Written

Case Study
Rory Costigan

Subjective:
1. Physical Appearance

Patient looked thin, but not wasted. Patient did not have sunken in cheek
bones or pronounced collar bones. Although patient is malnourished, patients
weight for age is in the 50th-75th percentile.

2. Diet History prior to admission
a. Feeding History

Patient reported she only consumed fruits, vegetables and lean
proteins. Patient stated she does not consume processed foods or fatty
foods such as peanuts, peanut butter or nuts. Patient stated she does not
consume any dairy foods. Patient also mentioned she has not consumed
sugar for the last 1.5 years.
b. Method of Feeding

Patient is able to consume food by mouth. Patient does not use any
other source for feeding.
c. Oral/Enteral Intake
Specific Formula
N/A
Mixing procedures
N/A
Caloric Density
N/A
Schedule
N/A
Fluid Flushes
N/A
WIC
N/A
24 hour recall or typical day
The patients mother stated she usually consumes one omelet with
vegetables in the morning. The patients mother also stated that the
patient would eat breakfast then skip meals until the following dinner.
The patient stated she only consumed fruits, vegetables and lean
proteins. The patient does not consume processed foods or fatty
foods such as peanuts, peanut butter or nuts. The patient does not
consume any dairy foods. The patient has not consumed sugar for the
last year in a half. The patient was referred from the Prosperity eating
disorder clinic because she had a heart rate of 39 beats per minute,
which is considered bradycardia.
Tolerance Issues
Patient does not have any tolerance issues.

Any other relevant information

Patient stated she has been restricting calories for 4 months. She then
became very restrictive with her intake 1 month ago. Patient stated in
January she was very stressed with school, causing her to restrict her
calories more than normal. Patient stated that she felt in control and
had better body image when she was restricting calories as well as felt
happy when losing weight. Patient stated that she had not consumed
sugar in 1.5 years and continues to restrict dairy foods,
carbohydrates, fatty foods, avocados and nuts. Patient stated she only
consumes fruits, vegetables and lean meats and consumes on average
500 calories per day. Patient stated that her goal weight was 54.5kg
(120 lbs) and her all time highest weight was 68.2kg (152 lbs) in
October 2014. Patients lowest weight was documented at 61.4 kg
(135 pounds), which is her weight currently. The patients mother
stated that the patients eating disorder may have been caused by the
Whole30 diet which the family participated in. During this diet the
individual is only to consume fruits, vegetables and lean meats and
then add a specific foods back into the diet each week. The mother
stated that the familys summer schedule was hectic therefore she did
not monitor the addition of foods back into her daughters diet. She
believes this was the start of her daughters eating disorder.
d. Vitamins or Mineral Supplements

Patient does not take multivitamins at home.
e. Food Allergies

Patient does not have any known food allergies.

PES:
1. Nutrition-related Diagnosis
a. Justify Nutritional Significance

Malnutrition (Acute, Mild)
b. Give brief or natural history of the diagnosis

The patient is malnourished which is defined as lack of proper
nutrition, caused by not having enough to eat, not eating enough of the right
nutrients, or being unable to use the food that one does eat. The patient lost
11% of her total body weight in the last 4 months. Patient weighed 152lbs
(68.2kg) in October 2014 and currently weighs 135lbs (61.4kg) 2/11/2015.
Patients BMI is in the 25th-50th percentile with a z-score of -0.22 SD.

2. Diet Order

Daytime meals: Eating disorder stage 1 diet. Initiate on 1200 calories divided
into 3 meals. Any uneaten calories to be supplemented with Boost, offer by mouth
first, then inserted through NG tube. Increase 300 calories per day until goal has
been reached at 2400 calories per day.
Overnight NG tube feeds: Nutren 1.5
Night 1: 40 ml/hr x 4 hours 60ml/hr x 4hours; 10kcal/kg/day
Night: 2: 50ml/hr x 4 hours, 80 ml/hr x 4 hours; 13kcal/kg/day

