NUT 4700 MNT I

Case Study 1: Malnutrition and Depression

Case Presentation

ML is an 80 year old widower who was brought to his primary care physicians office by the
local Older Americans Transportation Service. He had missed his two prior scheduled office
visits because of the recent death of his wife and a subsequent fall, which resulted in an
intertrochanteric fracture of his right hip.

On presentation, ML appeared withdrawn and much frailer than on previous visits. He answered
in a monotone with terse, nonspontaneous speech, and he lacked expression. When asked about
how he has been coping after the loss of his wife, he became tearful. He admitted that, in
addition to the loss of companionship, his wife had done all of the cooking and grocery shopping
which has caused additional hardship.

Past Medical History

ML tripped on the steps in his house 2 months ago and fractured his hip. He underwent an open
reduction/internal fixation surgery to repair the fracture, and the operation went well. He had no
serious operative complications, but he lost approximately 250cc blood during the procedure (1
unit = 500cc). ML underwent inpatient rehabilitation for 10 days after discharge from the
surgical service and then returned home, where he lives alone. He ambulates slowing with a cane
and can climb stairs only with difficulty.

During his inpatient rehabilitation stay, he was diagnosed with depression and was started on an
antidepressant. He has no major chronic diseases except for osteoporosis, discovered at the time
of his hip fractures 2 months ago. ML had an appendectomy at age 46 and bilateral cataract
surgeries 10 years ago. He has no previous history of pneumonia, tuberculosis, hepatitis, or
urinary tract infection.

Medications
ML is currently taking fluoxetine (Prozac), 20mg daily, for depression and an iron supplement
for anemia three times per day. He also self-medicates with over the counter (OTC) ibuprofen
(200-400mg three times a day) and frequently uses OTC laxatives and glycerin suppositories for
constipation, which he attributes to the iron tablets. He does not take a multiple vitamin, calcium
or vitamin D. He has no known food allergies.

Social History

ML lives alone in the four-bedroom, two-story home that he has occupied since he married 55
years ago. His son and daughter both live out of state. Although they call him every few weeks,
they have not visited since his wifes death. ML also explains that he used to attend church and
visit the local senior center regularly with his wife but has not been to either lately. ML explains
that he has no energy to get up and go anymore and he falls asleep in front of the television.
He also reports being constipated and that his food does not have much taste. He avoids alcohol
and tobacco and drinks three cups of coffee daily.

Review of Systems

General: Weakness, fatigue, weight loss, and depression.
Mouth: Food lacks taste (hypoguesia); dry, thick-feeling tongue; sores in corners of mouth.
Gastrointestinal (GI): Poor appetite, constipation.
Extremities: Hip pain when climbing stairs, some tenderness at old incision site, and chronic low
back pain

Physical Examination

Vital Signs

Temperature: 97.0 deg F
Heart rate: 88 BPM
Respiration: 18 BPM
Blood pressure: 130/80 mm Hg
Height: 511
Current weight: 145 lb
Usual weight: 170 lb

General: Thin, elderly man who is appropriately conversant but withdrawn. He is well groomed,
but his clothes are loose fitting, suggesting weight loss.
Skin: Warm to touch, patches of dryness and flaking to elbows and lower extremities
Head, ears, eyes, nose, throat (HEENT): Temporal muscle wasting, no enlargement of thyroid
Mouth: Ill-fitting dentures, sore beneath bottom plate, cracks/fissures at corners of mouth
(angular cheilitis)
Cardiac: Regular rate at 88 BPM
Abdomen: Well-healed appendectomy site scar, no enlargement of liver or spleen, diffusely
diminished bowel sounds.
Extremities: Well-healed hip surgery incision with slight surrounding erythema, no sores on feet,
traces pretibial edema to both lower extremities
Rectal: Hard stool in vault, stool test for occult blood negative
Neurologic: Alert, good memory, no evidence of sensory loss
Gait: Slightly wide-based with decreased arm swing, antalgic and tentative but with safe,
appropriate use of cane

Laboratory Data

Albumin: 2.5 g/dL (normal 3.5-5.8g/dL)
Hemoglobin: 11.0 g/dL (normal 11.8-15.5 g/dL)
Hematocrit 33.0% (normal 36-46%)

MLs 24 hour dietary recall:

At his physicians request, ML provided the following 24 hour recall, stating that this represents
his usual daily intake:

Breakfast (home)

1 Jelly donut
1 slice white toast
2 tbsp Jelly
1 cup coffee

Lunch (home)

1 cup chicken and noodle soup
3 saltine crackers
2 butter cookies
1 cup coffee

Dinner (home)

1 slice white bread
2 tbsp jelly
2 tbsp peanut putter
2 butter cookies
1 cup coffee

Total kcals: 1270
Protein: 25 gm/day (8% of kcals)
Fat: 42 gm (30% of kcals)
Carbohydrate: 201 gm (62% of kcals)
Calcium 153mg
Iron 4 mg

Case Study 1 Questions Name: Bethany Clearwater Section: 002

1. Calculations:
a. BEE (using Mifflin St Jeor and Harris Benedict- compare the results)
Mifflin St. Jeor: (9.99x 65.9) + (6.25x 180) (4.92x 80) + 5= 1,395 kcal
Harris Benedict: 66+ (13.7 x 65.9) + (5 x 180) (6.8 x 80) = 1,325 kcal
Total energy needs for repletion (weight gain)
b. Protein needs 1.2-2 g/kg= 79g
c. Fluid needs 25ml/kg= 1,648 ml
d. Ideal body weight106# + (6lbs x 11 in)] +/- 10%= 155-189 lbs
e. Percent ideal body weight 84%
f. Percent usual body weight -15%
g. BMI = 20.2

2. What do MLs BMI and percent weight change indicate about his nutritional status?
ML has an inadequate energy intake. He has unintentionally been losing weight, and has
not been getting the proper nutrients.

3. What nutrition-related issues do his lab values indicate?
Low protein intake, low fiber intake

4. Would a functional assessment of this patient yield any extra valuable information?
Justify your answer.
It might, but we already know that he has temporal wasting. So it would not surprise me
if he has further wasting. His skinfold test will also more than likely show that he is
underweight. So I may do a functional analysis, but Im not sure if it would really give
me a lot of new information.

5. What medical, environmental, and social factors have led to nutritional problems in this
patient?
His wifes death, age, hip fracture, depression, osteoporosis, lack of independence

6. What general conclusions can you draw regarding the adequacy of his current diet?
His current diet is inadequate, in protein and fiber. It is also very high in sugar and carbs.

7. How can MLs diet be improved to meet his energy requirements, achieve weight gain,
and relieve constipation? Plan a 1 day menu with specific amounts of foods and times to
eat that would improve MLs nutritional status.

His diet should include more protein and fiber, with less carbs. When I give him this
menu I would explain serving sizes and where he can get these foods.
Breakfast: 2 cups whole grain cereal, cup skim milk, 1 serving of fruit, coffee
Lunch: 2 slices of turkey, 2 pieces of whole grain bread, 1 serving of vegetable, coffee
Snack: 1 serving fruit or vegetable
Dinner: 1 serving of chicken (baked or grilled), 1-2 serving of vegetable, 1 serving of
brown rice