2. General Information
• Patient's initials
• AW
• Age, Height, Weight
• 54 y/o,
• 5’10” (70 in),
• 304.7 lbs,
• 43.7 BMI
• Occupation
• Employer: Licking Heights School, not sure of job
• Family responsibility
• Married
• Date of Admission
• 1/18/21
• Attending Physician
• Frank Boetang M.D.
• Unit
• Med/Surg.
• Unit #: BM00279733
3. Previous Medical History
• Disease(s) and/or conditions:
• Acute kidney failure, Unspecified N17.9
• Acute Respiratory Failure with Hypoxia J96.01
• Body Mass Index (BMI) 40.0-44.9, Adult Z68.41
• COVID-19 U07.1
• Essential (Primary) Hypertension I10
• Hypo-Osmolality and Hyponatremia E87.1
• Long Term (Current) Use of Hypoglycemic Drugs Z79.84
• Morbid (Severe) Obesity Due To Excess Calories E66.01
• Pneumonia Due to Coronavirus Disease 2019 J12.82
• Type 2 Diabetes Mellitus with Hyperglycemia E11.65
• Hospitalizations
• June 2020 – Lumbar Strain
• March 2020 – Upper Respiratory Infection
• May 2018 – Motor Vehicle Accident
4. Present Admission
• Diagnosis/Problem List
• Acute kidney failure, Unspecified N17.9
• Acute Respiratory Failure with Hypoxia J96.01
• COVID-19 U07.1
• Hypo-Osmolality and Hyponatremia E87.1
• Pneumonia Due to Coronavirus Disease 2019 J12.82
• Physical examination
• Could not complete NFPE due to COVID-19 dx.
• Other significant data:
• Chest x-ray, but unable to view
5. C
PRESENT
ADMISSION
– LABS
1/18 1/19 1/20
0:23
1/20
13:02
1/21 1/22 1/23 1/24 1/25
05:03
1/25
20:38
1/26
WBC 10.6 H 10.8 H --- --- 13.0 H 10.5 11.6 H 12.3 H 12.6 H --- 13.8 H
Hgb 14.3 14.5 --- --- 13.2 13.1 12.6 L 13.2 13.1 --- 13.3
Neut % 73.0 80.9 H --- --- 78.8 H 68.8 68.3 68.1 66.5 --- 66.3
Lymph % 16.2 L 14.4 L --- --- 11.9 H 17.6 L 16.3 L 17.9 17.6 L --- 19.2
Neut # 7.7 H 8.8 H --- --- 10.3 H 7.2 H 7.9 H 8.3 H 8.4 H --- 9.1 H
Mono # 1.0 .4 --- --- 1.0 1.2 H 1.3 H 1.2 H 1.2 H --- 1.1
Mono % 9.4 3.2 L --- --- 7.8 11.2 11.6 9.6 9.4 --- 8.2
Immature Gran 1.2 1.4 --- --- 1.3 2.1 3.5 4.2 H 6.1 H --- 5.8 H
Immature Gran .13 .15 --- --- .17 .22 H .40 H .52 H .76 H --- .80 H
Sodium 129 L 133 L --- 127 L 128 L 129 L 128 L 132 L 131 L --- 130 L
Potassium 4.5 4.9 --- 5.0 L 4.7 4.7 5.2 H 4.4 4.1 --- 4.1
Chloride 96 L 97 L --- 96 L 95 L 96 L 96 L 95 L 96 L --- 98
Carbon Dioxide 16 L 15 L --- 17 L 20 L 21 L 23 27 22 --- 22
Anion Gap 17.2 L 20.8 H --- 15.1 H 12.8 21 L 9.0 9.5 13.1 --- 9.9
BUN 63.0 H 70.0 H --- 85.0 H 86.0 H 68.0 H 55.0 H 41.0 H 34.0 H --- 29.0 H
Creatinine 2.10 H 2.06 H --- 1.73 H 1.51 H 1.27 H 1.17 1.08 .91 --- .75
Glucose 202 H 388 H --- 421 H 433 H 453 H 409 H 356 H 292 H 487 H 250 H
Calcium 8.3 L 8.6 --- 8.7 8.8 8.7 8.6 8.5 8.8 --- 9.0
Magnesium --- --- 2.4 H --- --- -- --- --- 2.3 --- 2.0
AST 79 H --- --- --- --- -- --- --- --- --- ---
Globulin 3.9 H --- --- --- --- -- --- --- --- --- ---
6. Study of Disease
(Brief)
• Definition
• Hypoxia – condition where not enough oxygen makes it to the cells
and tissues in the body
• COVID-19 - Merriam Webster definition: a mild to severe respiratory
illness that is caused by a coronavirus (Severe acute respiratory
syndrome coronavirus 2 of the genus Betacoronavirus), is
transmitted chiefly by contact with infectious material (such as
respiratory droplets) or with objects or surfaces contaminated by the
causative virus.