Night 3: 80 ml/hr x 4 hours, 100 ml/hr x 4 hours; 18kcal/kg/day

Night 4 and subsequent : 100 ml/hr x 8 hours; 20kcal/kg/day
3. Age: 16 years and 5 months

a. Corrected age

N/A

b. Justified use of Corrected Age

N/A

4. Weight: 60.9kg (admission weight, 2/11/2015)

a. Percentile

50th-75th percentile

b. Corrected Weight Percentile

N/A

c. Weight Age

N/A

d. Weight history

10/2014- 68.2kg (152 lbs)

1/11/2014- 60.9kg (134lbs)

e. Weights throughout admission

1/11/2014 (Admission weight)- 60.9kg (134lbs)

1/12/2014 62.9kg (137lbs)

f. Ideal body weight

62.7kg, based on BMI at 50th percentile

5. Height: 174.5 cm (admission height, 2/11/2015)

a. Percentile

95th percentile

b. Corrected Height Percentile

N/A

c. Height Age

N/A

6. Head Circumference:

a. Percentile

N/A

b. Corrected Head Circumference Percentile

N/A

c. Head Circumference Age

N/A

7. Weight/Height Percentile:

a. Justify rational for use of this number

Weight for Height is not calculated on a patient over the age of 2.

8. Body Mass Index/ Percentile:

BMI of 20, 25th-50th percentile; zscore: -0.22 SD

9. Plot Patient on Growth Chart:

a. Justify choice of growth chart
Patient is 16 years and 5 months old. This puts her into the age 2-20
category. Therefore, BMI for age, stature for age and weight for age growth
charts are used for tracking growth.
b. Evaluate patients growth
The patient is plotting at the 95th percentile; zscore: 1.82 SD for her height
for age percentile. The patient is plotting in the 50th-75th percentile; zscore
0.62 SD for her weight for age. The patient is plotting at the 25th-50th
percentile; zscore -0.22 SD for her BMI for age. The patient has lost 11% of
her body weight in the last 4 months, which is 6.8 kg in 4 months. The
patients height is on track with her previous growth charts, due to the recent
weight loss, the patients weight and BMI are not within normal limits of the
patients previous growth charts.

10. Estimated Requirements

a. Kcals/kg

51kcal/kg/day

b. Grams of Protein/Kg

1.3gm/kg/day

c. mL/day to meet maintenance fluid needs

38.06mL/Kg/day, 2,318mL/day

d. Justify how you determined these numbers
Increased calories and protein needs for nutrition rehabilitation; DRI X 1.5
for IBW. This is based off of the Childrens National Medical Center eating
disorder protocol. The patients DRI for energy is 1760 calories
(29kcal/kg/day) and 46g (0.75g/kg/day) of protein per day.

11. Nutrition Related Medications Reviewed

-Miralax 17gm BID for constipation
-Potassium Phosphate- Sodium phosphate (Phos-NaK powder) will monitor
for the prevention and treatment of refeeding syndrome
-Multivitamin
12. Pertinent Labs Reviewed

a.

2/11/2015
2/12/2014
2/13/2014
Sodium (mmol/L) 142
141
140
Potassium
4.2
3.7
3.8
(mmol/L)
Chloride
104
106
105
(mmol/L)
CO2 (mmol/L)
H 26
25
H26

Glucose (mg/dl)
63
88
95
BUN (mg/dl)
14
14
14
Creatinine
0.8
0.6
0.8
(mg/dl)
Calcium (mg/dl) 9.6
9.6
9.6
Total Protein
7.4
9.3
9.2
(mg/dl)
Albumin (mg/dl) 4.1
-
-
ALK (IU/L)
L 71
-
-
AST (IU/L)
17
-
17
Bilirubin (mg/dl) 0.3
-
0.3
ALT (IU/L)
21
-
0.1
Phosphorus
4.2
4.6
4.4
(mg/dl)
Magnesium
H 2.2
H2.2
H 2.1
(mg/dl)

b. Magnesium levels are slightly elevated by 0.1-0.2 (mg/dl), will continue to
monitor levels.

