organically begins in the skin, where
cholecalciferol (vitamin D3) is formed by the action of UVB radiation converting 7-
dehydrocholesterol (provitamin D3) in epidermal keratinocytes and dermal fibroblasts to pre-
vitamin D, which spontaneously isomerizes to form cholecalciferol. Subsequently,
cholecalciferol gets transported to the liver, where it is converted to calcidiol.
Signs & Symptoms:
 Pain felt in the bones and joints
 Muscle pain and weakness
 Bones that break easily

MNT:
 Eat foods high in vitamin D. Foods naturally rich in vitamin D includes oily fish and
egg yolks.
 Take supplements, if needed.

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 Case No: 01

Introduction:

Zubair is a 58 years old male admitted to hospital with active complaints of back and hip pain
from last 2 weeks, he slipped and fell into the bathroom. He diagnosed Osteoporosis with
significant history of hip fracture 2 years ago.

Patient Profile:

Weight: 80 Kg Height: 5’11’’ BMI: 23 Kg/m2 (Normal)

Goals:

 To maintain optimal nutritional status and achieve IBW of 78 Kg

 To preserve lean body mass
 To restore hydration status and electrolyte balance
 To reduce the risk of infections and improve quality of life
 Balanced, nutrient dense diet

Energy Requirements:

 TEE: 1835 Kcal/day (Must Consume)

 Consumption: 1340 Kcal/day (24-hrs Dietary Recall)

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Nutritional Diagnosis MNT Intervention
Assessment
Active Complaints TEE:1835Kcal/day Eat high
Name: Zubair fiber foods such
Complaining about hip Macronutrients as fruits,
Age: 53 years Ht: and back pain from last vegetables,
5’11’’ 2 weeks CHO 50%
legumes, and
Proteins 20% whole grains;
Wt: 80 k BMI: Current Diagnosis
they prevent
24kg/m2
Osteoporosis Fats 30% constipation and
IBW: 78 kg straining during
Previous Medical Micronutrients bowel movement.
Biochemical Data Condition
Vit B3,B6, B9,B12, D Provision of
Test Result Hip fracture last 2 Iron, zinc, Vit C, E, A, omega-3/omega-6
years ago omega-3, calcium fatty-acids in
Hb 12.5(low) (1:4) such as fish,
Drug nutrient Diet Order
fish oil, walnuts,
ALP 142(high) interaction
Mod Kcal, Mod CHO, flaxseeds etc.; to
K 1.6 (low) Acetaminophen: High protein, Mod fat, gain anti-
Interact with high High Calcium and Vit inflammatory
protein foods and D effect and to
cruciferous relief pain.
Clinical Signs & Food Groups
Symptoms vegetables
Exchanges
Lips: Dry, peeling Aspirin: interact
Fruits 3
with Mg oxide and
Skin: Dry, Rough decreased effect of Veges 4
aspirin
Nails: Pale, mottled Milk 3
Tongue: inflamed Cereals 8
Nutrition Diagnosis
Eyes: Pale Meat 6
Increased energy
Taste: altered expenditure (NI-1.1) Fat 5
Inadequate energy Foods Allowed
intake(NI-1.2)
24 hr’s dietary recall Whole grains, fresh
Inadequate fluid fruit and vegetables,
Breakfast: 1-1/2 roti intake (NI-3.1) lean meat, eggs, dairy
+1 egg fried and ½
products, legumes,
cup saag Inadequate iron milk
intake (NI-5.10.1.3)
Snack: tea 1 cup
Foods Not Allowed
Lunch: 1 roti with ½
Refined grains,
cup kaddu salan
processed, junk and
Dinner: rice 2/3 cup fast food, Saturated fat
with 3-4 mutton pc

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 Case No: 02

Introduction:

Haider Ali is a 30-year-old male admitted to hospital with active complaints of walking
disturbance, hip-joint pain, and cramps in both pelvic limbs. He is diagnosed with
osteomalacia.

Patient Profile:

Weight: 50 Kg Height: 5’5’’ BMI: 18.4 Kg/m2 (Underweight)

Goals:

 To maintain optimal nutritional status

 To achieve an ideal body weight of 62 Kg
 To preserve body mass and prevent unintended weight loss
 To fulfill daily lean energy requirements of body

Energy Requirements:

 TEE: 1691 Kcal/day (Must Consume)

 Consumption: 727 Kcal/day (24-hrs Dietary Recall)

69
 Nutritional Diagnosis MNT Intervention
Assessment
Active Complaints TEE:1691Kcal/day Provision of
Name: Haider Ali nutritionally balanced
Walking disturbance, Macronutrients diet from all 5 groups
Age: 30 years Ht: 5’5’’ Hip – Joint Pain for the correction and
CHO 50%
prevention of
Wt: 50 kg Current Diagnosis
Protein 30% micronutrient
BMI: 18.4kg/m2 Rheumatoid arthritis deficiencies.
Fats 20%
IBW: 62 kg Drug nutrient Provision of nutrient
interaction Micronutrients dense foods such as
Biochemical Data nuts, meat, egg, citrus
Calcitriol: Stomach Iron, Vit C, A, E, D, fruits, and vegetables
Test Result Pain, Constipation Ca, Vit B complex, to improve optimal
omega-3, calcium, Vit nutritional status.
Hb 13.8 = Calcium D, Zinc
Carbonate: Provision of high fiber
Na 138 = Diet Order foods to normalize GIT
Nausea, Vomiting, function and bowel
Alb. 4.3 = Headache Mod Kcal, Mod CHO,
frequency.
High protein, Mod fat,
High Calcium and Vit
D diet
Clinical Signs & Nutrition Diagnosis
Symptoms Food Groups
Inadequate Vit D Exchanges
Lips: Dry, peeling Intake ( NI-5.9.1)
Fruits 3
Mouth: Dry Inadequate Ca Intake
(NI- 5.10.1) Veges 3
Skin: Dry, Rough
Food and Nutrition Milk 3
Nails: Pale
related knowledge
Hair: Rough, frizzy deficits (NB-1.1) Cereals 8

Eyes: Pale Inadequate fluid Meat 10

Intake(NI-3.1)
Fat 2

24 hour’s dietary Foods Allowed

recall Whole grains, fruits,
Breakfast: 2 bread vegetable, lean meat,
slices with 1 cup tea legume, liver, omega-3

Lunch: 1 bowl boiled Foods Not Allowed

rice, potato curry Refined grains (white
Dinner: 1 bowl flour and rice), gas
boiled rice, ½ cup producing foods
legumes curry (cruciferous
vegetables)

70
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weigh-a-bed-ridden-patient&usg=AOvVaw1WEjrR-RNPCw85EC3pcCCZ
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bedridden-patients-
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patient/

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