• CDC definition of COVID-19 symptoms:
• Fever or chills
• Cough
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea
7. Study of Disease
(Cont.)
• MNT Treatment
• Energy Needs:
• 27 kcal per kg of body weight per day; total energy expenditure for
polymorbid patients aged >65 years.
• 30 kcal per kg body weight per day; total energy expenditure severely
underweight polymorbid patients.
• 30 kcal per kg per day; guiding value for energy intake in older
persons, this value should be individually adjusted with regard to
nutritional status, physical activity level, disease status and tolerance.
• **The target of 30 kcal/kg body weight in severely underweight
patients should be cautiously and slowly achieved, as this is a
population at high risk for refeeding syndrome.
• Protein Needs:
• 1 g protein per kg body weight a day in older persons; the amount
should be individually adjusted with regard to nutritional status,
physical activity level, disease status, and tolerance.
• >/ 1 g protein per kg body weight a day in polymorbid medical
inpatients in order to prevent body weight loss, reduce the risk of
complications and hospital readmission and improve functional
outcome.
• Complications and related diseases:
• Pneumonia, AKI, Hypoxia, azotemia
8. Medical Treatment
• Medications
• Remdesivir 100mg
• Insulin – Levemir, NovoLOG
• Lasix 40 mg
• Lovanox 40 mg
• Mucinex 600 mg
• Norvasc 10 mg
• Decadron 6 mg
• Heparin 5,000 units
• Sodium Chloride
• Tessalon Perlas 100 mg
• Zithromax 500 mg
• Duoneb 6 ml
• General Progress/Physician Progress Summary:
• 1/19/21 Progress Note Chief Complaint: “The patient is overall feeling
better. He notes that his respiratory status is improved from yesterday.”
• 1/20/21 Progress Note Chief Complaint: “Shortness of breath”
• 1/21/21 Progress Note Chief Complaint: “Shortness of breath, Patient
stated that he feels better, less short of breath, Still requiring 5 L nasal
cannula oxygen, with no evidence of respiratory distress, Continue current
measures, reevaluate next a.m., Likely will require home O2 prior to
discharge, once O2 requirements are improving”
• 1/22/21 Progress Note Chief Complaint: “Shortness of breath, hypoxia”
• 1/23/21 Progress Note Chief Complaint: “Hypoxia, Shortness of breath”
• 1/24/21 Progress Note Chief Complaint: “Patient is stable on 4 L
oxygen. Denies any worsening short of breath. Vitals stable.”
• 1/25/21 Progress Note Chief Complaint: “Patient is stable on 4 L oxygen,
denies any short of breath.”
• 1/26/21 Discharge in stable condition.
9. Medical Nutrition Therapy/Nutrition Care Process
Day 1 Full Assessment
Need for Nutritional Intervention/Alert
Met Criteria
Alert Generated
Nutrition Care Level
Moderate
Home Diet History
3 Meals/Day
Afternoon Snack
Narrative
Pt is a 54 yo male admitted for AKI and hypoxia with COVID-19 pneumonia. PMH of HTN, T2DM, obesity. Nutrition screen this date per MST score 3-
decreased appetite and wt loss. CBW 304.7 lbs (bed scale) reflects obese BMI of 43.7 kg/m^2. EMR wt hx:
• 6/14/20 329 lbs (actual)
• 3/10/20 340 (stated)
CBW reflects wt loss of 35.4 lbs (10.38%) in 10 months, which is not clinically significant per ASPEN malnutrition criteria. However, pt reports weight loss
of 15 lbs (4.7%) x 2 weeks. This report is clinically significant per ASPEN malnutrition criteria. No edema per nursing documentation. Pt ordered small
breakfast this date per CBORD. Spoke with pt via room phone. Pt reports decreased appetite since COVID-19 dx. Since dx, pt reports eating 2-3 bites of
food per day. Prior to dx, pt eating 3 meals per day and snacks on vegetables with 75% PO intake. Pt PO intake <50% estimated needs for </ 5 days. Pt
agreeable to trial chocolate Ensure TID. Pt denies N/V/C. C/o diarrhea since COVID-19 dx. Taken together, pt meets ASPEN criteria for severe
malnutrition in context of acute illness d/t poor po intake and wt loss.