Assessment:
1. Nutrition risk level

a. Patients nutrition risk level high due to mild, acute malnutrition. This was
decided from the current growth velocity chart which defines a patient greater than
2 years old with unintended weight loss x 6 weeks or suboptimal growth for 3
months. The patients BMI/ Weight for Length zscore was -0.22 SD. Acute mild
nutrition is also diagnosed by poor dietary intake or faltering growth prior to
nutrition assessment, which the patient shows signs of with 7.7kg (17lb) weight loss
over 4 months.

2. Pertinent Lab Values

a. Patient nutrition labs are within normal limits. Will monitor patients
magnesium, phosphorous, and potassium levels for refeeding syndrome.

3. IV Fluids

a. Patient was not given IV fluids during hospitalization visit. Patient was
malnourished, patient would have benefited from IV fluids during admission. The
patients mother stated her admission was during the night (11:00pm), which may
be a reason why she did not receive food or fluids until the morning.

4. Growth
a. Rate of Weight Change
Patient has gained 1.2kg since admission, averaging 1200 grams per day.
(Weight gain can be due to fluid)
b. Appropriateness of Growth

The growth is consistent with the PO and enteral intake. Patient

consumed 100% of breakfast and dinner on 2/12/2015 consisting of
1,000 calories (16kcal/kg/day). Patient required 150 mL Boost
supplement at lunch via PO. Overall patient received 1,500 calories via PO
on 2/12/2015. Patient also tolerated 400ml of NG feeds overnight of
Nutren 1.5 providing 600 calories (10kcal/kg/day). Due to the increase of
fluids, the patients weight gain could also be due to fluid.
c. Patient stated that she was previously restricting her energy intake to
300-500 calories per day. Patient received 2,100 calories
(35kcal/kg/day) on 2/12/2015 and received 2,640 calories
(43kcal/kg/day) on 2/13/2015 which provided her with calories to halt
weight loss and begin weight gain.

5. Diet Prior to Admission

a. Adequacy of macro and micronutrients
According to the estimated energy and protein requirements for infants
through adolescents, this patient should be consuming 1,760 calories
(33/kcal/kg/day) per day and 46gm (.85g/kg/day) of protein per day.
According to the Holliday-Segar Method, patients fluid intake is 2,318
mL/day (38mL/kg/day). Patient was only consuming 300-500 calories per
day, which is only about 28% of her macro nutrient needs, therefore the
patients diet prior to admission was inadequate.
b. Adequacy of fluids
According to the Holliday- Segar Method, patients fluid intake is 2,318
mL/day (38mL/kg/day). Per chart review patient was increasing water
intake in the last month to an estimated 1,050ml of fluid each day. Patient is
only consuming 45% of fluid intake
c. Appropriateness of supplements
Patient was not taking a supplement prior to admission
d. Contribution of supplements to overall intake
Patient was not taking a supplement prior to admission
e. Justify your assessment
Patient has been restricting calories for the last year and a half, starting in
summer of 2013 to admission date, January 11, 2015. Patient goal intake of
calories per day was 300 calories and normal intake of calories per day was
500 calories. Patient weight as of 10/2014 was 152 lbs (69kg) and had lost
17 lbs (37.4kg) at time of admission 11/2015. Overall weight loss was 11%
of body weight is 4 months. Patient was not consuming the sufficient amount
of calories to supply her body with the proper energy needs to maintain a
healthy body weight. Due to the restriction of calories patient experienced
severe weight loss.

6. Diet Order

a. Adequacy of macro and micronutrients
Patient is ordered to receive 1200 kcal/day :400 kcal/meal and increase by
300 kcal/day until reach goal of 2400 kcals/day via PO. Any uneaten calories

will be replaced by Boost (1mL= 1kcal) first offered by mouth then by NG

Tube. Patient is also ordered Nutren 1.5 via NG tube at 40 mL/hr, advance by
20 mL q 4 hours as tolerated until reach goal rate of 100mL/hr x 8 hours
overnight; goal provided 13mL/kg/day, 20kcal/kg/day and 0.8 g
protein/kg/day. Patient is also ordered for a multivitamin daily. Patient
would receive 100% of macro and micronutrients with goal diet plan.
b. Adequacy of Fluid
Patients estimated fluid requirements are 2,318mL (38mL/kg/day) per day.
Fluid order is according to the Holliday- Segar equation.
c. Appropriateness of supplement
Patient is ordered a Boost (1mL = 1 calorie) for any calories that are not
consumed at mealtime. Boost will supply the patient with the exact calories
that are not consumed by food.
d. Contribution of supplements to overall intake
Boost allow the patient to reach 100% on her nutrient needs.
e. Justify your assessment
Patient was initiated on the eating disorders protocol by the nutrition
assessment. Fluids are calculated by the Holliday-Segar method, calories and
protein are calculated by the DRI x 1.5 for IBW. The current diet order
provides the patient with adequate calories, protein and fluid needed to
supply adequate nutrition and reach the goal weight. The diet will also
provide nutrients to replenish the body with the proper nutrition that was
lost during the period of calorie restriction.

7. Accuracy of Data Available

Patient and patients mother were present during initial assessment and
follow up visits. The dietitian was able to speak with patient and mother separately
during the initial assessment to gain information. Patient is also monitored during
each meal to ensure food is being consumed. Patients intake is recorded.

Plan/Goals:
1. Oral nutrition
1200 kcal/day : 400 kcal/meal x 3; increase by 300 kcals/day until reach goal rate
of 2400 kcals. If patient refuses to consume all calories during meal time a Boost
(1mL = 1kcal) is given to replace the calories via PO, if patient refuses to consume
Boost by mouth, it is given via NG tube.

2. Enteral nutrition
Nutren 1.5 nighttime feedings via NG tube at 40 mL/hr, advanced by 20 mL q 4
hours as tolerated until reach goal of 100 mL/hr x 8 hours overnight. This provides
1,200 kcals/day, 20kcal/kg/day, 13mL/kg/day and 0.8 g protein/kg/day.

3. Parententeral nutrition
N/A

4. Labs/ Studies

Patients nutrition labs are monitored and within normal limits. Patient is
consuming 50-100% of meals and taking Boost via PO when needed. Patient is also
tolerating nighttime NG tube feedings.

5. Growth
Patient has gained 1.2 kg since admission date (2/11/2015), averaging 1200 grams
per day. Patient weight gain is planned and on track with eating disorder protocol.
Patients goal weight is 62.7 kg based on BMI for 50th percentile.

6. Additional information needed
Patients weight gain can also be due to fluid, therefore it is hard to tell what percent
of weight gain is due to fluid and what percent of weight gain is due to nutrition.
Additional information needed is how the patient feels about continuing the meal
plan when discharged from the hospital. To reach patients ideal body weight,
patient will have to continue to consume calories according to the discharge
assessment.

7. Follow Up
Follow up in 7 days to ensure diet has reached goal rate of 2,400 calories per day by
mouth on 2/15/2014 and Nutren 1.5 is tolerated at goal rate of 100mL/hr x 8 hours
overnight via NG tube. Monitor Boost given when patient is not consuming enough
calories. Evaluate implementation of multivitamin, and monitor, magnesium,
phosphorous and potassium daily for refeeding syndrome. Provide Potassium
Phosphate- Sodium phosphate (Phos-NaK powder) daily for re-feeding syndrome.
Follow up 25-hydrox D; supplement with Vitamin D as necessary. Measure blind
weight 2 x week: Monday and Thursday and monitor goal weight gain of 200-300
grams per day. Lastly, monitor for regular bowel movements and provide bowel
regimen as needed to promote regular bowel movements.

8. Justify your plan/goal
Patient entered hospital with acute mild malnutrition. Patient was also diagnosed
with anorexia nervosa therefore the eating disorder protocol was initiated. The
patient must consume adequate nutrition to replete the nutrients lost through
restriction periods. Adequate nutrition supplies the patient with adequate calories,
protein and fluids needed for the patient to reach her ideal body weight. To ensure
the patient is following the diet order and tolerating the tube feeds, patient will be
monitored daily to ensure proper nutrition is maintained.