Self-feeding Ability
Independent
PO Intake in Hospital
See narrative
Usual Weight
319.7 lbs
Religious/Cultural/Ethnic Food Preferences
No
Nausea/Vomiting Presence
None
Bowel Pattern
Diarrhea
Dental Type
Partial- Lower
10. Medical Nutrition Therapy/Nutrition Care
Process Day 1 Full Assessment
Current Food Consistency
Thin Liquid
Regular
Current Diet Order
Diabetic
Pertinent Medications
Insulin - Levemir, NovoLOG
Amlodipine
Remdesivir
Dexamethasone
Hx Dysphagia
No
Hx Diabetes
Yes
Hx Renal Disease
Yes - AKI
Hx Gastrointestinal Disorders
No
Hx Cancer
No
Patient Gender
Male
Patient Age
54 years
Current Height (inches)
70.0 inches
Current Weight (pounds)
304.7 lbs
Patient Weight
0 lb 4.875 oz
304.7 lb
Height/Weight Measurement Method
Built in Bedscale
Lab value comments per EMR
WBC 10.8 H
BUN 70.0 H
Creatinine 2.06 H
Glucose 388 H
Ideal Body Weight (IBW)
166.00 lbs
Adjusted Body Weight (ABW)
200.68 lbs
Percent Ideal Body Weight (%IBW)
184.00 lbs
Patient Height
70 in
Body Mass Index
43.72
Total Kilocalorie/Energy Requirements
IBW: 2265-2642.5 kcals
Method for Calculating Total Kilocalorie/Energy
Requirement
30-35 kcal/kg IBW
Protein Factor Value
.8-1.2 g/ kg IBW
Total Protein Requirement
60.4-90.6
Total Fluid Requirement
2265-2642.5 mL
Method for Calculating Total Fluid Requirement
1 mL/kcal
Degree of Malnutrition
Severe
Setting of Malnutrition
Acute
Diagnosis #1
PES: Severe malnutrition related to acute
illness of COVID-19 as evidenced by
suspected po intake </ 50% intake of
estimated energy needs for >/ 5 days
and wt loss >2% in 2 weeks.
11. Medical Nutrition Therapy/Nutrition Care
Process Day 1 Full Assessment
Nutritional Goal
Maintain Current Weight
Pt Will Accept Diet
Meal Intake > 75%
Nutritional Interventions
Provide Diet as Ordered
Reevaluate Pt in 3-5 days
Add Supplement
Monitor Labs & Intake
Monitoring & Evaluation
Diet Order
Medications
Total Energy Intake
Fluid/Beverage Intake
Protein Intake
Carbohydrate Intake
Electrolyte/Renal Profile
GI Profile
Glucose/Endocrine Profile
Nutritional Plan Comments
Nutrition care level is moderate per priority points; scored points for
poor po intake and wt loss.
POC:
1.Pt meets criteria for severe malnutrition in the context of acute
illness.
2.Will send chocolate Ensure Enlive TID, which provides 350 kcals and 20 g
pro per serving.
3.Will monitor adequacy of PO intake, weight trends, I/O’s, labs, and
supplement acceptance and follow up per protocol.
NPO
No
Diabetic
Consistent Carbohydrate
12. Medical Nutrition
Therapy/Nutrition Care
Process Day 2
• 1/20/21 – Called to follow up this date. Asked pt how
he was doing and if he liked the Ensure. He stated
that his appetite is not better and the Ensure gave
him bad heartburn. D/t heartburn, we put in an order
for Ensure clear to see if that would help. He also
stated that he got crackers to eat. He requested jello.
13. Medical Nutrition
Therapy/Nutrition Care
Process Day 3
• 1/21/21 – Called to follow up this date. Asked pt how
he was doing. He stated that his appetite was better.
He stated that he never got the Ensure clear or the
jello. We sent in another order to get this for him.
14. Medical Nutrition Therapy/Nutrition Care Process
Day 4 LOS Note
Nutrition Care Level
Moderate
Hx Weight Gain
No - No new wts since adm
PO Intake
Poor
Significant abnormal labs
BUN: 68.0 H
Cr: 1.27 H
Glucose from 1/19/21-1/22/21: 421 mg/dL-453 mg/dL
Pertinent Medications
NovoLOG
Levemir
Amlodipine
Dexamethasone
Narrative
Nutrition follow up assessment complete this date. CBW 304.7 lbs (bed scale) reflects obese BMI of 43.7 kg/m^2. No new wts to
assess this adm. Pt is net +1650 ml since adm per I/Os. Pt has edema per nursing documentation. No meal intake %s since adm. Pt is
skipping majority of meals per CBORD. This dietetic intern has been following up with pt daily via phone. On 1/20/21, pt c/o
chocolate Ensure giving him heartburn. Ensure clear was sent to see if that would improve. On 1/21/21, pt reports appetite improving.
Sent pt a tray with jello, chicken noodle soup, crackers, and Ensure clear.
Total Kilocalorie/Energy Requirements
2265-2642.5 kcal IBW
Method for Calculating Total Kilocalorie/Energy Requirement
30-35 kcal/kg IBW
Protein Factor Value
.8-1.2 g/kg
Total Protein Requirement
60.4-90.6 g
Total Fluid Requirement
2265-2642.5 mL
Method for Calculating Total Fluid Requirement
1 mL/ kcal
15. Medical Nutrition Therapy/Nutrition Care Process
Day 4 LOS Note
Degree of Malnutrition
Severe
Setting of Malnutrition
Chronic
Diagnosis #1
PES: Severe malnutrition related to acute illness of COVID-19 as evidenced by suspected po intake </ 50% intake of estimated energy needs for >/
5 days and wt loss >2% in 2 weeks.
Nutritional Goal
Maintain Current Weight
Follow Diet as Ordered
Meal Intake > 75%
Nutritional Interventions
Provide Diet as Ordered
Reevaluate Pt in 3-5 days
Add Supplement
Monitor Labs & Intake
Monitoring & Evaluation
Diet Order
Medications
Total Energy Intake
Fluid/Beverage Intake
Protein Intake
Carbohydrate Intake
Glucose/Endocrine Profile
Nutritional Plan Comments
Nutrition care level is moderate per priority points; scored points for poor po intake and wt loss.
POC:
1.Pt meets criteria for severe malnutrition in the context of acute illness.
2.No new wts since adm. Obtain new weight measurement if possible.
3.Will send Berry Ensure Clear TID, which provides 240 kcals and 8 g pro per serving.
4.Will monitor and follow up per protocol.
NPO
No
Diabetic
Consistent Carbohydrate
Regular
A Balanced Diet
No Restrictions
16. Medical Nutrition
Therapy/Nutrition Care
Process Day 5
• 1/25/21 (Monday) – Called to follow up this date.
Asked pt how he was doing. He said his appetite
improved and he only had to heartburn that one
time. He ate most of his breakfast this date: Eggs,
French toast, yogurt, Ensure, and chocolate milk.
Over the weekend, he had more to eat (still little):
cottage cheese, salmon, Ensure. On this date, 2 meals
with 100% PO intake.
18. Prognosis
• Medical – Good prognosis. Stable, discharged
1/26/21.
• Compliance to Nutrition Care Plan – Pt did comply
with trying the chocolate Ensure and got heartburn.
Then tried Ensure clear and seemed to be drinking it.
At the beginning of his time here, he was not eating.
That gradually improved as his length of stay
continued.
• Follow-up Plans – New diabetic, received diabetic
education upon discharge.
19. What Would I
Have Done
Differently?
• I wish I could have gone into his room
and done an NFPE. Unfortunately, I could
not d/t COVID-19 dx.
• Wish I would have asked if he noticed wt
loss anywhere in particular in reference
to the sites we look for on the NFPE’s.
• In addition, I also did not ask if the wt
loss was intentional. D/t his higher BMI, I
think it is reasonable to ask if the wt loss
is intentional. D/t it being significant
within a 2-week span, it probably wasn’t
intentional, but it never hurts to ask.
That answer could have affected his dx.
• Other than that, I think I did well with the
patient. I felt comfortable talking to him
on the phone, asking appropriate
questions, and following up in his care.
20. References
Barazzoni, R., Bischoff, S. C., Breda, J., Wickramasinghe, K., Krznaric, Z., Nitzan,
D., . & Singer, P. (2020). ESPEN expert statements and practical guidance for
nutritional management of individuals with SARS-CoV-2 infection.
Cascella M, Rajnik M, Cuomo A, et al. Features, Evaluation, and Treatment of
Coronavirus. [Updated 2020 Oct 4]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2020 Jan-.
Covid-19. (n.d.). Retrieved February 03, 2021, from https://www.merriam-
webster.com/dictionary/COVID-19
Symptoms of coronavirus. (n.d.). Retrieved February 03, 2021, from
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-
testing/symptoms.html
